Abstract:
The present invention provides an orthopedic surgical tool for moving an implant to a surgical sight and installing the implant. The tool allows the surgeon the ability to navigate the implant through a surgical tube, then rotate the implant after reaching the sight and effect installation of the implant, and then effect its release from the tool. The implant can be rotated at any time during its installation within the constraints of other surgical devices.

Description:
CROSS REFERENCE TO RELATED APPLICATIONS 
       [0001]    In accordance with 37 C.F.R. 1.76, a claim of priority is included in an Application Data Sheet filed concurrently herewith. Accordingly, the present invention claims priority to U.S. Provisional Patent Application No. 62/235,085, entitled “Surgical Instrument for Implant Insertion”, filed Sep. 30, 2015, and the present invention claims priority as a continuation-in-part of U.S. patent application Ser. No. 15/186,996, entitled “Bone Fixation Rod and Implantation Device for Insertion Thereof”, filed Jun. 20, 2016, which is a divisional of U.S. patent application Ser. No. 14/153,768, entitled “Bone Fixation Rod And Implantation Device For Insertion Thereof”, filed Jan. 13, 2014, which is now U.S. Pat. No. 9,370,384, which issued on Jun. 21, 2016, which claims priority as a continuation of U.S. patent application Ser. No. 13/107,189, entitled “Bone Fixation Rod and Implantation Device for Insertion Thereof”, filed May 13, 2011, which is now U.S. Pat. No. 8,628,535, which issued on Jan. 14, 2014, which claims priority to U.S. Provisional Patent Application No. 61/334,643, entitled “Bone Fixation Rod and Implantation Device for Insertion Thereof”, filed May 14, 2010. The present invention is related to U.S. patent application Ser. No. 11/726,865, entitled “Pivotable Interbody Spacer”, filed Mar. 22, 2007, which is now U.S. Pat. No. 8,043,293, which issued on Oct. 25, 2011; U.S. patent application Ser. No. 11/856,483, entitled “Pivotable Vertebral Spacer”, filed Sep. 17, 2007, which is now U.S. Pat. No. 8,157,845, which issued on Apr. 17, 2012; U.S. patent application Ser. No. 12/051,319, entitled “Pivotable Interbody Spacer System and Method”, filed Mar. 19, 2008, which is now U.S. Pat. No. 7,892,239, which issued on Feb. 22, 2011; U.S. patent application Ser. No. 13/006,186, entitled “Pivotable Interbody Spacer System and Method”, filed Jan. 13, 2011, which is now U.S. Pat. No. 8,444,650, which issued on May 21, 2013; U.S. Provisional Patent Application No. 61/678,891 entitled “Pivotable Lateral Cage and Method of Insertion”, filed Aug. 2, 2012; U.S. patent application Ser. No. 13/958,163, entitled “Pivotable Lateral Cage and Method of Insertion”, filed Aug. 2, 2013, which is now U.S. Pat. No. 9,345,587, which issued on May 24, 2016; all of which are now incorporated herein by reference. 
     
    
     FIELD OF THE INVENTION 
       [0002]    The instant invention relates to surgical instruments useful in positioning an implant device for insertion in a patient, such as disc repair or bone fixation procedures and methods of use thereof. Such implants include a bone fixation rod, such as a spinal rod used for insertion into a plurality of pedicle screws for alignment purposes during spinal procedures, and a spacer for insertion into an intervertabral disc between two vertebrae. 
       BACKGROUND OF THE INVENTION 
       [0003]    The central nervous system is a vital part of the human physiology that coordinates human activity. It is primarily made up of the brain and the spinal chord. The spinal chord is made up of a bundle of nerve tissue which originates in the brain and branches out to various parts of the body, acting as a conduit to communicate neuronal signals from the brain to the rest of the body, including motor control and sensations. Protecting the spinal chord is the spinal, or vertebral, column. Anatomically, the spinal column is made up of several regions, including the cervical, thoracic, lumbar and sacral regions. The cervical spine is made up of seven vertebrae and functions to support the weight of the head. The thoracic spine is made up of twelve vertebrae and functions to protect the organs located within the chest. Five vertebrae (vertebral bodies) make up the lumbar spine. The lumbar spine contains the largest vertebra and functions as the main weight bearing portion of the spine. Located at the base of the spine are the five fused vertebrae known as the sacrum. The coccyx sits at the base of the spinal column and consists of four fused vertebrae. An intervertabral disc (disc) is located between adjacent vertebrae. 
