Abstract:
A tissue removal method utilizes a tool having a shaft with a flexible inner member rotatable about the shaft and an outer member extending along the inner member. The inner and outer members are bent to a desired configuration and the inner member rotates relative to the outer member while maintaining the shaft in the desired configuration under the influence of the rigidity of the outer member during rotation of the inner member. A patient&#39;s body tissue is cut with a cutting element connected with the inner member during rotation and the body tissue cut from the patient is moved along a passage within the shaft while the shaft is maintained in the desired configuration.

Description:
RELATED APPLICATIONS 
     This application is a continuation of U.S. patent application Ser. No. 09/483,676, filed Jan. 14, 2000 now U.S. Pat. No. 6,468,289. The aforementioned application Ser. No. 09/483,676 is itself a continuation of U.S. patent application Ser. No. 09/323,326 filed Jun. 1, 1999, (now U.S. Pat. No. 6,174,313). The aforementioned application Ser. No. 09/323,326 is a continuation of U.S. patent application Ser. No. 08/834,835 filed Apr. 11, 1997 (now U.S. Pat. No. 5,935,131). The aforementioned application Ser. No. 08/834,835 is itself a divisional of U.S. patent application Ser. No. 08/695,274 filed Aug. 9, 1996, (now U.S. Pat. No. 5,694,951). The aforementioned application Ser. No. 08/695,274 is itself a divisional of U.S. patent application Ser. No. 08/353,494 filed on Dec. 9, 1994, (now U.S. Pat. No. 5,577,517). The aforementioned application Ser. No. 08/353,494 is itself a divisional of U.S. application Ser. No. 08/134,914 filed Oct. 12, 1993, (now U.S. Pat. No. 5,403,317). The aforementioned application Ser. No. 08/134,914 filed Oct. 12, 1993 is itself a divisional of U.S. application Ser. No. 07/545,908 filed Jun. 28, 1990, (now U.S. Pat. No. 5,269,785). The benefit of the earlier filing dates of the aforementioned application Ser. Nos. 09/483,676; 09/323,326; 08/834,835; 08/695,274; 08/353,494; 08/134,914 and 07/545,908 is hereby claimed. 
    
    
     BACKGROUND OF THE INVENTION 
     1. Technical Field 
     The present invention relates to the field of tissue removal and tissue grafting. More particularly, the present invention relates to an apparatus and method for the percutaneous cutting and removal of selected portions of tissue from a patient and the possible harvesting and implantation of the tissue portion in the donor. 
     2. Description of the Prior Art 
     There are various known methods and apparatus for the cutting and removal of tissue fragments from a human. Each of these, however, suffers from one or more deficiencies. 
     U.S. Pat. No. 4,832,683 shows an instrument for ultrasonic cutting of bones, with irrigation or suction. However, there is no suction while cutting, no removal of the cut bone or tissue, and no flexibility in the instrument. 
     U.S. Pat. No. 4,265,231 shows apparatus for drilling a curved hole having a flexible shaft confined in a rigid tubular sheath, but which shows no removal of cut bone or tissue. 
     U.S. Pat. No. 4,541,423 shows apparatus for drilling a curved hole having a flexible shaft confined in a semi-rigid tubular sheath, but which shows no removal of cut bone or tissue. 
     U.S. Pat. No. 4,589,414 shows a surgical cutting instrument with a reciprocatory cutting motion, but which has no removal of cut bone or tissue, and no flexibility in the instrument. 
     U.S. Pat. No. 4,603,694 shows a rotating arthroscopic shaver with suction, but which is not flexible and which has no removal of cut bone or tissue. 
     U.S. Pat. No. 4,751,922 shows a flexible medullary reamer with a plastic shaft and a guide rod, but which has no suction and no removal of the cut bone or tissue. 
     U.S. Pat. Nos. 4,798,213, 4,649,918, and 4,142,517 show various apparatus for bone coring. 
