Abstract:
A partial reverse shoulder prosthesis includes a humeral stem and a variable angle tray including a plate including a through hole including at least two cutouts oriented horizontally across from one another, and a repositionable variable angle stem occupying at least a portion of an internal cavity defined by the through hole and including a first washer including threads at least partially defining a first opening, a post at least partially occupying the internal cavity, and a pin insertable into the first opening and having a threaded head sized to engage the threads of at least one of the first washer and the post; wherein the wall of the internal cavity is sized to retain the first washer and at least a portion of the post.

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
     This application is a continuation of U.S. patent application Ser. No. 13/464,429 filed May 4, 2012, issued as U.S. Pat. No. 8,814,941 on Aug. 26, 2014, and entitled “Variable Angle Reverse Humeral Tray,” the disclosure of which is expressly incorporated in its entirety herein by this reference. 
    
    
     TECHNICAL FIELD 
     The present disclosure relates to retention devices for surgical procedures and, more specifically, relates to variable angle prosthetic components including reverse shoulder prostheses. 
     SUMMARY OF THE INVENTION 
     In accordance with one embodiment of the present disclosure, a partial reverse shoulder prosthesis is provided and comprises a humeral stem and a variable angle tray adapted to be coupled to the humeral stem. The variable angle tray comprises a plate including a through hole at least partially defined by a wall that at least partially defines an internal cavity, the through hole including at least two cutouts oriented horizontally across from one another, and a variable angle stem occupying at least a portion of the internal cavity, the variable angle stem being selectively axially repostionable with respect to the plate to change the axial position of the variable angle stem with respect to the plate. The variable angle stem comprises a first washer including threads at least partially defining a first opening and being insertable into the internal cavity, a post at least partially occupying the internal cavity, the post including a tapered crown and an appendage axially extending from the plate, where the appendage is sized to be received by the humeral stem via a friction fit, and a pin including a threaded head and a longitudinal shaft extending from the threaded head, the pin being insertable into the first opening, where the threaded head is sized to engage the threads of at least one of the first washer and the post. In accordance to this specific embodiment, the wall is sized to retain the first washer and at least a portion of the post within the through hole. 
     In accordance with another embodiment of the present disclosure, a partial reverse shoulder prosthesis comprises a humeral stem and a variable angle tray adapted to be coupled to the humeral stem. The variable angle tray comprises a plate including a through hole at least partially defined by a wall that at least partially defines an internal cavity, the through hole including at least two cutouts oriented horizontally across from one another, and a variable angle stem occupying at least a portion of the internal cavity, the variable angle stem being selectively axially repostionable with respect to the plate to change an axial position of the variable angle stem with respect to the plate, the variable angle stem comprising a first washer including threads at least partially defining a first opening and being insertable into the internal cavity, a second washer defining a second opening and being insertable into the through hole, the second washer including a widthwise dimension substantially greater than a thickness of the second washer, a post at least partially occupying the internal cavity, the post including threads, a tapered crown and an appendage axially extending from the plate, where the appendage is sized to be received by the humeral stem via a friction fit, and a pin including a threaded head and a longitudinal shaft extending from the threaded head, the pin being insertable into the first opening, where the threaded head is sized to engage the threads of at least one of the first washer and the post. In accordance with this embodiment, the wall is sized to retain the first washer and at least a portion of the post within the through hole. 
     In accordance with yet another embodiment of the present disclosure, a partial reverse shoulder prosthesis comprises a humeral stem and a variable angle tray adapted to be coupled to the humeral stem, the variable angle tray comprising a plate including a through hole at least partially defined by a wall that at least partially defines an internal cavity, the through hole including at least two cutouts oriented horizontally across from one another, and a variable angle stem occupying at least a portion of the internal cavity, the variable angle stem being selectively axially repostionable with respect to the plate to change an axial position of the variable angle stem with respect to the plate. The variable angle stem comprises a first washer including threads at least partially defining a first opening and being insertable into the internal cavity, a post at least partially occupying the internal cavity, the post including threads, a tapered crown and an appendage axially extending from the plate, where the appendage is sized to be received by the humeral stem via a friction fit, and a pin including a threaded head and a longitudinal shaft extending from the threaded head, the pin being insertable into the first opening, where the threaded head is sized to engage the threads of at least one of the first washer and the post. The wall is sized to retain the first washer and at least a portion of the post within the through hole, and the post includes a hollow adapted to receive at least a portion of the longitudinal shaft of the pin. 