         [0004]    Each of the vertebrae associated with the various spinal chord regions are made up of a vertebral body, a posterior arch, and transverse processes. The vertebral body, often described as having a drum-like shape, is designed to bear weight and withstand compression or loading. In between the vertebral bodies are the intervertebral discs. The intervertebral disc is filled with a soft, gelatinous-like substance which helps cushion the spine against various movements and can be the source of various diseases. The posterior arch of the vertebrae is made up of the lamina, pedicles and facet joints. Transverse processes extend outwardly from the vertebrae and provide the means for muscle and ligament attachment, which aid in movement and stabilization of the vertebrae. 
         [0005]    While most people have fully functional spinal chords, it is not uncommon for individuals to suffer some type of spinal ailment, including spondylolisthesis, scoliosis, spinal fractures, disc rupture and disc herniation. One of the more common disorders associated with the spinal chord is damage to the spinal discs. Damage to the discs results from physical injury, disease, genetic disposition, or as part of the natural aging process. Disc damage often results in intervertebral spacing not being maintained, causing pinching of exiting nerve roots between the discs, resulting in pain. For example, disc herniation is a condition in which the disc substance bulges from the disc space between the two vertebrae bodies. It is the bulging of the disc material which causes impingement on the nerves, manifesting in pain to the patient. For most patients, rest and administration of pain and anti-inflammatory medications alleviates the problem. However, in severe cases, cases which have developed into spinal instability or severe disc degeneration, the damaged disc material between the vertebral bodies is removed and replaced with spinal stabilization implants, such as intervertebral or interspinal inserts. Restoration to the normal disc height allows the pressure on the nerve roots to be relieved. 
         [0006]    There are many different approaches taken to alleviate or reduce severe spinal disorders. One surgical procedure commonly used is a spinal fusion technique. Several surgical approaches have been developed over the years, and include the Posterior Lumbar Interbody Fusion (PLIF) procedure which utilizes a posterior approach to access the patient&#39;s vertebrae or disc space, the Transforaminal Lumbar Interbody Fusion (TLIF) procedure which utilizes a posterior and lateral approach to access the patient&#39;s vertebrae or disc space, and the Anterior Lumbar Interbody Fusion (ALIF) which utilizes an anterior approach to access the patient&#39;s vertebrae or disc space. Using any of these surgical procedures, the patient undergoes spinal fusion surgery in which two or more vertebrae are linked or fused together through the use of a bone spacing device and/or use of bone grafts. The resulting surgery eliminates any movement between the spinal sections which have been fused together. 
         [0007]    In addition to the spinal implants or use of bone grafts, spinal fusion surgery often utilizes spinal instrumentation or surgical hardware, such as pedicle screws, plates, or spinal rods. Once the spinal spacers and/or bone grafts have been inserted, a surgeon places the pedicle screws into a portion of the spinal vertebrae and attaches either rods or plates to the screws as a means for stabilization while the bones fuse. Currently available systems for inserting the rods into pedicle screws can be difficult, particularly in light of the fact that surgeons installing these rods often work in narrow surgical fields, as for example, through tubes. This is well known in the art. Once the implant is moved through the access tube in a longitudinal orientation, it needs to be reoriented for attachment to the screws. Reorientation can be difficult when working through a surgical device such as an access tube. Moreover, since patients can vary with respect to their internal anatomy, resulting in varying curvatures of the spine, a surgeon may not always have a linear path or may have anatomical structures that need to be maneuvered around in order to properly insert the surgical rods into the pedicle screw assemblies. In addition to requiring surgical skill, difficulty in placing the rods correctly into the pedicle screws can result in unnecessary increases in the time it takes a surgeon to complete the surgical procedure. Prolonged surgery times increase the risk to the patient. More importantly, improperly aligning the rods and pedicle screw assemblies often results in complications for the patient and can require corrective surgical procedures. 