     SUMMARY OF THE INVENTION 
     The present invention is a percutaneous tissue removal apparatus including a flexible drill shaft and means for transmitting motion to the shaft. A cutting tip is mounted on the shaft to cut tissue fragments from the tissue. The tissue fragments are removed by suction along the flexible drill shaft to a location outside the body while cutting. One or more selected components of the removed tissue fragments may be collected for implantation, preferably into the body of the patient from whom they were removed. Because the drill shaft is flexible, the surgeon can guide the cutting tip into various locations within the tissue from a small (percutaneous) incision. The surgeon can cut around arcs or angles, rather than only being able to go in a straight line, to reach any desired location, and to avoid vital tissue which would otherwise be in the cutting path. For example, when removing unwanted tissue inside a knee joint the drill shaft can deform, and is therefore less likely to damage normal tissue or joint surfaces. None of these functions is possible with a straight line system. 
     GENERAL DESCRIPTION OF THE INVENTION 
     The present invention is a percutaneous tissue removal device and method. In the preferred embodiments described below, the apparatus and method are illustrated as used for removal of bone tissue, but such description is for illustrative purposes only. The invention is not limited to the removal of bone tissue and may be used for removal of cartilage, muscle, fetal tissue, etc. It may be used to break up and remove kidney stones, in the gall bladder for a stone or tumor, in the stomach, in the colon to remove a polyp or tumor, etc. It can reach spaces not currently available with the straight line systems currently available. 
     A percutaneous tissue removal apparatus in accordance with the present invention includes a flexible drill shaft for insertion inside a tissue. A cutting tip is mounted on the drill shaft for cutting the tissue. Either rotating motion or reciprocating motion is transmitted to the drill shaft to move the cutting tip against the tissue to cut tissue fragments from the tissue. While cutting, the tissue fragments are removed by suction to a location outside the body. The drill shaft and cutting tip are small enough to be usable percutaneously. They may also be used for endoscopic, arthroscopic or fiberoptic or open surgery. 
     Because the drill shaft is flexible, the surgeon can guide the cutting tip into various locations within the tissue from one percutaneous incision. The surgeon can cut around arcs or angles, rather than only being able to go in a straight line, to reach any desired location, and to avoid vital tissue which would otherwise be in the cutting path. The flexible drill shaft also allows the surgeon when working inside a bone, for example, to keep the cutting tip away from the harder outer cortical bone and to remove only the softer inner cancellous bone. None of these features is available with the current straight line cutting devices. 
     The drill shaft may be made of metal, of polymeric material to reduce friction, or of a composite material. Extensive use of polymers in the drill shaft, its housing if provided, and the cutting tip area reduces friction substantially, thus requiring less energy and generating less heat within the tissue. The drill shaft is drivable by hand (for improved feel) or by motor, at variable speeds based on the need for the tissue removed. 
     To provide for the collection of the tissue fragments to be harvested, the removal apparatus has an axially extending suction passage along the drill shaft through which the tissue fragments are removed. The suction passage has a smooth lining to keep the tissue fragments or graft material contained and to reduce friction of the harvested tissue fragments. This lining may be the inside diameter of the flexible drill shaft itself, or may be a separate liner sleeve which can be removed and disposed of when it becomes unsanitary or clogged, without having to remove the drill shaft and cutting tip. Alternatively, if a separate guide sleeve or guide rod is used the suction passage may be formed between the drill shaft and the guide sleeve or guide rod. In such a case, the drill shaft may be solid rather than hollow. 
     The cutting tip is made of a material which is harder than the material to be cut. The cutting tip may be slightly larger in diameter than the drill shaft. The cutting tip may be made of a polymeric material or a composite material. Alternatively, the cutting tip may be made of a ceramic material. The cutting tip is separable from the drill shaft, and several different cutting tips may be provided in varying hardnesses, so that the surgeon can selectively remove various portions of tissue as desired. 
