EP3451976A1

EP3451976A1 - Vertebral system, implant and inserts for a vertebral system

Info

Publication number: EP3451976A1
Application number: EP17725522.1A
Authority: EP
Inventors: Florian JOLY; Edouard JOUAN; Alexis Mercier; Thierry Millard
Original assignee: LDR Medical SAS
Current assignee: LDR Medical SAS
Priority date: 2016-05-03
Filing date: 2017-05-03
Publication date: 2019-03-13
Also published as: US20220015925A1; FR3050927A1; US20170333205A1; US20190336305A1; US10369009B2; US11154406B2; FR3050927B1; WO2017191223A1

Abstract

The present invention relates to a vertebral system comprising a vertebral implant (2) and a plurality of inserts, said implant being intended to be implanted in a vertebral segment composed of at least two vertebrae, and having a body (20) whose walls delimit a cavity (23) opening to the outside of the body (20) via at least one opening in at least one of said walls, at least one passage (21) extending through the implant (2) from the periphery to an upper or lower surface in order to receive a bone-anchoring device (1) suitable for anchoring the implant (2) in at least one of said vertebrae, the system being characterized in that it has at least two inserts selected from among the following inserts: at least one graft insert (3, 3A, 3B, 4, 5A, 5B, 6A, 6B, 6C, 6D, 202, 250) able to be colonized by bone tissue and/or to receive at least one bone tissue graft and/or at least one substitute; and/or at least one bone-anchoring insert (210) comprising said passage (21) for receiving said bone-anchoring device (1).

Description

Vertebral System, Implant and Inserts for Vertebral System

TECHNICAL FIELD OF THE INVENTION

The present invention relates to the field of orthopedic surgery and in particular spinal surgery. The present invention more particularly relates to a modular vertebral implant, in particular using various graft inserts and / or fixation inserts, but it also relates to at least one insert (modular) for such a modular implant and a modular system of implant with modular inserts.

BACKGROUND OF THE INVENTION A problem in the field of orthopedic implants and in particular spinal implants concerns arthrodesis, that is to say the fusion between two bone structures, which it is often desirable or necessary to to perform to treat a patient. The success of this type of treatment depends in general on the speed and / or the reliability of the bone fusion obtained. This speed and reliability are often linked and often rely on the quality of the immobilization of the two bone structures that one wishes to merge. Thus, a second problem in the field relates to the fixation of bone implants and in particular the reliability of this fixation. In addition, in the particular case of the spine, these problems are accompanied by various problems and constraints related to congestion around the sites to be treated. Indeed, it is sometimes sought to obtain a fusion of at least two vertebrae, for example when at least one of their adjacent intervertebral disks is damaged. It is known from the prior art various arthrodesis techniques, based on various types of implants, such as intersomatic cages (or arthrodesis) inserted in place of a disc to promote bone growth, or corpectomy cages that replace a vertebral segment sometimes including at least a portion of at least one vertebral body, generally in addition to at least one intervertebral disc. It is also known, especially at the lumbar and sacral level, solutions using facetted implants (interfacettaires or transfacretaires) to fix the facet joints of two vertebrae in order to obtain a fusion between them. Generally, these various solutions are intended to solve, in addition, the problem of stability of the implant and treated vertebral structures. It is necessary for an implant to be stable in its implantation site, in particular when arthrodesis is desired since the latter must take place in a relative position of the elements of the spine that is optimal (as desired by the surgeon). Stabilization and / or locking of the implant is (are) therefore often preferable (s).

These solutions have the disadvantages of not always correctly answering the general problems of the facility and / or the speed of implantation and invasiveness of the implants and the surgical techniques that depend on them. Indeed, it is generally desired that the implants can be implanted quickly and / or easily, with minimal invasiveness, that is to say that one seeks to limit the size of incisions and damage to the surrounding tissues. This problem of invasiveness concerns in particular the introduction of implants into the spine and in particular the access to the intervertebral spaces (disc spaces) which is often particularly delicate because of the bulk, for example because of the presence of vessels blood and nerves around the intervertebral space, as well as the proximity of the spinal cord.

Finally, another problem in the field of implants concerns the variability of individuals and pathologies. For example, the size of the vertebrae is very variable depending on the individual and depending on the position in the spine, but the great variability of the patient's disorders and pathologies makes the design of the implants even more complex. In order to have implants that can be used to meet the needs of a larger number of patients, a significant number of implants that differ in size and / or inclination of their bone contact surfaces and / or bone anchorage, etc. This multiplicity of implants required has a major disadvantage of cost of production and inventory management. In addition, a problem, which follows implicitly from those mentioned above, relates to the fact that it is sometimes useful to provide a system of implants (including arthrodesis) whose bone anchorage may vary according to the needs, even be decided at the last moment, that is to say just before the implantation of the system in the patient, or even during implantation. Indeed, the surgeon may sometimes wish to change the type of bone anchoring by providing bone anchoring means that exert a compression of the vertebrae around the implant system (that is to say, which tends to bring the two vertebrae adjacent to each other), such as bone anchoring means such as screws or anchors whose curvature is adapted to such an effect (as described in some documents of the prior art). In addition, the surgeon may wish (on the same vertebral floor of the same patient or on another vertebral floor of any patient) that the anchorage does not constrain the vertebrae in certain directions, or even in any direction (including the sense of compression). The surgeon is often faced with the problems of choosing the type of fixation, sometimes until the moment the surgery is already performed, while the prosthesis supplier is faced with the problems of cost and inventory management. while facilitating the surgeons surgical procedure.

In this context, it is interesting to propose a solution that can respond to at least some of these problems.

GENERAL DESCRIPTION OF THE INVENTION

The present invention aims to overcome certain disadvantages of the prior art by providing a vertebral implant, including interbody, and inserts for this implant, but preferably rather a system (eg, a kit or a set) comprising at least one vertebral implant and a a plurality of associated (or associable / assemblable) inserts with this type of implant, so as to form a system that is reliable, quick to implement and usable in a large number of cases, while preferably limiting costs and stocks (especially for providers of such systems). This object is achieved by a modular vertebral arthrodesis system, comprising at least one vertebral implant (2) and a plurality of integrable inserts in said implant, said vertebral implant (2) being intended to be implanted in a vertebral segment composed of at least two vertebrae and comprising, on the one hand, at least one body (20) whose walls delimit a cavity (23) opening on the outside of the body (20) by at least one opening in at least one of said walls; , and, on the other hand, at least one passage (21) passing through the implant (2) from the periphery to an upper or lower surface for receiving a bone anchoring device (1) adapted to anchor said implant (2) in at least one of said vertebrae, said system being characterized in that said plurality of inserts comprises at least two inserts selected from the following inserts:

At least one graft insert (3, 3A, 3B, 4, 5A, 5B, 6A, 6B, 6C, 6D, 202, 250) capable of being colonized with bone tissue and / or receiving at least one tissue graft bone and / or at least one substitute;

and or

At least one bone anchoring insert (210) comprising said passage (21) capable of receiving said bone anchoring device (1).

According to another feature, the shapes and dimensions of said opening in at least one of said walls of the implant are complementary, at least in one plane, to the shapes and dimensions of the graft insert and / or the anchoring insert. bone, so that insertion of last (or the latter) within the body of the implant is (or is) performed / performed through said opening. According to another feature, the shapes and dimensions of said opening in at least one of said walls of the implant are complementary forms and dimensions of the graft insert and / or the bone anchoring insert, which are themselves also complementary to each other.

According to another feature, the implant comprises at least one graft insert, but said passage is formed directly in at least one of said walls of the body without the need for a bone anchoring insert.

According to another feature, the implant comprises at least one bone anchoring insert, but said cavity is configured to directly receive a bone tissue graft or a substitute without a graft insert. According to another feature, the graft insert has at least one of the following elements:

a modular mesh element;

- a solid modular element;

- A loading element, said cassette, adapted to receive at least one such modular element mesh or full or directly a graft or substitute.

According to another feature, the graft insert comprises at least one solid or mesh reinforcement.

According to another feature, said bone anchoring insert and said body of the implant comprise reciprocal means for locking said bone anchoring insert in the implant.

According to another feature, the posterior portion of the body of the implant comprises an opening adapted to receive said bone anchoring insert.

In another feature, said opening extends from the upper surface to the lower surface of the body and provides a gap between two opposing surfaces in the walls of the rear portion of the body.

According to another feature, the reciprocal locking means of said bone anchoring insert in the implant are disposed inside said opening and on the edges of said bone anchoring insert. According to another feature, the posterior portion of the body comprises at least one attachment means intended to cooperate with a grasping end of an implantation instrumentation of the implant.

In another feature, the modular mesh element comprises at least one housing configured to receive at least one graft or bone substitute and / or at least one solid modular element inside the cavity.

According to another feature, the modular mesh element comprises a three-dimensional network comprising interconnected adjacent planes, each plane being formed of meshes. According to another feature, the three-dimensional network of the modular mesh element is obtained by a three-dimensional printing technique or additive manufacturing.

