JP2001520911A - Methods and devices for repairing endochondral and osteochondral defects - Google Patents

Abstract

(57) [Summary] Intrachondral or osteochondral defects, particularly articular cartilage defects, have a tissue column having a cylindrical hole (21) at the defect site and a living cartilage layer (2 ') on the front surface. The tissue column (2) is repaired by implanting (2), and the tissue column (2) is extracted, for example, from a joint part with less distortion. The success rate of this type of repair is increased by increasing the accuracy. For this purpose, a guiding device for accurately guiding the cutting or drilling device is used to form the hole (21). The guide device can be positioned and fixed within the defect site. As a result, high accuracy can be achieved with respect to the parallel relationship and positioning of the holes (21). Also, by determining the original cartilage surface and adapting the length of the axis of the tissue column (2) to be implanted and the angle between the cartilage surface and the column axis to the original surface, the original cartilage surface can be reconstructed. Can be accurately reconstructed. The gaps between the implanted tissue columns (2), as well as the edges of the defects in the reconstructed cartilage surface, are filled with another implant obtained from the cartilage layer (50) cultured in vitro. can do.

Description

DETAILED DESCRIPTION OF THE INVENTION

The present invention belongs to the field of medical technology and relates to a method and a device according to the preamble of the claims. The method and device comprises endochondral and osteochondral defects,
In particular, it serves to repair defects associated with articular cartilage or the articular cartilage and underlying bone tissue.

[0002] Defects in articular cartilage, or defects that affect articular cartilage and the underlying bone tissue, can be filled, according to the prior art, with artificial materials containing biological cells, if necessary, or cultured in vitro. It is repaired by transplanting the chondrocytes thus obtained or by removing the chondrocytes from an intact, preferably unstressed site and transplanting it as an autograft at the defect site. In particular, most autografts are columns whose outer end is cartilage and whose inner end is bone. For larger defects, multiple such pillars are usually implanted adjacent to each other in a mosaic-like fashion.

In order to implant a tissue column, a tissue tube is removed by punching out or boring, and then the bottom is cut off by rotation, or a chip forming drilling machine is used to make the defect site as accurate as possible. A tubular opening is formed. Next, a tissue column having a diameter slightly larger than the inner diameter of the opening formed at the defect site is excised at a stress-free joint site (eg, a femoral condyle site). The tissue column to be resected is bored out using a hollow punch and cut off at the bottom by rotation. Next, the resected tissue column is inserted into the opening of the formed defect by so-called “press-fitting”. This press-fit is possible due to the different diameters, fixing the tissue column to the opening. The opening created by the resection of the column is usually filled with material from the defect when the material is in good health, or by inserting artificial or in vitro cultured material. Closed.

[0004] An annular cut at one end is also usually used where appropriate for separating or resecting the tissue column to be implanted and for pushing or resectioning tissue from the opening at the defect site. A tubular instrument with a blade and with means for holding and guiding at the other end is used. To monitor the length and quality of extruded tissue columns, it is beneficial for such instruments to have corresponding windows. The extruded material is extruded from the tubular device with the help of a tappet adapted to the inside diameter of the device. This type of instrument set is available, for example, from Smith & Nephew. Inc., USA or Arthrex In
c., USA, available on the market. In order to provide an opening at a defect site by drilling, a flat drilling machine can be used.

[0005] The success of the above-described method of repairing articular cartilage defects by implantation of living tissue depends largely on the accuracy of the insertion of the repair tissue and the accuracy of the procedures the tissue undergoes during resection and implantation. I know that

Accordingly, the present invention provides a known method for repairing cartilage defects or defects associated with cartilage and its underlying tissue, in particular, articular cartilage defects, through implantation or transplantation of columnar shaped biological tissue. The aim is to improve the instrument set in terms of increasing the probability of success. The method and apparatus according to the invention comprise:
It makes it possible to increase the accuracy of the repair, while at the same time allowing the tissue to be manipulated to be handled very carefully. The device according to the invention is considered to be simple to manufacture and in particular easy to operate. Although the method and apparatus according to the present invention are believed to be particularly suitable for repairing larger defects using the mosaic method, it will be appreciated that small defects such as those repaired using only one implant may be used. Is at least partially applicable.

[0007] This object is met by a method and an instrument as characterized in the independent claims. The dependent claims characterize further embodiments.

It has been found that resolving the above general objectives requires improvement efforts in four partial aspects, one of which has the greatest effect, Other aspects may be omitted, as they have only a small effect or do not have a noticeable effect depending on the application. The four major improvements are:

In the implantation of a plurality of tissue columns, the positioning of the cylindrical opening formed at the defect site and the accuracy of the parallel relationship are improved. This is achieved by providing the openings with corresponding gauges. This method generally prevents tissue columns implanted in the opening from pressing against each other and being exposed to additional stress, while ensuring that each implant column is at least anchored in healthy tissue. Wound healing is improved as much as possible by the native tissue at the site.

[0010] The original topography, which is a cartilage surface without health or defects, is copied with high precision onto the cartilage surface of the repaired defect. to this end,
The axial length of the tissue column to be implanted and the orientation of the cartilage surface with respect to the column axis as far as possible are intentionally applied towards the cartilage surface to be imaged. This method is particularly important for relatively large defects that must be repaired with multiple implant columns. The better the original cartilage surface is imaged, the more uniform the stress on the surfaces of the individual implants when using the repaired joint, and the greater the overall load will be across the individual implants. More evenly distributed. This prevents undesired deformation or damage to the implant and the native cartilage surrounding the lesion to be repaired as a result of the repair.

The cartilage surface of the repaired defect is shaped more tightly or joined more tightly to the original cartilage. This cartilage surface without gaps, by combining the implanted or implanted tissue columns with cartilage tissue cultured in vitro, the gap between the transplanted tissue columns, and in some cases, the tissue columns and the original cartilage This is achieved by filling the gaps between The solid cartilage surface promotes simultaneous growth of the implant and native cartilage and prevents damage caused by synovial fluid penetrating through the gaps in the cartilage layer to the underlying bone tissue. This method is also important for larger defects that must be repaired with multiple implant columns, but for smaller defects, the first described "press fit" is sufficient.

The material to be implanted is removed in such a way that the tissue column implants and possibly also the in vitro-cultured implant parts are not subjected to uncontrollable deformation, thereby increasing the accuracy of the repair. Handle carefully with as little pressure as possible during and during implantation.