     In accordance with still another embodiment of the present disclosure, a partial reverse shoulder prosthesis comprises a humeral stem, a humeral cup, and a variable angle tray adapted to be coupled to the humeral stem and the humeral cup, the variable angle tray comprising a plate including an arcuate wall at least partially defining an internal cavity, the through hole including at least two cutouts oriented horizontally across from one another, a bearing adapted to occupy at least a portion of the internal cavity, the bearing being axially and rotationally repositionable with respect to the plate, the bearing operative to selectively expand in at least one dimension to wedge the bearing against the arcuate wall to inhibit axial and rotational repositioning of the bearing with respect to the plate, and a projection adapted to be coupled to the humeral stem in order to mount the variable angle tray to the humeral stem. The arcuate wall is sized to retain a portion of the bearing within the internal cavity, and the bearing comprises a plurality of washers and a threaded fastener. 
     Still other objects and benefits of the invention will become apparent from the following written description along with the accompanying figures. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       The above-mentioned aspects of the present invention and the manner of obtaining them will become more apparent and the invention itself will be better understood by reference to the following description of the embodiments of the invention taken in conjunction with the accompanying drawings, wherein: 
         FIG. 1  is a frontal representation of bones, overlaid by skin, of a human shoulder region subsequent to a shoulder replacement where a reverse shoulder prosthesis has been implanted; 
         FIG. 2  is a cross-sectional view of a first exemplary partial shoulder joint implant; 
         FIG. 3  is a top view of the exemplary plate shown in  FIG. 2 ; 
         FIG. 4  is a cross-sectional view taken along lines  3 - 3  of  FIG. 3 ; 
         FIG. 5  is a profile view of the exemplary washer of  FIG. 2 ; 
         FIG. 6  is an elevated perspective view of the exemplary washer of  FIG. 5 ; 
         FIG. 7  is an elevated perspective view of the exemplary pin of  FIG. 2 ; 
         FIG. 8  is an elevated perspective view of the exemplary post of  FIG. 2 ; 
         FIG. 9  is an elevated perspective view of the exemplary spring washer of  FIG. 2 ; 
         FIG. 10  is a profile view of an exemplary tool for use with the exemplary partial shoulder joint implant of  FIG. 2 ; 
         FIG. 11  is an elevated perspective view of a distal end of the exemplary tool of  FIG. 10 ; 
         FIG. 12  is a cross-sectional view of an alternate exemplary plate taken along line  13 - 13  of  FIG. 13 ; and 
         FIG. 13  is a top view of the alternate exemplary plate of  FIG. 12 . 
     
    
    
     Corresponding reference characters indicate corresponding parts throughout the several views. Although the exemplification set out herein illustrates embodiments of the invention, in several forms, the embodiments disclosed below are not intended to be exhaustive or to be construed as limiting the scope of the invention to the precise forms disclosed. 
     DETAILED DESCRIPTION 
     The embodiments of the present invention described below are not intended to be exhaustive or to limit the invention to the precise forms disclosed in the following detailed description. Rather, the embodiments are chosen and described so that others skilled in the art may appreciate and understand the principles and practices of the present invention. 
     Unless defined otherwise, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this invention belongs. Although any method and materials similar or equivalent to those described herein can be used in the practice or testing of the present invention, the specific methods and materials are now described. Moreover, the techniques employed or contemplated herein are standard methodologies well known to one of ordinary skill in the art and the materials, methods and examples are illustrative only and not intended to be limiting. 
     The exemplary embodiments of the present disclosure are described and illustrated below to encompass retention devices for surgical procedures and methods of fabricating the retention devices and using the retention devices in a surgical procedure. Of course, it will be apparent to those of ordinary skill in the art that the preferred embodiments discussed below are exemplary in nature and may be reconfigured without departing from the scope and spirit of the present invention. However, for clarity and precision, the exemplary embodiments as discussed below may include optional steps, methods, and features that one of ordinary skill should recognize as not being a requisite to fall within the scope of the present invention. 
     Referencing  FIGS. 1 and 2 , a first exemplary partial shoulder joint implant  100  comprises a portion of a reversible ball and socket joint. The ball portion of the joint is adapted to be coupled to a scapula  102 , and includes a scapula retainer  104  and a scapula ball  108 . In contrast, the socket portion of the joint comprises a humeral shaft  110  seated within an intramedullary canal of a proximal humerus  112  having a humeral cup  114  mounted to a variable angle tray  116  that is coupled to the humeral shaft. 