According to another feature, the fixing insert comprises at least one abutment surface separating two passages and on which the posterior part of the anchoring device rests, said abutment making it possible to maintain the implanted device in the vertebra through the passageway. .

According to another feature, the implant comprises at least one hollow separating two abutment surfaces.

According to another particular feature, the upper and lower surfaces of the reinforcement are situated, respectively, lower and higher than the respectively upper and lower surfaces of the implant, thus enabling the implant to marry any irregularities in shape. vertebral trays.

According to another feature the modular mesh element comprises at least one housing adapted to receive and / or marry the shape of at least one reinforcement.

According to another feature, said graft insert forms a lid that does not fill said cavity of the implant and thus leaves a portion of said cavity free, for example to receive bone graft or substitute. The present invention also aims to overcome certain disadvantages of the prior art by proposing in particular:

at least one implant capable of receiving at least one insert such as those of the system according to various embodiments of the invention and / or

at least insert for such a vertebral implant so as to form a system that is reliable and quick to implant and allows the implant to be used in a large number of cases, while preferably limiting costs and stocks.

This object is achieved by an implant and / or at least one graft insert and / or at least one anchoring insert, preferably at least one implant associated with a plurality of inserts, said inserts each comprising complementary shapes and dimensions. a body or skeleton of an implant in which said inserts are intended to be inserted to form said system or implant.

DESCRIPTION OF ILLUSTRATIVE FIGURES

Other features and advantages of the present invention will appear more clearly on reading the description below, made with reference to the accompanying drawings, in which:

FIGS. 1A, 1B, 1C and 1D respectively represent a view of the rear face, a profile view, a top view and a perspective view of an intervertebral implant comprising a graft insert according to a method of FIG. production ;

FIGS. 2A, 2B, 2C and 2D respectively show a view of the rear face, a profile view, a top view and a perspective view of an intervertebral implant comprising a graft insert and provided with two devices of FIG. anchoring according to one embodiment; FIGS. 3A, 3B, and 3D are respectively a view of the rear face, a profile view and a perspective view of an embodiment of an intervertebral implant adapted to receive a graft insert and the graft insert before assembly, Figure 3C shows a top view of this implant and this insert after assembly;

FIGS. 4A, 4B and 4D show, respectively, a view of the rear face, a top view and a perspective view of an embodiment of an intervertebral implant adapted to receive a graft insert and an insert. prior to assembly, FIG. 4C represents a profile view of this implant and this insert after assembly;

FIG. 5A represents a perspective view of an embodiment of a graft insert and an intervertebral implant capable of receiving this graft insert, FIG. 5B represents a profile view of this graft insert inserted in FIG. 5C and 5D show, respectively a profile view and a perspective view, of another embodiment of a graft insert and an intervertebral implant adapted to receive this graft insert;

FIG. 6 is a perspective view of an embodiment of two graft inserts and an intervertebral implant adapted to receive these graft inserts;

FIG. 7A represents a perspective view of an embodiment of a graft insert and a reinforcement intervertebral implant adapted to receive this graft insert, FIG. 7B represents a perspective view of this intervertebral implant and graft inserts according to another embodiment;

FIG. 8A is a top view of an embodiment of a reinforcement intervertebral implant having graft inserts, FIG. 8B is a perspective view of this intervertebral implant and these graft inserts prior to assembly;

FIGS. 9A, 9B and 9C show a perspective view of an embodiment, graft inserts and a reinforcement intervertebral implant. adapted to receive these graft inserts in the upper, side and lower surfaces, respectively before, during and after assembly;

FIGS. 10A, 10B and 10C show a perspective view of an embodiment of an anchoring insert and a reinforcement implant with an opening at the rear adapted to receive this anchoring insert, respectively , before, during and after assembly and FIG. 10D shows a perspective view of this implant equipped with this insert and two bone anchoring devices;

FIG. 11A is a perspective view of an embodiment of an anchoring insert, and FIGS. 11B, 11C and 11D, and 11C are a perspective view of FIG. an embodiment of this anchoring insert and a reinforcement intervertebral implant with an opening at the rear adapted to receive this anchoring insert respectively before insertion, after insertion, after pivoting and after translation, of this insert in the rear opening of this implant;

FIG. 12A is a perspective view of an embodiment of an anchoring insert, and FIGS. 12B, 12C and 12D, and 12E are perspective views of an embodiment of this insert of FIG. anchoring and a reinforcement intervertebral implant with a rear opening adapted to receive this anchoring insert, respectively before insertion, after insertion, after pivoting and after translation, this insert in the rear opening of this implant;

FIGS. 13A, 13B and 13C, 13D and 13E show a perspective view of an embodiment of an anchoring insert and a reinforced intervertebral implant with a rear opening adapted to receive this anchoring insert. , respectively before insertion, after insertion, after pivoting, after translation but before locking and after locking, this insert in the rear opening of this implant;

FIGS. 14A, 14B, 14C, 14D and 14E are perspective views of a centrally reinforced intervertebral implant having a posterior insert according to five different embodiments comprising, respectively, two plate-shaped anchoring devices provided with lateral retraction abutments, two plate-shaped anchoring devices with a central withdrawal stop, no anchoring device, two L-section anchors and two screw anchors split tip;

FIG. 15B shows a perspective view of an embodiment of an anchoring insert, FIGS. 15A and 15D show perspective views of this anchoring insert and an embodiment of a intervertebral implant with reinforcement with a rear opening adapted to receive this anchoring insert, respectively before and after assembly, and Figure 15C shows a side view of this anchoring insert and this intervertebral implant before assembly;

FIG. 16B represents a perspective view of an embodiment of an anchoring insert, FIGS. 16A and 16C show perspective views of this anchoring insert and an embodiment of a intervertebral implant with reinforcement with a rear opening adapted to receive this anchoring insert, respectively before and after assembly, and Figure 16D shows a top view of this anchoring insert and this intervertebral implant before assembly;

FIGS. 17A and 17C show perspective views of an embodiment of an anchoring insert and a reinforcement intervertebral implant with an opening at the rear adapted to receive this anchoring insert, respectively before and after assembly, and FIG. 17B shows a side view of this intervertebral implant and this anchoring insert before assembly;

FIGS. 18A and 18B show perspective views of an embodiment of an intervertebral implant open at the rear and adapted to receive a graft insert or a graft and an anchoring insert, respectively before and after the insertion of these in this implant;

FIGS. 19A and 19B show perspective views of an embodiment of two graft inserts and a centrally reinforced intervertebral implant with an opening at the front adapted to receive these two graft inserts, respectively before and after after assembly, and FIGS. 19C and 19D represent a profile view of this implant and these inserts, respectively, before and after assembly;

FIGS. 20A and 20B show respectively front and rear perspective views of an anchoring insert according to one embodiment; FIGS. 20C and 20D show perspective views of a reinforcement intervertebral implant with a transition to In order to receive the same anchoring insert, respectively before and after assembly, FIGS. 20E and 20F show, in another embodiment, perspective views of a reinforcement intervertebral implant with at least one attachment to the rear to receive the same anchoring insert, respectively before and after fixing the same anchor insert at the rear of the implant;

FIGS. 21A and 21B show perspective views of an embodiment, respectively of an anchoring insert and a pivotally opening intervertebral implant about a horizontal axis, and FIGS. 21 D are perspective views of this insert and this implant, respectively during and after their assembly by closing the implant;

FIGS. 22A and 22B, 22C and 22D show perspective views of an embodiment, respectively of an anchoring insert and a pivotally opening intervertebral implant about a vertical axis, and FIGS. and 22D and 22E show perspective views of this insert and this implant, respectively during and after their assembly by closing the implant, FIG. 22E is a sectional view along the sectional plane 22E-22E of FIG. 22D, of this implant closed with its insert inside its rear part