In all cases, the implanted tissue columns are advantageously autografts excised at unstressed sites, but have been pre-cultured in vitro with cartilage tissue on bone substitute material. It may be made up of those that have been used. Such columns to be implanted are advantageously produced from correspondingly prepared parts by stamping or drilling (hollow drilling machines) during the repair operation, respectively.

The method and apparatus according to the present invention are suitable for both repair surgery performed as open surgery and for arthroscopy. With reference to the following drawings, exemplary embodiments of an improved method and instrument set for repairing endochondral or osteochondral defects, particularly within joints, are described in more detail.

FIG. 1 shows a cartilage defect repaired according to the known mosaic method as shown in a plan view (left) and a sectional view (right). In plan view, the surface of the original cartilage layer 1 can be seen, together with the rounded surface of the cartilage layer 2 'of the tissue column 2 implanted for repair. In the sectional view, the original bone tissue 3 below the original cartilage layer 1 and
A tissue column 2 implanted in the corresponding tubular opening can be seen, the tissue column 2 comprising a cartilage layer 2
Underneath it is an inner bone part 2 "which, in the case of implanted columns, consists of bone tissue and in the case of columns cultured in vitro, of bone substitute material.

In order to minimize the gaps created in the repaired cartilage surface or to minimize the area of defective cartilage material, it is usually the goal to place the columns as close as possible. For this reason, it is important that the openings for the columns 2 to be implanted extend parallel as far as possible. When the precision of the parallel relationship is high, the openings can be provided very close without overlapping each other. Overlapping openings can make implantation difficult and add additional stress to the implanted column. As will also be explained with reference to FIGS. 9 and 10, when filling the intermediate space between the columns 2 with another implant, not only the high accuracy of the parallelism of the openings to be formed, but also the positioning of the openings High accuracy is also required.

FIG. 2 shows an exemplary embodiment of a guiding device, with the aid of which a plurality of guides can be produced with significantly higher precision compared to the previous visual assessment of the surgeon. Can be provided in the cartilage defect site.
The exemplary embodiment of the illustrated guiding device is suitable for achieving a restoration as shown in FIG. The guiding device comprises a substantially hollow cylindrical ring guide 10 and at least two tubular punching or drilling guides 11 and 12, all of which are shown in plan view (repaired defect on the left in FIG. 1). (Similar to the plan view of
Is shown in

The ring guide 10 is arranged so as to surround the defect and is fixed with the help of, for example, Kirschner steel wire, which is guided in a specially provided hole 13 or by other suitable fixing means. Is done. In this, a ring guide is selected from the set of ring guides, the ring guide having an inner surface of a shape and size adapted as closely as possible to the defect to be repaired. The punching or drilling guides 11 and 12 have an inner diameter that matches the punching or drilling tool used and have on their outside, for example, at least one axial direction for accurate positioning in the ring guide 10. The comb portion 14 is fitted in a corresponding groove 15 extending in the axial direction on the inner surface of the ring guide 10, and the length of the comb or the comb portion 14 in the radial direction is equal to that of the inner surface of the ring guide 10. It corresponds to the distance between the openings to be formed. In FIG. 2, the punch or piercing guide 10 is intended to form the central opening of the restoration shown in FIG. 1, and the punch or piercing guide 12 is intended to form the peripheral opening. ing.

Each of the guides 11 and 12 has two comb portions 14.
Are arranged in the grooves 15 of the ring guide 10 facing each other. If the grooves and combs are provided correspondingly, only one comb may be provided for each punching or drilling guide.

The guide device shown in FIG. 2 is provided for a substantially annular defect.
Similarly, a guide device for differently shaped defects can be provided. The ring guide 10 of the guide device according to FIG. 2 is fixed around the defect to be repaired, for example by Kirschner wire. In order to avoid applying additional stress to the defect site when fixing the ring guide 10, the ring guide 10 is separated from the defect site of the bone where the defect to be repaired is located, for example, by three-point fixing means. Can also be fixed at the fixed position. This type of fixation is known by joint prosthetic surgery. These fixations can be used for both open surgery and arthroscopy.

[0021] To minimize the obstruction of the surgeon's line of sight during the formation of the opening, it is advantageous for at least the ring guide 10 to be made of a transparent material or to have a corresponding window.

The guide device shown in FIG. 2 represents an exemplary embodiment of such a device.
Generally, such a guide device has means for positioning the defect to be repaired and means for guiding the punching or drilling device to a plurality of positions.

An instrument set according to the present invention for repairing a cartilage defect may be envisaged for a joint to be treated and possibly a punch, in addition to a punch or drill guide to form an opening for implanting a tissue column. Different sets of guide instruments adapted to different defects. The surgeon performing the repair selects an appropriate guide instrument from the set and places and secures the ring guide 10 over the defect. The punching or drilling guide 11 or 12 is then inserted into the ring guide 10 and used to guide the punching or drilling tool used to form the corresponding opening. The punch or piercing guide is removed or repositioned to form a further opening.

FIG. 3 shows a cross section of a cartilage defect 20 at a joint where a strong arc is drawn. Defects having such dimensions are not uncommon in knee and hip joints. The defect 20 and 3 formed in the defect site using, for example, a guide device according to FIG.
The two openings 21 are shown by solid lines. The original cartilage surface 22, which is to be reproduced as faithfully as possible by the repair, is indicated by a dashed line. FIG. 3 clearly shows that an estimate of the depth of the opening formed in the defect is inaccurate in determining the axial length of the tissue column required for repair. ing.

To increase the accuracy of the estimation, it has been proposed to estimate the original cartilage surface 22 with the help of a shape gauge 23. In this case, the gauge 23 that best fits the defective cartilage site is selected by placing various such gauges from a corresponding set of gauges before forming the opening.

The gauge 23 of the gauge set is, for example, a simple one-dimensional roundness gauge, and is used to estimate the original cartilage surface 22 as a spherical surface. However, one- or two-dimensional gauges 23 adapted to the normal size and shape of a particular joint site
Are also considered.

FIG. 4 shows an exemplary embodiment of an instrument for determining the axial length of a tissue column for implantation in an opening 21 formed in a defect 20 according to FIG.
The style of the drawing is similar to that of FIG. 3, in which the axial section of the instrument for determining the length of the column is depicted. The instrument is substantially constituted by the ring guide 10, the surface template 24 and the measuring rod 25.

