text:
|Publication number
|Publication type
|Application number
|Publication date
|15 Jun 2006
|Filing date
|10 Feb 2006
|Priority date
|20 Oct 1999
|Also published as
|Publication number
|Joseph Cauthen, Matthew Burns, Lawrence Wales, Brian Dukart, Bradley Wessman, Rodney Houfburg, Paul Burmeister
|Original Assignee
|Anulex Technologies, Inc.
|Export Citation
|BiBTeX, EndNote, RefMan
|Patent Citations (17), Referenced by (52), Classifications (61), Legal Events (5)
|External Links: USPTO, USPTO Assignment, Espacenet
This application is a continuation of U.S. patent application Ser. No. 10/327,106, filed Dec. 24, 2002, which is a continuation-in-part of U.S. patent application Ser. No. 09/947,078, filed Sep. 5, 2001, which is a continuation of U.S. patent application Ser. No. 09/484,706, filed Jan. 18, 2000, which claims the benefit of U.S. Provisional Application No. 60/160,710, filed Oct. 20, 1999. This application also claims the benefit of U.S. Provisional Application No. 60/309,105, filed Jul. 31, 2001. This application is also related to, and claims the benefit of, U.S. patent application Ser. No. 10/075,615, filed on Feb. 15, 2002, and U.S. patent application Ser. No. 10/085,040, filed Mar. 1, 2002.
The invention generally relates to methods and implantable medical devices for the closure, sealing and/or repair of an aperture in the intervertebral disc annulus. The term "aperture" refers to a hole in the annulus that is a result of a surgical incision into the intervertebral disc annulus, or the consequence of a naturally occurring tear (rent). The invention generally relates to surgical devices and methods for intervertebral disc wall repair or reconstruction. The invention further relates to an annular repair device, or stent, for annular disc repair. These stents can be of natural or synthetic materials. The effects of said reconstruction is restoration of disc wall integrity and reduction of the failure rate (3-21%) of a common surgical procedure (disc fragment removal or discectomy).
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 the disc, collapse of the intervertebral space occurs, contributing to abnormal joint mechanics and premature development of 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 loose 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. The annulus loses much of its flexibility and resilience, becoming more dense and solid in composition. The aging annulus may also be marked by the appearance or propagation of cracks or fissures in the annular wall. Similarly, the nucleus desiccates, increasing viscosity and thus losing its fluidity. In combination, these features of the aged intervertebral discs result in less dynamic stress distribution because of the more viscous nucleus pulposus, and less ability to withstand localized stresses by the annulus fibrosus due to its desiccation, loss of flexibility and the presence of fissures. Fissures can also occur due to disease or other pathological conditions. 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.
Surgical repairs or replacements of displaced or herniated discs are attempted approximately 390,000 times in the USA each year. Until the present invention, there was no known way to repair or reconstruct the annulus. Instead, surgical procedures to date are designed to relieve symptoms by removing unwanted disc fragments and relieving nerve compression. While results are currently acceptable, they are not optimal. Various authors report 3.1-21% recurrent disc herniation, representing a failure of the primary procedure and requiring re-operation for the same condition. An estimated 10% recurrence rate results in 39,000 re-operations in the United States each year.
An additional method of relieving the symptoms is thermal annuloplasty, involving the heating of sub-annular zones in the non-herniated painful disc, seeking pain relief, but making no claim of reconstruction of the ruptured, discontinuous annulus wall.
Some have also suggested that the repair of a damaged intervertebral disc might include the augmentation of the nucleus pulposus, and various efforts at nucleus pulposus replacement have been reported. The present invention is directed at the repair of the annulus, whether or not a nuclear augmentation is also warranted.
In addition, there has been experimentation in animals to assess various surgical incisions with and without the direct surgical repair of the annulus. These studies were performed on otherwise healthy animals and involved no removal or augmentation of nucleus pulposus. The authors of these experiments conclude that direct repair of the annulus does not influence the healing of the disc.
The present inventors have found, advantageously and contrary to accepted practice, that the annulus tissue may be sutured and that annular healing may be facilitated by reapproximation of annular tissue. Methods and devices for carrying out annular repair and/or reconstruction are a subject of the present invention.
The present invention provides methods and related materials for reconstruction of the disc wall in cases of displaced, herniated, ruptured, or otherwise damaged intervertebral discs. In accordance with the invention, a method is disclosed for intervertebral disc reconstruction for treating a disc having an aperture in the wall of the annulus fibrosis, wherein the aperture provides a path for the migration of nucleus pulposus from the subannular space. The method of the invention includes, in one embodiment providing an expandable patch having a first configuration dimensioned to pass through the aperture and a second expanded configuration having at least one dimension at least as large as the aperture and having at least one dimension larger than a corresponding dimension in said first configuration; inserting the patch through the aperture into the subannular space when the device is in the first collapsed configuration; and causing or allowing the patch to expand in the subannular space into the second expanded configuration to bridge the aperture. The method according to the invention occludes the aperture, helps to prevent the migration of nucleus pulposus through the aperture, and promotes healing of the aperture through tissue reapproximation.
The objects and various advantages of the invention will be apparent from the description which follows. In general, the implantable medical devices are placed, positioned, and affixed to the annulus to reduce re-extrusion of the nucleus through the aperture by: closing or partially closing the aperture; restoring the natural integrity of the wall of the annulus; and promoting healing of the annulus through the reapproximation of disc wall tissue. Increased integrity and faster and/or more thorough healing of the aperture is intended to reduce future recurrence of herniation of the disc nucleus from the intervertebral disc, and the recurrence of resulting back pain. In addition, it is believed that the repair of the aperture could promote enhanced biomechanics and reduce the possibility of intervertebral disc height collapse and segmental instability, thus resulting in a decrease in the recurrence of back pain after a surgical procedure.
Moreover, the repair of the aperture with the reduction of the re-extrusion of the nucleus may also advantageously reduce adhesion formation surrounding the nerve roots. The nuclear material of the disc is toxic to the nerves and is believed to cause increased inflammation surrounding the nerves, which in turn can cause increased scar formation (adhesions or epidural fibrosis) upon healing. Adhesions created around the nerve roots can cause continued back pain. Any reduction in adhesion formation is believed to reduce future recurrence of pain.
The methods and devices of the present inventions may create a mechanical barrier to the extrusion of the nucleus from the disc space, add mechanical integrity to the annulus and the tissue surrounding the aperture, and promote faster and more complete healing of the aperture.
Although much of the discussion is directed toward the repair of the intervertebral disc after a surgical procedure, such as discectomy (a surgical procedure performed to remove herniated fragments of the disc nucleus), it is contemplated that the devices of the present invention may be used in other procedures that involve incisions into the annulus of the intervertebral disc. An example of another procedure that could require a repair technique involves the replacement of the nucleus (nucleus replacement) with an implantable nucleus to replace the functioning of the natural nucleus when it is degenerated. The object of the invention in this case would be similar in that the repair would maintain the replacement nucleus within the disc space.
According to an embodiment of the invention, a sub-annular patch/stent can be employed to repair an intervertebral disc annulus. In its simplest form, the repair of the annulus involves the placement and fixation of a fascial autograft patch to the sub-annular space. The patch, when used, can be secured in place with two or more sutures, while re-approximating the tissues surrounding the aperture. The invention, through involvement of the sub-annular space and wall for the repair of the aperture has several advantages over the prior art, for example, sealing the aperture only on the outer surface or sealing the aperture only within the aperture. The first advantage of a repair that involves the sub-annular surface derives itself from the physical nature of a circular (or an elliptical) compressed chamber with a radius, like an intervertebral disc. Sealing the inside wall has the inherent advantage of being at a smaller radius of curvature versus the outer wall and thus, according to LaPlace's Law, the patch would be subjected to lower stresses at any given pressure, all else held equal.
Another advantage of utilizing the inner surface to accomplish sealing is that the natural pressure within the disc can enhance the sealing of the device against the inner wall of the disc space. Conversely, if the repair is performed on the outer surface of the annulus there is an inherent risk of leakage around the periphery of the device, with the constant exposure to the pressure of the disc.
Another advantage of the present invention over the prior art in utilizing the inner surface of the annulus is the reduction of the risk of having a portion of the device protruding from the exterior surface of the annulus. Device materials protruding from the exterior of the annulus pose a risk of damaging the nerve root and/or spinal canal which are in close proximity. Damage to these structures can result in continued pain, incontinence, bowel dysfunction and paralysis.
The present invention incorporates the concept of pulling the tissues together that surround the aperture, the inner surface, and the outer surface of the annulus to help close the aperture, increase the integrity of the repair, and promote healing.
An example of the technique and placement of the device according to one embodiment of the invention is as follows:
1. An aperture is created measuring approximately, for example, 6 mm�2 mm in the wall of the annulus after performing a discectomy procedure in which a portion of the nucleus is also removed from the disc space, as shown in
2. Two or more sutures are passed through the upper and lower surfaces of the aperture and they are pushed within the intervertebral disc space to create a "sling" to receive the fascial autograft as shown for example in
3. A piece of para-spinal fascial tissue is removed from the patient measuring approximately, for example, 10 mm�5 mm.
4. The autograft is folded and compressed to pass through the aperture in the annulus, as shown for example in
5. The autograft takes a second shape, within the annulus that is uncompressed and oriented to be in proximity of the subannular wall of the annulus, within the sling, as shown for example in
6. The sutures are tightened, as shown for example in
7. The sutures are tied and the ends of the sutures are cut.
8. A piece of autograft fat tissue may be placed over the discectomy site for the prevention of adhesion formation, a typical surgical technique.
9. Standard surgical techniques are utilized to close the access site of the surgical procedures.
