Patent Publication Number: US-11660207-B2

Title: Microfracture apparatuses and methods

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
     This application is a continuation of U.S. patent application Ser. No. 14/863,554, filed Sep. 24, 2015, now U.S. Pat. No. 10,702,395, issued Jul. 7, 2020, which claims the benefit of priority to U.S. Provisional Patent Application No. 62/058,190, filed Oct. 1, 2014, hereby incorporated by reference in their entirety. 
    
    
     BACKGROUND 
     1. Field of the Invention 
     The present invention relates generally to orthopedic treatments, more particularly, but not by way of limitation, to devices and methods for treating and/or creating microfractures (e.g., in subchondral bone). 
     2. Description of Related Art 
     Examples of treatment methods and apparatuses for creating microfractures in bone are disclosed in (1) J. P. Benthien, et al.,  The treatment of chondral and osteochondral defects of the knee with autologous matrix - induced chondrogenesis  ( AMIC ):  method description and recent developments , Knee Surg Sports Traumatol Arthrosc, August 2011, 19(8):1316-1319; (2) Thomas J. Gill, MD, et al.,  The Treatment of Articular Cartilage Defects Using the Microfracture Technique , Journal of Orthopaedic &amp; Sports Physical Therapy, October 2006, 36(10):728-738; (3) L. de Girolamo,  Treatment of chondral defects of the knee with one step matrix - assisted technique enhanced by autologous concentrated bone marrow: In vitro characterisation of mesenchymal stem cells from iliac crest and subchondral bone , Injury, Int. J. Care Injured  41  (2010) 1172-1177; (4) Pub. No. US 2009/0143782; (5) Pub. No. US 2005/0043738; (6) Pub. No. US 2005/0021067; and (7) Pub. No. US 2004/0147932. 
     SUMMARY 
     This disclosure includes embodiments of apparatuses, kits, and methods for treating and/or creating microfractures in bone (e.g., subchondral bone). At least some of the present embodiments are configured to deliver and/or localize active ingredients or biological responses near the microfracture site, such as, for example, growth factor(s), anticoagulant(s), protein(s), medicine(s), and/or the like, using a membrane to enclose, at least partially, the microfracture site. 
     Some embodiments of the present apparatuses comprise: a guide (e.g., comprising: a platform having a first side, a second side, and a hole extending through the first and second sides, the first side configured to receive a membrane; and a guide tube having a first end, a second end, and a channel extending from the first end to the second end, the first end configured to be coupled to the platform such that the hole of the platform is in fluid communication with the channel of the guide tube); and an applicator comprising a first end, a second end, and an elongated body extending from the first end to the second end, the elongated body having a length greater than a length of the guide tube, the second end of the applicator configured to push a membrane through the guide tube to an application site in a patient. In some embodiments, the first side of the platform includes a recess that is configured to receive a membrane. In some embodiments, the platform and the guide tube are unitary. In some embodiments, the first end of the applicator includes an enlarged handle. In some embodiments, the first end of the applicator is configured to be engaged by a machine. In some embodiments, the second end of the applicator includes a resilient tip. In some embodiments, the second end of the applicator has a rounded shape. In some embodiments, the second end of the applicator has a transverse dimension that is larger than a transverse dimension of the elongated body. 
     Some embodiments of the present surgical guide apparatuses comprise: a platform having a first side, a second side, and a hole extending through the first and second sides, the first side including a recess that is configured to receive a membrane; and a guide tube having a first end, a second end, and a channel extending from the first end to the second end, the first end configured to be coupled to the platform such that the hole of the platform is in fluid communication with the channel of the guide tube. 
     Some embodiments of the present apparatuses comprise: a platform for a surgical guide, the platform having a first side, a second side, and a hole extending through the first and second sides, the first side including a recess that is configured to receive a membrane, where the platform is configured to be coupled to a guide tube. In some embodiments, the first side of the platform has a maximum transverse dimension that is at least twice as large as a maximum thickness of the platform. In some embodiments, the platform has an elongated shape with rounded ends. In some embodiments, the recess is rectangular. In some embodiments, the recess has a maximum depth of 5 millimeter (mm). In some embodiments, the first end of the guide tube has a first outer transverse dimension and the second end of the guide tube has a second outer transverse dimension that is smaller than the first transverse dimension. In some embodiments, the channel has an inner maximum transverse dimension of 10 millimeters (mm) at a point located nearer the second end of the guide tube than the first end. 