If the opening is formed with the aid of a guiding device according to FIG. 2, the ring guide 10 of this device advantageously serves as a ring guide for length measurements. A surface template 24 is disposed thereon. This surface template 24 is selected from a set of templates 24 of various shapes, corresponding to the gauge 23 selected before the formation of the opening for reproducing the original cartilage surface 22 into its shape (curvature). And has a pattern of the measurement opening 26 corresponding to the pattern of the opening 21 formed. The measurement opening 26 of the surface template 24 is oriented toward the pattern of the opening 21 by, for example, a positioning cam 27 fitted in the groove 14 of the ring guide 10.

It is also conceivable that the measurement template 24 is used directly as the shape gauge 23.
In this case, it is advantageous that the measurement template 24 is made of a transparent material. The measuring rod 25 comprises a measuring opening 26 as well as the original cartilage surface 22 and the measuring template 2.
4 has the same diameter as the measuring gauge 28 taking into account the distance between the two. The required length of the tissue column to be created for the repair can be read directly from the measuring scale 28, for example, to within one-half millimeter.

Each of the shape gauges 23 of the gauge set is easily converted into the measurement template 2 of the determined template set.
For the purpose of associating with 4, these are marked in association, which is realized, for example, using color codes. The measuring template 24 extends parallel to the original cartilage surface 22 and the distance between the surface and the measuring template substantially corresponds to the axial height of the ring guide 10, so that only one measuring rod 25 can It can respond to measurement. In order to be able to easily ensure a beveled opening between the opening axis and the original cartilage surface 22 (peripheral opening of the defect according to FIG. 3), and always with the same opening depth The measurement rod 25 and the measurement opening 26 can be provided with axially extending grooves and combs (not shown in FIG. 4) through which the measurement rod 25 can be measured. Can be guided into the measuring opening 26 only at defined rotational positions.

The device according to FIGS. 3 and 4 for determining the original topography of the defect site and for determining the length of the tissue column for repairing the defect is an exemplary embodiment. A common instrument of this type has a shape gauge for determining the topography and means adapted to the shape gauge for measuring the length of the column, so that the shape gauge itself is the length of the column. It can form part of the means for determining the weight.

A surgeon performing the repair of the defect shown in FIG. 3 performs the following steps. Determining the surface template 24 corresponding to the defect, possibly using the gauge 23; -Arrange and mount the ring guide 10; Forming openings 21 using guides 11 and 12 as the case may be;

Positioning of the surface template 24 to determine the axial length of the tissue column to be implanted; -Adjust the punching or piercing instrument to cut the tissue column to a predetermined axial length.

At the resection position, the column is resected and implanted in the opening. FIG. 5 is a view showing a defect similar to that of FIG. 3 in a joint portion where a strong arc is drawn. From FIG. 5 it can be seen that the angle α. Between the original cartilage surface and the axes of the openings 21.1, 21.2 and 21.3. 1, α. 2 and α. 3 shows that the original cartilage surface 22 can be reconstructed with high accuracy when the original cartilage surface 22 is reconstructed intentionally rather than as expected. Therefore, in order to increase the probability of successful transplantation, the angle α for different tissue columns to be transplanted is determined, and the tissue columns are correspondingly intentionally excised from other sites, or the tissue columns are cultured in vitro using cartilage. It is beneficial to push out from the.

Searching for an excision position for excision of a transplant tissue column having the same shape as the shape of the defect site,
It may be easiest to resect a tissue column in the same location as the opening created at the defect site. However, this is not only beneficial, but is not possible in practice. Available for resection is a particularly stress-free femoral condyle, which has a unique shape. Therefore, it is beneficial to perform the resection continuously, and to keep the interval between the resection positions as large as possible.

For this reason, to accurately reconstruct the original cartilage surface 22, the angle α
And the post must be cut at that angle at the cut position. FIG. 6 shows such an ablation position and the openings 21.1, 21.2 and 21.
3 shows the tissue columns 2.1, 2.2 and 2.3 to be resected, corresponding to 3 and the cartilage surface and the axis of the column for the openings 21.1, 1.2 and 21.3. Angle α between
Is the angle α. 1, α. 2 and α. Corresponds to 3.

For the resection of the tissue columns 2.1, 2.2 and 2.3 according to FIG. 6 and for implanting them into the openings 21.1, 21.2 and 21.3 according to FIG. By providing an instrument, and with the aid of this instrument, it is possible to resect a column at a given column axis and cartilage surface angle and at a given rotational position, and likewise implant the column at a given rotational position. can do.

FIG. 7 shows an exemplary embodiment of such a cutting device consisting essentially of an extractor guide 30 and an extractor 31. The extractor guide 30 is substantially tubular and has a support flange 32 at one end at an angle α to the tube axis. Although FIG. 7 shows an exemplary embodiment in which the angle α relative to the tube axis is strictly specified, it is clear that the instrument can also be designed such that the angle α is adjustable. The support flange 32 may have a hole (not shown) for fixation through which the support flange 32 may be securely nailed to tissue by Kirschner wire. For fixation of the extractor guide, an external three-point fixation as described earlier in connection with FIG. 2 can also be used.

The extractor guide 30 has an inner diameter adapted to the extractor 31 and a guide groove 33, which extends axially on its inner surface, for example at the highest or lowest point of the support flange 32. Extends to a corresponding inner circumference location. In the enlarged end region 34 of the extractor guide 30 that opens to the support flange 32, the inner diameter increases in the radial direction of the guide groove 33.

The extractor 31 is likewise tubular and has the same inner diameter as the diameter of the column to be cut. One end face is sharpened like a blade. The extractor 31 has, on its outer surface, a guide cam 35 for moving the guide groove 33 of the extractor guide 30 when guiding the extractor 31 to the extractor guide 30. When the pointed end of the vessel reaches a depth corresponding to the length of the column to be resected in the tissue, the guide cam 35 is placed in the enlarged end region 34 of the extractor guide. So that they are arranged in the axial direction. By providing a guide cam, the extractor 31 can be inserted into the extractor guide 30 only in a predetermined rotational position, while being rotatable in the extractor guide to cut off the pillar at the bottom.

During the separation by rotation, the column to be separated is the extractor 31.
In order to prevent rotation in the extractor 31, the extractor 31 has at least one detent 36 as close as possible to the pointed end of its inner surface.
6 protrudes into the internal cavity, extends in the axial direction and is advantageously blade-shaped. The radial length of such a detent does not need to be greater than one millimeter.