Several devices according to the present invention can be used to practice the above illustrative inventive steps to seal and/or repair the intervertebral disc. In each of the representative devices of this embodiment of the invention, there is: an expandable patch/stent (note: patch, stent and device are used interchangeably) that has, in use, at least a portion of the device in proximity to the sub-annular space of the intervertebral disc annulus; a means to affix the patch to stay in proximity with the annulus; a means to draw the patch and the annular tissue together and fasten in tension; and a means to help reduce the relative motion of the surfaces of the aperture after fixation, and thus promote healing. According to one feature and object of the present invention, close approximation of tissue, while reducing the motion of the surfaces, provides the optimal environment for healing.
The concepts disclosed hereinbelow accomplish these objectives, as well as advantageously additionally incorporating design elements to reduce the number of steps (and time), and/or simplify the surgical technique, and/or reduce the risk of causing complications during the repair of the intervertebral disc annulus. In addition, the following devices may become incorporated by the surrounding tissues, or to act as a scaffold in the short-term (3-6 months) for tissue incorporation.
In an exemplary embodiment, one or more mild biodegradable surgical sutures can be placed at about equal distances along the sides of a pathologic aperture in the ruptured disc wall (annulus) or along the sides of a surgical incision in the annular wall, which may be weakened or thinned.
Sutures are then tied in such fashion as to draw together the sides of the aperture, effecting reapproximation or closure of the opening, to enhance natural healing and subsequent reconstruction by natural tissue (fibroblasts) crossing the now surgically narrowed gap in the disc annulus.
A 25-30% reduction in the rate of recurrence of disc nucleus herniation through this aperture has been achieved using this method.
In another exemplary embodiment, the method can be augmented by creating a subannular barrier in and across the aperture by placement of a patch of human muscle fascia (muscle connective tissue) or any other autograft, allograft, or xenograft acting as a bridge or a scaffold, providing a platform for traverse of fibroblasts or other normal cells of repair existing in and around the various layers of the disc annulus, prior to closure of the aperture.
A 30-50% reduction in the rate of recurrence of disc herniation has been achieved using the aforementioned fascial augmentation with this embodiment.
Having demonstrated that human muscle fascia is adaptable for annular reconstruction, other biocompatible membranes can be employed as a bridge, stent, patch or barrier to subsequent migration of the disc nucleus through the aperture. Such biocompatible materials may be, for example, medical grade biocompatible fabrics, biodegradable polymeric sheets, or form fitting or non-form fitting fillers for the cavity created by removal of a portion of the disc nucleus pulposus in the course of the disc fragment removal or discectomy. The prosthetic material can be placed in and around the intervertebral space, created by removal of the degenerated disc fragments.
In some clinical instances, for instance, where a wall of an annulus contains a sufficiently small aperture, or where a wall of the annulus is weakened or thin, the present invention may be advantageously accomplished without the use of a patch. Thus, in another embodiment, the present invention also includes a method of repairing or reconstructing an annulus comprising placing at least one fixation device into, or through, the wall of an annulus surrounding the aperture (or weakened or thin portion of the annulus) and causing, or allowing, the devices to be drawn in tension thereby pulling together, wholly or partially, the tissues surrounding annular tissue. Devices for use with the method are also disclosed. The inventive method forms a mechanical barrier, or partial mechanical barrier, to the migration of nucleus pulposus and/or helps to promote healing of the aperture through tissue reapproximation.
Additional objects and advantages of the invention will be set forth in part in the description which follows, and in part will be obvious from the description, or may be learned by practice of the invention. The objects and advantages of the invention will be realized and attained by means of the elements and combinations particularly pointed out in the appended claims.
It is to be understood that both the foregoing general description and the following detailed description are exemplary and explanatory only and are not restrictive of the invention, as claimed.
The accompanying drawings, which are incorporated in and constitute a part of this specification, illustrate illustrative embodiments of the invention and, together with the description, serve to explain the principles of the invention.
Reference will now be made in detail to selected illustrative embodiments of the invention, with occasional reference to the accompanying drawings. Wherever possible, the same reference numbers will be used throughout the drawings to refer to the same or like parts.
In one embodiment of the present invention, as shown in
Additionally, to repair a weakened or thinned wall of a disc annulus 42, a surgical incision 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 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 of human muscle fascia or any other autograft, allograft or xenograft 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. FIGS. 8A-B, for example, show a biocompatible membrane employed as an annulus stent 10, being placed in and across the aperture 44. The annulus stent 10 acts as a bridge in and across the aperture 44, providing a platform for a 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 some embodiments the device, stent or patch can act as a scaffold to assist in tissue growth that healingly scars the annulus.
In an illustrative embodiment, as shown in
Additionally, the upper section 14 of the centralized vertical extension 12 may be any number of different shapes, as shown in
The upper section 14 of the centralized vertical extension 12 can comprise a slot 18, where the slot 18 forms an orifice through the upper section 14. The slot 18 is positioned within the upper section 14 such that it traverses the upper section's 14 longitudinal axis. The slot 18 is of such a size and shape that sutures, tension bands, staples or any other type of fixation device known in the art may be passed through, to affix the annulus stent 10 to the disc annulus 42.
In an alternative embodiment, the upper section 14 of the centralized vertical extension 12 may be perforated. The perforated upper section 14 contains a plurality of holes that traverse the longitudinal axis of upper section 14. The perforations are of such a size and shape that sutures, tension bands, staples or any other type of fixation device known in the art may be passed through, to affix the annulus stent 10 to the disc annulus 42.
The lower section 16 of the centralized vertical extension 12 can comprise a pair of lateral extensions, a left lateral extension 20 and a right lateral extension 22. The lateral extensions 20 and 22 comprise an inside edge 24, an outside edge 26, an upper surface 28, and a lower surface 30. The lateral extensions 20 and 22 can have an essentially constant thickness throughout. The inside edge 24 is attached to and is about the same length as the lower section 16. The outside edge 26 can be about 8 mm-16 mm in length. The inside edge 24 and the lower section 16 meet to form a horizontal plane, essentially perpendicular to the centralized vertical extension 12. The upper surface 28 of the lateral extensions 20 and 22 can form an angle from about 0�-60� below the horizontal plane. The width of the annulus stent 10 may be from about 3 mm-8 mm.
Additionally, the upper surface 28 of the lateral extensions 20 and 22 may be barbed for fixation to the inside surface of the disc annulus 42 and to resist expulsion through the aperture 44.
In an alternative embodiment, as shown in
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 bioabsorable) 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.
In further embodiments, as shown in FIGS. 5AB-6AB, the left and right lateral extensions 20 and 22 join to form a solid pyramid or cone. Additionally, the left and right lateral extensions 20 and 22 may form a solid trapezoid, wedge, or bullet shape. The solid formation may be a solid biocompatible or bioresorbable flexible material, allowing the lateral extensions 20 and 22 to be compressed for insertion into aperture 44, then to expand conforming to the shape of the annulus' 42 inner wall.
Alternatively, a compressible core may be attached to the lower surface 30 of the lateral extensions 20 and 22, forming a pyramid, cone, trapezoid, wedge, or bullet shape. The compressible core may be made from one of the biocompatible or bioresorbable resilient foams well known in the art. The core can also comprise a fluid-expandable membrane, e.g., a balloon. The compressible core allows the lateral extensions 20 and 22 to be compressed for insertion into aperture 44, then to expand conforming to the shape of the annulus' 42 inner wall and to the cavity created by pathologic extrusion or surgical removal of the disc fragment.
In an illustrative method of use, as shown in FIGS. 11A-D, the lateral extensions 20 and 22 are compressed together for insertion into the aperture 44 of the disc annulus 42. The annulus stent 10 is then inserted into the aperture 44, where the lateral extensions 20, 22 expand. In an expanded configuration, the upper surface 28 can substantially conform to the contour of the inside surface of the disc annulus 42. The upper section 14 is positioned within the aperture 44 so that the annulus stent 10 may be secured to the disc annulus 42, using means well known in the art.
In an alternative method, where the length of the aperture 44 is less than the length of the outside edge 26 of the annulus stent 10, the annulus stent 10 can be inserted laterally into the aperture 44. The lateral extensions 20 and 22 are compressed, and the annulus stent 10 can then be laterally inserted into the aperture 44. The annulus stent 10 can then be rotated inside the disc annulus 42, such that the upper section 14 can be held back through the aperture 44. The lateral extensions 20 and 22 are then allowed to expand, with the upper surface 28 contouring to the inside surface of the disc annulus 42. The upper section 14 can be positioned within, or proximate to, the aperture 44 in the subannular space such that the annulus stent 10 may be secured to the disc annulus, using means well known in the art.
In an alternative method of securing the annulus stent 10 in the aperture 44, as shown in
It is anticipated that fibroblasts will engage the fibers of the polymer or fabric of the intervertebral disc stent 10, forming a strong wall duplicating the currently existing condition of healing seen in the normal reparative process.
In an additional embodiment, as shown in FIGS. 10A-B, a flexible bladder 60 is attached to the lower surface 30 of the annulus stent 10. The flexible bladder 60 comprises an internal cavity 62 surrounded by a membrane 64, where the membrane 64 is made from a thin flexible biocompatible material. The flexible bladder 60 is attached to the lower surface 30 of the annulus stent 10 in an unexpanded condition. The flexible bladder 60 is expanded by injecting a biocompatible fluid or expansive foam, as known in the art, into the internal cavity 62. The exact size of the flexible bladder 60 can be varied for different individuals. The typical size of an adult nucleus is about 2 cm in the semi-minor axis, 4 cm in the semi-major axis, and 1.2 cm in thickness.
In an alternative embodiment, the membrane 64 is made of a semi-permeable biocompatible material. The mechanical properties of the injectate material may influence the performance of the repair and it is contemplated that materials which are "softer" or more compliant as well as materials that are less soft and less compliant than healthy nucleus are contemplated within the scope of certain embodiments of the invention. It must be understood that in certain embodiments the volume added to the subannular space may be less than equal to or larger than the nucleus volume removed. The volume of the implant may vary over time as well in certain embodiments.
In an illustrative embodiment, a hydrogel is injected into the internal cavity 62 of the flexible bladder 60. A hydrogel is a substance formed when an organic polymer (natural or synthetic) is cross-linked via, covalent, ionic, or hydrogen bonds to create a three-dimensional open-lattice structure, which entraps water molecules to form a gel. The hydrogel may be used in either the hydrated or dehydrated form.