     Some embodiments of the present kits comprise: an embodiment of the present platforms having a recess configured to receive a membrane; a membrane disposed in the recess of the platform; a package within which the platform and membrane are disposed; and where the platform and membrane are sterile. 
     Some embodiments of the present kits comprise: an embodiment of the present apparatuses in which the first side of the platform includes a recess configured to receive a membrane; a membrane disposed in the recess of the platform; a package within which the apparatus and membrane are disposed; where the apparatus is sterile. 
     Some embodiments of the present methods comprise: pushing a membrane through a guide tube to cover a microfracture in an articular surface of a patient with the membrane, where the guide tube extends through the patient&#39;s skin such that a distal end of the guide tube is adjacent the microfracture as the membrane exits the guide tube. Some embodiments further comprise: providing a platform with a first side, a second side, a hole extending through the first and second sides, where the first side includes a recess that is configured to receive a membrane, and the membrane is disposed in the recess; and coupling the platform to a guide tube prior to pushing the membrane through the guide tube. In some embodiments, the membrane is at least partially folded as it enters the guide tube and at least partially returns to its pre-folded form at the end of the applicator as the applicator pushes the membrane past the first end of the guide tube. 
     Any embodiment of any of the present apparatuses and methods can consist of or consist essentially of—rather than comprise/include/contain/have—any of the described steps, elements, and/or features. Thus, in any of the claims, the term “consisting of” or “consisting essentially of” can be substituted for any of the open-ended linking verbs recited above, in order to change the scope of a given claim from what it would otherwise be using the open-ended linking verb. 
     Details associated with the embodiments described above and others are presented below. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       The following drawings illustrate by way of example and not limitation. For the sake of brevity and clarity, every feature of a given structure is not always labeled in every figure in which that structure appears. Identical reference numbers do not necessarily indicate an identical structure. Rather, the same reference number may be used to indicate a similar feature or a feature with similar functionality, as may non-identical reference numbers. The figures are drawn to scale (unless otherwise noted), meaning the sizes of the depicted elements are accurate relative to each other for at least the embodiment depicted in the figures. 
         FIG.  1 A  depicts a perspective view of an apparatus for creating subchondral bone microfractures having a cannula and a penetrator. 
         FIG.  1 B  depicts a cross-sectional view of the apparatus of  FIG.  1 A . 
         FIG.  1 C  depicts a cross-sectional view of an enlarged head of the penetrator shown in  FIG.  1 A . 
         FIG.  1 D  depicts a cross-sectional view of a first end of the cannula shown in  FIG.  1 A . 
         FIG.  2 A  depicts a perspective view of the apparatus of  FIG.  1 A , with the penetrator shown in the cannula. 
         FIG.  2 B  depicts a cross-sectional view of the apparatus of  FIG.  1 A , with the penetrator shown in the cannula. 
         FIG.  2 C  depicts a cross-sectional view of a portion of the apparatus of  FIG.  1 A  that includes a second end of the cannula and a distal end of the penetrator, with the penetrator shown in the cannula. 
         FIG.  3    depicts a perspective view of a second embodiment of an apparatus for creating subchondral bone microfractures. 
         FIGS.  4 A and  4 B  depict perspective views of the apparatus of  FIG.  3    positioned for use relative to a patient&#39;s knee, and are not drawn to scale. 
         FIG.  5 A  depicts a perspective view of a first embodiment of the present apparatus for applying a membrane to an articular surface. 
         FIG.  5 B  depicts an enlarged perspective view of a portion of the apparatus of  FIG.  5 A . 
         FIG.  6 A  depicts a perspective view of the apparatus of  FIG.  5 A  shown with a membrane. 
         FIG.  6 B  depicts a perspective view of the apparatus of  FIG.  5 A  shown with a membrane having been guided through a guide tube by an applicator. 
         FIG.  6 C  depicts a perspective view of the apparatus of  FIG.  5 A  with a membrane expanding for application to a microfracture site after passing through the guide tube. 