         [0008]    Similar problems are also encountered with other surgical procedures; for example, when implanting an interspinal insert. Once the implant is moved through the tube to the surgical site, it is turned to re-orient it for insertion between two vertebra. Reorientation can be difficult when the surgical tube that provides access has a small cross-sectional area, as the implant needs to be inserted along the tube in a longitudinal orientation. This is true for disc implants as well. 
         [0009]    There exists, therefore, a need for an improved surgical implantation instrument that can be used by a surgeon to easily and safely insert an implant device such as a bone fixation rod to a plurality of members of a bone fixation system, such as pedicle screws which have been inserted into various bone structures, or insert an intervertebral insert, particularly when a tube is used to provide access to the surgical site. U.S. Pat. No. 8,157,845, entitled “Pivotable Vertebral Spacer” filed Sep. 17, 2007; U.S. Pat. No. 7,892,239, entitled “Pivotable Interbody Spacer System and Method” filed Mar. 19, 2008; and U.S. Pat. No. 8,444,650 entitled “Pivotable Interbody Spacer System and Method” filed Jan. 13, 2011, disclose an interbody spacer suitable for use with the present tool. U.S. Pat. No. 8,628,535 entitled “Bone Fixation Rod and Implantation Device For Insertion Thereof” filed May 13, 2011, discloses a fixation rod and insertion tool usable in a method to implant the rod. The entirety of these applications is incorporated herein by reference. 
       DESCRIPTION OF THE PRIOR ART 
       [0010]    U.S. Pat. No. 6,530,929 discloses an installation instrument for placement of a brace or rod into pedicle screws. The instrument is mounted to anchors secured to the pedicle screws utilizing extensions coupled to the anchors. The instrument is movable with respect to the anchors to position a brace in a position more proximate the anchors. The brace can be inserted into the pedicle screws and manipulated away from the installation instrument utilizing a thumb screw. However, a disadvantage associated with the installation instrument for placement of a brace or rod into pedicle screws described therein is that the brace can not be rotated about its longitudinal axis. 
         [0011]    U.S. Pat. No. 7,188,626 discloses methods and instruments for placing a brace or connecting element into a plurality of anchors or pedicle screws similar to U.S. Pat. No. 6,530,929. Insertion of the connecting elements is accomplished by a linear insertion method, therefore failing to teach a connecting element that cannot be rotated about its longitudinal axis. 
         [0012]    U.S. Pat. No. 7,520,879 discloses a device for positioning a connecting element adjacent the spinal column using so called minimally invasive procedures. An inserter instrument guides the connecting element from a location remote from one or more anchors to a location proximate to the one or more anchors. The extensions are mountable to anchors, and the inserter instrument is mountable to the connecting element for positioning the connecting element adjacent the anchors in a so-called minimally invasive procedure. The inserter instrument does not have to be mounted to the anchors or to the anchor extensions, and are operable independently to position the connecting element into the patient along a minimally invasive insertion path from a location remote from the anchor extensions. While the inserter instrument can rotate the connecting element along its longitudinal axis, it can not be repositioned on the connecting element to gradually rotate the connecting element in a given direction. Moreover, it cannot be rotated about an axis normal to its longitudinal axis. 
         [0013]    U.S. Publication No. 2007/0078460 discloses a method and instrumentation for performing spinal fixation surgery. A first incision is made through the skin and a passageway is created to the spine. A screw is inserted through the passageway and into a vertebra. The screw has a head portion including a channel. An insertion guide is operably connected to the screw. Additional screws may each be inserted through separate incisions or through the first incision. Insertion guides may be operably connected to a head portion of each screw. A sleeve may be positioned into one insertion guide in a first position to guide a rod through at least one other insertion guide. The sleeve is rotated to a second position to allow the rod to move down the slots of the insertion guides and into the head portion of the screw. Additionally, a holding instrument can be employed to position a rod. Two types of connections between the holding instrument and the rod are described. These connections permit the rotation of the rod about its longitudinal axis, but fail to teach a rod which can be repositioned on the connecting element to gradually rotate the connecting element in a given direction. 