DESCRIPTION OF THE PREFERRED EMBODIMENTS OF

THE INVENTION

Various embodiments of the present invention relate to a vertebral implant (preferably intervertebral and in particular intersomatic, in particular for an arthrodesis of at least two vertebrae adjacent) and inserts for this implant, but preferably rather a system (eg, kit or assembly) comprising at least one vertebral implant and a plurality of associated inserts (integrable into or associatable with or connectable with) this type of implant. 'implant. Various embodiments of the present invention therefore relate to a system of vertebral implants and modular inserts comprising at least one bone implant, intended to be implanted generally between two bone structures or inside a cavity in a single bone structure. Various embodiments of the present invention are particularly suitable for use in the spine and therefore particularly relates to a vertebral implant for implantation into a vertebral segment composed of at least two vertebrae. This implant is intended to be customizable, adjustable with various inserts that will be mounted in or on the implant to provide it with means to perform various functions detailed in this application. Various embodiments therefore relate to a system also comprising inserts for equipping such implants. In particular, this implant may be an "intervertebral" type implant implanted between two adjacent vertebrae or a "corpectomy" type implant implanted on a segment that may extend beyond a single intervertebral space, or even on several bodies. and / or vertebral space, but it may also be a "facet" type implant implanted between two articular facets or in the sacroiliac joint. Indeed, various embodiments relate to implants with at least one insert facilitating bone growth and making it possible to propose an efficient fusion (bone fusion) in various implantation sites, and the examples provided above must not therefore be considered as limiting. Thus, various embodiments may provide an implant that is not intended for the spine but configured (particularly in terms of three-dimensional shape) for another type of bone of the musculoskeletal system. It will be noted that an insert can facilitate arthrodesis by the fact that it leads to bone growth because of a particular configuration, in particular of shape (graft insert) but also by the fact that it fixes and immobilizes ( at least partially) the bones that one wishes fusing (bone anchoring insert). On the other hand, the present application describes various embodiments of a bone anchor for the implant, and thus details various types of bone anchors, generally called "anchors" in the present application, although it may also be a screw implanted by screwing (spiral rotation), for example as shown in Figures 14A, or a device planted in the bone following a rectilinear translation or following a curvilinear path, for example as illustrated in Figures 14A, 14B or 14D. The term anchor is therefore used here only with reference to its anchoring function and does not imply any limitation of shape or structure, except that the anchor is preferably elongated along a longitudinal axis which extends between a first end, here referred to as "anterior end", intended to penetrate into a bone (a vertebra in general) and a second end, designated here as "posterior end" generally intended to remain in the implant to retain it , keep it in place. It will be noted that the designations of the "posterior" and "anterior" ends of the anchor (1), the implant (2) or any other element are used in the present application with reference to the meaning in which the anchor ( 1) is inserted. Thus, for the anchor (1), the first end, said anterior, is the one intended to be inserted first and intended to penetrate into a vertebra to secure an implant. Regarding the implant, its wall or its end designated as posterior is that by which it is generally required to be implanted, whether the wall is actually posterior to the implant or not during implantation. In the case of the spinal implants described in the present application, this posterior end may actually be placed towards the rear of the patient or not, particularly for implants which are essentially intended for posterior or transforaminal implantation. Therefore, the terms "anterior" and "posterior" are not intended to refer simply to the patient or to one of its anatomical features, but to the direction of insertion of the anchor into the implant and / or implant itself (whether this implant is itself implanted along an anteroposterior axis or not). On the other hand, the term "height" is generally used here and "Thickness" the dimensions of the elements in an orientation parallel to the axis of the spine (once implanted in) and the terms "upper" and "lower" (or above and below) are generally defined also in this orientation (vertical when the patient is standing), without limiting implication for the invention. Similarly, the terms "vertical" and "horizontal" are used in a nonlimiting manner with reference to the axis of the spine by considering the patient standing and the implant positioned in the spine. On the other hand, the terms "width" and "length" mean dimensions in a plane perpendicular to the axis of the rachis (a transverse plane), with the width generally being in the mediolateral direction while the length will be in the anteroposterior direction, without this conventional definition having the slightest limiting implication for the invention. Note also that reference is made here to a longitudinal axis between two ends and that this longitudinal axis optionally corresponds to an anteroposterior axis of the anchor (1), but that this axis is generally oriented obliquely with respect to the implant since the anchor is often inserted from the periphery of the spine into a vertebral structure (a vertebral body most often and usually in a vertebral plateau). In addition, this axis of the anchor even follows a curved path in many embodiments and is in fact, on the one hand, parallel to a tangent to the arc described by the anchor and on the other hand , therefore referred to as anteroposterior to the ends of the anchor rather than to the spine. Similarly, the axis of the passage is designated using the same references while it is oblique and can be curvilinear or rectilinear. It will also be noted that the term "substantially" or "substantially" is regularly used in the present description, in particular with respect to a characteristic such as an orientation or a direction, so as to indicate that the characteristic concerned may in fact be slightly different and not not exactly as designated (for example, the expression "substantially perpendicular" should be interpreted as "at least approximately perpendicular" because it may be possible to choose an orientation that is not exactly perpendicular to nevertheless be able to fulfill substantially the same function). In addition, terms such as the term "substantially" used in this application may also be interpreted to mean that the technical characteristics may be "in general"("generally"), and often "preferably" as indicated, but that other embodiments or configurations may be within the scope of the present invention. The various elements composing the system of implants and adjustable inserts will now be described, with reference to the figures but without limitation. Indeed, the system, but also the implants and / or the inserts can individually take on particular technical aspects that should be examined individually without limiting them to other aspects, although various embodiments of the present invention relate more particularly the advantageous combinations provided by the combination, or even the synergy of the various implants and inserts described in the present application.

Preferably, the vertebral implant (2) comprises, in a general manner, a body (20) whose walls delimit a cavity (23) opening on the outside of the body (20) by at least one opening in at least one of said walls. In particular, the body may comprise one or more openings, preferably several such that the cavity opens on several faces of the implant which is thus open from one side to the other, which will allow the bone to colonize it entirely. Thus, the body may comprise at least one lateral opening and / or at least one rear opening and / or at least one front opening and, of course, at least one upper and / or lower opening as often observed in the prior art. Moreover, in the case of an implant (2) having at least one cavity (23), for example as particularly visible in certain embodiments shown in FIGS. 20E, 20F and 21B, holes (201, 254) can be arranged in at least one of the walls of the implant (the side walls on the examples shown), so as to also allow the growth of bone tissue transversely to the disc space (that is, through the implant, parallel to the vertebral endplates)

In addition, the implant (2) preferably comprises at least one passage (21) passing through the implant (2) from the periphery (a lateral or anterior or posterior surface) to an upper or lower surface for receiving a device. bone anchor (1) adapted to anchor the implant (2) in at least one of said vertebrae. On the other hand, the system comprises at least one implant (2) which comprises at least one of the following two types of inserts, but which is preferably combined with a plurality of graft inserts and / or inserts. bone anchors selected from at least one of the following types of inserts:

Various embodiments therefore relate to an implant whose walls define a kind of skeleton generally capable of supporting at least partially the stresses exerted on the implant, in particular to maintain or restore a distance (often a height) between two bone structures (vertebrae by example). In addition, this skeleton defines an inner cavity adapted to receive various types of interchangeable inserts and not exclusive to each other, depending on the needs of the patient or the wishes of the surgeon. In particular, certain inserts, here called graft inserts, may serve as a bone growth support structure and other inserts, here called fixation inserts, may be used to host the anchoring of the implant in The vertebrates. Indeed, various graft inserts, hollow, solid, mesh, lattice or not can be used to at least partially fill the cavity. Various embodiments of these graft inserts will be able to be colonized by bone tissue of the patient and / or to receive a graft and / or a substitute, for example to accelerate and / or promote bone growth. These inserts may in particular have the purpose that the fusion is done for example between 2 vertebrae, but also to promote the attachment of the implant on the bone, for example on the vertebral plates, or to form a surface, at least higher or possibly lower, limiting the risk of insertion of the implant into the bone, in particular the adjacent vertebral bodies. Note that the terms "to be colonized" and "graft and / or substitute" also encompasses the known possibilities of various combinations of substances promoting bone growth, such as autologous graft or as including growth factors or any type of favorable chemical composition . Thus, it will sometimes be taken advantage of the fact that the graft insert allows bone growth by facilitating its colonization by the surrounding bone tissue, for example by its geometry and / or its mesh structure and / or composition. This possibility of allowing the graft insert to be colonized, without adding bone graft, can be particularly advantageous, particularly for the patient, for example if only because it makes it possible to avoid or limit the samples taken. of the patient's bones, which are often painful, especially in the iliac crest. Note also that the present application refers to the term "insert" any device, element or structure that is actually insertable inside the implant (possibly flush or protruding from the periphery), and to the extent that several inserts can be introduced in place of each other or complementary to each other, that these inserts can be fixed in the implant or not and that they can be removed or not. In addition, in some embodiments, the implant is in fact open on one of its faces and its cavity thus opens on the periphery of the implant. Thus, at least one of the inserts, preferably a bone anchoring insert (but not only) may in fact be added to the implant to form one of the walls, for example as shown in at least FIGS. 7B, 9B, 10B, 11C, 12C, 13C, 15D, 16C, 17C, 18B, or 20C and 20D. In some embodiments, it is even possible that at least one of the inserts is not really introduced inside the implant, that is to say inside the cavity but may in fact be attached to the periphery of the implant, at the level of at least one face (generally posterior), for example as shown in FIGS. 20E and 20F. This type of configuration sometimes makes it possible to add an insert to an implant, especially during implantation, but it is generally preferred that the insert is actually inside the area defined by the walls of the body so that the Reliability of the assembly is not likely to be weakened by means of coupling between an attached insert and an implant, to limit the risk that they will dissociate. Note also that the present application refers to bone grafts or substitutes and that these terms should also be interpreted to mean in fact any type of material or composition that allows bone growth, which can be optimized or controlled, without any limitation whatsoever. It is known, for example in the prior art, to use various types of grafts or substitutes, such as, for example, autologous bone grafts (that is to say from a sample taken from the patient himself), possibly with a treatment, in particular a preliminary grinding, or bovine bone grafts whose structure is close to that of human bone, but also substitutes such as tricalcium phosphate β (β -TPC) whose composition , very close to the mineral components of the bone, is perfectly biocompatible and whose bioactivity allows a total resorption and an optimal bone regrowth in a few months or the hydroxyapatite (PAH) whose composition is also very close to the mineral composition of the bone and therefore also biocompatible, but whose resorption will generally be slower. Thus, the term "graft" is generally used in the present application to denote autologous bone tissue as well as a substitute or any other grafting substance or any type of compound or chemical composition. On the other hand, it is understood that various embodiments make it possible to limit the costs of manufacturing and stock management while providing a wide variety of implants that the surgeon can customize. Indeed, instead of providing an implant for each type of desired content, various embodiments of the invention allow to provide only a common skeleton in which we adapt various types of inserts, for example depending on the bone growth characteristics desired or depending on the desired bone anchoring types or the desired radiolucency of the implant. For example, the surgeon may wish in particular for an implant which is very resistant to compression, at least in certain directions (for example as shown in FIGS. 5A, 5B, 5C, 5D, 6A, 7B, 8B) and / or which is very conducive to rapid bone growth (for example as shown in FIGS. 4D or 9A, among others) and / or which has a minimally invasive or very deep anchorage or a compressive anchorage (for example as shown in FIGS. 14A, 14B, 14C, 14D and 14E). The modularity of the implants of the present application makes it possible to respond effectively to the great diversity of desirable technical characteristics for an implant and the figures show illustrative, nonlimiting and non-exclusive examples of them for the most part. It is therefore understood that various embodiments may relate to assemblies formed of an implant forming the skeleton as described and a combination of several graft inserts and / or bone anchoring inserts. Indeed, a common base is formed by the hollow implant and various "accessory" inserts can be added. In particular with regard to the graft inserts, the following description details solid, hollow and mesh inserts which will be used alone or in combination with each other to meet the requirements of the anatomical structures of the patient and the needs of the surgeon.