The extractor 31 guided by the extractor guide 30 can be used to push out the tissue column, as indicated by the line S, and to cut it off at the bottom by rotation. However, it is useful to pre-drill the pillars along line S before extracting them with a hollow drilling machine (not shown). This type of hollow drilling machine corresponds in shape to the extractor 31 and does not have the guide cam 35 and the rotation stopper 36. Advantageously, the sharpened edges are made from or coated with a diamond-containing material. Furthermore, the drilling machine has suitable means for determining the depth of the hole.

FIG. 7 further shows a tappet 37 for projecting the extracted tissue column from the extractor 31. Advantageously, the tappet has, as in the case of the support flange 32, a tip face that forms an angle α with the tappet axis. In order to be able to guide the tappet 37 to the extractor only in the rotational position corresponding to the flange position, the tappet 37 has a guide groove 38 extending in the axial direction, and the extractor 31 has a corresponding guide comb 39. However, the comb portion 39 does not reach the position of the tissue column arranged in the extractor. The distal end of tappet 37 is reduced in diameter so that it can be pushed past rotation stop 36 to the end of extractor 31.

FIG. 8 shows an implantation device for implanting a tissue column cut by the cutting device according to FIG. The device is depicted in plan view. The implantation guide 40 is designed similarly to the punching or drilling guides 11 and 12 of FIG. 2 and can be placed in the same ring guide 10 (indicated by the dashed circle). The inner diameter of the implantation guide 40 matches the outer diameter of the extractor 31. In order to be able to guide the extractor only in the predetermined rotational position into the implantation guide 40, the implantation guide 40 has a guide groove 41 extending in the axial direction on its inner surface, and the extractor is provided in the guide groove 41. 31 guide cams 35 can be arranged.

The angle α of the tissue columns to be implanted is uniquely determined by the preselected shape of the surface template 24 (FIG. 4) for each column. It is therefore sufficient for the surgeon to have access to a resection instrument having a different set of extractor guides 30, such sets of extractor guides 30 being correspondingly provided, for example, by means of a code. It can be associated with a measurement opening in the surface template, or a corresponding opening formed in the defect site. Possible codes include different numbers of lines for different pairs of measurement openings and extractor guides for the surface templates to be associated, these lines being different for different surface templates. It is like having different colors. The extractor guide 30 can also be labeled with the magnitude of the angle α and can be labeled with these dimensions next to the measurement openings on the surface template.

The device according to FIGS. 7 and 8 illustrates an exemplary embodiment. Generally, a cutting instrument for cutting a column at an angle between the cartilage surface and the column axis at a cutting position is a fixing device for guiding an extractor and possibly a hollow drilling machine at a predetermined angle. A possible means and an implantation tool are provided, wherein the resection tool and the implantation tool have correlated means for performing resection and implantation in a correlated rotational position.

To reconstruct the angle between the column axis and the original cartilage surface, the surgeon reads in the surface template 24 which extractor guide 30 to use to cut each tissue column. Become. The surgeon mounts the extractor guide 30 in the appropriate resection position, pre-drills the tissue column guided by the extractor guide 30 by internal and external cooling, pushes the extractor 31 into this pre-hole, and extracts at the bottom. The tissue column is separated by rotating the machine, the extractor 31 is rotated back to the original rotation position, and the extractor 31 having the tissue column is removed from the extractor guide 30. Next, the implantation guide 40 is inserted into the ring guide 10 still attached to the defect site, the extractor is pushed into the implantation guide 40 by the tissue column, and the tissue column is assisted by the tappet 37.
It is preformed by the surgeon and extruded into an opening below the implantation guide, for example, as described in connection with FIGS.

The axial length of the resected tissue column is essentially determined given the means by which the depth of the bone and the depth at which the extractor can be guided into the tissue are provided. You.
Nevertheless, it is instructive to check this length before implantation and correct it in a timely manner.
To this end, a window (see also FIGS. 13 and 17) is provided in the extractor 31 and the window is arranged such that the cartilage surface of the resected column is in the window section and the window section has a length. A scale can be provided to determine the distance between the sharp edge of the extractor and the cartilage surface of the tissue column with the help of this length scale. If the resected tissue column is too long, the tissue column is pushed slightly forward with the help of the tappet 37 and the part protruding from the extractor is cut off.

FIGS. 9 and 10 are plan and sectional views of a repaired cartilage defect having an implanted cartilage layer 50 cultured in vitro, in addition to the implanted tissue column 2. The cartilage layer 50 fills the gap between the tissue columns 2 and the gap between the tissue column 2 and the original cartilage layer 1. When the defect is deeper than the thickness of the cartilage layer 50, the implanted cartilage layer 50 is filled below with a suitable filling material 51.

The repair according to FIGS. 9 and 10 with the implanted cartilage layer 50 has the following main advantages compared to the repair according to FIG. 1 without such a cartilage layer: In other words, the gap between the implanted tissue columns 2 is completely closed by the cartilage layer 50, thereby preventing the synovial fluid from penetrating into the bone tissue. This allows the pillars to be implanted without any problem, even at some distance from each other, with the whole surface surrounded by the original bone tissue, resulting in a significant increase in the complete growth rate of the original tissue and the implanted tissue.

The repair according to FIGS. 9 and 10 using the implanted cartilage layer 5 and the implanted tissue columns only requires the in vitro cultured cartilage layer (possibly underfilled with a suitable material). The following advantages are obtained as compared with the restoration that is not used. That is, most of the stress is removed by the transplanted cartilage having sufficient mechanical strength, and the cartilage cultured in vitro immediately after the repair operation can mature under protection (low stress), A final mechanical strength equivalent to the original cartilage can be achieved.

The cartilage layer 50 is pre-cultured from autologous cells on a bone substitute material base or without such a base. In this case, the shape of the resulting cartilage is determined by the space made available to the cells during culture.

For transplantation, the cartilage layer 50 cultured in vitro must be punched out or cut as accurately as possible so as to have the same shape as the opening formed in the defect site to be repaired. Also, an opening for the tissue column must be formed therein, and the opening must have a somewhat smaller diameter than the tissue column for "press-fitting." In addition, the thickness of the cartilage layer to be cultured must also be determined in order to perform an accurate underfilling of the cartilage layer or the cutting of the corresponding defects.