         [0014]    U.S. Publication No. 2005/0277934 discloses a so-called minimally invasive spinal fixation system used for spinal arthrodesis or motion preservation spinal repair. The system includes a plurality of pedicle screws and an attachment assembly for connecting the pedicle screws. The attachment assembly includes a connector for attaching to the first screw and second screw, and a removable guide for percutaneously attaching the connector to the first screw and second screw. The removable guide includes a number of different embodiments for connecting the attachment assembly to the connector. A snap type lock is used to secure the attachment to the connector. While this does permit the connector to be repositioned by rotating it about its longitudinal axis, the repositioning can occur at only 90 degree increments. Moreover, it cannot be rotated about an axis normal to the longitudinal axis of the connector. 
         [0015]    U.S. Pat. No. 7,892,239, and U.S. Publication Nos. 2007/0225808 and 2008/0009880 describe a system and a method for pivotably inserting an interbody spacer device into a surgical site. The system includes an interbody spacer and an insertion instrument with a pivotable element configured to manipulate an interbody spacer. A plurality of teeth is formed on at least one end of the spacer, and matching teeth are formed on an insertion instrument. An exemplary insertion instrument includes an expandable tip configured to be inserted and mated with a gap within an interbody spacer to aid in selective retention and manipulation of the interbody spacer. 
       SUMMARY OF THE INVENTION 
       [0016]    The present invention provides for a tool usable by a surgeon for orthopedic procedures to move an implant to a surgical site, and when clear of obstruction, rotate the implant by remote action to facilitate the fixing of the implant in the patient at the surgical site, and then remotely release the implant from the tool. 
         [0017]    The tool has means for releasably securing an implant at its distal end, and means at the proximal end to remotely effect rotation of the implant relative to the tool from a first insertion orientation and a second installation orientation. The tool has means forming a jaw arrangement operable to capture an axle on the implant and secure the implant to the tool. The opening of the jaw structure allows for securing and release of the implant. Retention and release of the implant are independent of operating the tool for rotation of the implant. The implantation device also provides the surgeon with the ability to maneuver the implant remotely in a non-linear fashion around tissue structures by incrementally changing the rotational position of the implant. 
         [0018]    Accordingly, it is a primary objective of the instant invention to provide an improved tool for inserting an implant into a patient. 
         [0019]    It is a further objective of the instant invention to provide a tool for angular adjustment of the implant during insertion. 
         [0020]    It is yet another objective of the instant invention to provide an implant insertion tool which can lock the implant in rotational position in order to maintain an angular position. 
         [0021]    Other objects and advantages of this invention will become apparent from the following description taken in conjunction with any accompanying drawings wherein are set forth, by way of illustration and example, certain embodiments of this invention. Any drawings contained herein constitute a part of this specification and include exemplary embodiments of the present invention and illustrate various objects and features thereof. 
     
    
     
       BRIEF DESCRIPTION OF THE FIGURES 
         [0022]      FIG. 1  is a isometric view of a surgical tool for installing an implant; 
           [0023]      FIG. 2  is an exploded isometric view of the surgical tool of  FIG. 1 ; 
           [0024]      FIG. 3A  is side view of the surgical tool of  FIG. 1 , illustrated with an intervertebral implant secured thereto; 
           [0025]      FIG. 3B  is an enlarged fragmentary view, taken along lines  3 B- 3 B of  FIG. 3A , of the distal end of the tool of  FIG. 1  having an intervertebral implant device rotated to a first position for movement to the surgical site; 
           [0026]      FIG. 4  is an enlarged fragmentary side view of the distal end of the tool of  FIG. 1  having an intervertebral implant device rotated to a second position for insertion or after insertion at the surgical site; 
           [0027]      FIG. 5  is an enlarged exploded fragmentary side view of the distal end of the tool of  FIG. 1  taken along lines  5 - 5  of  FIG. 2  showing details of the structure; 
           [0028]      FIG. 6  is an enlarged exploded fragmentary perspective side view of the distal end of the tool of  FIG. 1  to show details of the structure; 
           [0029]      FIG. 7  is an enlarged fragmentary side view of the tool; 
           [0030]      FIG. 8  is an enlarged fragmentary perspective view of the distal end of the tool and implant; 
           [0031]      FIG. 9  is an exploded partial end view of the distal end of the tool; 
           [0032]      FIG. 10  is an isometric view of a surgical tool for installing an implant; 
           [0033]      FIG. 11  is an isometric view of a surgical tool for installing an implant; 
           [0034]      FIG. 12  is an isometric view of a surgical tool illustrated with an intervertebral implant in a first position; 
           [0035]      FIG. 13  is an isometric view of a surgical tool illustrated with an intervertebral implant in a second position; 
           [0036]      FIG. 14  is an isometric view of a surgical tool illustrated with a rod, in a first position, for connecting spinal implants; 
           [0037]      FIG. 15  is an isometric view of a surgical tool illustrated with a rod, in a second position, for connecting spinal implants; 
           [0038]      FIG. 16  is a partial isometric and partially exploded view illustrating assembly of the surgical tool; 
           [0039]      FIG. 17  is a partial isometric and partially exploded view illustrating assembly of the surgical tool; 
           [0040]      FIG. 18  is a partial isometric and partially exploded view illustrating assembly of the surgical tool; 
           [0041]      FIG. 19  is an enlarged isometric view taken along lines  19 - 19  of  FIG. 18 ; 
           [0042]      FIG. 20  is a partial side view of the surgical tool; and 
           [0043]      FIG. 21  is a partial isometric view of the surgical tool. 