In a method of use, where the annulus stent 10 has been inserted into the aperture 44, as has been previously described and shown in FIGS. 12 A-B, an injection instrument, as known in the art, such as a syringe, is used to inject the biocompatible fluid or expansive foam into the internal cavity 62 of the flexible bladder 60. The biocompatible fluid or expansive foam is injected through the annulus stent 10 into the internal cavity 62 of the flexible bladder 60. Sufficient material is injected into the internal cavity 62 to expand the flexible bladder 60 to fill the void in the intervertebral disc cavity. The use of the flexible bladder 60 is particularly useful when it is required to remove all or part of the intervertebral disc nucleus.
The surgical repair of an intervertebral disc may require the removal of the entire disc nucleus, being replaced with an implant, or the removal of a portion of the disc nucleus thereby leaving a void in the intervertebral disc cavity. The flexible bladder 60 allows for the removal of only the damaged section of the disc nucleus, with the expanded flexible bladder 60 filling the resultant void in the intervertebral disc cavity. A major advantage of the annulus stent 10 with the flexible bladder 60 is that the incision area in the annulus 42 can be reduced in size, as there is no need for the insertion of an implant into the intervertebral disc cavity.
In an alternative method of use, a dehydrated hydrogel is injected into the internal cavity 62 of the flexible bladder 60. Fluid, from the disc nucleus, passes through the semipermeable membrane 64 hydrating the dehydrated hydrogel. As the hydrogel absorbs the fluid the flexible bladder 60 expands, filling the void in the intervertebral disc cavity.
In an alternative embodiment, as shown in
As shown in
In an alternative embodiment, the radial extension 76 has a greater thickness at the central hub 66 edge than at the outside edge.
In an embodiment, the annulus stent 10 is a solid unit, formed from one or more of the flexible resilient biocompatible or bioresorbable materials well known in the art.
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.
Alternatively, as shown in
In an additional embodiment, as shown in
In an alternative embodiment, the membrane 88 is made of a semi-permeable biocompatible material.
In a method of use, as shown in
It is anticipated that fibroblasts will engage the fibers of the polymer of fabric of the annulus stent 10, forming a strong wall duplicating the currently existing condition of healing seen in the normal reparative process.
In an alternative method of use, as shown in
In one illustrative embodiment, the barbs 82 on the upper surface 68 of one or more strut 67 or other feature of the radial extension 76, engage the disc annulus' 42 inner wall, holding the annulus stent 10 in position.
In a method of use, as shown in
It should be noted that in any of the "bag" embodiments described herein one wall or barrier can be made stiffer and less resilient than others. This relatively stiff wall member can then be placed proximate the annulus wall and can advantageously promote, in addition to its reparative properties, bag containment within the annulus.
Turning to
Stents can expand to be planar, for example as shown hereinabove in
Patches can be folded and expanded in a single plane or in three dimensions. As shown in
Patches can also be constructed of a single component, as shown for example in
Multiple components could include a frame to help with expansion of the device and a covering to obtain biocompatibility and tissue ingrowth. Examples of different frame configurations might include an expandable "Butterfly" or "Figure-8" configuration that could be constructed of wire material, such as Nitinol or multiple wires. Exemplary embodiments showing frame members 502 are depicted in
The frame could be cut from a single material, such as flat stock Nitinol to accomplish the same objective, as shown for example in
Another frame configuration, also not shown, is that of a spiral or coil. The "Coil" design can be, for example, a spring steel or other biocompatible material that is wrapped to a first "wound" smaller configuration and expands to a larger unwrapped, unwound configuration.
Depending on the size of the openings in the frames described above, each of these concepts may or may not have a covering over them in order to assure that the nucleus does not re-extrude from the intervertebral disc space after placement of the device, as well as to serve as substrate for the surrounding tissue to naturally incorporate the device. Coverings might include ePTFE, polyester, silicone, or other biocompatible materials. Coverings could also include natural materials such as collagen, cellulose, autograft, xenograft, allograft or similar materials. The covering could also be biodegradable in nature, such as polyvinyl lactic acid.
Frames that are not covered may be permeable, such as a patch that is porous and allow for normal movement of fluids and nutrients through the patch into and out of the annular ring while maintaining nucleus fragments larger than the porosity of the stent/patch within the subannular space. Depending on the material that the frame is constructed, a surface finish may be added to promote tissue ingrowth into the patch. For example, a titanium sputtering of the device may allow it to be more easily incorporated within the disc space. Alternatively, a NiTi or tantalum foam could be added to the outer surface of the patch to promote tissue ingrowth.
It is understood that there can be a variety of device designs of patches to accomplish the expansion of a device from a first configuration, to a second configuration to occupy the sub-annular space and reduce re-extrusion of the nucleus. The following device concepts are further discussed for additional embodiments of a device and/or system for the repair of an intervertebral disc annulus.
As mentioned hereinabove, the stent/patch according to the present invention may comprise a mass of fascial autograft, and that autograft may be contained in a covering of material to form what will be referred to herein as a "bag". Of course, this term is used not necessarily to connote a five-sided closed container so much as to denote the notion of flexibly surrounding the volume of a patch/stent material so that it can be manipulated in space.
In the most simplistic form, a prefabricated device of sutures could be used to form the "sling" to hold the fascial implant as discussed above. The advantage of this design over simple placement of sutures to hold the autograft is better containment and control of the autograft during and after implantation. The "sling" or a "bag" surrounds the fascial autograft to hold it in place. It is contemplated that other materials, such as a polyester mesh, could be used instead of the fascial autograft.
Other constructions can also be used to accomplish the same objective, such as a "bag" 404 formed of expandable PTFE as shown in
There are a variety of ways to affix the device to the subannular wall of the annulus in addition to those discussed hereinabove. 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. Discussed hereinabove is the use of sutures, staples and other fixation devices, such as those passed through slot 18 to affix the patch to the annulus as shown in
The advantage of this design described above is that it requires very little time and skill to place and secure the patch to the annulus while also drawing the tissues together.
Materials of the patch could be similar to materials discussed hereinabove. Anchoring barbs could be made of a biocompatible material, for example a metallic material (e.g., NiTi alloy, Stainless steel, Titanium), or a polymeric material (e.g., polypropylene, polyethylene, polyurethane). Anchoring barbs could also be a biodegradable/bioabsorbable material, such as a polyglycolic acid (PGA), a polylevolactic acid (PPLA), a polydioxanone (PDA) or for example a racemic polylactic acid (PDLLA). If the barbs included a biodegradable/bioabsorbable material, it is anticipated that the barbs might have sufficient holding strength for a sufficient period of time to allow the patch to be incorporated into the annulus during the healing process. The advantage of having the anchoring barb of
It is also possible that the barbs could be made of both a biocompatible component and a biodegradable/bioabsorbable component. For example, the very tip of the barb could be made of a biodegradable material. The barb could penetrate the annulus wall with a rather sharp point, but after degradation the point of the barb would become dull. In this embodiment, the point would no longer induce continued scar formation after the patch has been incorporated, nor pose a risk of penetrating out of the annulus onto the nerve root.
Another fixation means includes the passing of "anchoring bands" 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 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
Another example of fixating the device to inner wall of the annulus is shown in
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 with a suture 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 bands are placed into the annulus, these anchor bands 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 have the barbs as described hereinabove 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 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 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 crisscrossed 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 are 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.
One objective in the designs discussed hereinabove is to provide a way to "pull up the slack" in a system to adjust the length of sutures and for anchor bands. According to the present invention, a technique referred to as the "Lasso Cinch Knot" was developed as a means to draw the anchor bands together with a suture cinch line that is incorporated into the patch design.
It is also contemplated within the scope of the present invention that sutures 710′ can be preattached directly to a stent/patch. As shown in
An alternative embodiment for securing a patch 902 and reapproximating a rent or incision is to provide each of the separate barbs with sutures having variable lengths as shown in
Alternatively, the locking mechanism can be as shown in
The cinch line and the Lasso concepts in essence try to facilitate the re-approximation and drawing of tissues together in a fast and simple way. Other contemplated embodiments for "tension" elements include using an elastic coupler as a part of the anchor band used to fixate the device. The elastic coupler can be expanded for placement, and upon release, can draw tension to pull the tissues together. The coupler could be made of a biocompatible metal or polymer, or could be constructed of a biodegradable/bioabsorbable material.
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 which one end can be attached to the anchor bands and the other end attached to the patch. Alternatively, the anchor bands might, 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.
Although cinch lines have been described as using a knot to "lock" the length of the suture, other mechanisms could also lock the band locking device, as shown in
Although the embodiments of
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.) and U.S. Pat. No. 5,376,120 (Sarver 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, 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, propylene, 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.
The foregoing discussion relates to the use of a patch (or stent). In some clinical instances, the method of the invention may be accomplished without the use of a patch, however. Moreover, 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.
A comparatively simple embodiment of this method is shown in
The use of sutures alone may be insufficient. Accordingly, the present invention also provides additional fixation devices that may be used to reapproximate and hold annular tissue. Such fixation devices, as described above, may contain an anchor portion and a band portion. The anchor portion serves to fix the fixation device in the annular tissue. The band portion, attached to the anchor portion, serves to reapproximate annular tissue when tightened and secured. At least one fixation device is placed into, or though, the wall of an annulus in a portion surrounding the aperture (or in a boundary region surrounding a thin or weakened portion of the annulus). The device is then drawn in tension to pull together, wholly or partially, the surrounding annular tissue.