     By virtue of its flexibility, the flexible drill shaft, when removing bone tissue, may stay within the cortical confines of the bone. Alternatively, it may work with a guide device to control the location of the cutting tip within the bone. The guide means may be a guide rod extending within the flexible drill shaft, or a hollow guide sleeve outside the flexible drill shaft. The guide rod or guide sleeve may be rigid in a particular shape, to fit a particular application; or it may be bendable into a particular shape which it will hold; or it may be selectively rigidifiable into a particular shape in situ. The guide means may include structure for positioning the tip of the flexible drill shaft. The guide means may also be inserted into a separate flexible tube system to guide it to a specific location, then removed, allowing the flexible drill to be inserted. 
     Fluid may be injected through the flexible drill shaft to a location adjacent the cutting tip to increase the efficiency of the tissue removal and to limit thermal necrosis. Alternatively, a fluid injection passage may extend axially along the flexible drill shaft, the drill shaft. Alternatively, fluid may be injected through the suction passage, alternating with the suction. The fluid injection may be constant or it may be pulsatile in nature. If fluid injection is used, centrifuging of the harvested material may be performed. 
     Means for collecting one or more selected components of the harvested tissue fragments may include a known trap or filter connected to the outlet of the suction passage. Removed tissue may be centrifuged to separate its components. Thus, the tissue fragments are not merely removed from the body and may be harvested for implantation of the fragments, preferably into the body of the patient from whom they were removed. In order to maintain the sterility of the tissue removed, the entire suction apparatus including the suction passage and the trap or filter is sterilized, and, if necessary, is disposable. 
     With the present invention all work is done by going percutaneously through the skin to a specific tissue area to minimize the damage to skin, muscle, and bone. For example, when removing bone tissue, trauma is limited to a small opening in the hard outer structural cortical bone, limiting postoperative bleeding from the bone which is difficult to stop, because the small operative hole can easily be plugged after the grafting procedure is completed, preventing postoperative bleeding into soft tissue. There is only intraosseous bleeding, so that fewer complications, and less pain, are likely to arise. The operation does not create stress risers which would weaken the bone. Thus, the present invention provides a safe and efficient way to collect and reuse a patient&#39;s own tissue. 
     Human tissue grafting works best using the patient&#39;s own tissue as donor material. Therefore, the harvested tissue may be implanted in the donor&#39;s own body for grafting. To implant one or more selected components of harvested bone fragments, for example, a cannula is inserted through the skin and muscle to the area of the bone where the graft is to be placed. A drill or curette is then used to remove a portion of the outer cortical bone. A curette or probe is inserted through the cannula to clear out the area where the graft is to be placed, either in open surgery or through X-ray guidance in percutaneous surgery. The harvested tissue fragments may be packed or compressed into a plug of tissue graft material, of a specific shape, with or without blood or fibrin for adhesion. Or, a retaining material such as a biodegradable mesh may be used to hold the graft material together as a unit. The graft material and its retaining material are then inserted at the graft location in the bone. Alternatively, the graft material is inserted and then sealed in place with a mass of formable polymeric material inserted over the graft material to hold the graft together in position. 
     A method of percutaneous tissue removal in accordance with the present invention includes the steps of placing within a tissue mass a flexible drill shaft having mounted thereon a cutting tip for cutting the tissue; transmitting motion to the drill shaft to move the cutting tip against the tissue to cut tissue fragments from the tissue; and removing the tissue fragments by suction to a location outside the tissue mass while cutting the tissue. The method may further include the step of controlling the location of the cutting tip within the tissue with a guide rod, the step of collecting one or more selected components of the harvested tissue fragments, and/or the step of implanting the fragments into the body of the patient from whom they were removed. 