Various embodiments relate to at least one insert for at least one implant for implementing the invention. Thus, some of these embodiments relate to a graft insert, provided for example alone, configured for use in an implant as described herein. request. Indeed, it is possible to propose a multitude of inserts that will be able to be inserted into an implant of the type of those of the present application, in particular integrated with coupling means or not. It is therefore important that it is understood that the scope of the present application can extend to an insert alone, as long as it is intended for its integration into an implant of the type of those of the present application. It is naturally the same with at least one bone anchoring insert, as long as it is configured for use in an implant such as those of the present application. It is the same for any combination of these inserts between them.

Moreover, the various components of the implant system (implant body, reinforcement, insert, anchors), used in various embodiments, sometimes rely on the use of additive manufacturing techniques (three-dimensional printing or 3D printing). but the scope of the present application is not limited to this technique. Indeed, it is now more and more common to use this type of techniques for the manufacture of implants. In particular, the present application refers to inserts with a mesh structure (often called "lattice", in particular in English) which are in fact various shaped elements (for example polyhedral and / or rounded), whose body is not full but composed of a network of meshes, with variable geometries which also have the advantages of generally promoting bone growth and / or allow good visibility of this bone growth after surgery by imaging means and / or to add a surface limiting the risks of insertion of the implant and / or to add a surface of hanging of the implant on the bone surface, etc. Additive manufacturing techniques are particularly useful for this type of mesh structure, and therefore preferably used for these elements, but also possibly for bone anchors or for the body of the implant forming the skeleton receiving these elements for example. Nevertheless, these techniques often involve a certain inaccuracy which is often acceptable for elements such as inserts and the body, but this inaccuracy is more problematic in the case of an element that requires a more precise adjustment, such as bone anchors that must cooperate with portions that retain the anchors relative to the implant and thus hold the implant in place in or against the bone tissue. Moreover, it is very likely that these additive manufacturing techniques improve and improve their tolerances quickly, so as to offer even more advantages. It may therefore sometimes be preferred to use either more conventional machining or molding techniques or techniques. additive manufacturing for the various elements of the implant and / or the insert and / or anchoring, in particular according to the tolerances of these elements and the qualities achieved by these various techniques. Thus, the fact of proposing modular implants (eg, comprising modules that can be assembled together, such as a body and inserts) makes it possible to take advantage of the various manufacturing techniques for the various elements. Thus, for example, it may provide a mesh insert in additive manufacturing but an anchor insert machined or molded with an anchor or a screw machined or molded also, all assembled with a body obtained by machining or molding or additive manufacturing. Similarly, the use of a mesh insert, including filled graft, separately from the body of the implant (skeleton), can provide a number of significant benefits. For example, one advantage relates to obtaining complex shapes for the insert, especially shapes that would be inaccessible and therefore impossible to obtain by machining, while they are by additive manufacturing and / or the fact that the insert can be machined separately. Another advantage relates, for example, to the possibility of a more homogeneous filling of the graft insert with a substance that promotes bone growth, for example by dipping it in this substance, or by injecting this substance while the void is being made around it. of the insert, or by printing this substance within the insert, or even by preparing the insert with stem cells in an organized manner within the network, or even by performing cell culture therein. On the other hand, the various elements in the present application can be manufactured in particular PEEK, acronym for polyetheretherketone (Poly-Ether-Ether-Keton in English) which have elasticity, in particular similar to known cortical bone of the prior art and / or titanium and / or various materials or biocompatible alloys and usable with the manufacturing techniques mentioned above. An illustrative and nonlimiting example of an advantageous combination of materials comprises, on the one hand, a machined or molded PEEK body which would make it possible to optimally withstand the forces in vivo with a modulus of elasticity close to that of the bone and thus limit the constraints at the bone / implant interface and, secondly, a titanium mesh graft insert that would allow the reception of a grafting substance (graft or substitute or substance leading or stimulating growth ). The anchors could then either pass directly through the implant, or through an anchor insert. If the body of the implant is made of titanium, it is generally preferred that it is much more hollow than if it were PEEK given the superior mechanical characteristics of titanium, which allows to leave more room for the graft and also reduce the "stiffness" of the body that might be too important in titanium (vis-à-vis the contact with the bone). Moreover, a PEEK or titanium implant body can accommodate various types of graft inserts and the same graft insert adapts to a body regardless of its material as long as the complementarities of shapes and configurations are provided as described in this application. In some embodiments, the vertebral implant (2) has at least one bone anchoring insert (210), but said cavity (23) is configured to directly receive a bone graft or a substitute, without a graft insert. (3, 3A, 3B, 4, 5B, 6A, 6B, 6C, 6D, 202, 250). Thus, some embodiments may relate to an implant having just a bone anchoring insert for receiving the anchors and fix the implant which is otherwise configured to receive directly from the implant. graft or substitute in its cavity, for example as already known from the prior art. Thus, such an implant has a cavity that does not necessarily include means (openings, locks, etc.) capable of cooperating with graft inserts, but includes at least one anchoring insert such as those described in the present application, which have various advantages and therefore meet various problems in the field, including the modularity of the type of bone anchorage that may be desired by the surgeon, for example as illustrated in Figures 14A, 14B, 14C, 14D and 14E.

Conversely, in certain embodiments, the vertebral implant (2) comprises at least one graft insert (3, 3A, 3B, 4, 5A, 5B, 6A, 6B, 6C, 6D, 8, 202, 250), but said passage (21) is formed directly in at least one of said walls of the body (20) without the need for a bone anchoring insert (210). Thus, the body (20) comprises at least a portion, generally posterior, which comprises at least one passage (21) for a bone anchor. The figures of plates 1 to 9 and 19 show illustrative and non-limiting examples of such implants in which a bone anchor is provided directly in the walls of the body. In these embodiments, a passage (21) is formed directly in at least one wall of the body (20), in general the rear wall since the anchor can be inserted therein. The figures of the boards 10 to 18 and 20 to 22 instead show non-limiting examples of implants provided for anchoring via an anchoring insert.

On the other hand, various embodiments of course combine the two types of inserts, for the graft and for anchoring. In addition, in various embodiments, the anchoring can be done at least with the aid of an anchoring insert, but it is possible to have an additional anchorage directly via a passage in a wall of the implant. in addition to this anchoring via an anchoring insert. Similarly, it is clear that the implant may comprise both a graft insert to receive a graft and at least one cavity (or part of cavity) directly receiving the graft without requiring a specific insert. In addition, each of the illustrative and Non-limiting examples described below concerning the graft inserts and the anchoring inserts are of course combinable with each other unless the reverse is explicitly mentioned or apparent to the skilled person. Similarly, in general, it will be understood from reading the present application that each of the technical characteristics of each element, described in at least one embodiment or configuration, may be isolated from the other characteristics of the object concerned. (or objects concerned and / or associated) by said embodiment or said configuration (and thus concerning the same element or a different element) and / or may be combined with any other technical characteristic described here, in various modes embodiments or configurations, unless the reverse is explicitly mentioned, or that these characteristics are incompatible with one another and / or that their combination does not work, in particular because the structural adaptations that may be required by such isolations or combinations of characteristics are directly derivable from the appreciation of functional considerations provided in this application.