     
    
    
     DESCRIPTION OF ILLUSTRATIVE EMBODIMENTS 
     The term “coupled” is defined as connected, although not necessarily directly, and not necessarily mechanically; two items that are “coupled” may be unitary with each other. The terms “a” and “an” are defined as one or more unless this disclosure explicitly requires otherwise. The term “substantially” is defined as largely but not necessarily wholly what is specified (and includes what is specified; e.g., substantially 90 degrees includes 90 degrees and substantially parallel includes parallel), as understood by a person of ordinary skill in the art. In any embodiment of the present apparatuses, kits, and methods, the term “substantially” may be substituted with “within [a percentage] of” what is specified, where the percentage includes 0.1, 1, 5, and/or 10 percent. 
     The terms “comprise” (and any form of comprise, such as “comprises” and “comprising”), “have” (and any form of have, such as “has” and “having”), “include” (and any form of include, such as “includes” and “including”) and “contain” (and any form of contain, such as “contains” and “containing”) are open-ended linking verbs. As a result, an apparatus or kit that “comprises,” “has,” “includes” or “contains” one or more elements possesses those one or more elements, but is not limited to possessing only those elements. Likewise, a method that “comprises,” “has,” “includes” or “contains” one or more steps possesses those one or more steps, but is not limited to possessing only those one or more steps. 
     Further, an apparatus, device or system that is configured in a certain way is configured in at least that way, but it can also be configured in other ways than those specifically described. 
     Referring now to the drawings, and more particularly to  FIGS.  1 A- 2 C , shown therein and designed by the reference numeral  10  is one embodiment of an apparatus for creating microfractures in bone (e.g., subchondral bone). In the embodiment shown, apparatus  10  comprises a penetrator  14 , a cannula  18 , and a handle  22  coupled to cannula  18 . In other embodiments (e.g., as shown in  FIG.  3   ), handle  22  may be omitted. In the embodiment shown, cannula  18  has a first end  26 , a second end  30 , and a channel  34  extending between the first end and the second end. Such first and second ends should be understood as the locations of the beginning and end of the channel. In this embodiment, cannula  18  has a primary portion  38  and a distal portion  42 , with primary portion  38  extending between first end  26  and distal portion  42  (e.g., a majority of the length of the cannula, as in the embodiment shown), and with distal portion  42  extending between primary portion  38  and second end  30 . The distal portion can be configured such that a second end of the channel (at second end  30 ) is disposed at an angle relative to a first end of the channel (at first end  26 ). For example, in the embodiment shown, distal portion  42  is disposed at an angle  46  relative to the primary portion. In the embodiment shown, angle  46  is between 10 and 30 degrees (e.g., 20 degrees). In other embodiments, angle  46  can be any size that permits apparatus  10  to function as described in this disclosure (e.g., angle  46  can be equal to, or between any two of: 0, 10, 20, 30, 40, 45, 50, and/or 60 degrees). In other embodiments, angle  46  can be greater than 60 degrees (e.g., equal to, or between any two of: 60, 70, 80, 90, and/or more degrees). As a further example, distal portion  42  can include a curved or hooked shape such that angle  46  is effectively larger than 90 degrees (e.g., equal to, or between any two of: 90, 120, 150, 180, and/or 180 degrees). 
     Primary portion  38  has a transverse dimension  50  (e.g., a diameter, in the embodiment shown). Penetrator  14  and cannula  18  can comprise any suitable material that permits the apparatus to function as described in this disclosure (e.g., and permits the penetrator and the cannula to be sterilized). For example, in some embodiments, penetrator  14  comprises nickel-titanium alloy (e.g., Nitinol), and/or cannula  18  comprises metal, such as stainless steel (e.g., a surgical stainless steel). Embodiments of the present cannulas are rigid and configured not to flex or bend during use. In other embodiments, penetrator  14  can comprise a biocompatible metal such as stainless steel (e.g., 316L stainless steel). 