    
    
     BRIEF DESCRIPTION OF THE DRAWINGS 
     Further features of the present invention will become apparent to those skilled in the art to which the present invention relates from reading the following specification with reference to the accompanying drawings, in which: 
     FIG. 1 is a schematic view of a tissue removal system in accordance with the present invention and including a flexible drill; 
     FIG. 2 is a schematic view of a hand-powered flexible drill for use in the system of FIG. 1; 
     FIG. 3 is a schematic view of a portion of a hollow flexible drive shaft for the flexible drill; 
     FIG. 4 is a schematic view similar to FIG.  3  and showing a guide rod inside the hollow flexible drive shaft; 
     FIG. 5 illustrates a portion of a flexible drill including a hollow flexible inner cutting shaft within a flexible outer sleeve and a suction passage between the two shafts; 
     FIG. 6 is a view similar to FIG. 5 with a suction passage within the inner shaft; 
     FIG. 7 illustrates a portion of a flexible drill including a solid flexible inner cutting shaft within a flexible outer sleeve and a suction passage between the two shafts; 
     FIG. 8 illustrates a portion of a flexible drill including a solid formable inner guide rod within a flexible outer cutting sleeve and a suction passage between; 
     FIG. 9 illustrates a portion of a flexible drill including a hollow flexible inner cutting shaft within a solid formable outer sleeve and a suction passage between; 
     FIG. 10 is a view similar to FIG. 9 with a suction passage within the inner shaft; 
     FIG. 11 illustrates a portion of a flexible drill including a solid flexible inner cutting shaft within a solid formable outer sleeve and a suction passage between; 
     FIG. 12 illustrates a portion of a flexible drill including a relatively flexible portion between two relatively rigid portions; 
     FIG. 13 illustrates the use of a liner sleeve in a suction passage; 
     FIGS. 14A-14G are views illustrating a number of different cutting tips usable with the flexible drill; 
     FIGS. 15 and 16 are schematic views illustrating the provision of a plurality of separately inflatable bladders as a guide mechanism for a flexible structure and the operation of a guidance system for locating the tip of the flexible structure; 
     FIGS. 17A and 17B are schematic views illustrating the forming of harvested tissue fragments into a compressed plug suitable for implantation; 
     FIG. 18 is a schematic view illustrating the implantation of harvested bone fragments using a polymeric mesh as a retainer; and 
     FIGS. 19A and 19B are schematic views illustrating the implantation of harvested tissue fragments using a formable polymeric sealant as a retainer. 
    
    
     DESCRIPTION OF PREFERRED EMBODIMENTS 
     The present invention is described herein with reference to a percutaneous bone removal and harvesting apparatus and method. It should be understood that the present invention is not limited to the removal of bone tissue, but is useful in the removal of any hard or soft tissue in the body such as excess, unwanted, or tumorous tissue or tissue used for reimplantation or grating. 
     A percutaneous bone removal apparatus  10  (FIG. 1) in accordance with the present invention includes a flexible drill  12 . The flexible drill  12  has a flexible shaft  14  and a cutting tip  16  at the distal end of the shaft  14 . The proximal end of the flexible shaft  14  is connected by a housing  18  to a motor or other power source  20  to provide rotational motion or reciprocating motion in a manner known in the art. Alternatively, the drill  12  may have an angled drive, such as 90° drive or any angle, with the motor drive connected at an angle to the longitudinal extent of the suction and cutting apparatus. 
     Control means indicated schematically at  21  may include one or more switches or valves to turn on or off the suction, irrigation, and motor drive control A fluid injection source  22  is connected by a fluid injection line  24  to the housing  18  of the flexible drill  12 . A suction source  26  acts through a trap or filter or strainer  28  and a suction line  30  to provide suction capabilities for the flexible drill  12 . 
     FIG. 2 illustrates a flexible drill  12   a  in which the housing  18   a  is connected to a hand controller  20   a . The hand controller  20   a  allows the surgeon to operate the flexible drill  12   a  by hand, imparting either rotational or reciprocating movement to the flexible shaft  14   a  and cutting tip  16   a.    