On the other hand, the modularity is generally provided by the fact that the implant is arranged to receive several different types of inserts, but it is clear that the reciprocal is possible since it is still generally provided various types of implants, if only for various surgical approaches (anterior, lateral, posterior, transforaminal). Thus, various embodiments provide that the same insert can be used on several implants and even via means of assembly and / or coupling and / or different locking. FIGS. 20C and 20E show particularly relevant examples of this modularity since the implant, for example anterior or lateral, of FIG. 20C receives the same attachment insert as the implant, for example posterior or transforaminal, of FIG. 20C, while possibly using a different coupling mechanism since FIG. 20D shows that this same insert can be introduced into the implant of Figure 20C, but just attached to another implant in Figure 20E. This example therefore demonstrates the variety of couplings that are made possible by various embodiments.

In some embodiments, the graft insert (3, 3A, 3B, 4, 5B, 6A, 6B, 6C, 6D, 8, 202, 250) has at least one of the following:

a modular mesh element (3, 3A, 3B, 6C, 6D);

a solid modular element (4, 5A, 5B, 6A, 6B, 8), which may in fact sometimes be a graft or substitute or a grafting substance;

a loading element, called cassette (6A), capable of receiving at least one such modular element (3, 3A, 3B, 6C, 6D) or solid (4, 5A, 5B, 6A, 6B, 8), which can be directly a graft or substitute or a grafting substance.

In some embodiments, the modular mesh element (3, 3A, 3B, 6C, 6D) comprises a three-dimensional network comprising interconnected adjacent planes, each plane being formed of meshes (30). The present application designates this type of structure by the term "meshed" or "mesh" or "lattice", to illustrate the fact that these structures comprise at least one open network composed of points interconnected by edges, which result in patterns repeated, more or less identical to each other, such as honeycomb networks, or rectangles or lozenges or any type of network whose mesh may have various shapes, even within the same network of a same insert. In certain embodiments, as mentioned elsewhere in this application, the mesh network is configured such that the openings of a given plane of the network are aligned, in a determined direction, with those of other planes of the network, so that one can see through the openings by looking in that determined direction and thus see through the implant. Figures 1B and 2B show advantageous examples of such alignments, which can be used to monitor bone growth by viewing X-rays taken in profile. As mentioned elsewhere in the present application, this type of network is generally easier to obtain with an additive manufacturing technique than with other techniques, for example such as machining or molding. Thus, in certain embodiments, the three-dimensional network of the meshed modular element (3, 3A, 3B, 6C, 6D) is obtained by a three-dimensional printing technique or additive manufacturing. In some embodiments, the modular mesh element (3, 3A, 3B, 6C, 6D) comprises at least one stabilizing means (33, 32A, 32B), for example such as a cutout, allowing said element of adapting to and / or marrying the shape of the body of the implant (2) and / or a reinforcement (202), for example as shown in Figures 7A, 8B and 9A. so as to stabilize the modular element meshed on (or in) the body of the implant. In some embodiments, the modular mesh element comprises at least one locking means (31) disposed on at least one of the faces of said element, for example as shown in Figure 9A. The locking element (31) may for example be formed by a clip, a clip, a hook or any similar element to lock and / or stabilize the modular element meshed on the reinforcement (202) of the body of the implant. (2). In some embodiments, at least one graft insert (250) is introducible (thus introduced during use) preferably into the implant, for example through at least one lateral opening, preferably so as to be locked in the implant. implant, or even to lock the latter. Preferably, the graft insert (250) is meshed (251 B), for example so as to rapidly obtain a bone fusion. Said insert (250) comprises at least one locking means (252A, 252B), which can in particular be formed by at least one clip, a hook or any similar element making it possible to lock and / or stabilize the graft insert (250) on the lateral wall (25) of the implant. In addition, the graft insert (250) generally comprises notches (251 A) disposed on at least one of its upper and lower surfaces, in particular so as to improve the stability of the implant between the vertebrae and to avoid any displacement. of the implant between the vertebrae between which it is intended to be implanted, at least as long as the bone fusion is not yet sufficient to immobilize the assembly.

In certain embodiments, the modular element (4, 5A, 6A, 6B, 8) has a tubular shape (for example FIGS. 5A, 5B, 8A, 8B) or any other form adapted to its insertion into the body of the body. implant (e.g. FIGS. 5C, 5D, 7B, 18A, 18B), so as to strengthen the bone structure and / or accelerate bone fusion. It is thus understood that there is in fact provided a complementarity of form between said element and said body of the implant. In certain embodiments, for example as shown in FIGS. 18A and 18B, a graft insert (8) comprises at least one bearing surface (83) against at least one attachment insert (210) and / or at least one a bearing surface (81) complementary with at least one surface, for example upper and / or lower, of the implant (2), and / or an extension (82) for filling, at least partially, with less an opening of the implant, for example in the lateral wall (25) and / or anterior or posterior of the implant. Note that in these embodiments, the inserts (4, 5A, 6A, 6B, 8) can also be graft inserts, for example such as hollow, mesh or solid inserts and they can fill the cavity of the implant partially or totally. In certain embodiments, the solid modular element may be inserted into a housing of a modular mesh element, for example as shown in a nonlimiting manner in FIGS. 5A and 8B, and / or in a housing (60A) of FIG. a loading element, for example as shown in Figure 5D. This type of arrangement makes it possible, for example, to strengthen the system and / or the bone structure and / or to accelerate bone fusion. Thus, different configurations allow to use various types of graft inserts (and / or attachment) interchangeable and not exclusive to each other, depending on the needs of the patient and / or the wishes of the surgeon.

In certain embodiments, the shapes and dimensions of said opening in at least one of said walls of the implant (2) are complementary, at least in one plane, to shapes and dimensions of the graft insert (3, 3A, 3B, 4, 5A, 5B, 6A, 6B, 6C, 6D, 202, 250) and / or the bone anchoring insert (210). Thus, said opening allows the insertion of the graft insert (3, 3A, 3B, 4, 5A, 5B, 6A, 6B, 6C, 6D, 202, 250) and / or the bone anchoring insert (210) within the body (20) of the implant (2). Thus, a meshed modular element (3, 3A, 3B, 6C, 6D) can be inserted easily by at least one translation, in particular vertical (for example as in FIGS. 1C, 3D, 7A, 8B, 9A) and / or horizontal (for example as in Figures 4D, 5A, 6, 19A), for example through at least opening in at least one of said walls of the implant (the side walls, posterior, upper and / or lower on the examples shown). ). Similarly, a solid modular element (4, 5A, 5B, 6A, 6B, 8) can be inserted (preferably easily and quickly) by at least one translation, in particular vertical (for example as in FIGS. 7B and 8B) and or horizontal (for example as in Figures 5B, 5D, 18A), through at least one opening of the implant (2). In addition, since the implant (2) may have several openings on different faces, it is possible to provide that the various inserts are introduced by at least one of the various openings and are configured (mainly by their shapes and dimensions) so as not to being able to exit through at least one of the other openings, so that they are thus retained inside the implant. As an alternative or in addition, it is possible to provide shapes and dimensions of these elements so that the introduction of the inserts into the body is possible while their output is not, or at least that this first is easier than the latter. Thus, as described previously and hereinafter, various embodiments are provided to provide assembly and / or locking means (31, 252A, 252B, 203, 230B, 203C, 2030, 204A, 2040A, 204B, 2040B , 205, 255, 2155, 209A, 209B, 2090A, 2090B, 2070, 2080, 220, 2120), preferably complementary between the implant and the inserts. For example, such means may be provided on the graft inserts (3A, 3A, 3B, 4, 5A, 5B, 6A, 6B, 6C, 6D, 8, 202, 250) to facilitate insertion and their fasteners in the implant body and prevent removal of said inserts from the body of the implant. The openings in these various variants are therefore complementary inserts, and conversely, in at least one plane and preferably in a single plane, so that the inserts can be inserted into the implant without filling the entire cavity and / or while limiting the risks that they do not come out of the implant unexpectedly.