The anchor portion and bands are as described above, and preferably (though not necessarily) shaped to enter the annular tissue relatively easily and to resist removal. Examples of suitable anchor devices include but are not limited to barbs, T-anchors, or combinations thereof.
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 suture 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.
As described above, the fixation materials may be biocompatible or reabsorbable, or both. Examples of biocompatible or reabsorbable materials for use, e.g., in band and/or barb (or anchor), include, but are not limited to, polylactic acid, polyglycolic acid, silk suture, polyethylene, stainless steel, polypropylene, nickel titanium alloy, polyester and their functional equivalents. Advantageously, the very tip of the barb could be made of biodegradable material. The barb may be constructed of a material having a shape sufficiently sharp to penetrate the annulus wall, but sufficiently susceptible to wear to dull upon insertion.
As an example of the foregoing, the embodiment depicted in
The function of the fixation devices of
The fixation devices of the invention could be delivered as a pair of barbs attached by a single band, as shown in
As previously mentioned, the present invention also encompasses delivery devices of the following description. The delivery devices of the present invention are configured to deliver at least one fixation device into (or through) the annulus or other surface or tissue. The delivery device will typically comprise a device or shaft having proximal and distal ends.
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 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.
Advantageously, the shaft of the device will have a cross-sectional shape suitable to accommodate an ejection rod and at least one fixation device. 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, described below.
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 include polymers, such as acrylic polymers, polyurethane; and metals, such as stainless steel and titanium.
The delivery device may be configured to accommodate and deploy at least one fixation device, such as a barb or T-anchor with one or more associated bands. Advantageously, the distal end of the delivery device will comprise a hollow needle or cannula 711, having a circular, elliptical, triangular, hexagonal or other inner cross sectional area, suitable to accommodate the cross-sectional shape of the fixation device within. The distal point of the cannula 711 is advantageously sharpened, as a needle, to accommodate insertion. The cannula 711 is advantageously cut obliquely as shown in
The delivery device 708 will also advantageously contain within it an ejection rod 715. The proximal end of the ejection rod 715 typically will 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 device 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
Although this drawing shows the passage of the bands superior and inferior to the aperture, these bands could also be placed in a multitude of locations to effect desired or equivalent outcomes.
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
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 as previously described in
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
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.
|Cited Patent
|Filing date
|Publication date
|30 Apr 1982
|4 Jun 1985
|The Regents Of The University Of California
|Growing of long-term biological tissue correction structures in vivo
|7 Oct 1992
|27 Sep 1994
|Jay Erlebacher
|Percutaneous arterial puncture seal device and insertion tool therefore
|3 Feb 1993
|2 May 1995
|Kensey Nash Corporation
|Hemostatic vessel puncture closure system utilizing a plug located within the puncture tract spaced from the vessel, and method of use
|29 Aug 1997
|19 Jan 1999
|Kensey Nash Corporation
|Hemostatic puncture closure system including closure locking means and method of use
|29 Dec 2000
|14 Jan 2003
|Aga Medical Corporation
|Method and apparatus for occluding aneurysms
|28 Jun 2002
|27 Apr 2004
|Advanced Catheter Engineering, Inc.
|Patches and collars for medical applications and methods of use
|22 Mar 2001
|31 Aug 2004
|Keraplast Technologies, Ltd.
|Implantable prosthetic or tissue expanding device
|30 Apr 2003
|25 Apr 2006
|Raymedica, Inc.
|Self-transitioning spinal disc anulus occulsion device and method of use
|8 Nov 1999
|31 Oct 2006
|Ev3 Endovascular, Inc.
|Method and device for left atrial appendage occlusion
|26 Jun 2002
|27 Feb 2003
|Ferree Bret A.
|Devices used to treat disc herniation and attachment mechanisms therefore
|5 Sep 2003
|15 Jul 2004
|Neville Alleyne
|Seal for posterior lateral vertebral disk cavity
|21 Apr 2003
|21 Oct 2004
|Trieu Hai H.
|Implant system and method for intervertebral disc augmentation
|22 Feb 2006
|31 Aug 2006
|Aesculap Ag & Co. Kg
|Implant for closing an opening in the annulus fibrosus
|2 May 2005
|2 Nov 2006
|The Board Of Trustees Of The Leland Stanford Junior University
|Systems and methods for augmenting intervertebral discs
|22 Aug 2006
|14 Dec 2006
|Lambrecht Gregory H
|Methods of reinforcing an intervertebral disc annulus
|17 Nov 2006
|22 Mar 2007
|Anova Corporation
|Methods and apparatus for reconstructing the anulus fibrosus
|27 Oct 2005
|3 May 2007
|O'neil Michael
|Nucleus augmentation delivery device and technique
|Citing Patent
|Filing date
|Publication date
|22 Oct 2004
|9 Feb 2010
|Intrinsic Therapeutics, Inc.
|Resilient intervertebral disc implant
|16 Feb 2006
|2 Mar 2010
|Anulex Technologies, Inc.
|Spinal disc annulus reconstruction method
|15 Sep 2006
|2 Mar 2010
|Anulex Technologies, Inc.
|Intervertebral disc annulus stent
|5 Feb 2003
|18 May 2010
|Intrinsic Therapeutics, Inc.
|Apparatus delivery in an intervertebral disc
|21 Jun 2004
|1 Jun 2010
|Intrinsic Therapeutics, Inc.
|Device for delivering an implant through an annular defect in an intervertebral disc
|15 Mar 2007
|6 Jul 2010
|Anulex Technologies, Inc.
|Method and apparatus for the treatment of the intervertebral disc annulus
|20 Sep 2004
|6 Jul 2010
|Intrinsic Therapeutics, Inc.
|Method of reducing spinal implant migration
|30 Aug 2006
|7 Dec 2010
|Anulex Technologies, Inc.
|Spinal disc annulus reconstruction method and deformable spinal disc annulus stent
|14 Mar 2008
|11 Jan 2011
|Intrinsic Therapeutics, Inc.
|Intervertebral disc anulus implant
|3 May 2006
|1 Feb 2011
|Intrinsic Therapeutics, Inc.
|Method of performing a procedure within a disc
|9 Nov 2006
|22 Mar 2011
|Anulex Technologies, Inc.
|Intervertebral disc annulus stent
|14 Nov 2006
|12 Apr 2011
|Anulex Technologies, Inc.
|Spinal disc annulus reconstruction method and deformable spinal disc annulus stent
|26 Sep 2005
|3 May 2011
|Anulex Technologies, Inc.
|Method and apparatus for enhanced delivery of treatment device to the intervertebral disc annulus
|12 Jan 2007
|31 May 2011
|Anulex Technologies, Inc.
|Method and apparatus for the treatment of the intervertebral disc annulus
|16 Jan 2007
|14 Jun 2011
|Intrinsic Therapeutics, Inc.
|Intervertebral anulus and nucleus augmentation
|8 Oct 2008
|21 Jun 2011
|Anulex Technologies, Inc.
|Method and apparatus for the treatment of the intervertebral disc annulus
|19 Dec 2006
|5 Jul 2011
|Intrinsic Therapeutics, Inc.
|Devices and methods for bone anchoring
|6 Nov 2006
|26 Jul 2011
|Anulex Technologies, Inc.
|Methods and devices for spinal disc annulus reconstruction and repair
|8 Dec 2006
|9 Aug 2011
|Anulex Technologies, Inc.
|Spinal disc annulus repair system and methods
|17 Nov 2006
|16 Aug 2011
|Intrinsic Therapeutics, Inc.
|Intervertebral disc herniation repair
|20 Sep 2004
|23 Aug 2011
|Intrinsic Therapeutics, Inc.
|Method for the treatment of the intervertebral disc anulus
|21 Jul 2009
|20 Sep 2011
|Intrinsic Therapeutics, Inc.
|Versatile method of repairing an intervertebral disc
|27 Apr 2009
|27 Sep 2011
|Intrinsic Therapeutics, Inc.
|Method of rehabilitating an anulus fibrosus
|9 Nov 2006
|11 Oct 2011
|Anulex Technologies, Inc.
|Spinal disc annulus reconstruction method and spinal disc annulus stent
|22 Dec 2005
|1 Nov 2011
|Anulex Technologies, Inc.
|Intervertebral disc annulus stent
|23 Mar 2006
|3 Jan 2012
|Anulex Technologies, Inc.
|Spinal disc annulus reconstruction method and deformable spinal disc annulus stent
|20 Aug 2009
|14 Feb 2012
|Intrinsic Therapeutics, Inc.
|Anchoring system for disc repair
|14 Oct 2008
|6 Mar 2012
|Anulex Technologies, Inc.
|Method and apparatus for the treatment of the intervertebral disc annulus
|3 Sep 2009
|24 Apr 2012
|Anulex Technologies, Inc.
|Method and apparatus for the treatment of the intervertebral disc annulus
|3 May 2006
|31 Jul 2012
|Intrinsic Therapeutics, Inc.
|Method of treating a herniated disc
|10 Jan 2011
|4 Sep 2012
|Intrinsic Therapeutics, Inc.
|Methods of intervertebral disc augmentation
|12 Nov 2009
|4 Dec 2012
|Intrinsic Therapeutics, Inc.
|Impaction grafting for vertebral fusion
|29 Jan 2013
|Intrinsic Therapeutics, Inc.
|Soft tissue impaction methods
|1 Jul 2011
|12 Mar 2013
|Intrinsic Therapeutics, Inc.
|Vertebral anchoring methods
|10 Jan 2011
|2 Apr 2013
|Intrinsic Therapeutics, Inc.
|Methods of repairing herniated segments in the disc
|20 Aug 2009
|4 Jun 2013
|Intrinsic Therapeutics, Inc.
|Method for vertebral endplate reconstruction
|17 Sep 2010
|4 Jun 2013
|William T. MCCLELLAN
|Systems and methods for tissue expansion with fluid delivery and drainage system
|5 Apr 2012
|4 Jun 2013
|Anulex Technologies, Inc.
|Method and apparatus for the treatment of tissue
|10 Aug 2010
|11 Jun 2013
|Anulex Technologies, Inc.
|Intervertebral disc annulus repair system and method
|12 Nov 2010
|15 Oct 2013
|Anulex Technologies, Inc.
|Tissue anchoring system and method
|26 Sep 2006
|21 Jan 2014
|Anulex Technologies, Inc.
|Apparatus and methods for the treatment of the intervertebral disc
|10 Aug 2010
|18 Feb 2014
|Anulex Technologies, Inc.
|Intervertebral disc annulus repair system and bone anchor delivery tool
|7 Mar 2013
|26 May 2015
|Intrinsic Therapeutics, Inc.
|Bone anchor systems
|5 May 2010
|9 Jun 2015
|Stryker Spine
|Expandable spinal implant apparatus and method of use
|12 Nov 2010
|14 Jul 2015
|Anchor Orthopedics Xt Inc.
|Devices and methods for treating tissue defects
|23 Jan 2012
|4 Aug 2015
|Krt Investors, Inc.
|Method and apparatus for the treatment of the intervertebral disc annulus
|29 Jun 2011
|25 Aug 2015
|Krt Investors, Inc.
|Methods and devices for spinal disc annulus reconstruction and repair
|5 Feb 2003
|6 Jan 2005
|Lambrecht Gregory H.
|Apparatus delivery in an intervertebral disc
|30 Jun 2006
|9 Nov 2006
|Bogomir Gorensek
|Minimally invasive method for delivery and positioning of intervertebral disc implants
|30 Aug 2006
|21 Dec 2006
|Cauthen Joseph C Iii
|Spinal disc annulus reconstruction method and deformable spinal disc annulus stent
|7 Jan 2010
|Intrinsic Therapeutics, Inc.
|Anchoring system for disc repair
|5 Feb 2010
|17 Nov 2011
|Newvert Ltd.
|Implantable device for sealing a spinal annular fissure tear and method for deploying the same
|U.S. Classification
|606/75, 623/17.16
|International Classification
|Cooperative Classification
|European Classification
|28 Dec 2006
Owner name: PROTOSTAR, INC., MINNESOTA
Free format text: ASSIGNMENT OF ASSIGNORS INTEREST;ASSIGNOR:CAUTHEN RESEARCH GROUP;REEL/FRAME:018687/0590
Effective date: 20010315
Owner name: ANULEX TECHNOLOGIES, INC., MINNESOTA
Free format text: ASSIGNMENT OF ASSIGNORS INTEREST;ASSIGNOR:PROTOSTAR, INC.;REEL/FRAME:018687/0620
Effective date: 20010316
Owner name: CAUTHEN RESEARCH GROUP, FLORIDA
Free format text: ASSIGNMENT OF ASSIGNORS INTEREST;ASSIGNOR:CAUTHEN, JOSEPH C., DR.;REEL/FRAME:018687/0561
Effective date: 20001016
Owner name: ANULEX TECHNOLOGIES, INC., MINNESOTA
Free format text: ASSIGNMENT OF ASSIGNORS INTEREST;ASSIGNORS:CAUTHEN, JOSEPH C., III;WESSMAN, BRADLEY J.;BURNS, MATTHEW M.;AND OTHERS;REEL/FRAME:018687/0649;SIGNING DATES FROM 20050906 TO 20051011
|1 Feb 2011
|Certificate of correction
|9 Apr 2014
|Fee payment
Year of fee payment: 4
|6 Nov 2014
Owner name: KRT INVESTORS, INC., TEXAS
Free format text: ASSIGNMENT OF ASSIGNORS INTEREST;ASSIGNOR:ANULEX TECHNOLOGIES, INC.;REEL/FRAME:034116/0550
Effective date: 20131227
|24 Mar 2015
Owner name: KRT INVESTORS, INC., TEXAS
Free format text: CORRECTIVE ASSIGNMENT TO CORRECT THE ASSIGNEE ADDRESS PREVIOUSLY RECORDED AT REEL: 034116 FRAME: 0550. ASSIGNOR(S) HEREBY CONFIRMS THE ASSIGNMENT;ASSIGNOR:ANULEX TECHNOLOGIES, INC.;REEL/FRAME:035305/0955
Effective date: 20131227