     As shown in  FIGS. 3 and 4 , the variable angle tray  116  includes a plate  120  having an oblong vertical profile. Generally centered within the plate  120  is a through orifice  122  extending between top and bottom surfaces  124 ,  126 . The vertical cross-section of the through orifice  122  is not constant, but rather changes along an axis extending vertically through the orifice. More specifically, an inner circumferential wall  130  of the plate  120  partially defines a spherical cavity  132  where the diameter of the through orifice  122  is at a minimum at the top and bottom surfaces  124 ,  126 , but is at a maximum at the vertical midpoint of the through orifice. In this first exemplary plate  120 , the spherical cavity is partially defined by a removable cap  136  that includes threads  138  that engage corresponding threads  140  of a primary portion  142  of the plate. In this fashion, the cap  136  may be disengaged from the primary portion  142  in order to allow components to be seated within the spherical cavity  132  and thereafter reattached to the primary portion to inhibit certain components from egressing from the spherical cavity. The underside of the cap  136  includes an inner circumferential wall  144  that partially defines the spherical cavity  132 . The diameter of the inner circumferential wall  144  increases from the underside of the cap  136  to the top planar surface  146  of the cap having an opening  148  formed therein to accept the pin  160 . 
     Alternatively, the cap  136  need not threadably engage the primary portion  142  of the plate  120 . Instead, the threaded cap  136  may be secured to the primary portion  142  by using a snap ring or a taper (not shown) received within a corresponding cavity of the primary portion. 
     Referencing  FIGS. 2-6 , a washer  150  is adapted to be seated within the spherical cavity  132 . This washer  150  comprises a Belleville washer having a convex, rounded exterior surface  152  (that may be smooth or textured) that converges and meets a substantially planar exterior surface  154 . The rounded exterior surface  152  may include one or more depressions  155  that circumscribe an orifice  156  extending linearly through the rounded exterior surface  152  at its apex. As will be discussed in more detail hereafter, the one or more of the depressions  155  are adapted to receive projections from a driver  260  that may be used to retain the relative orientation of the washer. The through orifice  156  is substantially perpendicular to the planar exterior surface  154  and is delineated by a circumferential, circular wall having a series of threads  158  adapted to be engaged by a pin  160 . 
     While the washer  150  is shown in exemplary form as a continuous washer, it is also within the scope of the disclosure for the washer to include a radial cut  157  (shown in phantom) that renders the washer discontinuous. In this manner, the circumferential dimension of the washer  150  can more readily expand and contract depending upon the presence or absence of the pin  160 . Moreover, while the washer is shown in exemplary form as a Belleville washer, it should also be known that one may use a helical washer, a wave spring washer, or a helical coil in place of the spring washer. 
     Referring to  FIGS. 2-7 , the pin  160  comprises a cylindrical shaft  162  having a convex, semispherical distal end  164 . Opposite the distal end  164  is a proximal end  166  including a substantially planar surface  168  that circumscribes an opening extending into the interior of the proximal end to create a proximal cavity  170 . In exemplary form, this proximal cavity  170  is delineated by a series of vertical walls  172  having a hexagonal configuration. An outer circumference of the proximal end  164  includes a series of threads  174  sized to engage the threads of the  158  of the washer  150 . In this manner, the pin  160  may extend into the orifice  156  of the washer  150  and be vertically repositioned therein by rotating the pin with respect to the washer. In addition to engaging the washer  150 , the pin  160  is also adapted to engage a post  180 . 
     Referencing  FIG. 8 , the post  180  comprises an elongated stem  182  with a generally circular axial cross-section that tapers from proximal to distal. A proximal end  184  of the post  180  includes a generally planar top surface with a circular edge  186  defining the circumferential boundary of the adapter. Inset and centered with respect to the circular edge  186  is a depression  190  formed into the interior of the post  180 . In exemplary form, the depression is bounded by a semispherical wall  192  having a diameter that is large enough to accommodate a portion of the proximal end  164  of the pin  160 . More specifically, in this exemplary embodiment, the diameter of the semispherical wall  192  is one and a half times the diameter of the pin  160 . 
     Extending proximally from the circular edge  186 , a peripheral surface  196  of the post  180  embodies the curvature of a partial sphere and tapers from proximal to distal until reaching a conical surface  198  that circumscribes a frustoconical projection  200  having a substantially planar distal surface  202 . In exemplary form, the horizontal cross-section of the frustoconical projection  200  is circular, the diameter of which decreases from proximal to distal between the endpoint of the peripheral surface  196  and the circular perimeter of the planar distal surface  202 . In this manner, the frustoconical projection  200  is centered along a longitudinal axis  204  that vertically extends through the depression  190 . 