       
    
    
     DETAILED DESCRIPTION OF THE INVENTION 
       [0044]    While the present invention is susceptible of embodiment in various forms, there is shown in the drawings and will hereinafter be described a presently preferred, albeit not limiting, embodiment with the understanding that the present disclosure is to be considered an exemplification of the present invention and is not intended to limit the invention to the specific embodiments illustrated. 
         [0045]    Referring generally to  FIGS. 1-21 . The reference numeral  1  designates a surgical tool adapted for holding an implant device, preferably an orthopedic implant, designated generally as  2 , in a secure manner and operable for selectively allowing incremental reorientation of the implant  2  from a longitudinally extending first position as shown in  FIG. 1  to a second transverse orientation as seen in  FIG. 4  about axis  99 . The orientation of the implant  2  as seen in  FIG. 1  is for allowing the tool  1  to move the implant through a tube or distractor (not shown) to a surgical site, such as a patient&#39;s spine, while the position of the implant  2  as seen in  FIG. 4  is for insertion into a desired position in the patient. As seen, the tool  1  includes a handle section  3  having a movable grip  4  for effecting movement of a gear rack  5  ( FIG. 4 ) movably carried by an elongate probe  6  which is secured to the handle  3 . In a preferred embodiment, the tool  1  includes biasing means such as leaf springs  11  and lock means  14  which will selectively lock the grip  4  in a selected pivoted position, and thus the implant  2  at any desired rotational position. The tool  1  has a proximal end portion  15  and a distal end portion  16 . 
         [0046]    The handle section  3  includes a shank  18  that is connected to both the probe  6  and the grip  4 . As shown, the grip  4  is pivotally mounted between a pair of ears  19  via a pivot pin  20 . In a preferred embodiment, the probe  6  is secured to the shank  18  via a leg portion  22 . As shown, the leg portion  22  is positioned at an incline between the shank  18  and a distal end  16  portion of the probe  6 . In the illustrated embodiment, the grip  4  is comprised of a D loop portion or handle  23  that can be removably secured to a lever portion  24 , as with threaded fasteners  25 , such as socket head screws. The handle  23  defines a through opening  26  for receiving therethrough the fingers of the tool operator, such as a surgeon. The handle  23  has spaced runs  27 ,  28  defining the opening  26  on opposite sides and allows the operator to both positively pull the grip  4  toward the shank  18  and to push the handle  23  away from the shank  18  for a purpose later described, and to effect pivoting movement of the grip  4 . The leaf springs  11  are configured to also provide a movement of the handle  23  away from the shank  18  from force applied by the springs  11 . As shown, one of the springs  11  is suitably removably secured to the shank  18 , and one is suitably removably secured to the handle  23  as with suitable button head or truss head screw fasteners  30 . As shown, the shank  18  has a grip portion  33  removably secured to an elongate grip mount member  34  that is preferably in the form of an elongate channel member. Securement can be by suitable threaded fasteners such as socket head screws  35 . In the illustrated embodiment, the grip mount  34  is tubular and has a generally rectangular cross section. 