     In the embodiment shown, penetrator  14  has a proximal end  54 , an enlarged head  58  adjacent proximal end  54 , a primary portion  62 , a distal end  66  (e.g., pointed distal end  66 , as shown), and a penetration portion  70  adjacent distal end  66 . In this embodiment, penetration portion  70  has a length  74  that is a minority of the length of penetrator  14  between proximal end  54  and distal end  66 . In some embodiments, penetrator  14  has a transverse dimension of less than 1.2 mm (e.g., between 1 mm and 1.1 mm; less than 1.1 mm, less than 1.05 mm, less than 1 mm; less than, or between any two of, 0.5, 0.6, 0.7, 0.8, 0.9, and/or 1 mm). For example, in the embodiment shown, penetration portion  70  has a circular cross-section with a diameter  78  of between 0.7 and 0.8 mm (e.g., 0.78 mm). In some embodiments, penetration portion  70  has a circular cross-section with a diameter of between 1 and 1.1 mm (e.g., 1.04 mm). Penetrator  14  is configured to be disposed in channel  34  of cannula  18  such that penetrator  14  is movable between a (1) retracted position (e.g., in which distal end  66  of the penetrator does not extend beyond second end  30  of the cannula) and (2) an extended position in which distal end  66  of the penetrator extends beyond second end  30  of the cannula by a penetration distance  82 . In some embodiments, penetration distance  82  is at least (e.g., greater than) 5 mm (e.g., 7 mm, 8 mm, 8-10 mm, more than 10 mm) and/or at least (e.g., greater than) 5 times (e.g., greater than, or between any two of: 6, 7, 8, 9, 10, or more times) a transverse dimension (e.g., diameter) of penetrator  14  (e.g., diameter  78  of penetration portion  70 ). For example, in the embodiment shown, penetration distance  82  is between 8 mm and 10 mm (e.g., 10 mm), which is greater than 12 times diameter  78 . In the embodiment shown, diameter  50  of primary portion  38  is larger than diameter  78  of penetration portion  70 . In some embodiments, diameter  50  is also less than 1.2 mm (e.g., between 1 mm and 1.1 mm, less than 1.1 mm, less than 1.05 mm). In some embodiments, diameter  50  is substantially equal to diameter  78 . In some embodiments, penetrator  14  comprises a central wire defining diameter  78  that is encircled or encased by an outer tubing (e.g., metallic tubing, plastic shrink wrap, and/or the like along the length of primary portion  62  to define transverse dimension  50 . 
     In some embodiments, a coating is disposed on at least penetration portion  70  of penetrator  14  (the coating may also be disposed on primary portion  62  of the penetrator). In some embodiments, the coating is hydrophilic. Examples of hydrophilic coatings include Hydro-Silk coatings available from TUA Systems of Florida (U.S.A.). In some embodiments, the coating comprises silver ions. In some embodiments, the coating comprises one or more active ingredients configured to elicit or stimulate a biological response in (e.g., bone or cartilage) tissue, such as, for example, growth factor(s), anticoagulant(s), protein(s), and/or the like. Such coatings can be applied as known in the art for the materials used in particular embodiments. 
     In the embodiment shown, cannula  18  is configured to provide lateral support for penetrator  14 , such as to prevent the penetrator from bending or buckling while being driven into the hard subchondral bone. For example, in the embodiment shown, diameter  50  of primary portion  62  of the penetrator is nearly as large as (e.g., greater than, or between any two of: 95, 96, 97, 98, 99, and or 100 percent of) the diameter of channel  34 , and diameter  78  of penetration portion  70  is greater than 75% (e.g., greater than, or between any two of: 75, 80, 85, 90, 95, and/or 100 percent of) the diameter of channel  34  (e.g., the diameter of channel  34  adjacent second end  30  of the cannula). In some embodiments, penetrator  14  is substantially straight prior to being disposed in channel  34  of cannula  18 , such that inserting the penetrator into the cannula causes the penetration portion  70  of the penetrator to be angled relative to primary portion  62 . In some such embodiments, penetrator  14  may be resilient enough to (e.g., at least partially) return to its straight shape after removal from the cannula. 