     FIG. 3 illustrates a portion of a basic version of a flexible drill having a cutting tip  16  mounted on a flexible drive shaft  31 . The drive shaft  31  has an outer surface  32  and an inner surface  34  defining a longitudinally extending suction passage  36 . The cutting tip  16  has a cutting edge  40  and an opening  38  through which tissue fragments cut by the cutting tip  16  may be aspirated. The tissue fragments are drawn through the suction passage  36  in the flexible drive shaft  31  and thence into the suction line  30  (FIG. 1) for collection in the trap or filter or strainer  28 . 
     FIG. 4 illustrates the use of a pre-inserted guide rod  42  with a flexible drill of the present invention. The guide rod  42  extends through the suction passage  36  of the flexible drive shaft  31 . The guide rod  42  may be any suitable structure including a K-wire or other known device. The cutting tip  16  may have a centrally located opening in its distal end to allow insertion of the flexible drill over the guide rod  42 . The guide rod  42  is first placed in the body, then the flexible drill is inserted over the guide rod  42  and guided to the location from which tissue is to be harvested. 
     FIG. 5 illustrates an embodiment of a flexible drill having an outer sleeve  44  circumscribing a flexible drill shaft  41 . The flexible outer sleeve  44  may be formed of a metal or composite material or may be formed of a polymeric material which may be the same as or different from the material of the flexible inner cutting shaft  31 . The outer sleeve  44  is fixed (non-moving) to minimize tissue damage. A suction passage  46  is defined between the outer surface of the flexible inner shaft  31  to which the cutting tip is attached, and the inner surface of the flexible outer sleeve  44 . Alternatively, as shown in FIG. 6, a suction passage  48  may be defined within the flexible inner cutting shaft  50 . In this case, the outer surface of the flexible inner shaft  50  is preferably, as illustrated in FIG. 6, in close proximity to the inner surface of the outer sleeve  44  to increase stability. The use of polymeric materials for both the inner shaft  50  and the outer sleeve  44  provides for reduced friction between the sleeve  44  and the shaft  50  for ease of operation and reduced heat generation. 
     FIG. 7 illustrates an alternate embodiment of the apparatus of FIG. 5 in which the flexible inner cutting shaft  52  is formed as a solid shaft rather than a hollow shaft. The harvested tissue fragments travel through the suction passage  46  between the inner shaft  52  and the outer sleeve  44 . 
     FIG. 8 illustrates apparatus similar to FIG. 7 in which a fixed (non-moving) inner shaft  54  is made of a solid, formable, material and the cutting tip is mounted on a flexible rotating outer sleeve  56 . Suction is drawn through a suction passage  58  between the shaft  54  and the sleeve  56 . The inner shaft  54  is made from a semi-rigid material which is bendable to a desired curvature, at the use site, to select the curvature of the hole to be drilled, and which is rigid enough to retain that curvature in use while the drill shaft  56  rotates around it. Such material is disclosed in U.S. Pat. No. 4,541,423, the disclosure of which is incorporated herein by reference. 
     FIGS. 9,  10  and  11  illustrate embodiments of the flexible drill of the present invention in which a flexible inner cutting shaft, which may be hollow or solid, is disposed within a non-moving formable outer sleeve. The formable outer sleeve  60  is made of a semi-rigid bendable shape retaining material as described above with reference to FIG.  8 . In FIG. 9, a hollow flexible inner cutting shaft  62  is disposed within the outer sleeve  60  and defines therebetween a suction passage  64 . In FIG. 10, a hollow flexible inner cutting shaft  66  is disposed in close proximity to and within the outer sleeve  60 , with a suction passage  68  formed within the flexible inner cutting shaft  66 . In FIG. 11, a solid flexible inner cutting shaft  70  is disposed within the outer sleeve  60 , defining therebetween a suction passage  72 . 