text:
The EOS 50D features a newly-designed 15.1-megapixel APS-C sized CMOS sensor which is capable of recording up to 4752 x 3168 pixels with full 14-bit A/D conversion for extremely fine tonal gradation. Ready to capture images in an instant, the sensor is designed to work with Canon's EF and EF-S lenses with a conversion factor of 1.6x. It's capable of recording at sensitivities previously too noisy for shooting in low light or subjects in motion. With a maximum ISO rating of 12800 combined with a 4-level High ISO speed noise reduction function, images that would have been impossible without the use of a strobe or flash become simple to record.
15.1 Megapixel APS-C Size CMOS Sensor

subset: commoncrawl


text:
- Home
- News
- Sports
- Opinion
- Obituaries
- Features
- Special Sections
- Classifieds
- Public Notices
Forgot Password? | Not a User? Sign up
The following marriage dissolutions have been granted in Hardin Circuit Court in Elizabethtown.
David M. Donaldson, 30, and Rachel D. Luce, 30, both of Radcliff. Married six years.
James R. Brown Jr., 46, Radcliff, and Deanna S. Blackford, 45, Owensboro. Married 16 years.
If you currently subscribe or have subscribed in the past to the The News Enterprise, then simply find your account number on your mailing label and enter it below.
Click the question mark below to see where your account ID appears on your mailing label.
|ZIP Code:


text:
There are different videos available for progressive download, all in H.264 FL9 format. If you do not have Flash Player 9, please click on the link below to download and install. The resolution quality of the video is reduced as the compression of the downloaded file increases.
You may stop the video on a single frame to observe the detail quality.
Hardware: A computer and monitor combination that can playback 1080p video at 30 frames per second is recommended. The capability of the graphics card in the computer could cause uneven or jerky playback of the video files. Still frame pause is usually not affected.
Internet Connection: A broadband (cable, DSL, etc.) is suggested to minimize download times.
Software: Flash Player 9 is required to playback the video files. If you do not have Flash Player 9, please click on the link below to download and install.
Adobe Flash Player 9:
Prices and specifications subject to change without notice. Actual prices are determined by individual dealers and may vary.