     In some embodiments, penetrator  14  is configured to be moved or advanced (e.g., substantially without rotation of the penetrator) from the retracted position to the extended position ( FIG.  2 B ) to form a microfracture in subchondral bone (e.g., in a patient&#39;s knee or shoulder joint), the microfracture having a depth of at least (e.g., more than) 5 mm (e.g., 7 mm, 8 mm, 8-10 mm, more than 10 mm) and/or at least (e.g., greater than) 5 times (e.g., greater than, or between any two of: 6, 7, 8, 9, 10, or more times) a transverse dimension (e.g., diameter) of penetrator  14  (e.g., diameter  78  of penetration portion  70 ). For example, in the embodiment shown, penetrator  14  is configured to be moved or advanced (e.g., substantially without rotation of the penetrator, which includes no rotation up to rotation of less than one full revolution clockwise and/or counterclockwise from the position at which distal end  66  of the penetrator first contacts the bone) from the retracted position to the extended position ( FIG.  2 B ) to form a microfracture in subchondral bone (e.g., in a patient&#39;s knee or shoulder joint), the microfracture having a depth of between 8 mm and 10 mm (e.g., 10 mm), which is greater than 12 times diameter  78 . In the embodiment shown, penetrator  14  is configured to be moved or advanced manually to the extended position. As used in this disclosure, moved or advanced “manually” means without the assistance of an external energy source other than that provided by a user. For example, if the penetrator is moved or advanced with a battery-powered or spring-driven driver, it would not be “manually.” Conversely, the penetrator would be moved or advanced “manually” if a mallet, hammer, or other tool is swung by a user (e.g., in the user&#39;s hand) to impact first end  26  of the penetrator. In some embodiments, the present apparatuses are configured such that the penetrator can (but need not) be rotated as it is advanced or moved from the retracted position to the advanced position. For example, a portion of the penetrator (e.g., enlarged head  58 ) can be disposed in the chuck of a drill such that the drill can rotate the penetrator. In such embodiments, the penetrator may (but need not) be substantially straight or axial (without bends) along its entire length (e.g., prior to being disposed in a cannula with an angled distal portion). 
     In the embodiment shown, penetration distance  82  (and the depth of the microfracture the apparatus is configured to create) is limited by enlarged head  58  contacting the cannula (e.g., penetration distance is maximized when enlarged head  58  contacts the cannula, as shown in  FIG.  2 B ). For example, in the embodiment shown, cannula  18  includes a recessed portion  86  and a shelf  90 . As shown, recessed portion  86  extends from first end  26  toward second end  30  (inwardly), and shelf  90  is disposed between recessed portion  86  and second end  30  such that penetration distance  82  is limited by enlarged head  58  contacting shelf  90 . For example, in the embodiment shown, enlarged head  58  has a cylindrical (e.g., circular cylindrical, as shown) with a first end  94  and a second end  98 , and is configured such that second end  98  contacts shelf  90  when the penetrator is in the extended position relative to the cannula ( FIG.  2 B ). In some embodiments, recessed portion  86  can be configured to maintain the orientation or alignment of enlarged head  58  as the penetrator is moved or advanced from the retracted position to the extended position. For example, in some embodiments, recessed portion  58  has a depth  102  that is at least as large as (e.g., is greater than, or between any two of: 100, 110, 120, 130, 140, 150, or more percent of) penetration distance  82  (e.g., such that enlarged head  58  is at least partially within recessed portion  86  when distal end  66  extends beyond second end  30  of the cannula), and/or enlarged head  58  has a transverse dimension (e.g., diameter) that is at least 90% (e.g., greater than, or between any two of: 90, 92, 94, 96, 98, and/or 100 percent) of a corresponding transverse dimension of recessed portion  86  (e.g., such that cannula  18  limits tilting of enlarged head  58  relative to cannula  14 , and/or limits misalignment of enlarged head  58  relative to primary portion  62  of the penetrator). 
     For example, in the embodiment shown, depth  102  of recessed portion  58  is between 175% and 250% (e.g., between 200% and 225%) of penetration distance  82 . In this embodiment, enlarged head  58  and recessed portion  86  each has a circular cross section, and enlarged head  58  has a diameter  106  that is between 90% and 100% (e.g., between 95% and 100%) of diameter  110  of recessed portion  86 . In some embodiments, a length  114  of enlarged head  58  is at least 150% (e.g., at least, or between any two of: 150, 175, 200, 225, 250, 300, or more percent) of penetration distance  82 . For example, in the embodiment shown, length  114  is over 300% of penetration distance  82 , such that a portion of enlarged head  58  that is at least as long as penetration distance  82  is disposed in recessed portion  86  when distal end  66  of the penetrator is even with second end  30  of the cannula (and the orientation of enlarged head  58  relative to cannula  18  is thereby maintained). In some embodiments, enlarged head  58  has an elongated shape such that length  114  is greater than (e.g., greater than, or between any two of: 2, 3, 4, 6, 8, or more times) diameter  106 . For example, in the embodiment shown, length  114  is between 8 and 12 times diameter  106 . 