     Referencing  FIG. 9 , a spring washer  210  is adapted to interpose the first washer  150  and the post  180  when positioned within the spherical cavity  132 . The function of the spring washer  210  is to force the rounded exterior surface  152  of the first washer  150  and the peripheral surface  196  of the post  180  against the inner circumferential walls  130 ,  144  of the plate  120  and cap  136 . The force of the spring washer is chosen to allow axial and rotational repositioning of the assembly (post  180  and washers  150 ,  210 ), but provide sufficient resistance to rotational motion of the first washer  150  so that this washer substantially stays in a fixed position when the pin  160  is inserted into the orifice  156  and rotated so the threads  158 ,  174  engage one another and the pin vertically advances with respect to the first washer. 
     In this exemplary embodiment, a domed spring washer  210  is utilized. This spring washer  210  includes a convex top surface  214  and a concave bottom surface that are generally parallel to one another and are spaced apart by a thickness dimension. An orifice  216  is axially centered and extends through the spring washer  210 . In this exemplary embodiment, the orifice is generally circular. But it should be noted that other shaped orifices could be alternatively used. The outer periphery  218  of the spring washer  210  takes on a circular shape so that the washer has a constant radial distance between the outer periphery and the boundary defining the orifice  216  along the entire circumference, to provide a ring shape. In this exemplary embodiment, the spring washer  210  is fabricated from a metal that includes material properties providing partial elasticity that allows the washer to be compressed (from top and bottom) and spring back into shape when not compressed. 
     Referring to  FIGS. 10 and 11 , an exemplary tool  240  for use with the partial shoulder joint implant  100  includes an outer housing  242  defining a cylindrical bore occupied by an inner shaft  244  that is longitudinally and rotatably repositionable with respect to the outer housing. The distal end  246  of the outer housing  242  includes four projections  248  evenly spaced and oriented in a circular pattern. In this exemplary embodiment, each projection  248  includes an outer arcuate surface  250  spaced apart from an inner arcuate surface  252  by two planar side surfaces  254  and a bottom surface  256 . As will be discussed in more detail below, the projections  248  are adapted to be received within the recesses  155  of the washer  150  in order to inhibit rotation of the washer with respect to the inner shaft  244 . At a distal end of the inner shaft  244  is a hexagonal driver  260  having six vertical sidewalls and a substantially planar bottom surface  264 . Again, as will be discussed in more detail below, the driver  260  is adapted to be received within the proximal cavity  170  of the pin  160  in order to rotate of the pin with respect to the outer housing  242  and the washer  150 . 
     Referring to  FIGS. 1-9 , assembly of the partial shoulder joint implant  100  includes seating the humeral shaft  110  within the intramedullary canal of the proximal humerus  112 . To ensure the shaft  110  maintains its position with respect to the humerus  112 , the shaft  110  may incorporate bone ingrowth materials or features in addition to the use of adhesives or cements interposing the shaft and humerus. This shaft  110  may include a socket adapted to directly receive a portion of the elongated stem  182  of the post  180  via a friction fit, thereby inhibiting relative movement between the post  180  and shaft  110 . Conversely, the shaft  110  may include a socket adapted to directly receive a stem adapter  230 , which itself includes a cavity  232  for receiving a portion of the elongated stem  182  of the post  180 . Relative movement between the stem adapter  230  and the humeral shaft  110  is inhibited after the adapter and shaft are secured via a friction fit. Alternatively, or in addition, the stem adapter  230  may be mounted to the humeral shaft  110  using an adhesive or cement. For purposes of explanation, the assembly will be discussed to include a stem adapter  230 . 
     After the shaft  110  is mounted to the humerus  112  and the stem adapter  230  is mounted to the shaft  110 , the variable angle tray  116  may be mounted to the stem adapter. Prior to mounting the variable angle tray  116  to the stem adapter  230 , at least a portion of the tray must be assembled. Assembly of the tray  116  begins with the plate  120  without the humeral cup  114  or the removable cap  136  being mounted thereto and without any components being seated within the spherical cavity  132 . Thereafter, the post  180  is inserted into the orifice  122  so that a portion of the elongated stem extends beyond the bottom surface  126  of the plate  120 . Generally, the peripheral surface  196  of the post  180  will contact the inner circumferential wall  130 . Given that the diameter of the orifice  122  is greater than the diameter of the elongated stem  182 , but less than the diameter of the proximal end  184  of the post  180 , the post is able to be rotationally and axially repositioned with respect to the tray  120 . 