text:
GRAND RAPIDS (G.R. Business Journal) -- Mercy Health Saint Mary's in Grand Rapids has been named one of the nation's top 55 urban hospitals by the The Leapfrog Group, a national nonprofit organization representing major employers concerned about hospital safety, quality and affordability.
Saint Mary's was one of 1,324 hospitals participating in Leapfrog's 2013 annual survey, which the organization used in determining what it believes are the nation's top 55 urban hospitals, top 22 rural hospitals, and top 13 children's hospitals.
The only other Leapfrog Top Urban Hospital in 2013 in Michigan was Detroit Receiving Hospital and University Health Center. There were two top rural hospitals: Spectrum Health's Kelsey Hospital in Lakeview and OSF St. Francis Hospital and Medical Group in Escanaba. The only top children's hospital in Michigan was DMC Children's Hospital of Michigan in Detroit.
You can read the entire article on the website of our partner, the Grand Rapids Business Journal, or pick up the latest edition of the Buisness Journal on your newsstand.


text:
Statusbet is regulated by the Isle of Man Gambling Supervision Commission under a license issued to NOVIGROUP (Company Number 124281C) on 27th of May 2010 and based on the Online Gambling Regulation Act 2001.
For players from the United Kingdom, Statusbet is licensed and regulated by the
United Kingdom Gambling Commission (license number 000-039440-R-319360-003).
Statusbet is operated by Novigroup Limited, PO Box 227, Clinch's House, Lord Street, Douglas, Isle of Man, IM99 1RZ
© Square Enix Limited 2012 Tomb Raider, Lara Croft and the Tomb Raider logo, Hitman and the Hitman logo, are trademarks of Square Enix Ltd. Square Enix and the Square Enix logo are trademarks or registered trademarks of Square Enix holdings Co. Ltd. All rights reserved.
© Terminator 2, T2, The Terminator, Endoskeleton, and any depiction of Endoskeleton are trademarks of Studiocanal S.A. All Rights Reserved. ©2014 Studiocanal S.A. ® All Rights Reserved.
Official HBO Licensed Product © 2014 Home Box Office, Inc. All Rights Reserved. HBO and related trademarks are the property of Home Box Office, Inc. Under license to Microgaming.
BATMAN and all related characters and elements are trademarks of and © DC Comics. © 2012 Warner Bros. Entertainment Inc. All rights reserved.
© Hellboy™ 2009 Mike Mignola. Dark Horse Comics, Inc. and the Dark Horse logo are trademarks of Dark Horse Comics, Inc.
THE DARK KNIGHT RISES and all related characters and elements are trademarks of and © DC Comics.(s13)
© 2012 Universal Network Television LLC.
© 2012 Rodston Ltd.


text:
Moderator: All Things Mods
Instant Noodles wrote:During a vaguely religious discussion during math, I mentioned my pastafarian faith, and to my dismay was met with ridicule and laughter. Upon explaining our church more in depth I was cut off by the phrase " Boy! I am going to get a bible, and beat you over the head until I knock some Jesus in your blood!â€. This didn't seem to be a joke of any kind, and fire was in his eyes. Under the pressure, I made the mistake of retaliating in an unconvincing mannor saying "the Flying Spagettie Monster has filled my blood with Jesus antibodies!†This mistake did not help my cause.
I'm thinking of wearing a noodly appendaged helmet for a while, just in case.
A short time later a jerk I'm forced to interact with on occasion threatened to take this very sight via hacking. While I doubt he is capable, just thought you might want to be on your toes
Instant Noodles wrote:i was a bit to uninformative. When i say, in math class, i meant, i had this conversation with a couple people around me, in low volume, while ignoring the teacher (its ok, she was just showing the mentally undeveloped some remedial cos graphing, and knows that the people i was talking to already understand it)
and by vaugly religious, we were commenting on a drawing of a guy being crucified in a clock tower done by one of them. Time came to list off Sects; Baptist, methodist, Catholic, CFSM. after some confusion, followed by laughter, followed by explanation, followed by threat.
im not worried about the hacker, im just amazed by the attacks which were unwarented.
Duke wrote:At my school, in Hawaii, only about 10-20% of the school is religious. And less in Marin.
Alpaca wrote:Our school has something called the Fellowship of Christian Athletes. It's scary.
Instant Noodles wrote:Duke wrote:At my school, in Hawaii, only about 10-20% of the school is religious. And less in Marin.
wow, at mine there was an anouncement today saying " Burgers and Bibles will not be meeting at Coach Brashes house today...", theres a Donut based prayer session around the flag pole each morn, and put up posters EVERYWHERE. When several of my friends requested to hold a pagen function of the same nature, we were shut down Unmercifully. The cheerful [wtf i wrote g a y, why did it change my text? ]and Lesbian club had a sufficiant number of signatures and the $200 needed (the only 2 things needed to form a club[so says the admin]) and they were refused utterly.
Instant Noodles wrote:well, every week, or every month, depending on the time of year, the school clubs meet for an hour between 2nd and 3rd period. they have a club sponser teacher, and a couple of official reqirments, like infostructure IE president, and do some communitiy service.
oh and membership is ither open or selective. every year theres a list of clubs and you pick 3, if your lucky youl get your top pick... or any pick. of the selective, you need an aplication approved by club officers just to have a chance to be rejected because of overcrowding.
Users browsing this forum: No registered users and 1 guest


text:
Flue liner size for boiler?
Discussion in 'Boiler Forum' started by NH Homesteader, Sep 16, 2009.
Similar Threads: Flue liner
|Boiler Forum
|Properly venting a Wei-McLain CGi-4E boiler into a flue?
|Jan 28, 2010
|Boiler Forum
|Boiler Flue Vent Connection Question
|Sep 21, 2009
|Boiler Forum
|Classic Fanned Flue Gas Boiler SE18 FF
|Sep 11, 2009
|Boiler Forum
|?'s about new proposed system to replace arcoliner
|Oct 13, 2011
|Boiler Forum
|American Standard Arcoliner - Control for Domestic Hot Water
|Aug 21, 2011


text:
- Musician's Friend Best Selection, Price & Service. Guaranteed.
Call our Gear Heads
at: 800-449-9128
Call our Gear Heads
at: 800-449-9128
Results 1 - 1 of 1 matches
This precision, American made all-purpose guitar tool is the last one you need to buy. Guitar Tech, Fred...
Our product catalog varies by country due to manufacturer restrictions. If you change the Ship-To country, some or all of the items in your cart may not ship to the new destination.


text:
Today is December 1st which means Movember is officially over. As the women cheer, thousands of men like myself will happily be shaving off their Movember mustache today. On the other hand, some men may have finally found that stylistic edge they were looking for and will make it part of their new persona. As you can see from my picture, that will not be the case for me. This morning I removed what I like to call the "Old-Timey- Villain" or the "Deadwood" mustache, officially ending my Movember. In honor of the closing of mustache season, I've put together my top 12 Movember Mustaches I think you will enjoy. Although my mustache raised more eyebrows than funds this year I enjoyed every minute of wearing it. More than anything, I like idea of making a statement and explain to other why I'm wearing such a ridiculous thing on my face. After all, that's the whole point of Movember, to engage in conversation and awareness about men's health issues. Love them or hate them Mustaches are becoming more and more common come November. That's because the 'stache craze is for a good cause. Movember is raising awareness and funds for men's health issues, particularly prostate & testicular cancer.
Before I show you my top 12 Movember mustaches let me first explain to the unknowing what Movember is. You laugh, but I had to explain to my Parents today why I wore that ridiculous thing on my face for a month. You'd be surprised how many people don't know what Movember is and how it works. It's scary because I can only imagine what's going through their mind as mustaches start showing up everywhere.
The month of November has become Movember! (Moustache November). Over the last few years Movember has become more and more popular around the world as a time for guys to grow a moustache to draw attention to prostate cancer and other men's health issues. It's essentially the male version of women wearing pink during Breast Cancer Awareness month (which was October). Men have now claimed November as their own to shed light on health issues. The Movember & Sons movement started in Melbourne, Australia and has become a worldwide event. In 2011 over 854,00 Men & Women got on Board and raised $126.3 Million Us Dollars. It's really easy to be part of and anyone can do it. First you register at www.movember.com, men start November 1st clean-shaven. For the rest of the month, these men (Mobros) or MoSistas wear a mustache proudly and seek sponsorship for their efforts and fundraising page. These mustaches basically become a walking talking billboard for Men's health issues for the next 30 days. Even if they're not raising money a lot of men will wear a mustache to support the efforts and keep men's health issues literally under people's nose. Funds go to the following charities. Prostate Cancer Foundation, LIVESTRONG Foundation, Awareness & Education, and Global Action Plan
Now, Let's take a look at my top 12 Movember Mustaches that in my opinion capture the spirit of the Movember campaign. *Keep in mind, these are in no particular order, just a random selection of personal connection Movember Mustaches. Click "READ FULL STORY" TO SEE


text:
Weed Eliminator
Customers Also Bought
Handy Crevice Weeder
- Pointed tip is great for working in tight spaces
- Lightweight with a comfortable grip
- Extend your reach by attaching a threaded broom handle (not included)
Here is the perfect tool for evicting pesky weeds from nooks and crannies between bricks and pavers. Great for the sidewalk, driveway or patio. Attach broom handle for back-saving ease.
- Plastic with a carbon steel blade
There are no special shipping restrictions or charges associated with this item. For detailed information about our delivery methods and charges, click here.
We're proud of the fact that this item is shipped to you directly from our warehouse in Vermont, by one of our 250 employee-owners. In-stock items are packed with care and shipped within the next business day to ensure prompt delivery to your home and garden!