         [0047]    Referring to  FIGS. 1-3 and 10-18 . In the illustrated structure, the lock means  14  includes a latch member  38  pivotally mounted on the lever  24 , as at  36 , with pivot pin  42  and has a plurality of notches  39  on a surface  37  that is positioned adjacent to a proximal end of the grip mount  34 . A suitable catch, such as a detent  40 , extends outwardly from the grip mount  34  to selectively engage a surface defining a notch  39  to releasably fix the grip  4  in a preselected pivoted position by engaging a notch  39  on the latch  38 . A tab  41  has a portion thereof exposed to assist in releasing the latch  38  from retention and allowing the grip  4  to move. 
         [0048]    Referring to  FIGS. 1-21 . In the illustrated embodiment, the probe  6  includes a plurality of components mounted to one another in a manner for selective relative movement. As shown, the shaft includes components  43 ,  44  and  45 . The component  43 , is a guide housing having an offset leg portion  48  (comprising part of the leg  22 ) and an arm portion  49  extending therefrom. Extending from the leg portion  48  is a lug  50 . The guide housing  43  defines a channel  52  extending from the end adjacent the handle section  3  to the distal end  16 . Portions of the components  44 ,  45  are received within the channel  52  as later described. Preferably, the channel  52  has a generally rectangular transverse cross-sectional shape. The guide housing  43  can be provided with indicia  51  to assist the surgeon in knowing the position of the distal end  15  in a surgical tube. 
         [0049]    The component  45  is a support member that is suitably secured to the handle section  3  as with fasteners  53  such as button head or truss head screw fasteners. The support member  45  has a leg portion  59  (comprising part of the leg  22 ) received within the leg  48  and an arm portion  60  received within the arm  49 . The guide housing  43  is selectively movable relative to the support member  45  in a longitudinal direction along the length of the arms  49 ,  60 . The guide housing  43  may have suitable perforations  57  through walls thereof to allow viewing inside the channel  52  and to reduce weight. In a preferred embodiment, the cross-sectional shape of the channel  52  and the components  43 ,  44  and  45  is generally rectangular, which prevents relative rotation between the components. 
         [0050]    The guide housing  43  and rack carrier  44  are selectively longitudinally movable relative to the handle  3  and support member  45 . The support member  45  also includes an extension  61  that is suitably secured to the handle  3 , as with suitable fasteners  53  such as button head or truss head screws, as best seen in  FIG. 1 . As illustrated, the support member  45  preferably has a generally rectangular transverse cross-sectional shape. Preferably, the cross-sectional shape is a solid. The support member  45  has a distal end  63  and a proximal end  64 . The proximal end  64  is positioned adjacent the handle  3 , and the distal end  63  is positioned adjacent the distal end  16 . The support member  45  includes retainer means  55  to help retain an implant removably secured to the tool  1 . In a preferred embodiment, the retainer means  55  is removable from the support member  45  as with fasteners  65  such as button head or truss head screws. The retainer means  55  includes a tip  67  that, at its free end, includes a hook  68  that opens generally away from the probe  6 . The hook  68  is operable for helping retain an implant  2  releasably attached to the tool  1 . In a preferred embodiment, and as best seen in  FIGS. 2, 18 and 19 , means is provided to releasably fix the support member  45  from retraction movement along the channel  52  of the guide housing  43  during use of the tool  1 . The illustrated means includes a pair of laterally spaced apart second hooks  70  which receive a portion of the guide housing  43  in their mouths. 
         [0051]    The tool  1  is provided with the rack carrier  44  operably associated with the lever  24  such as with a pivot pin  78  extending through openings or holes  81 ,  83  in ears  79  on the lever  24  and ears  80  on the grip mount  34 . The carrier  44  has a leg section  74  (comprising part of the leg  22 ) and an arm section  75 , both of which preferably have a generally rectangular transverse cross-sectional shape and are solid. The arm  75  and leg  74  are juxtaposed with the arm  60  and leg  59  respectively. An extension  76  extends from the leg  74  into the handle  3 . The extensions  61 ,  76  are preferably also juxtaposed. The leg  74  and extension  76  are positioned at least partially within the channel  52  in the leg  48 . A connector  77  is preferably integral with, and extends into, the handle  3  from the extension  76 . The lever  24  is connected to the connector  77  in a pivotal manner as with a pivot pin  78  extending through holes  81  in ears  79  of the lever  24 , and holes  82  through ears  80  of the grip mount  34 , and a hole  83  through the connector  77 . As shown, the holes  81  are elongate to allow pivoting of the lever  24 . When the lever  24  is moved in either direction, it effects longitudinal movement of the arm  75  within the channel  52  and longitudinally relative to the arms  49 ,  60 . At the distal end of the arm  75 , there is provided a rotation means  84  to effect selective rotation of an implant mounted to the tool  1 . As shown, the rotation means  84  includes the gear rack  5  having a channel  85  positioned between two rows of gear teeth  86 . The gear teeth  86  face the tip  67 . As seen in  FIG. 9 , the channel  85  is T-shaped and receives therein a correspondingly T-shaped slide  84  which is part of the arm  60  of the support member  45  for retained sliding relative longitudinal movement. 