     After the post  180  is inserted into the tray  120 , the spring washer  210  is inserted into the spherical cavity  132  so that the orifice  216  is axially aligned with the depression  190  of the post  180 . Thereafter, the washer  150  is inserted into the spherical cavity  132  so its orifice  156  is axially aligned with the orifice  216  of the spring washer  210  and the depression  190  of the post  180 . At this point, after the washer  150 , spring washer  210  and post  180  have been inserted into the spherical cavity  132 , the cap  136  is mounted to the plate  120  via a threaded connection between the threads  138  of the cap and threads  140  of the plate. The cap  136  is rotated with respect to the plate  120  until the cap can no longer be rotated, thereby securing the cap to the plate via a friction fit. At this time, the washer  150 , spring washer  210  and the post  180  cannot be removed from the spherical cavity  132 . But the compilation of the washer  150 , spring washer  210  and the post  180  are rotationally and axially repositionable within the spherical cavity  132  at this point. 
     In order to lock the position of the washer  150 , spring washer  210  and the post  180  within the spherical cavity  132 , the pin  160  is inserted (distal end  164  first) through the opening  148  of the cap  136 , through the orifice  156  of the washer, and through the orifice  216  of the spring washer  210 . Eventually, the pin  160  is inserted deep enough that its threads  174  engage the threads  158  of the washer  150 . At this point, further penetration of the pin  160  requires the pin to be rotated with respect to the washer  150 . 
     The tool  240  is thereafter used to rotate the pin  160  with respect to the washer  150 , as well as axially reposition the washer  150 , spring washer  210  and the post  180  with respect to the plate  120 . Depending upon the desired angle a surgeon wants to set the tray  116  with respect to the humeral shaft  110 , the surgeon manipulates the tool  240  to the desired angle to lock the relative position of the washer  150 , spring washer  210  and the post  180  with respect to the plate  120 . In exemplary from, the driver  260  is inserted into the proximal cavity  170  of the pin  160  so that rotation of the driver will result in rotation of the pin in the same direction. Likewise, the projections  248  of the outer housing  242  are received within recesses  155  of the washer  150  so that if the outer housing  242  is stationary, so too is the washer. After the tool  240  has engaged the pin  160  and the washer  150 , the driver  260  is rotated so the threads  158 ,  174  engage one another to draw the pin deeper into the spherical cavity  132 . At a predetermined point, the distal end  164  of the pin  160  contacts the semicircular wall  192 . After this point, continued movement of the pin  160  operates to moves the washer  150  vertically away from the proximal end  184  of the post  180  to eventually form a wedge locking the washer and post in position. This wedge is exhibited when no further rotational motion of the pin  160  with respect to the post  180  is available. When the wedge is created, the axial position of the post  180 , and hence its elongated stem  182 , is locked in position with respect to the plate  120 . At this time, the tool  240  may be removed and the tray  116  mounted to the stem adapter  230 . In this manner, relative movement between the stem adapter  230  and the tray  116  is inhibited after the adapter and tray are secured via a friction fit. Alternatively, or in addition, the stem adapter  230  may be mounted to the tray  116  using an adhesive or cement. After the tray  116  is mounted to the stem adapter  230 , the humeral cup  114  may be mounted to the tray. 
     Referring to  FIGS. 12 and 13 , an alternate exemplary plate  320  may be used in place of the foregoing plate  120 . In contrast to the foregoing plate  120 , this alternate exemplary plate  320  does not include a removable cap  136 . As with the first exemplary plate  120 , this alternate exemplary plate  320  includes an oblong vertical profile. Generally centered within the plate  320  is a through orifice  322  extending between top and bottom surfaces  324 ,  326 . The vertical cross-section of the through orifice  322  is not constant, but rather changes along an axis extending vertically through the orifice. More specifically, an inner circumferential wall  330  of the plate  320  partially defines a spherical cavity  332  where the diameter of the through orifice  322  is at a minimum at the top and bottom surfaces  324 ,  326 , but is at a maximum at the vertical midpoint of the through orifice. But the spherical cavity  332  is not entirely spherical. A pair of cutouts  336  are formed vertically through the top surface  324  and radially into the plate  320  to accommodate insertion of washers. The cutouts  336 , in exemplary form, may be oriented on the same side of a diametric line and formed vertically to a midpoint of the plate  320 . The dimension of the cutouts  336  accommodate vertical insertion of the washers when the washers are turned so that the vertical dimension (i.e., thickness) of the washers is oriented horizontally so the washers can be inserted into the spherical cavity  332  and then axially repositioned so the vertical dimension is oriented vertically. In other words, the thickness of each of the washers is less than the width of the cutouts  336 . Because the cutouts  336  do not extend around the entire circumference of the cavity  332 , once the washers are inserted into the cavity and axially repositioned, the washers may not be removed from the cavity unless the washers are axially repositioned so that the horizontal position is vertically oriented. 