text:
Contact Toyota
Whether you're a Toyota owner or just have a question about our products, Toyota is committed to providing a rewarding customer experience. Select the most convenient way to reach us, and we look forward to assisting you.
Need help? Have a question? Get instant answers 24/7.
We're here to help. Whether you have questions about your vehicle, our products, navigation, Entune™, ToyotaCare, warranty and more, your answers are just a click away. It's available 24/7. Please visit our Frequently Asked Questions today.
800-331-4331 Fax:
M-F 5:00 am - 6:00 pm PT
Sat 7:00 am - 4:00 pm PT
Before you email us, please check out our FAQ section. Many of our visitors have found quick answers to their questions by searching our FAQs.
Postal Mail
Toyota Motor Sales, U.S.A., Inc.
19001 South Western Ave.
Dept. WC11
Torrance, CA 90501
Toyota Owners
A website just for you. Keep track of service history, watch how-to videos, chat with other Toyota owners, and more.
Toyota Financial Services (TFS)
From explaining credit to providing information on buying and leasing, we'll help you learn what's best for you.
Dealer Locator
Whether you're across town or across the country, use this feature to find the nearest Toyota dealer.
Toyota USA Newsroom
For more information about Toyota, or to register as a journalist and access contact information for our public affairs team, log on to pressroom.toyota.com.


text:
20 Design pattern and Software design interview questions for Programmers
23 comments :
- trgoofi said...
Can you explain how "abstract class is slightly faster than interface" ?
- June 5, 2012 at 5:09 AM
- Javin @ Sort List in java said...
Hi trgoofi, I have also read this somewhere, but I logic is that abstract class can still participate in static binding by declaring static method but since interface can not have any method implementation all binding will be dynamic.I am still looking for more convincing and detailed reason and let you know if I found it, if you have more convincing logic, please let us know.
- June 5, 2012 at 5:25 AM
- Mike said...
design pattern questions are more popular on J2EE interviews rather than in core Java interviews. Though decorator, Singleton, Factory are both applicable to Java and J2EE. J2EE specific patterns like MVC, ViewResolver patter, Front Controller patter, Service Locator are missing from your list of design pattern question. Question like How will you ensure Scalability, high avaibility should be asked on software design part as well.
- June 5, 2012 at 9:26 PM
- Anand VijayaKumar said...
Javin & trgoofi
Actually speaking these days, the difference in performance between an Abstract class and an Interface could be negligible or non-existent. In the olden days this could've been true for the following reason:
A Class can extend from only one parent class while it can implement multiple interface. Since at runtime the JVM may have to scan through multiple interfaces to find a method while it needs to scan only one class, an abstract class could have given a marginally better performance when compared to an interface.
However, these days, the fire-power that computers have (in terms of processing) is many times higher than what it was just even a couple of years ago + JVMs have been optimized over generations.
So, I would say this abstract class, Interface thingi is non-existent or inconsequential now :)
If you feel otherwise please feel free to let me know..
- July 6, 2012 at 10:47 AM
- Anand VijayaKumar said...
You have a very good collection of questions on design patterns Javin. I too have an article on interview questions on design patterns.
Click Here to see it.
Pls, share your thoughts on the questions.
- July 6, 2012 at 10:48 AM
- Java programmer said...
One of the best list of java design interview questions and answers I found around web, Thanks for sharing this great list of Java design pattern interview questions and answers. I have 6 years experience in Java and found that many design pattern questions actually appeared in Senior Java interview. Once again thanks a lot.
- September 17, 2012 at 9:08 PM
- Prabhat said...
Can anyone please share Java design pattern questions asked on Capegemini and Infosys interviews ?
- September 17, 2012 at 9:32 PM
- satya said...
- This comment has been removed by the author.
- October 6, 2012 at 1:34 PM
- satya said...
One thing i want to high light here do you think this questions are from design pattern or Design consideration ????? I think design pattern is bit different?
- October 8, 2012 at 11:24 PM
- Praveen Kumar Basavaraj said...
Questions are good. But answers are very short. Detailed explanation would help a lot. Thanks
- November 14, 2012 at 10:49 PM
- Anonymous said...
@Javin - Can you please share some detailed answers or design for ATM machine example or Market data example?
- November 18, 2012 at 8:53 AM
- Anonymous said...
Hi Javin,
Great job as always.
keep doing and helping people to clear there doubts and crack java interviews..
God Bless You !!!!!!
Best Regards,
- December 17, 2012 at 4:08 AM
- Ramakrishna Allam said...
How do we ensure an application is 100% available? can someone answer this please?
- February 12, 2013 at 1:26 AM
- Anonymous said...
Does Design patterns help in memory management?
Can someone explain on this?
- March 10, 2013 at 10:04 AM
- Anonymous said...
Regarding Answer 6, related to design of Market data provider, I think there are couple of more approaches.
1) Let different implementation comes with different JAR file e.g. Reuters implementation comes with Reuters JAR, Bloomberg comes with bloomberg.jar and Wombat comes with there own JAR.
2) Make them to implement MarketData interface as MarketDataImpl. Since all JAR will be using same class name, using different JAR with different provider make things simple, you don't need any runtime configuration, because the class which will be available in Classpath will be instantiated.
3) Make sure to include correct jar during build time.
- April 21, 2013 at 8:34 PM
- RAJAT said...
Regarding, whether abstract class is faster than interface, that's true, because of different byte code generated, when calling a method using abstract class or interface. When you access a method using interface type, it involves scanning to multiple implementation.
- April 21, 2013 at 8:38 PM
- Anonymous said...
One of the popular question I have seen on Object Oriented Analysis and Design is designing and implementing Elevator (Lift) system for multi-story buildings, with lot of variants e.g. ground floor + car park, multiple lifts, improving algorithm so that lift can reach quickly on request etc. It would be great, if anyone can elaborate how to deal with such Object oriented design questions in limited time during interviews.
- April 23, 2013 at 4:47 AM
- Rats said...
which design pattern is application to implement elevator or hw can we implement elevator class.
- March 12, 2014 at 4:10 AM
- Karthik PPS said...
Javin, interesting to read each and every page of yours. Nicely written!
- April 29, 2014 at 8:09 AM
- Koi nahi said...
Calender is not implementing singleton, but factory.
Nice article (like all other article on this blog)!
- May 6, 2014 at 9:32 AM
- Anonymous said...
Can you explain how "abstract class is slightly faster than interface" ?
Abstract classes are slightly faster than Interfaces because the class compilation and loading happens immediately with Abstract Classes whereas for the Interfaces (specially marker interface) the class loader has to go through the libraries to find the package and then the interface class associated with the call
- October 21, 2014 at 11:09 AM
- Kabir said...
Some more questions for Java developers who are preparing design pattern hard :
1) What is difference between Factory and Abstract Factory design patttern?
2) What is difference between State and Strategy Pattern?
3) Differnece between Proxy and Decorator design Pattern?
4) Why Composition is better than Inheritance? Give two reasons
5) Difference between aggregation, assoication and composition in OOP?
6) Difference between Template and Strategy design pattern?
7) Why Singleton pattern is bad? Give atleast two reasons
8) When do you use Command Pattern?
9) When should you use Prototype Design Pattern?
10) Why use Visitor design Pattern? What is the advantage of using Visitor?
11) Difference between Creational and Behavioral Design patterns?
12) Can you write code for double checked locking in Java?
Sorry, but I don't know the answer and I have posted it here so that someone can answer these question :-)
- December 16, 2014 at 8:26 PM
- Anonymous said...
Design pattern and software design are two completely different thing, how can interviewer mix design pattern and software design ? designing software require experience in terms of scalability, stability, performance and lot more rather than just using MVC design pattern in Spring or Struts.
- December 17, 2014 at 7:43 AM


text:
Welcome to Smogon! Check out the Smogon Info Hub for everything you need to know about starting out in the community. Don't forget to introduce yourself in the Introduction Thread, too!
Welcome to Smogon Forums! Please take a minute to read the rules.
Completed Pwnemon and Rajaion Tagami in an insanity-inducing crack in the time-space continuum
Discussion in 'ASB' started by Objection, Feb 23, 2012.
- Thread Status:
- Not open for further replies.
- Thread Status:
- Not open for further replies.