In some embodiments, said graft insert (3, 3A, 3B, 4, 5A, 5B, 6A, 6B, 6C, 6D, 8, 202, 250) forms a lid that does not fill said implant cavity and leaving a portion of said cavity free, for example to receive bone graft or substitute. This cover can be formed by a mesh graft insert and therefore open or by a solid graft insert and therefore closed. This insert configuration makes it possible in particular to fill the implant with a larger amount of graft, but also to choose to which extent the cavity must be filled, and especially to choose which faces of the implant must remain open, closed by a lid or partially obstructed, in particular by the presence of a mesh structure insert, the density of which may vary as required. Thus, this type of configuration provides a wide range of possibilities for each of the openings of the implant, whether lateral, posterior, anterior, superior or inferior. In addition, various advantages can be obtained by the choice of the type of structure and material of the wall on the various faces of the implant and / or the choice of a contact between the graft and the bone structure. Thus, once again, the modularity of the various embodiments described in the present application provides numerous advantages, particularly for the therapeutic choices of surgeons. In addition, various characteristics combined with each other provide interesting synergies that only the modularity of the present implants makes it possible to operate easily and at will. For example, a titanium upper or lower wall makes it possible to have a bone contact which is known to provide a good bone grip (and even more so if the titanium portion of the implant is rough, for example because it is obtained by additive manufacturing), and as a wall mesh that remains partially open allows to preserve a satisfactory contact between the graft and the bone structure and / or a satisfactory blood and / or cell circulation (s), the probabilities of obtaining a reliable arthrodesis are increased by an insert with a mesh structure in titanium, especially if this insert retains a good cavity in the implant to place a substantial graft. On the other hand, the fact of closing the lateral walls may make it possible to better contain the graft, which should generally favor a predominantly vertical arthrodesis, but since the visualization of bone growth is often desired, it may be preferred, for example for monitoring the patient, to choose a lateral wall preserving a good visibility of the interior of the implant, but sometimes also able to contain the graft or sometimes a partially open and closed structure. Figure 1 B also illustrates an example of mesh providing a particularly advantageous visibility in a side view of the implant. This visibility is achieved by the fact that the spaces between successive meshes in a given direction are aligned with each other, to provide increased visibility or visibility unobstructed from one side to the other. Moreover, the modularity of the implant also makes it possible to choose which are the faces by which the graft will be loaded into the implant and to choose the desired compression exerted on the graft to improve its contact with the bone of the implant. patient. For example, it is sometimes advantageous to provide implants intended for loading the graft by the upper or lower surface, because this method seems to improve the contact between the graft and the vertebrae by providing a good compression of the one on the other.

It is understood that various embodiments further respond to the problem of stability by bone anchoring, generally through at least one passage (21) in the implant (in its body or in its anchoring insert). The passage (21), which is provided directly in the body (20) of the implant or in the fixing insert, is generally configured to accommodate at least one anchoring device (1), preferably rigid and curve (For example in the form of a plate) so as to allow the passage of this anchoring device (1), preferably without deformation despite its curvature. This passage (21) passes through the implant (2) from the periphery to an upper or lower surface, preferably in a rectilinear path (or generally consisting of at least two rectilinear portions coplanar but forming an angle between them) and oblique adapted at the curvature of the anchoring device (1), so as to orient the anchoring device (1) towards the bone in which the anchoring device (1) is to be fixed. In addition, as mentioned above, the anchor is preferably elongate along a longitudinal axis which extends between a first end, here referred to as "anterior end", intended to penetrate a bone (a vertebra in general) and a second end, referred to here as "posterior end" generally intended to remain in the implant to retain it, hold it in place, which remains true in general for an anchorage via a passage which is directly in one of the walls of the body of the implant itself or an insert added to the body. In certain embodiments, the implant (2) comprises at least one stop (212, Fig. 1A) comprising at least one abutment surface, for example inside or just at the entrance of the passage (21) and oriented towards the outside of the implant (2) and intended to cooperate with at least one stop (12) of the anchoring device (1) so that this stop (12) stops the movement of the device ( 1) anchoring in the implant when it is sufficiently anchored in a vertebra through the passage (21), for example as shown in Figures 2B or 14A, 14B, 14D or 14E and as known from the prior art , including previous applications by the plaintiff of this application. This mechanism possibly allows retaining the implant (2) against the bone, in particular the vertebra. On the other hand, in some embodiments, the anchoring device (1) comprises at least one stop (13, 1 12) retaining (or abutment) preventing it from backing (or limiting the risks that it does not go back) inside the passage (21) once anchored in the vertebra through the implant. This stop may be formed for example by a tab or a flexible lock (13) of the anchoring device (4) or of the implant (2) which is pushed during the sliding of the anchoring device (1) in the passage (21) to abut against a complementary surface (29), respectively of the implant (2) or the device anchor

(I). Thus, in a complementary manner, the vertebral implant (2) may comprise, for example on the upper surface and / or the lower surface of the body

(20), at least one abutment surface (29, 29A) for retaining the body (10) of the anchoring device (1). Similarly, the vertebral implant (2) may comprise at least one abutment surface (29B) so as to retain a graft insert (3,3A, 3B, 4,5A, 5B, 6A, 6B, 6C, 6D, 8 , 202, 250) of the implant body (2), for example on the upper and / or lower surface of the body (20), for example at or near the front end. Preferably, this abutment surface is close to the rear part of the body (20), at the exit or near the exit of the passage (21) towards the upper surface and / or the lower surface. This stop may be formed by lateral tabs, for example as shown in FIG. 14A, or by a central tongue, for example as in FIG. 14B, but other variants are possible. In particular, anchors locked by a latch housed in the implant are known and it is possible to provide the same mechanism in an insert of the type described here. On the other hand, this type of abutment can take the form of at least one abutment surface (21 1) outside the passage (21) and cooperating with a notch (1 12) of a rib

(II) (or a second plate) of the anchoring device (1). In some embodiments, the body (20) has two passages (21) each directed towards one of the upper and lower surfaces of the implant (2), so as to allow the anchoring of a device (1) of anchoring in each of the vertebrae between which the implant (2) is intended to be implanted. In some embodiments, the fastening insert (210) comprises at least one abutment surface (2101) separating two passages (21) and on which the rear portion (12) of the anchoring device (1) is supported. , said stop (2101) for maintaining stable the device (1) implanted in the vertebra through the passage (21), for example as shown in Figures 10A, 1 1A, 12A or 14A. In some embodiments, this insert vertebral fixation device (210) comprises at least one access, for example a recess (2102), separating two abutment surfaces (2101). In some embodiments, the rear end of the backing (202) also includes an access, for example a protrusion, or a recess or a recess (2071) intended to face the recess (2102) of the recess. fixation insert (210) when the latter is attached to the implant (2). This type of recess or housing actually provides access to the anchor, including the stops, to be able to shoot and remove if necessary. In some embodiments, the attachment insert (210) includes a passage (21) consisting of at least one stop (2104A, 2104B) for holding the anchor (1) implanted in the vertebrae through to through the passage (21), for example as shown in Figs. 20A-20F.

It will be understood that anchors of various types may involve various embodiments of the implant intended to receive them either directly or via an anchoring insert, as shown, for example, by the diversity of the embodiments illustrated in FIGS. 14A, 14B, 14C, 14D and 14E which are of course not limiting and demonstrate just how any type of bone anchoring is made possible by various embodiments presented here. Indeed, these figures show five different embodiments of which various characteristics are combinable with each other. As explained above, this diversity makes it possible to provide the surgeons with an infinite choice at a lower cost, for example for a minimally invasive or very deep anchoring or else a compressive anchoring, etc. Thus, for example, FIG. 14A shows two plate-shaped anchoring devices provided with lateral withdrawal stops, two plate-shaped anchoring devices provided with a central withdrawal stop, no anchoring device, no two L-section anchoring devices and two slotted-point screw anchors.

In some embodiments, the body of the implant has at least one opening adapted to receive at least one insert. In some of these embodiments, the shapes and dimensions of said opening in at least one of said walls of the implant (2) are complementary to the shapes and dimensions of the graft insert (3, 3A, 3B, 4, 5A, 5B, 6A, 6B, 6C, 6D, 8, 202, 250) and / or the bone anchoring insert (210). In addition, a coupling secures the implant to this (or these) insert (s). In addition, if the implant is intended to receive these two types of inserts, they are preferably provided for themselves also complementary to each other, or a coupling allows them to be joined together.