         [0052]    As best seen in  FIG. 8 , the distal end  16  of the arm  49  has notches  87  to receive a gear section  88  of the implant  2  in the provided clearance for rotation. The arm  49  also has an implant support finger  89  positioned at its distal end for engaging an axle portion  90  (shown hidden in  FIG. 4 ) positioned between two gear sections  86  of the implant  2 . As shown, the finger  89  fits between the two hooks  70  and has a notch  91  ( FIG. 5, 20 ). The finger  89  has a portion configured and positioned to retain the implant  2  removably mounted to the tool  1 , and a portion of which prevents the arm  49  from moving past the axle  90  when the arm  49  is being moved relative to the arm  60  for loading and releasing an implant  2 . 
         [0053]    In the illustrated embodiment, the guide housing  43 , rack carrier  44  and support member  45  are configured to prevent relative rotation therebetween while allowing relative longitudinal movement therebetween. In particular, the rack carrier  44  is movable relative to the guide housing  43  and support member  45  by movement of the lever  24 . The use of the D loop handle  23  permits the user to positively move the rack carrier  44  longitudinally in two directions. When the gear rack  5  moves in a direction from the proximal end  15  to the distal end  16 , the implant  2  will rotate to a counterclockwise position as seen in  FIG. 4 . When the gear rack  5  moves in the direction from the distal end  16  toward the proximal end  15 , the implant  2  will rotate to a clockwise position as seen in  FIG. 3 . In its initial position for movement to the surgical site, the implant  2  has its longitudinal axis generally parallel to the longitudinal axis of the probe  6  for insertion through a surgical tube. Once in the surgical site and clear of the surgical tube, the implant  2  can be rotated for insertion into the patient and then released from the tool  1  in a manner described below. In a preferred embodiment, the tool  1  has the support member  45  affixed to the handle section  3  in a manner to be immovable relative thereto through the use of the fasteners  53 . The rack carrier  44  can move relative to the handle  3  and the support  45  via movement of the lever  24 . In a preferred embodiment, movement of the lever  24  toward the grip portion  33  will move the support member  45 , and hence the gear rack  5 , to an extended position. Movement of the lever  24  away from the grip portion  33  will move the rack carrier  44  and the gear rack  5  to a retracted position. During these latter described movements of the rack carrier  44 , the guide housing  43  remains stationary relative to the support member  45 . 
         [0054]    The implant  2  is releasably mounted to the tool  1  for movement by the gear rack  5  as seen in  FIGS. 3, 4 . As best seen in  FIGS. 1, 3B and 12-15 , the implant  2 ,  102  is secured to the tool  1  adjacent its distal end  16 . The implant  2 ,  102  is provided with the axle  90  which is selectively captured by the hook  68  and finger  89 . To release the implant  2 ,  102  from securement to the tool  1 , the guide housing  43  is moved relative to the handle  3  and the support member  45 . This in turn moves the finger  89  relative to the hook  68  to provide a passage  92  for the axle  90  to move into and out of the throat  98  of the hook  68 . This movement by the operator can be facilitated by use of the lug  50  on the housing  43  and a lug  95  on the handle  3 . The finger  89  and hook  68  form jaw means operable to retain the axle  90  in the throat  98  of the hook  68 , allowing the implant  2 ,  102  to be selectively rotated by movement of the lever  24  and gear rack  5 . The lugs  50 ,  95  provide operator finger engaging means. By retracting the finger  89  toward the handle  3  through movement of the guide housing  43  toward the distal end  16 , the passage  92  is formed, allowing insertion or removal of the implant  2 ,  102 . By moving the finger  89  in the opposite direction, the passage  92  is closed and closes the throat  98  of the hook  68 , securing the implant  2 ,  102  in position. Preferably, the implant  2 ,  102  is positioned in a longitudinal orientation relative to the longitudinal axis of the probe  6  for insertion into a surgical tube and the patient. Once in position outside of the surgical tube, the lever  24  can be moved to rotate the implant  2 ,  102  by moving the gear rack  5  in a direction from the proximal end  15  to the distal end  16  as described above. The implant may be an intervertebral implant  2  or it may be a connecting implant, such as a connecting rod  102  or any other implant that can utilize the axle and gear to facilitate rotation of the implant without departing from the scope of the invention. 