text:
Probably the best point the book made: Anybody that would create this world for whatever reasons (I'm a Satanist so I'm going to say Self Serving) is an egotistical maniac. Hence: The Creator is an egotistical maniac.
Also slightly incompetent.
But what does that say about his Noodlyness? Is His Holy Noodle perhaps offended by this? Is this yet another test of our faith???? Does he admit that he's an egotistical maniac?
Maybe He's a Satanist.....


text:
Give your dog a unique biscuit made from a true Louisiana delicacy - crawfish! These delicious, bite-sized biscuits offer natural, premium ingredients, including real crawfish from sustainable farms and harvests in Louisiana. These dog treats contain no wheat, corn, or soy, but instead have a base of barley, oats, rice and potato. The result is a richly flavored, highly palatable treat that will bring dogs running. Natural reward for pets of all sizes contains no artificial colors, flavors, preservatives or additives. USA made. Treats measure 1.5" x 1.5" x 3/8" thick. 16 oz (454 g) package contains approximately 70 treats.
Please click on "More Information" for ingredients, guaranteed analysis and feeding guidelines.


text: Que tipo de ajuda necessita? (Exemplo:"Panda AdminSecure", "erro 2093") Tweet How do I upgrade my version of Panda AdminSecure? Information applies to: Products Panda for DesktopsPanda for File Servers (Windows)Panda for ExchangePanda for DominoPanda for ISAWhat is the latest version of Panda AdminSecure? How do I know what version I have installed?The latest version of Panda AdminSecure is 4.50.00. To check the installed version, follow the steps below:Access the Panda AdminSecure console.Click Help-> About Panda. The version number is displayed. Steps for upgrading the productApply the following steps for upgrading to the latest version of the product if you have version 3.06.06 or later:Go to the Downloads for clients area of Panda corporate website.Enter your user name and password and click Enter.If you have several Panda security solutions, select the one that corresponds to this product in the Products purchased area.Read more information about Panda's exclusive Downloads for clients area.In the Downloads available for section, select Software. Click the Upgrade folder and download the file with the upgrade to version 4.50.00 (upg45000.exe).Save the file to the Windows Desktop or any folder of your choice.Once you have downloaded the file, run it on the computer where you have the full version of Panda AdminSecure installed. Select a language and click OK.A welcome screen opens, click Next.A window is displayed with the Upgrade Panda AdminSecure now option selected. Click Next.Note: Users are recommended not to let too much time pass since the last time they restarted the computer with AdminSecure. The upgrade checks whether the computer has been working for over 48 hours. If so, it advises the user to restart the computer before carrying out the updateOnce the process finishes, a message is displayed informing you that Panda AdminSecure has upgraded correctly. Click Next.A window is displayed with the packages that can be upgraded or installed on the Panda AdminSecure repository. Select the packages to install or upgrade and click Next.Click Finish to complete the upgrade process.In Panda AdminSecure, go to Help-> About Panda, and check that the version has been upgraded correctly.We advise you to configure Panda AdminSecure to upgrade automatically from the Internet. Additional informationRemember that you must carry out these steps on every computer where you have an additional repository installed. This upgrade includes changes to all the protection modules on the network We advise you to configure upgrades to be automatically installed from the repositories. Additionally, you can also read information on how to manage Panda AdminSecure repositories.Help nº- 20121210 40024 EN Ajude-nos a melhorar o nosso serviço partilhando a sua opinião. As suas sugestões ajudar-nos-ão a resolver as suas questões de forma mais rápida e eficaz. Esclareceu a sua questão com este artigo? SIM NÃO Obrigado pela sua resposta De que modo poderíamos melhorar este artigo? Pretende contactar o Suporte Técnico?


text:
Layout selectors
The Ed Show 08/06/14
One educators big act of kindness
The interim President of Kentucky State University took a stand in the fight against income inequality, requesting a pay cut in order to increase employee wages. Ed Schultz and James Peterson discuss. ... more Duration: {{video.duration.momentjs}}
One educators big act of kindness
Striking for safe working conditions
American jobs on the chopping block
NLRB rules in favor of Wal-Mart workers
Green energy a 'game changer' for midterms?
Will this Democrat replace Michele Bachmann?
15,000 postal service jobs could disappear
It's easy being green
Fast food strikers fight for wages
The importance of buying American tires
Bachmann hints she may seek presidency again
Scott Walker's outsourcing attack
Giant hole, giant global warming impact
Sending jobs away from the Badger State
Dire situation in Detroit
Keystone permit expires in SD
Another day, another damaging oil spill
What would world be under 'President' Cheney?
Cheney tries to reclaim position in the GOP
Will won't apologize over controversial...
Retrieving data...
- Information
Retrieving Data...
- Information
The Ed Show The Punch Out
U.S. News on msnbc
Wrong drug used in Oklahoma execution
Gloria Allred on Cosby deposition
UCC marks 1 week since mass shooting
DA: Officers not wearing body armor
Tanker burns on NJ Turnpike
VP Biden jokes about 'demotion'
Death toll rises across the Carolinas
Coast Guard suspending search for El Faro
Clinton: 'We can't let them get away with it'
Columbia mayor: 'We're not out of the woods'
DOJ to release 6,000 prisoners
Chaffetz: 'I think we need a fresh start'
Question surround airstrike at Afghan...
Structural damages occurring in SC dams
Search continues to survivors of cargo ship
SC Mayor: 'We are resilient people'
Networks of dams failing in South Carolina
Curfew imposed in Columbia, SC due to floods
Pilot dies during Phoenix to Boston flight
Coast Guard found body of one crew member
Rachel Maddow
'Shock!' as McCarthy bails on speakership
Wrong drug used in Oklahoma execution
Maddow: Obvious GOP choices are non-viable
Clinton lead holds, Democratic debates ahead
Trump not fading, readies second offensive
Clumsy speech marks odd choice for speaker
Reckless Russia escalates Middle East danger
Biden gets early taste of dirty 2016 politics
Stalkers, abusers the object of new gun bill
Conservatives disrupt GOP speaker selection
Democratic candidates pressure Obama on guns
Democrats stand up to GOP abuse of Benghazi
GOP vote schedule leaves front runner exposed
Baghdad Green Zone opens to the public
Networks of dams failing in South Carolina
GOP designs primary to cut weak candidates
McCarthy hurt by blurt, draws challenger
Disturbing racial pattern in Alabama closings
Breyer offers window on death penalty views
Obama talks Russia, Syria, Congress and guns
The Last Word
Fmr. Newtown teacher responds to Ben Carson
Trump takes credit for McCarthy dropping out
GOP in chaos searching for new speaker
One-on-one with 'Veep' star Matt Walsh
Ben Carson: Arm kindergarten teachers
Will bad attendance be Rubio's Achilles heel?
Patrick Kennedy breaks family code of silence
Pope grants private audience to gay couple
Clinton calls out GOP rivals on guns
VP Biden reacts to Oregon mass shooting
Pres. Obama: 'We should politicize' shootings
What we know about the Oregon gunman
Sheriff refuses to say name of Oregon shooter
'There has to be an outrage… we're at war'
The Pope, Kim Davis, and the secret meeting
McCarthy 'couldn't have said anything worse'
What do voters think of Donald Trump?
Romney: Trump will not be the GOP nominee
How would Clinton and Trump respond to Syria?
Trump and Clinton's plans for Syria and Putin
Best of MSNBC
Limited options may trap Boehner as speaker
'Shock!' as McCarthy bails on speakership
Wrong drug used in Oklahoma execution
Ethics of Planned Parenthood challenged in DC
McCarthy's withdrawal plunges GOP into chaos
Is the Republican party still a party?
Ryan 'shocked' by McCarthy withdrawal
Trump welcomes enthusiastic fan on stage
UCC marks 1 week since mass shooting
Biden on importance of helping middle class
Senate Democrats push for fight against...
Clinton lead holds, Democratic debates ahead
Reckless Russia escalates Middle East danger
Clumsy speech marks odd choice for speaker
House creates committee on Planned Parenthood
Trump not fading, readies second offensive
Rachel Maddow to moderate candidates forum
Sanders speaks on Clinton's TPP opposition
VP Biden jokes about 'demotion'
Obama apologizes to Doctors Without Borders


text:
|Men's Cross Country » Schedule » Roster » News » Coaches » Camps » Recruiting Questionnaire
2011 Cross Country: Competed in six meets… Earned a 37th-place finish at the Powerade Invitational with a career-best 17:09s 5K mark… Placed ninth at the Chattanooga Cross Country Festival with a 30:18.24s run… In the silver race of the Louisville Cross Country Classic, he finished 129th with a personal-best 8K mark of 28:28.19s.
2011 Track: Contributed on relays and in the middle distances as a freshman... Part of fifth-place distance medley team at the Ed Temple Invite (Jan. 8, 11:24.34s) and the runner-up at the Tennessee State Invitational (Jan. 29, 10:39.46s)... Season-best 800m run came at the Vanderbilt Black and Gold, where he finished 13th with a 1:59.99s run.
2010 Cross Country: Competed in five meets during his freshman campaign... Opened his career with a 68th-place, 17:58.43 5K mark at the Belmont Opener... Finished a season-best 56th at the Powerade Invitational with an 18:24 mark... Season-best 8K mark of 29:26 came at the Louisville Invitational.
2011-12 Men's Cross Country