       FIG.  3    depicts a second embodiment  10   a  of a microfracture apparatus. Apparatus  10   a  is substantially similar to apparatus  10 , with the exception that apparatus  10   a  does not include a handle (e.g., handle  22 ). 
     Embodiments of microfracture device kits can comprise one or more of the present cannulas (e.g., cannula  14 ) and a reusable tray or other container in a package (e.g., a sealed pouch or the like), where both the cannula(s) and the tray are or can be sterilized (and can be re-sterilized in advance of being re-used). Both the tray and the package may be rectangular in shape. In addition, some embodiments of microfracture device kits can also include two or more penetrators configured to create different microfractures. For example, some embodiments of the microfracture device kits comprise one or more of the present cannulas, a sterilizable tray, a first penetrator configured to have a penetration distance of between 5 mm and 8 mm when used in combination with the cannula, and a second penetrator configured to have a penetration distance greater than 8 mm when used in combination with the cannula. More specifically, some embodiments of the microfracture device kits may include a package (e.g., a box or a flexible package) that comprises sterilized versions of these items. Other embodiments of the microfracture device kits comprise one or more of the present penetrators (e.g., a single penetrator or two penetrators having different penetration depths, different tip diameters, different tip shapes, and/or the like) that are sterile and disposed in a package. Embodiments of the microfracture device kits may also include, in more specific embodiments, instructions for use, which instructions may be inside the package (e.g., as an insert) or outside the package (such as a sticker on the package). 
       FIGS.  4 A and  4 B  depict an example of microfracture methods (e.g., using embodiment  10   a  of the microfracture apparatuses). Some embodiments of these methods comprise: disposing an embodiment of the present microfracture apparatuses (e.g.,  10 ,  10   a ) adjacent to subchondral bone of a patient (e.g., in the knee, shoulder, or other joint). For example, in the embodiment shown, apparatus  10   a  is disposed adjacent to subchondral bone of articular surface  150  in a patient&#39;s knee  154  (e.g., with second end  30  of cannula  18  in contact with the subchondral bone, as shown). Some embodiments further comprise moving or advancing penetrator  14  relative to cannula  18  (e.g., from  FIG.  4 A  to  FIG.  4 B ) until distal end  66  of the penetrator extends into the subchondral bone (as in  FIG.  4 B ) to form a microfracture having a depth of at least 5 mm. For example, in the embodiment shown, penetrator  18  is manually advanced substantially without rotation of the penetrator by striking or impacting proximal end  54  of the penetrator with a mallet  158  until distal end  66  extends into the subchondral bone by a distance of, and forms a microfracture  162  having a depth of, 10 mm. In the embodiment shown, the position of second end  30  of the cannula relative to the subchondral bone remains substantially constant while advancing the penetrator into the bone. In some embodiments of the microfracture methods, the apparatus is repeatedly disposed adjacent the bone (e.g., with second end  30  of the cannula in contact with the subchondral bone and/or in contact with cartilage, such as, for example, cartilage around the perimeter of a lesion), and the penetrator is repeatedly advanced into the subchondral bone to form a plurality of microfractures (e.g., having substantially the same depths). In some embodiments, the microfracture methods can be performed on and/or in the surfaces of other joints, such as, for example, the shoulder, the ankle, the hip, and/or the patellofemoral joint within the knee. 