In some embodiments, the posterior portion of the body (20) of the implant (2) comprises an opening (20P) adapted to receive said bone anchoring insert (210). In some embodiments, said opening (20P) extends from the upper surface to the lower surface of the body (20) and provides a gap between two opposing surfaces (20S) in the walls of the rear portion of the body (20). . The figures of the boards 10, 1 1, 12, 13, 14, 15, 16, 17 and 18 show examples of such an arrangement, which has the advantage of providing an anchoring insert of a substantial size relative to to the implant and able to receive a satisfactory anchorage. In some embodiments, the reciprocal locking means (203, 2030, 204A, 2040A, 204B, 2040B, 220, 2120, 2050, 2070, 2080, 2090A, 2090B, 2155) of said bone anchoring insert (210) in the implant (2) are disposed within said opening (20P) and at the edges of said bone anchoring insert (210). Various embodiments are shown on these various boards to illustrate the many possibilities. Among these various embodiments, there may be mentioned in a nonlimiting manner a particular embodiment, in which the fixing insert (210) comprises at least one female locking means (2070) complementary to at least one locking means. male (207) of the reinforcement (202) of the implant (2). Said female locking means, for example a housing (2070), is delimited by at least one lip (2080) and adapted to receive the male locking means, such as a projection, for example towards the posterior end (207) , for example as represented in a nonlimiting manner in FIGS. 15A, 15B and 15C. Thus, the housing (2070) of the fixing insert (210) is able to be fixed in a stable manner on the posterior end (207) of the reinforcement (202) of the implant (2). Note that it is possible to reverse the locking configuration of the fixation insert on the implant, that is to say to provide a male locking means on the fixing insert which will be complementary to a female locking means on the implant reinforcement, thereby varying the fixing combinations of the fixation insert on the implant. In certain embodiments, the fastening insert (210) comprises at least one male locking means (for example a rib, a projection, a profile, a tongue, a stop, a stud, a tenon or their combinations; examples being valid, of course, for all the male elements described in the present application, in particular identified under the references: 2040A, 2040B, 2050, 2090A, 2090B, 2130B, 2130C, 2155), complementary to at least one female locking means of the implant (2) (for example a groove or a housing or an opening or any equivalent, these examples being of course also valid throughout the present application, including the elements identified under the references: 205, 209A, 209B , 230B, 230C, 255), for example as shown in a nonlimiting manner in FIGS. 1 1A to 1 1C, 12A to 12C, 13A, 13B, 16A, 16B, 16D, 18A, 18B and 20E. The male locking means is inserted, preferably easily, by translation, sliding and / or clipping, into the female locking means so as to stably fix the fixation insert on the implant (on the posterior end of the the implant). In order to strengthen and maintain the stability of fixation of the fixation insert on the implant, the fixation insert (210) may comprise a recess (2130A) for separating the male locking means (2130B, 2130C) and optionally providing support for at least one abutment surface (230A) of the implant (2), for example a posterior surface. Note that it is also possible to stabilize the fixation of the fixation insert on the implant, for example by arranging said male locking means (2040A, 2040B, 2050, 2090A, 2090B, 2130B, 2130C, 2155) on the implant or the reinforcement of the implant, for example so that said means of female lock (205, 209A, 209B, 230B, 230C, 255) is complementary to the fixing insert. This type of locking means prevents the fixation insert from dissociating itself from the implant and, preferably, also prevents the graft inserts (3, 3A, 3B, 4, 5A, 5B, 6A, 6B, 6C, 6C, 6D, 8, 202, 250) contained in the body of the implant (2) are disengaged.

In some embodiments, said bone anchoring insert (210) and said implant body (20) comprise reciprocal locking means (203, 2030, 204A, 2040A, 204B, 2040B, 220, 2120 , 2050, 2070, 2080, 2090A, 2090B, 2155) of said bone anchoring insert (210) in the implant (2). Indeed, various embodiments provide an assembly of the implant with the insert. The present application may therefore also relate to an implantation method or, more generally, a method for preparing the implants prior to implantation. Indeed, the supply of the various assemblable elements, whether embodied in a separate supply or in a kit, must be considered as being within the scope of the application and the method of assembly naturally follows from the functional considerations provided by the present application. . Various embodiments allow an assembly in situ, that is to say during implantation, in particular because the assembly of an insert with the implant is substantially in the plane of the anteroposterior axis as as defined in this application. The figures of the plate 15 and the plate 18 are good non-limiting examples, but the figures of the boards 16 or 19 and 20 show that various variants are possible. In some embodiments, the inserts and the implant are configured such that they are retained in the implant, for example by means of coupling using a "force" insertion such as clipping. Being able to assemble the components in this way could allow in situ assembly, ie insert the skeleton first into the patient, then load the graft (insert or not), then the insert. anchoring, then anchoring. In addition, locking means can be provided that the inserts do not separate from the implant after assembly, for example as shown in Figures 13D, 13E and 20A to 20F. Indeed, in some embodiments, provision can be made for at least one locking means, for example such as a part or a screw (7) fixed on the fixing insert (2010) and the implant (2). through at least one locking means, for example a housing (206, 2067), so as to immobilize the vertebral implant and the insert implanted between the vertebrae. In other embodiments, the locking means, for example such as a screw (2152), is attached to the fixation insert (210) and / or the reinforcement (202) and / or the implant ( 2), for example through a housing (52A, 52B), so as to lock and / or immobilize the attachment insert and implant inserted between adjacent vertebrae. Thus, an assembly before implantation is provided so that the risk of dislocation is limited and that the implant is made reliable, for example as shown in the figures of plate 17. When the direction in which one carries out the implantation is parallel even identical to that preferred for assembly, this assembly can easily be made in situ. On the other hand, when it is parallel but in the opposite direction, for example as in the figures of plate 19, an assembly in situ remains possible but less easy, while the locking is then facilitated. Thus, the coupling of the insert with the implant can be realized so that they provide a lock when the implant will be implanted, since the coupling and the assembly must be performed in a sequence that is not reproducible. implanted implant, as for example the translation sequences, or even pivoting and translation involved by the embodiments of the figures of the boards 10, 1 1, 12, 13 or the pivotal closures of articulated portions of the body around the at least one axis of articulation, particularly as illustrated in a nonlimiting manner in the figures of the boards 21 and 22.

In some embodiments, the graft insert (3, 3A, 3B, 4, 5B, 6A, 6B, 6C, 6D, 8, 202, 250) has at least one solid or meshed backing (202, 250). Such a reinforcement may for example comprise at least one bar extending from one wall to another of the implant, for example from one peripheral wall to another, in order to strengthen the structure of the implant. The figures show examples of such a reinforcement disposed in the horizontal plane of the implant, but various orientations are possible depending on the type of implant and the type of reinforcement that is desired. In some embodiments, it is the implant itself that has this reinforcement formed directly inside the body of the implant, but it is advantageous to provide that it can also be modulated as part of the implant. graft insert or as an independent structure. In addition, it will be noted that this element is designated by the term reinforcement with reference to its support function to reinforce the structure, but that this reinforcement also makes it possible to strengthen the graft and / or the graft insert because it provides a restraint on which they can rely, or even fix, and which therefore strengthens their structure and stability in the implant. Thus, according to various embodiments, the reinforcement will be an attachment reinforcement inserts or a retaining reinforcement in the implant or both. In some embodiments, the upper and lower surfaces of the reinforcement (202) are located, respectively, lower and higher than the respectively upper and lower surfaces of the implant (2). This shape allows for example the implant (2) to marry any shape irregularities of the vertebral trays. In addition, in some cases, this shape allows the reinforcement, which is therefore set back relative to the upper and / or lower surfaces, not to be in contact with the vertebral plates to prevent it from sinking into the cancellous bone in the center of the vertebral plateau and that only the walls of the implant support the loads by their contact with the stronger cortical bone. In some embodiments, the backing (202) includes meshes (2020) for rapid bone fusion. In addition, notches (2023) may be provided on at least one of the upper and lower surfaces of the reinforcement, in particular to make it possible to reinforce the stability of the implant between the vertebrae (thus to avoid its displacement), in particular before the bone fusion. In some embodiments, the backing (202) includes at least one abutment surface (208) on which at least partially rests the fixing insert (210), for example at the front end of this fixing insert (210). Said abutment makes it possible in particular to maintain the reinforcement in the cavity of the implant fixed between the vertebrae. In some embodiments, the reinforcement (202) comprises a portion (2021) chamfered and / or beveled on at least one peripheral portion, for example at least one of its upper and / or lower surfaces, so as to facilitate the insertion of the implant (2) between the vertebrae, for example as illustrated in Figures 19A and 19B. In certain embodiments, the graft insert and / or the anchoring insert is configured to be complementary to at least one of the other elements of the implant, that is to say that it cooperates with one another with another insert (whether of the same type or different, in terms of anchoring or fixation), either with the implant or with the reinforcement of the implant. In addition, in some cases, this cooperation allows these elements to cooperate by possibly providing synergy in at least one function. Thus, in some embodiments, the meshed modular element (3, 3A, 3B, 6C, 6D) comprises at least one housing (35A) configured to receive at least one solid modular element (4, 5A, 5B, 6A, 6B) within the cavity (23). For example, FIGS. 5A and 5D or 8B show examples of inserts complementary to one another, in particular with an insert inserted inside another for a support or other functions relating to the problems targeted. In other configurations representative of this type of cooperation, the modular mesh element (3) may comprise at least one housing (35B) adapted to receive and / or marry the shape of at least one reinforcement (202). For example, FIGS. 9A and 10C show a cooperation between at least one insert and at least one reinforcement. Finally, as already mentioned to illustrate further examples of coupling and / or interlocking between insert and implant, FIGS. 7A, 7B, 9A and 19B show a cooperation between at least one insert and the implant that accommodates them. Various Coupling means and / or cooperation thus stabilize the assembly provided by various embodiments.