     FIG. 12 illustrates a portion of a flexible drill shaft  80  in accordance with the present invention in which a pair of relatively rigid drill portions  82  and  84  are joined by a relatively flexible drill portion  86 . The relatively rigid drill portion  82  includes an outer sleeve  88 , an inner shaft  90 , and a suction passage  92  therebetween. The relatively rigid drill portion  84  includes an outer sleeve  94  like the outer sleeve  88 , an inner shaft  96  like the inner shaft  90 , and a suction passage  98  therebetween. The drill portion  86  includes a relatively flexible inner shaft portion  100  disposed within a relatively flexible outer sleeve portion  102 , defining therebetween a suction passage  104 . The relatively flexible inner shaft portion  100  connects the relatively rigid inner shaft portions  90  and  96 . The relatively flexible outer sleeve portion  102  connects the relatively rigid outer sleeve portions  88  and  94 . The suction passage  104  in the relatively flexible drill-shaft portion  86  connects the suction passages  92  and  98 . Either the inner shaft or the outer sleeve of the flexible drill  80  may have a cutting tip mounted thereon. Thus, with a flexible drill shaft made in this manner, it is not necessary that the entire drill shaft be made of flexible materials, but rather “joints” such as are formed by the relatively flexible portion  86  may be placed along the longitudinal extent of a relatively rigid drill shaft as desired. 
     FIG. 13 illustrates how a disposable single-use liner sleeve  110  may be used in a flexible drill of the present invention. The liner sleeve  110  shown in FIG. 13 is located within an outer sleeve  112  and is shown about a guide rod or guide wire  114 . Suction is drawn through a passage  116  within the liner sleeve  110 . The disposable single-use liner sleeve  110  provides an absolutely sterile environment through which harvested tissue fragments may pass. The inner surface  118  of the liner sleeve  110  is extremely smooth in order to facilitate passage of the harvested tissue fragments therethrough. It should be understood that a liner sleeve like the liner sleeve  110  may be used with any suitable flexible drill shaft configuration in accordance with the present invention, and not merely with the configuration shown in FIG.  13 . 
     FIGS. 14A-14G illustrate several different cutting tips which may be attached in a known manner to a flexible drill shaft in accordance with the present invention. The technology for the cutting tips is not specific to the present invention, but rather the cutting tips may be designed in accordance with known principles. 
     The cutting tip  120  (FIGS. 14A-14G) has a cutting edge  122  at least partially defining an opening  123  through which suction is drawn. The cutting tip  124  includes a plurality of cutting edges  126  defining a plurality of suction openings  128  disposed along the outer circumferential portion of the cuffing tip  124 . The cutting tip  130  is similar to the cutting tip  124  but includes cutting edges  126   a  and suction openings  128   a  which extend to the end of the cutting tip  130 . Furthermore, the cutting tip  130  is blunt rather than sharp, to avoid perforation of tissue, such as bones. 
     The cutting tip  132  has a spiral cutting edge  134  defining a spiral suction opening  136 . The cutting tip  138  has at least one longitudinally extending cutting edge  140  at least partially defining a longitudinally extending suction opening  142 . The cutting tip  143  is formed as a burr with fluted cutting edges  144  and suction openings  145 , and is especially suited for shaving operations such as removal of bone spurs, etc. The cutting tip  146  has twin cutting edges  147  and  148  and a suction opening  149 . The cutting edges  157  and  148  can be configured with the leading edge to grab the tissue and the trailing edge to cut the tissue. 
     The configuration of a cutting tip for use in accordance with the present invention is a design choice within the skill of the art. The goals to be met are proper cutting and suction capabilities, controllability and shape so as to avoid unwanted damage to areas of tissue not to be cut. For example, when removing the softer cancellous portion of bone, the cutting tip may be made of a material which is harder than the cancellous material of the bone but softer than the cortical portion of the bone to avoid damage thereto. Metal may be useful, and suitable polymers are also readily available. Ceramic materials and composites are also suitable. Also, the cutting tip may be arranged as a rotating flexible shaft within a fixed flexible outer shaft, with a cutting edge on the rotating shaft to cut tissue off against the fixed edge. In such a case, the apparatus may be advantageously configured with one shaft being metal and the other polymeric, to minimize friction and heat buildup. 