       FIGS.  5 A and  5 B  depict an embodiment  500  of the present apparatus for treating subchondral bone surfaces (e.g., microfractures in an articular surface of bone). In the embodiment shown, apparatus  500  comprises a guide  504  and an applicator  508 . In this embodiment, guide  504  comprises a platform  512  and a guide tube  516 . As shown, platform  512  has a first side  520 , a second side  524 , and a hole  528  extending through the first and second sides. In the depicted embodiment, first side  520  of platform  512  includes a recess  532  that is configured to receive a membrane (e.g.,  600  in  FIG.  6 A- 6 C ). In this embodiment, guide tube  516  has a first end  536 , a second end  540 , and a channel  544  extending from the first end to the second end. As shown, first end  536  of the guide tube is configured to be coupled to platform  512  such that hole  528  of the platform is in fluid communication with channel  544  of the guide tube. In the embodiment shown, applicator  508  has a first end  548 , a second end  552 , and an elongated body  556  extending from the first end to the second end. As shown, body  556  has a length  560  (between first and second ends  548 ,  552 ) that is greater than a length  564  of the guide tube (between first and second ends  536 ,  540 ), and second end  552  of the applicator is configured to push a membrane (e.g.,  600 ) through the guide tube to an application site (e.g.,  604 ) in a patient. 
     In the embodiment shown, guide tube  516  is unitary with platform  512 . In other embodiments, the guide tube (e.g.,  516 ) and the platform (e.g.,  512 ) are not unitary, such that, for example, a user can replace the platform (e.g., if different platforms are needed in a given procedure, such as, for example, for different types of membranes). In some embodiments, the platform (e.g.,  512 ) is preloaded with a membrane (e.g., in a sterile kit or by an assistant aiding a physician in a microfracture procedure), and/or coupled to the guide tube (e.g.,  516 ) while the membrane is disposed in the recess of the platform. Such preloaded embodiments can simplify the use of membranes, which may be difficult to handle during surgery, and/or may reduce the risk of infection by limiting handling of the membrane before it is placed in a patient. 
     In the embodiment shown, first end  548  of the applicator includes an enlarged handle to assist with manipulation of the applicator. In other embodiments, the first end of the applicator can be configured to be engaged by a machine. In the embodiment shown, second end  552  of the applicator has a transverse dimension that is larger than a transverse dimension of elongated body  556 . As shown, second end of the applicator can have a rounded shape. In this embodiment, second end  552  of the applicator comprises a resilient tip  568 . Resilient tip  568  can comprise plastic, polymer, latex, rubber, cotton, gauze, textiles and/or the like. 
     In the embodiment shown, first side  520  of the platform has a maximum transverse dimension that is at least twice as large as a maximum thickness of the platform. As shown, the platform can be an elongated shape with rounded ends. In some embodiments, the platform geometry can be varied based on ergonomic considerations; membrane shape, size, and/or type; manufacturing costs; and/or other considerations, such as for a particular implementation or use. In the embodiment shown, recess  532  is rectangular and has a maximum depth of 5 millimeters (mm). In other embodiments, recess  532  can comprise any shape that is suitable to receive a membrane for a microfracture site (e.g., square, circular, oval, triangular, and/or the like). For example, in some embodiments, certain microfracture sites may be more-readily accessed and/or treated with a membrane that has a circular shape. 
     In the embodiment shown, channel  544  has an inner maximum transverse dimension of 10 mm at a point located nearer second end  540  of the guide tube than first end  536 . In this embodiment, first end  536  of guide tube  516  has a first outer transverse dimension and second end  540  of the guide tube has a second outer transverse dimension that is smaller than the first transverse dimension. In the embodiment shown, for example, adjacent second end  540 , the guide tube has an outer diameter of 0.234 inch, and an inner diameter of 0.210 inch, which dimensions may differ in other embodiments (e.g., 0.234±0.05 inches, and 0.210 0.05 inches). In some embodiments, the guide tube has a variable profile. For example, in the embodiment shown, the guide tube has a first section with a substantially uniform outer transverse dimension (e.g., diameter, as shown) along a majority of the length of the guide tube  516 , and a second section having a larger and substantially constant outer transverse dimension (e.g., diameter, as shown). In other embodiments, the guide tube can have an outer transverse dimension that tapers along at least a portion of the length of the guide tube. 