In order to form an opening for the cartilage layer 50 to be implanted, for example, a ring guide 10 (FIG. 2) is attached to the defect site and the native cartilage tissue is cut along the implantation site with a corresponding annular perforation. Make a longitudinal incision using an instrument or a scalpel and make sure that the cartilage or bone surface inside the ring guide is deeper than the original cartilage surface at least everywhere by the thickness of the cartilage layer to be implanted. Remove or resect in the direction of the defect as it comes.

The repair using the six rotationally symmetrically arranged tissue columns 2 is shown in FIGS. 9 and 10.
Is shown in Other arrangements of columns using other numbers of tissue columns, especially when one tissue column is used, can also be implemented in a similar manner.

FIG. 11 illustrates an exemplary embodiment of a punching device for forming a desired implant from the cartilage layer 50 to perform a repair as shown in FIGS. 9 and 10.
The punching device is substantially constituted by the support surface 60 and the matrix 61. The shape (arc) of the support surface 60 corresponds to the shape of the cartilage surface 22 (FIGS. 3 and 4) to be reconstructed, or the basis for reconstructing the cartilage surface, such as the surface template 24 (FIG. 4). It is beneficial. The mold 61 has a shape corresponding to the support surface 60 and has a punching blade 62 corresponding to the contour of the implant to be formed and the opening for the tissue column to be formed, the punching blade comprising: , Having a width greater than the thickness of the cartilage layer to be extruded.

In order to perform the punching in more detail, it is advantageous to attach a very small width opposing blade (not shown) corresponding to the punching blade 62 of the mold 61 on the support surface 60.

The cultured cartilage layer 50 is placed on the support surface 60, and the matrix 61 is moved in parallel by suitable propulsion means until the punching blade 62 abuts on the support surface 60 or on the opposing blade. Move in the direction of 60 to completely separate the cartilage layer 50 at the given location.

FIG. 12 shows an exemplary embodiment of an instrument for determining the thickness of a cartilage layer 50 cultured in vitro (with or without a base layer of bone substitute material). The instrument comprises a measuring block 70 having recesses 71 of substantially different depths,
Advantageously, the weight block 72 comprises a transparent material, the weight of the block relative to the support surface substantially corresponding to the compressive force used in implantation. Advantageously, the recesses 71 each have the shape of a defect to be repaired or the shape of an opening formed in such a defect site for cartilage layer implantation.

To determine the thickness, the extruded cartilage layer 50 is placed in one of the recesses 71 and weighted by a weight block 72. The thickness of the cartilage layer 50 related to the implantation corresponds to the depth of the recess 71, and when the cartilage layer 50 is placed in the recess 71, the weight block 72 is released from the abutment state.

Thus, the device set according to the invention for repairing a defect according to FIGS. 9 and 10 comprises, in addition to at least part of the device described above, a support surface 60 and a master 61
And an instrument for punching or cutting the cartilage layer 50 cultured in vitro. In addition, it would be advantageous for the instrument set to have instruments for measuring the thickness of such cartilage relevant for implantation, or for such various defect shapes.

To perform the repair as shown in FIGS. 9 and 10, the surgeon performs, for example, the following steps in the following order. -Determine the shape of the cartilage surface 22 to be reconstructed. Determine the opening for the cartilage layer 50 to be implanted, as well as the pattern of the tissue column 2 to be implanted.

-Forming an implant from the cartilage layer 50 cultured in vitro and determining the thickness of the cartilage layer 50; -Install the ring guide 10. Forming an opening for the cartilage layer 50 to be implanted; For each tissue column 2, an opening 21 is formed, the tissue column 2 is excised and the tissue column 2 is implanted into the opening 21.

The ring guide 10 is removed. If necessary, insert the filling material 51; Implant the extruded cartilage layer 50; FIGS. 13 to 16 show a part of a further exemplary embodiment of a device for resection and implantation of tissue columns (FIGS. 13 to 15 in cross section parallel to the axis) and in fact FIG.
3 is an extractor 31.1, FIG. 14 is an extractor guide 30.1 for guiding the extractor 31.1 when cutting the tissue column, and FIG. 15 is an extractor 31 for implanting the tissue column. .
FIG. 15 shows a tappet 37.1 for projecting a tissue column from the extractor 31.1.

The instrument sections 31.1, 30.1, 40.1 and 37.1 are functionally equivalent instrument sections 31, 30, 40 and 3 as already described in connection with FIGS.
7 and many features are consistent. Therefore, in the following, the instrument parts 31.1, 30
. Only the different features of 1,40.1 and 37.1 will be described. Further features are indicated by reference numbers in FIGS.

At this point, opposite the pointed distal edge, the extractor 31.1 has two opposing windows 80 and a longitudinal scale for examining and measuring the length of the resected tissue column. And Furthermore, on the side of the window 80 opposite the pointed distal edge, the extractor is provided with two axially extending slits 82 arranged opposite one another, so that two extractors are longitudinally extended towards its opposite end. It is divided into container parts. For ease of use, a handle 83 is provided at the end of the extractor opposite the pointed distal edge, which is likewise divided into two parts and the extractor 31 In order to limit the guide depth of .1 the corresponding guides 30.1, 40.1 are limited.

Here, the extractor's rotation stop 36 shown in FIG. 8 or two rotations shown in FIG. 13 of the extractor prevent rotation of the extractor with respect to the tissue column during rotation. Stopper 36 (after all, the tissue column is pivotally removed from the bottom with the tissue column still "tethered" to the bottom) is also shown in FIG.
It should be noted that it can be significantly longer than that shown in FIG. 3 or FIG. In particular, such a detent 36 can in each case extend over the maximum length that the tissue column to be resected can take with the corresponding extractor, or over the entire length of the extractor. The extractor with the long rotation stop 36 is most importantly the support required for the surgeon or orthopedic surgeon to push the extractor into the spongy site, but at the bottom where the sponge site is tethered to remove the tissue column. This is useful when you are not in a state of receiving However, by using the long rotation stop 36, the rotation stop always extends to the site of the tissue column, and ensures that the tissue column can be reliably rotated even when sponges are formed. Give enough support to guarantee. This is not possible with a short rotation stop 36.

The extractor guide 30.1 does not have the angle α (FIGS. 6 and 7) for accurate ablation like the extractor guide 30 and cannot be fixed in the ablation position. For this reason, it is not at all suitable as a guide for hollow drills. The function of this extractor guide is rather to provide the surgeon with an additional retaining means in addition to the handle 83 during extraction of the tissue column, and the extractor 31.
1 is rotatable, while at the same time preventing the two extractor parts separated from each other by a slit 82 up to the pointed distal edge region from being unnecessarily expanded.