     FIGS. 15 and 16 illustrate an alternate guidance system for positioning a flexible drill shaft  150  and its associated cutting tip. Disposed within the sleeve  150  is a guidance mechanism  152  including a plurality of inflatable elements spaced serially. The inflatable elements, when inflated, rigidify and become straight, while when in the deflated condition they are soft and flexible and may be curved or bent. Thus, as seen in FIG. 15, both the inflatable elements designated  154  and the inflatable elements  156  are curved. In FIG. 16, the inflatable elements  154  have rigidified and straightened, while the inflatable elements  156  remain in their curved position. The inflatable elements may also be accordion shaped, expanding in length as they are inflated. The mechanism  152  may be augmented with a known cable guidance system. 
     By selectively and individually controlling the rigidification of any or all of the inflatable elements of the mechanism  152 , the inflatable mechanism  152  and its associated outer sleeve  150  may be selectively formed into almost any desired shape or position. Suitable control and valving apparatus is provided for controlling the inflation of the inflatable elements. Such apparatus may be, when only a few elements are present, a simple mechanical valving apparatus. When more elements are present, or more sophisticated or complex control thereof is desired, a microprocessor may be used to control the inflation of each segment. Separate inflation and deflation lines can be used, or one line can, by alternating valving, serve both functions. In such case, the control signals may be multiplexed down the structure via electric wire, optical fiber, or radio control, for example. 
     At the distal end of the mechanism  152  is a tip guidance mechanism  160  including a plurality of inflatable members  162 . The inflatable members  162  when in a deflated condition are flexible and relatively straight. When inflated, as shown in FIG. 16, the members  162  assume a preformed shape which may be curved or straight and which is illustrated herein as a curved shape, bending radially outwardly to engage the surface of adjacent tissue  164  and curve the end of the device into an appropriate position. The members  162  may be constructed, using known principles, to assume any desired shape. By controlling the positioning of one or more of the elements  162 , the tip portion  168  of the guidance mechanism  152  may be selectively placed in any position relative to the tissue  164 , thus positioning the end of the sleeve  150 . The air bladder guidance system as described may be used in conjunction with a flexible tube separate from the flexible drill shaft, order to guide the flexible tube to a specific location and position it there, thereafter removing the guidance system and allowing a flexible drill to be inserted. 
     Means for collecting one or more selected components of the harvested tissue fragments includes a mechanism  28  (FIG. 1) which may be a known trap or filter connected to the outlet of the suction passage  30 . Removed tissue may also be centrifuged if necessary or desired, keeping the components such as bone, cells, and blood and discarding fluid. These components and connections, and their uses, are well known in the art and thus are not described herein in greater detail. The harvested tissue fragments are not merely removed from the body of the patient, but are also collected in the structure  28  and thus harvested or saved for later implantation of the fragments, preferably into the body of the patient from whom they were removed. Such harvesting and implantation are desirable because human tissue grafting works best using the patient&#39;s own tissue as donor material. 
     In preparing the harvested graft material for implantation, the tissue fragments alone are spun or compressed (see FIG. 17B) to form them into the desired shape. When the tissue is harvested, blood and blood clots are often drawn along with the tissue fragments. The blood component fibrin is a sticky clotting component, and can be used to aid in holding the tissue fragments together for implantation. Thus, the blood can be separated from the tissue fragments and then spun to separate the fibrin for use with the tissue fragments. Alternatively, the entire mass of tissue fragments and blood is compressed into a specific shape to form the mass into a specific, appropriate shape for implantation into the body. 
     The surgeon can also place other substances into the graft material to be implanted, such as other tissue graft material, collagen, antibiotics, or ceramic hydroxyapatite or tricalcium phosphate to aid in bone ingrowth. In such a case, when the blood or fibrin is used also, the graft has the adhesive qualities of the blood or fibrin and the biological properties of the bone (or other) tissue, along with the appropriate medical properties of any other material included. 