     Using the alternate exemplary plate  320  requires using a modified post  180 . In this manner, the elongated stem  182  is removable from the proximal end  184  via a threaded connection. More specifically, the elongated stem  182  includes a male threaded connection that is received with a female threaded connection of the proximal end  184 . As a result, only the proximal end  184  of the post  180  need to inserted in between the cutouts  336 . After the proximal end  184  of the post  180  is within the spherical cavity  332 , the elongated stem  182  is coupled to the proximal end by engagement of the threaded connections. Beyond these modifications, all other aspects are substantially the same as the first exemplary embodiment. 
     Following from the above description and invention summaries, it should be apparent to those of ordinary skill in the art that, while the methods and apparatuses herein described constitute exemplary embodiments of the present invention, the invention contained herein is not limited to this precise embodiment and that changes may be made to such embodiments without departing from the scope of the invention as defined by the claims. Additionally, it is to be understood that the invention is defined by the claims and it is not intended that any limitations or elements describing the exemplary embodiments set forth herein are to be incorporated into the interpretation of any claim element unless such limitation or element is explicitly stated. Likewise, it is to be understood that it is not necessary to meet any or all of the identified advantages or objects of the invention disclosed herein in order to fall within the scope of any claims, since the invention is defined by the claims and since inherent and/or unforeseen advantages of the present invention may exist even though they may not have been explicitly discussed herein. 
     The terminology used herein is for the purpose of describing particular illustrative embodiments only and is not intended to be limiting. As used herein, the singular forms “a”, “an” and “the” may be intended to include the plural forms as well, unless the context clearly indicates otherwise. The terms “comprises,” “comprising,” “including,” and “having,” are inclusive and therefore specify the presence of stated features, integers, steps, operations, elements, and/or components, but do not preclude the presence or addition of one or more other features, integers, steps, operations, elements, components, and/or groups thereof. The method steps, processes, and operations described herein are not to be construed as necessarily requiring their performance in the particular order discussed or illustrated, unless specifically identified as an order of performance. It is also to be understood that additional or alternative steps may be employed. 
     When an element or layer is referred to as being “on”, “engaged to”, “connected to” or “coupled to” another element or layer, it may be directly on, engaged, connected or coupled to the other element or layer, or intervening elements or layers may be present. In contrast, when an element is referred to as being “directly on,” “directly engaged to”, “directly connected to” or “directly coupled to” another element or layer, there may be no intervening elements or layers present. Other words used to describe the relationship between elements should be interpreted in a like fashion (e.g., “between” versus “directly between,” “adjacent” versus “directly adjacent,” etc.). As used herein, the term “and/or” includes any and all combinations of one or more of the associated listed items. 
     Although the terms first, second, third, etc. may be used herein to describe various elements, components, regions, layers and/or sections, these elements, components, regions, layers and/or sections should not be limited by these terms. These terms may be only used to distinguish one element, component, region, layer or section from another region, layer or section. Terms such as “first,” “second,” and other numerical terms when used herein do not imply a sequence or order unless clearly indicated by the context. Thus, a first element, component, region, layer or section discussed below could be termed a second element, component, region, layer or section without departing from the teachings of the example embodiments. 
     Spatially relative terms, such as “inner,” “outer,” “beneath”, “below”, “lower”, “above”, “upper” and the like, may be used herein for ease of description to describe one element or feature&#39;s relationship to another element(s) or feature(s) as illustrated in the figures. Spatially relative terms may be intended to encompass different orientations of the device in use or operation in addition to the orientation depicted in the figures. For example, if the device in the figures is turned over, elements described as “below” or “beneath” other elements or features would then be oriented “above” the other elements or features. Thus, the example term “below” can encompass both an orientation of above and below. The device may be otherwise oriented (rotated 90 degrees or at other orientations).