The transplant guide 40.1 also has no means for fixing to the defect site. The implantation guide 40.1 also has windows 80 disposed opposite one another, through which the rotational position is determined from the orientation of the tissue columns relative to the windows in the extractor 31.1 during implantation. be able to. The inner diameter of the implantation guide 40.1 coincides only with the outer diameter of the extractor 31.1 in the distal region, and in any part is larger than the outer diameter of the extractor 31.1. Thereby, the two extractor portions divided by the slit 82 can be expanded. The tappet 37.1 is, for expansion of the extractor part described above,
It has a conical portion 84.

The expansion of the extractor portion reduces the friction between the extractor and the tissue column during implantation, thereby reducing the pressure required on the cartilage layer of the tissue column to push the extractor. Thus, the treatment of the tissue column can be performed more safely.

The tappet 37.1 has a handle 85 which functions for ease of operation and which ensures that the tappet is pushed only towards the sharp distal edge of the extractor 31.1. ing.

The features of the instrument parts 31.1, 30.1, 40.1 and 37.1 according to FIGS. 13 to 16 are the features of the instrument parts 31, 30, 40 and 37 according to FIGS. And in any desired manner.

FIG. 17 shows a three-dimensional view of the instrument parts 31.1, 40.1 and 37.1 according to FIGS. 13, 15 and 16. 18 and 19 show a further exemplary embodiment for an implantation guide 40.2 and tappet 37.2, similar to the implantation guide 40.1 and tappet 37.1 of FIGS. 15 and 16. Extractor 31.1 and extractor guide 30.
1 can be substantially the same as the configuration shown in FIG. 13 or FIG. 14, respectively, but in particular the detent 36 can extend over the entire length of the extractor 31.1.

As can be seen from FIG. 13, the handle 83 has a contact pin 830 projecting downward on the bottom surface. The abutment pin 830 may have a corresponding recess 831 for the extractor guide 30.1 (FIG. 14) to receive the abutment pin 830, and this recess 831 rotates with the corresponding abutment pin. Apart from that, it has no significance for resection of the tissue column at the extraction site. On the other hand, the abutment pin 830 plays a very important role in the corresponding design in the implantation guide. To illustrate this importance, in the following discussion the contact pin 8
Assume that 30 has a height of, for example, 3 mm (measured from the bottom surface of handle 83).

The tissue column is excised at the extraction location with the aid of the extractor 31.1 and the extractor 3
1.1, and if the tail is flush with the extractor 31.1, this tissue column is implanted-as already explained-in the corresponding hole or recess at the defect site. Should be done. This transplant places the tissue column lightly in the hole at the defect site.
Press fit "to fit. As described above, the original shape of the cartilage (ie, the shape before the defect occurred) is copied as closely as possible to the cartilage so that the cartilage can retain its original shape as much as possible after the treatment process. When taken, it is particularly beneficial to the success of this type of endograft / implant.

In order to achieve this, in order to make the original shape of the cartilage copied as faithfully as possible, depending on the size of the defect, the tissue column is implanted with the implantation guide 40.2 and the tappet 37. With the help of 2 (FIG. 18 or 19, respectively), push down completely to the bottom of the hole formed in the defect, or allow the tissue column to have a predetermined length from the bottom after being pushed. In no case should the tissue column be pushed down below the bottom of the hole. This danger arises, above all, when the bottom of the hole is in the (porous) sponge. To accomplish or avoid all this, a simple instrument should be placed in the surgeon's or orthopedic surgeon's hand.

For this purpose, the implantation guide 40. 2 has a distal surface (FIG. 18)
For example, it has two concave portions 832 and 833 which are arranged to face each other, the concave portion 832 has a depth of 1 mm, for example, and the concave portion 833 has a depth of 3 mm. Contact pin 83
When guiding the extractor 31.1 (FIG. 13), which contains a tissue pillar having a zero, to the implantation guide 40.2 (FIG. 18) during implantation, the abutment pin 830 will
Can be inserted at three different positions.

In the first position, the abutment pin 830 is located in the recess 833. Contact pin 8
30 has a length of 3 mm in the selected exemplary embodiment and the recess 8
33 also has a depth of 3 mm, so that the handle 8 of the extractor 31.1.
The bottom surface of 3 is flush with the distal end surface of implantation guide 40.2.

In the second position, the abutment pin 830 is located in the recess 832. Recess 832
Has a depth of 1 mm, so that when the contact pin 830 is placed on the bottom of the recess 832, the bottom surface of the handle 83 of the extractor 31.1 is 2 mm higher than the distal end surface of the implantation guide 40.2.

In the third position, it is not placed in either of the two recesses 832 or 833, but rather on the distal end of the implantation guide 40.2. In this position, the extractor 31
. The bottom surface of the handle 1 is 3 mm higher than the distal end surface of the implantation guide 40.2.

The implantation guide 40. The surgeon now has the surgeon in any one of the three positions.
Assuming that the extractor has just been introduced in Fig. 2, the implantation guide 40.2 is placed on the defect site, and the distal end surface of the implantation guide 40.2 is actually located below the costal cartilage around the already formed hole. It is placed on the bone. The tissue column is then pushed out of the extractor and into the bone with the help of a tappet.

The tappet is in principle formed such that when the tappet is completely introduced into the extractor, the bottom surface of the handle of the tappet lies on the proximal face of the extractor 31.1. In this state, the tip of the tappet is flush with the tip of the extractor, and the tip of the tappet pushes the tissue column completely out of the extractor, but not necessarily completely.
It is not necessary to push from 0.2. This depends on the position where the extractor was introduced in the implantation guide 40.2.

The abutment pin 830 of the extractor fits into the recess 833 (first position) of the implantation guide 40.2
When the tappet 37.2 is engaged so as to abut the tissue column completely (since the tip of the extractor is flush with the tip of the implantation guide).
2, which normally pushes the tissue column toward the bottom of the hole at the defect, but does not protrude beyond the costal cartilage bone.