In some embodiments, at least one of the upper and lower surfaces of the body (20) has notches (24), for example as shown in most of the figures, to prevent movement of the implant (2) between the vertebrae between which it is intended to be implanted before the bone fusion is sufficient. In addition, in various embodiments, the body (20) has at least one portion (22) beveled and / or chamfered on at least one peripheral portion of at least one of its upper and lower surfaces, so as to facilitate insertion of the implant (2) between the vertebrae, for example as illustrated in most of the figures, especially Figures 1C, 3C, 6A etc. On the other hand, in certain embodiments, the posterior portion of the body (20) comprises at least one attachment means intended to cooperate with a gripping end of an implantation instrumentation of the implant (2). The attachment means may comprise for example an oblique opening (200), for example as shown in Figures 1A and 2A, for gripping and / or holding (preferably fixed) of the implant during the surgical procedure. Preferably, two means (26,27) are provided, one of the two attachment means preferably comprising a means of attachment and / or maintenance in a direction not parallel to the axis of insertion of the implant, for example such as an oblique opening, which in particular makes it easier to manipulate in rotation. In addition, at least one of these means may have a non-parallel path to the implantation axis, so as to facilitate this type of manipulation and limit the risk of slamming by movement parallel to the axis of implantation without requiring screwing the implant on the instrument that carries it via these attachment means. In addition, stabilizing means (28) may be provided, generally laterally, preferably on the edges of the implant. Finally, in some embodiments, for example as shown in Figs. 20C-20F, the implant (2) includes ports (241, 242B), Examples such as openings or holes, so as to inject graft or bone substitute, for example if deemed necessary by the surgeon, in particular to improve arthrodesis in the patient.

In certain embodiments, for example as shown in FIGS. 21A to 21D and 22A to 22E, the vertebral implant (2) comprises at least one actuating means (A2), for example such as an axis of pivoting. Such a means notably allows access to an opening of the implant for inserting the graft inserts (3, 3A, 3B, 4, 5A, 5B, 6A, 6B, 6C, 6D, 8, 202, 250), preferably easily and quickly, in the cavity (23) of the implant (2) and / or allows the assembly of the inserts and the implant, so as to allow closure of the implant then forming a stable structure between the vertebrae. Note that the actuation, for example via the pivot axis (A2), can be vertical, for example as shown in Figure 21 B, or horizontal, for example as shown in Figure 22B. This actuation or pivot axis makes it possible to assemble, in a fast and reliable way, the implant and the graft inserts intended to be implanted in the vertebrae. These configuration modes make it possible to propose a kit that is pre-assembled and ready for surgical implantation, to save the surgeon time during the surgical operation.

The present application describes various technical features and advantages with reference to the figures and / or various embodiments. Those skilled in the art will appreciate that the technical features of a given embodiment may in fact be combined with features of another embodiment unless the reverse is explicitly mentioned or it is evident that these characteristics are incompatible or that the combination does not provide a solution to at least one of the technical problems mentioned in this application. In addition, the technical features described in one embodiment given may be isolated from other features of this mode unless the reverse is explicitly mentioned.

It should be obvious to those skilled in the art that the present invention allows embodiments in many other specific forms without departing from the scope of the invention as claimed. Therefore, the present embodiments should be considered by way of illustration, but may be modified within the scope defined by the scope of the appended claims, and the invention should not be limited to the details given above.

Claims

1. A modular vertebral arthrodesis system, comprising at least one vertebral implant (2) and a plurality of integrable inserts in said implant, said vertebral implant (2) being intended to be implanted in a vertebral segment composed of at least two vertebrae and comprising, on the one hand, at least one body (20) whose walls delimit a cavity (23) opening on the outside of the body (20) by at least one opening in at least one of said walls, and, on the other hand, at least one passage (21) passing through the implant (2) from the periphery to an upper or lower surface for receiving a bone anchoring device (1) adapted to anchor said implant (2) in at least one of said vertebrae , said system being characterized in that said plurality of inserts comprises at least two inserts selected from the following inserts:

· At least one graft insert (3, 3A, 3B, 4, 5A, 5B, 6A, 6B, 6C,

6D, 202, 250) capable of being colonized with bone tissue and / or receiving at least one bone tissue graft and / or at least one substitute;

and or

2. System according to claim 1, characterized in that the shapes and dimensions of said opening in at least one of said walls of the implant (2) are complementary, at least in one plane, shapes and dimensions of the insert of graft (3, 3A, 3B, 4, 5A, 5B, 6A, 6B, 6C, 6D, 202, 250) and / or the bone anchoring insert (210), so that insertion of the latter (or these) within the body (20) of the implant (2) is (or are) made / made through said opening.

3. System according to one of claims 1 and 2, characterized in that the shapes and dimensions of said opening in at least one of said implant walls (2) are complementary to the shapes and dimensions of the graft insert (3, 3A, 3B, 4, 5A, 5B, 6A, 6B, 6C, 6D, 202, 250) and / or the bone anchoring insert (210), which are themselves complementary to each other. 4. System according to one of the preceding claims, characterized in that it comprises at least one graft insert (3, 3A, 3B,

4, 5A, 5B, 6A, 6B, 6C, 6D, 202, 250), but said passage (21) is formed directly in at least one of said walls of the body (20) without the need for a bone anchoring insert (210). ).

5. System according to claim 1, characterized in that it comprises at least one bone anchoring insert (210), but said cavity (23) is configured to directly receive a bone tissue graft or a substitute, without insert of graft (3, 3A, 3B, 4, 5B, 6A, 6B, 6C, 6D, 202, 250).

6. System according to one of the preceding claims, characterized in that the graft insert (3, 3A, 3B, 4, 5B, 6A, 6B, 6C, 6D, 202, 250) comprises at least one of the following elements:

a modular mesh element (3, 3A, 3B, 6C, 6D);

a solid modular element (4, 5A, 5B, 6A);

a loading element, called cassette (6A), able to receive at least one such modular element (3, 3A, 3B, 6C, 6D) or full (4, 5A, 5B, 6A) or directly a graft or substitute.

7. System according to one of the preceding claims, characterized in that the graft insert (3, 3A, 3B, 4, 5B, 6A, 6B, 6C, 6D, 202, 250) comprises at least one solid reinforcement or mesh (202, 250).

8. System according to one of claims 1 to 5, characterized in that said bone anchoring insert (210) and said body (20) of the implant (2) comprise reciprocal means of locking (203, 2030 , 204A, 2040A, 204B, 2040B, 220, 2120) of said bone anchoring insert (210) in the implant (2).

9. System according to one of claims 1 to 6, characterized in that the rear part of the body (20) of the implant (2) comprises an opening (20P) adapted to receive said bone anchoring insert (210)

10. System according to claim 7, characterized in that said opening (20P) extends from the upper surface to the lower surface of the body (20) and provides a space between two opposite surfaces (20S) in the walls of the part. posterior of the body (20).

1 1. System according to one of Claims 6 to 8, characterized in that the reciprocal locking means (203, 2030, 204A, 2040A, 204B, 2040B, 220, 2120) of said bone anchoring insert (210) in the implant (2) are disposed within said opening (20P) and at the edges of said bone anchoring insert (210).

12. System according to one of the preceding claims, characterized in that the rear part of the body (20) comprises at least one attachment means for cooperating with a gripping end of an implantation instrumentation of the implant (2). ).

13. System according to one of claims 6 to 12, characterized in that the modular mesh element (3, 3A, 3B, 6C, 6D) comprises at least one housing (35A) configured to receive at least one graft or substitute bone and / or at least one solid modular element (4, 5A, 5B, 6A) within the cavity (23).

14. System according to one of claims 6 to 13, characterized in that the meshed modular element (3, 3A, 3B, 6C, 6D) comprises a three-dimensional network comprising interconnected adjacent planes, each plane being formed of meshes ( 30).

15. System according to claim 14, characterized in that the three-dimensional network of the meshed modular element (3, 3A, 3B, 6C, 6D) is obtained by a three-dimensional printing technique or additive manufacturing.

16. System according to one of claims 1 to 15, characterized in that the fixing insert (210) comprises at least one abutment surface (2101) separating two passages (21) and on which the rear part (12) of the anchoring device (1) rests, said abutment (2101) making it possible to keep the device (1) implanted in the vertebra stable through the passage ( 21).

17. System according to claim 16, characterized in that it comprises at least one hollow (2102) separating two abutment surfaces.

(2101).

18. System according to one of claims 7 to 17, characterized in that the upper and lower surfaces of the reinforcement (202) are located, respectively, lower and higher than the surfaces, respectively, upper and lower of the implant. (2), thus allowing the implant (2) to marry any shape irregularities of the vertebral endplates.

19. System according to one of claims 6 to 18, characterized in that the modular mesh element (3) comprises at least one housing (35B) adapted to receive and / or marry the shape of at least one reinforcement (202). ).

20. System according to one of claims 1 to 19, characterized in that said graft insert (3, 3A, 3B, 4, 5A, 5B, 6A, 6B, 6C, 6D, 202, 250) forms a lid not not filling said cavity of the implant and thus leaving free a portion of said cavity, for example to receive bone graft or substitute.

21. Graft insert, characterized in that it comprises complementary shapes and dimensions of at least one opening of an implant in which said insert is configured to be inserted into an implant to form a system according to one of claims 2 to 20.

22. A bone anchoring insert, characterized in that it comprises complementary shapes and dimensions of at least one opening of an implant in which said insert is configured to be inserted into an implant to form a system according to one of Claims 2 to 20.