     Harvested tissue fragments before implantation are preferably packed or compressed into a plug of tissue graft material. Alternatively, the tissue fragments may be left in a more loose state, or only certain selected cells, components, or tissue fragments are used. Any suitable means of packing or compressing fragments may be used. FIGS. 17A and 17B illustrate schematically a simple apparatus for doing so. As viewed in FIGS. 17A and 17B, the harvested tissue pieces  170  are placed into a form or mold  172  and then compressed by a movable compressor  174  to form a plug  176  of a desired shape or size. Unwanted fluid drains out through one or more fluid outlets  178 , while the graft, cells, fibrin, and blood clot tissues remain within the form  172 . 
     Referring to FIG. 18, to implant one or more selected components of the harvested tissue fragments, for example in grafting bone tissue onto a bone, a cannula  180  is inserted through the skin  182  and must be  184  to the area of the bone  186  where the graft is to be placed. A curette or probe is then inserted through the cannula  182  to clear out the area  188  where the graft is to be placed. 
     The harvested tissue fragments are compacted or compressed into a plug  190  of tissue graft material. A retaining material such as a known biodegradable or other polymeric mesh  192  is then used to hold the graft material  190  together as a unit. The retaining material may also be a sac of biodegradable material used to hold the graft material. The sac can be closed by a clamp or by crimping or heat sealing. The graft material  190  and its retaining material  192  are then inserted into the graft area of the bone. The cannula  180  may then be removed. Alternatively, the tissue graft material may be held in place by a mass of biodegradable or other polymeric material used as a sealant for the opening in the bone  186 . The graft material can be compressed or spun into a specific shape. Thus, if an implant is needed to fit a specific shape of bone defect, the graft material can be formed in the shape needed and packed directly into the bone gap. 
     Referring to FIGS. 19A and 19B, the bone graft material may also be implanted in the loose condition as described above. The bone graft material  194 , if loose, can be inserted through a funnel  196  and a sleeve  198  located within the cannula  180 , to the area  188  to be grafted. It is then packed in place as desired using a suitable instrument. Next, an injector  200  is used to inject a mass of flowable biodegradable or other polymeric material  202  for use as a sealant to seal the bone graft material  194  in position. The use of a flowable biodegradable material is preferable in that it allows the surgeon to form in situ a custom shaped sealant plug to seal the opening in the tissue graft area, which will eventually resorb as new tissue grows into its place. 
     The apparatus may include, as noted above, fluid injection means  22  and  24  for injecting fluid through the flexible drill to a location adjacent the cutting tip to aid in cutting and removal of the harvested tissue fragments. For example, in the drill shaft structure illustrated in FIG. 5, fluid may be injected through a fluid injection passage  204  within the flexible inner cutting shaft  31 , while suction is drawn in the opposite direction through the suction passage  46 . Alternatively, the suction may be intermittently discontinued and fluid may be injected through the suction passage, alternating with the suction. The fluid injection may be constant or it may be pulsatile in nature. 
     The present invention thus provides a method of percutaneous tissue removal which includes the steps of placing adjacent to a tissue mass a flexible drill shaft  14  having mounted thereon a cutting tip  16  for cutting the tissue; transmitting motion to the drill shaft  14  to move the cutting tip  16  against the tissue to cut tissue fragments from the tissue; and removing the tissue fragments by suction to a location outside the tissue mass while cutting the tissue. The method may further include the step of controlling the location of the cutting tip within the tissue with a guide mechanism, the step of collecting one or more selected components of the harvested tissue fragments, and/or the step of implanting the fragments into the body of the patient from whom they were removed. 
     From the above description of the invention, those skilled in the art will perceive improvements, changes and modifications. Such improvements, changes and modifications within the skill of the art are intended to be covered by the appended claims.