         [0055]    Suitable means is provided for fixing the guide housing  43  in selective non-moving relationship to the support member  45 , while also allowing movement between the guide housing  43  and support member  45 . In the illustrated structure in  FIGS. 1 and 17 , a pin  93  is positioned for extending through a slot  94  that extends through the proximal end  64  of the support member  45 . The pin  93  may be either moved laterally such that a portion of the pin may freely move within the slot  94 , or the slot  94  can be figured as, for example, in a  FIG. 8  such that the pin can pass through a central reduced size portion of the slot  94 , but only with applied force. The pin  93  can be mounted to the guide housing  43  via a mounting block  96  that is suitably secured to the guide housing  43  as with screw fasteners  97  such as button head or truss head screws. 
         [0056]    In a preferred embodiment, the components of the tool  1  are made of metal alloys suitable for surgery, such as stainless steel and/or titanium. These provide strength, wear resistance and the ability to be sterilized and reused. The tool  1  can also be partially or completely disassembled to assist in cleaning, maintenance and repair. In order to be used in surgical access tubes, the sides of the arm  49  of the probe  6  is less than about ½ inch in width, and preferably less than about ⅜ inch. 
         [0057]    In operation, the tool  1  has an implant  2 ,  102  removably secured thereto. The passage  92  is opened by movement of the arm  49  toward the proximal end  15 . The implant  2 ,  102  has the axle  90  inserted into the throat  98  of the hook  68  and positioned rotatably as desired, but preferably longitudinally as seen in  FIG. 1 . The arm  49  is then moved so that the finger  89  closes the passage  92  and captures the axle  90  in the throat of the hook  68 . The probe  6  and implant  2 ,  102  are moved to the surgical sight, such as through a surgical tube if present. Once the implant  2 ,  102  is at the location for installation, the implant  2 ,  102  is rotated about its axle  90  by movement of the lever  24  and the gear rack  5  to the desired rotational position, such as that seen in  FIG. 4 . The implant  2 ,  102  is installed and then released from the tool  1 . The tool  1  is then removed from the patient and surgical sight. The lock means  14  are operable to fix the implant  2 ,  102  at any desired rotational position. 
         [0058]    All patents and publications mentioned in this specification are indicative of the levels of those skilled in the art to which the invention pertains. All patents and publications are herein incorporated by reference to the same extent as if each individual publication was specifically and individually indicated to be incorporated by reference. 
         [0059]    It is to be understood that while a certain form of the invention is illustrated, it is not to be limited to the specific form or arrangement herein described and shown. It will be apparent to those skilled in the art that various changes may be made without departing from the scope of the invention, and the invention is not to be considered limited to what is shown and described in the specification and any drawings/figures included herein. 
         [0060]    One skilled in the art will readily appreciate that the present invention is well adapted to carry out the objectives and obtain the ends and advantages mentioned, as well as those inherent therein. The embodiments, methods, procedures and techniques described herein are presently representative of the preferred embodiments, are intended to be exemplary and are not intended as limitations on the scope. Changes therein and other uses will occur to those skilled in the art which are encompassed within the spirit of the invention and are defined by the scope of the appended claims. Although the invention has been described in connection with specific preferred embodiments, it should be understood that the invention as claimed should not be unduly limited to such specific embodiments. Indeed, various modifications of the described modes for carrying out the invention which are obvious to those skilled in the art are intended to be within the scope of the following claims.