When the contact pin 830 of the extractor 31.1 is fitted in the concave portion 832 and is in contact therewith (the second position), the tappet completely fitted into the extractor (when the tip of the extractor is Obviously, the tissue column is completely extracted (because it is flush with the tip of the implantation guide).
. 1 but not completely extruded from the transplant guide, and as a matter of fact, 3 mm (the length of the contact pin 830) minus 1 mm (the depth of the concave portion 832)
That is, 2 mm in length, and the tissue column remains protruding from the subchondral bone by that length, but in larger defects, the shape of the original cartilage remains true to its original shape. This is very desirable for copying to

When the contact pin 830 is located on the proximal side of the extractor 31.1 (third position)
The tissue column protrudes by 3 mm into the implantation guide 40.2 or, when the tappet is fully introduced, from the subchondral bone at the defect site. It is clear that these values for the depths of the recesses 832 and 833 are to be considered merely examples, and that other values are possible. The surgeon or orthopedic surgeon determines in each case the extent to which it is desirable to push the tissue column into the hole according to the condition at the defect site.

The tappet 37.2 shown in FIG. 19 has one singularity compared to the tappet 37.1 (FIG. 16). That is, the handle of tappet 37.2 includes two parts, an upper handle portion 851 rigidly connected to the axis of the tappet and a lower handle portion 852 movable along the axis, the outer wall of the handle having a distal end. It is tapered conically in the direction. The lower handle portion 852 is movable at the highest point along the axis to the bulge 853. When introducing the axis of the tappet 37.2 into the extractor 31.1, the lower handle part 852 can be moved into the extractor,
With the help of its conical outer surface, the extractor 31.1 with a longitudinal slit can be easily expanded. The lower handle portion 852 is a lower handle portion 852.
Can be advanced only until the bottom surface of the extractor 31.1 contacts the proximal end surface of the handle 83 of the extractor 31.1. In the extractor 31.1 thus slightly expanded, the easily expanded extractor further pushes the tissue column out of the extractor to facilitate the pushing out of the tissue column into the hole at the defect site. Or, the extrusion of the tissue column into the hole is facilitated. In order to be able to easily push the tissue column out of the extractor,
The surgeon or orthopedic surgeon can also utilize a small hammer with which the upper handle portion 851 contacts the lower handle portion 852 and then the handle 83 of the extractor 31.1. You may tap lightly until it comes into contact with the base end face.

[Brief description of the drawings]

FIG. 1 is a schematic view of a cartilage defect repaired according to a known mosaic method, and is a plan view and a cross-sectional view for explaining an improved aspect of accuracy in positioning and parallelism of an opening formed in a defect site.

2 is a diagram of an exemplary embodiment of a gauge for forming an opening at a defect site to be repaired according to FIG. 1;

FIG. 3 illustrates a cartilage defect to illustrate an improved aspect of reconstructing the original cartilage surface by matching the axial length of the tissue column to be implanted, and an example for reconstruction of the original cartilage surface. Schematic diagram of a target gauge.

4 is a diagram of an exemplary embodiment of an instrument for determining the distance between the original cartilage surface and the bottom surface of the opening formed at the site of the defect to be repaired according to FIG. 3;

FIG. 5 is a schematic illustration of a cartilage defect to illustrate an improved aspect of reconstructing the original cartilage surface by matching the angle between the cartilage surface and the axis of the tissue column to be implanted.

FIG. 6 is a schematic view of a resection site to illustrate an improved aspect of reconstructing the original cartilage surface by matching the angle between the cartilage surface and the axis of the tissue column to be implanted.

FIG. 7 is a diagram of an exemplary embodiment of an instrument for resecting a tissue column and implanting at an angle α between the cartilage surface and the column axis.

FIG. 8 is a view of a gauge according to FIG. 2 provided for implanting a tissue column in a predetermined rotational position.

FIG. 9 is a schematic plan view of a repair cartilage defect for explaining an improved aspect of eliminating a gap on the surface of the repair cartilage.

FIG. 10 is a schematic cross-sectional view of a repair cartilage defect for explaining an improved aspect of eliminating a gap on the surface of the repair cartilage.

FIG. 11 shows an exemplary embodiment of a punch for making an implant from cartilage tissue cultured in vitro for repair according to FIGS. 9 and 10.

FIG. 12 illustrates an exemplary embodiment of an instrument for determining the thickness of a layer of cartilage cultured in vitro.

FIG. 13 illustrates an embodiment of a cooperating device for carefully resecting and implanting a tissue column (cross-section parallel to the axis).

FIG. 14 illustrates an embodiment of a cooperating device for carefully cutting and implanting a tissue column (cross-section parallel to the axis).

FIG. 15 illustrates an embodiment of a cooperating device for carefully resecting and implanting a tissue column (cross-section parallel to the axis).

FIG. 16 illustrates an embodiment of a cooperating device for carefully resecting and implanting a tissue column.

FIG. 17 is a perspective view of the device according to FIGS.

FIG. 18 illustrates an embodiment of an implant guide having a recess in an end surface for receiving a contact pin provided on an extractor.

FIG. 19 illustrates an embodiment of a tappet for projecting a tissue column from an extractor.

──────────────────────────────────────────────────続 き Continuation of front page (81) Designated country EP (AT, BE, CH, CY, DE, DK, ES, FI, FR, GB, GR, IE, IT, LU, MC, NL, PT, SE ), CA, JP, KR, US (72) Inventor Zager, Christoph CH-Switzerland CH-3035 Friesville-Aubele Schmiede (72) Inventor Menil-Walle, Pierre Switzerland CH-3005 Bern-Wild-Strasse 9 (72) Inventor Zech, Manfred CH-8450 Anderfingen Hintervühlstraße 21 (72) Inventor Müller-Glauser, Werner CH-8542 Wiesendangern Vanenstrasse 6F term (reference) 4C060 EE21 FF1 7 FF25 LL08 LL13 MM22 4C097 AA01 AA30 BB01 BB04 CC05 DD15 MM09

Claims (29)