     In the embodiment shown, apparatus  500  is configured to enable controlled and precise placement of membrane  600  at a surgical site. For example, placement of a membrane over a microfracture site can facilitate localization of the biological response created by the microfractures in tissue (e.g., bone or cartilage), such as, for example, generation of growth factor(s), anticoagulant(s), protein(s), and/or the like. In some embodiments of the present apparatus, methods and kits, the membrane can comprise an amniotic membrane such as the PalinGen Flow or PalinGen Membrane available from Amnio Technology LLC. Other human-derived membranes (e.g., human dermal grafts), animal-derived membranes (e.g., animal dermal grafts, and/or therapeutic synthetic membranes can also be used. In other embodiments, the membrane can comprise other materials (e.g., that localize certain biological materials around the microfracture site while allowing other biological materials to leave the microfracture site). The membrane itself may be coated with medication(s), growth factor(s), anticoagulant(s), protein(s), and/or the like. 
     Some embodiments of the present methods comprise: pushing a membrane (e.g.,  600 ) through a guide tube (e.g.,  516 ) to cover a microfracture in an articular surface of a patient with the membrane. In at least some of the present methods, the guide tube can extend through the patient&#39;s skin such that a distal end of the guide tube is adjacent the microfracture as the membrane exits the guide tube.  FIGS.  6 A- 6 C , for example, illustrate an example of the present method of placing a membrane at a subchondral bone microfracture site  604  in a patient using apparatus  500 . In  FIG.  6 A , membrane  600  is shown between second or distal end  552  of applicator  508  and recess  532  of platform  512 . While shown external to recess  532  for illustration purposes, in at least some embodiments, membrane  600  will be positioned in recess  532  for stability and positioning prior to being contacted by applicator  508 . End  552  of applicator  508  can then be inserted through hole  528  to collapse and/or fold (as membrane  600  wraps around end  552 ) and push membrane  600  into and through channel  544 . 
       FIG.  6 B  shows end  552  of applicator  508  exiting channel  544  of guide tube  516 , such that membrane  600  is partially beyond second end  540  but still held in the collapsed or folded state by guide tube  516 . As the membrane exits the end of the guide tube, the membrane can at least partially return to its pre-folded or pre-collapsed form. Collapsing or folding the membrane for delivery through a guide tube allows for delivery of the membrane to the application site (e.g.,  604 ) through a relatively smaller incision than would be required without guide tube, and/or without exposing the membrane to fluids around the surgical site. 
     In some embodiments, the present methods further comprise providing a platform (e.g.,  512 ) with a membrane disposed in a recess (e.g.,  532 ) of the platform; and coupling the platform to a guide tube (e.g.,  516 ) prior to pushing the membrane through the guide tube. 
     Some embodiments of the present kits comprise: a platform (e.g.,  520 ) for a surgical guide and that is configured to be coupled to a guide tube. Some embodiments further comprise, a membrane disposed in a recess of the platform; and a package within which the platform and membrane are disposed; where the platform and membrane are sterile. 
     Some embodiments of the present kits comprise: an embodiment of the present apparatuses (e.g.,  500 ). Some embodiments further comprise a membrane disposed in the recess of the platform. Some embodiments further comprise a package within which the apparatus is disposed where the apparatus is sterile. 
     The above specification and examples provide a complete description of the structure and use of exemplary embodiments. Although certain embodiments have been described above with a certain degree of particularity, or with reference to one or more individual embodiments, those skilled in the art could make numerous alterations to the disclosed embodiments without departing from the scope of this invention. As such, the various illustrative embodiments of the present devices are not intended to be limited to the particular forms disclosed. Rather, they include all modifications and alternatives falling within the scope of the claims, and embodiments other than the one shown may include some or all of the features of the depicted embodiment. For example, penetrator  18  and/or channel  34  can have any suitable cross-sectional shape (e.g., triangular, square, rectangular, and/or the like) that permits the present apparatuses and methods to function as described in this disclosure. For example, components may be combined as a unitary structure, and/or connections may be substituted. Further, where appropriate, aspects of any of the examples described above may be combined with aspects of any of the other examples described to form further examples having comparable or different properties and addressing the same or different problems. Similarly, it will be understood that the benefits and advantages described above may relate to one embodiment or may relate to several embodiments. 
     The claims are not intended to include, and should not be interpreted to include, means-plus- or step-plus-function limitations, unless such a limitation is explicitly recited in a given claim using the phrase(s) “means for” or “step for,” respectively.