[Claims] 1. An instrument set for repairing endochondral and osteochondral defects (20) by implanting a graft column (2) carrying a living cartilage layer (2 ') on one end surface. The instrument set includes an instrument for forming a limited cylindrical opening (21) for implanting a tissue column (2) at a site of a defect (20), and a tissue column (2) for living tissue. Instrument for forming a tissue column (2) from a cartilage layer cultured in vitro, and for implanting the tissue column (2) into a formed cylindrical opening (21). A device for substantially improving the parallelism and positioning of the cylindrical opening (21), the original cartilage surface (22) at the defect site. Instrument for the formed cylindrical opening Bottom and the original cartilage surface (21) (22
Instrument for determining the distance between the cartilage surface and the column axis (α)
An instrument for forming a graft from the cartilage layer (50) cultured in vitro to fill the interstices in the cartilage surface repaired by the tissue column (2) Instrument set, further comprising at least one instrument from the instrument group consisting of instruments for: 2. A device for increasing the accuracy of the parallelism and positioning of the cylindrical opening (21) is a guide device (10, 11) for a punching or drilling device for forming the opening (21). The instrument set according to claim 1, characterized in that the guide instrument has means for fixing to a defect to be repaired. 3. An instrument for determining an original cartilage surface comprises a plurality of shape gauges (
23. The instrument set according to claim 1, wherein the instrument set is 23). 4. The determined cartilage surface (22) and the formed cylindrical opening (21).
The instrument for measuring the distance to the bottom of the surface template (21) is associated with a shape gauge (23) having a measuring opening (26) associated with the formed opening (21). 24. The instrument set according to claim 3, comprising: 5. An instrument for resecting a tissue column at a predetermined angle (α) between a cartilage surface and a column axis is a means for guiding the resection instrument, wherein the instrument is used to guide a resection instrument at a predetermined position in the resection position. 4. An instrument set according to claim 1 or claim 3, comprising means that can be fixedly positioned at an angle (?). 6. An apparatus for forming an implant from a cartilage layer (50) cultured in vitro to fill gaps in the cartilage surface repaired by the tissue column (2) comprises a punching instrument ( 60, 61) or an implement set as a cutting instrument. 7. The instrument set according to claim 6, wherein the set further comprises instruments (70, 72) for measuring the thickness of the cartilage layer (50). 8. For implantation of a tissue column (2) having a living cartilage layer (2 ′),
An instrument for improving the accuracy of parallelism and positioning of a cylindrical opening (21) formed in cartilage or at a site of osteochondral defect (20), wherein the instrument comprises:
A device characterized as being designed as a guide device (10, 11, 12) for a punching or drilling device that can be fixedly positioned at the site of the defect (20). 9. The method according to claim 8, comprising a ring guide and at least one punching or drilling guide which can be arranged in the ring guide. Appliances. 10. An instrument for determining the original cartilage surface (22) at the site of endochondral or osteochondral defect (20) to be repaired, said instrument comprising a plurality of shape gauges (23).
). 11. An instrument for determining the distance between the bottom surface of a cylindrical opening (21) formed in a cartilage or at a site of osteochondral defect (20) and the original cartilage surface (22). An instrument comprising means for copying the original cartilage surface and a measuring rod. 12. The means for copying the original cartilage surface (22) comprises a surface template (2) having a measurement opening (26) associated with the formed cylindrical opening (21).
The device according to claim 11, wherein the device is (4). 13. The device as claimed in claim 12, wherein the surface template (24) is insertable on a ring guide (10) which can be fixedly positioned in the defect site (20). 14. An instrument for resecting a tissue column at a predetermined angle (α) between a cartilage surface and a column axis for implantation in an endochondral or osteochondral defect (20). And a tissue column fixedly positioned at an angle (α) at the resection position (
An instrument having means for guiding the instrument for resection in 2). 15. The guide means comprises a substantially tubular extractor guide (30, 3).
0.1) and the resection tool is designed as an extractor (31, 31.1) guided in an extractor guide (30, 30.1).
The device according to 4. 16. Device according to claim 15, wherein the extractor (31.1) has a window. 17. The extractor (31.1) has two slits (82).
17. The device according to claim 15 or 16, wherein the device is divided into two extractor portions connected from a tip extractor region having a pointed distal edge. 18. The extractor guide (30) according to claim 15, wherein the extractor guide (30) has a support flange (32) at an angle (α) to the axis of the tube. Appliances. 19. An apparatus for forming an implant from an in vitro cultured cartilage layer (50) to fill gaps in a cartilage surface repaired by a tissue column (2), said apparatus comprising: Is designed as a punching tool (60, 61) or as a cutting tool. 20. The device is designed as a punching device (60, 61) and, together with a punching die having a punching blade (62), together with the original cartilage surface (60).
20. Device according to claim 19, having a support surface (60) in the form of (22). 21. An instrument for determining the thickness of a cartilage layer (50) cultured in vitro, comprising a measuring block (70) having cuts (71) of different depths.
) And a weight block (72). 22. Repair of defects in cartilage and osteochondral by implanting a transplantation column (2) carrying a living cartilage layer (2 ') on one end surface into a cylindrical opening provided at a defect site. The guide device (10, 11, 12) is fixedly positioned at the defect site in order to accurately guide the punching or drilling device for forming the cylindrical opening (21). A method characterized by the following. 23. Repair of defects in cartilage and osteochondral by implanting a graft column (2) carrying a living cartilage layer (2 ') on one end surface into a cylindrical opening provided at a defect site. Prior to performing the repair, the original cartilage surface (22).
And reconstructing the original cartilage surface (22) by repair. 24. The bottom surface of the formed cylindrical opening (21) and the surface of the original cartilage (22).
24. The method according to claim 23, characterized in that a distance is determined between the first and second openings, and the axial length of the implantation column (2) to be implanted in the opening (21) is adapted to said distance. 25. Repair of defects in cartilage and osteochondral by implanting a transplantation column (2) carrying a living cartilage layer (2 ') on one end surface into a cylindrical opening provided at a defect site. A method for determining the angle (α) between the cartilage surface to be formed (22) and the axis of the formed cylindrical opening (21) and implanting in the opening (21) The method characterized in that the implantation column (2) has the same angle (α) between the column axis and the cartilage surface and is implanted in a fixed rotational position. 26. Repair of defects in cartilage and osteochondral by implanting a transplantation column (2) carrying a living cartilage layer (2 ') on one end surface into a cylindrical opening provided at a defect site. In the method for transplanting tissue columns (2
3.) The gap between the interstices and the edge of the defect (20) and the implanted tissue column (2) is filled with a further cartilage layer (50) implant cultured in vitro. how to. 27. The cartilage layer (50) is punched or cut into a shape or shape corresponding to the opening for the implanted tissue column (2) for implantation. The method according to claim 26. 28. Determining the thickness of an in vitro cultured cartilage layer (50) and forming a minimum depth opening for yet another implant formed from the cartilage layer. 28. The method according to claim 26 or 27, wherein the minimum depth substantially corresponds to the thickness of the cartilage layer cultured in vitro. 29. An implant according to claim 26, wherein the graft of cartilage layer (50) cultured in vitro is at least partially filled posteriorly with a filling material (51). the method of.