Patent Publication Number: US-2012035656-A1

Title: External maintenance feature for magnetic implant

Description:
RELATED APPLICATIONS 
     This Application claims priority to U.S. Provisional Patent Application No. 61/372,005 filed on Aug. 9, 2010. Priority is claimed pursuant to 35 U.S.C. §119. The above-noted Patent Application is incorporated by reference as if set forth fully herein. 
    
    
     FIELD OF THE INVENTION 
     The field of the invention generally relates to medical devices for treating disorders of the skeletal system. 
     BACKGROUND 
     Scoliosis is a general term for the sideways (lateral) curving of the spine, usually in the thoracic or thoracolumbar region. Often, there is also a rotation of the spine as well as curvature. Scoliosis is commonly broken up into different treatment groups, Adolescent Idiopathic Scoliosis, Early Onset Scoliosis and Adult Scoliosis. 
     Adolescent Idiopathic Scoliosis (AIS) typically affects children between ages 10 and 16, and becomes most severe during growth spurts that occur as the body is developing. One to two percent of children between ages 10 and 16 have some amount of scoliosis. Of every 1000 children, two to five develop curves that are serious enough to require treatment. The degree of scoliosis is typically described by the Cobb angle, which is determined, usually from x-ray images, by taking the most tilted vertebrae above and below the apex of the curved portion and measuring the angle between intersecting lines drawn perpendicular to the top of the top vertebrae and the bottom of the bottom. The term idiopathic refers to the fact that the exact cause of this curvature is unknown. Some have speculated that scoliosis occurs when, during rapid growth phases, the ligamentum flavum of the spine is too tight and hinders symmetric growth of the spine. For example, as the anterior portion of the spine elongates faster than the posterior portion, the thoracic spine begins to straighten, until it curves laterally, often with an accompanying rotation. In more severe cases, this rotation actually creates a noticeable deformity, wherein one shoulder is lower than the other. Currently, many school districts perform external visual assessment of spines, for example in all fifth grade students. For those students in whom an “S” shape or “C” shape is identified, instead of an “I” shape, a recommendation is given to have the spine examined by a physician, and commonly followed-up with periodic spinal x-rays. 
     Typically, patients with a Cobb angle of 20° or less are not treated, but are continually followed up, often with subsequent x-rays. Patients with a Cobb angle of 40° or greater are usually recommended for fusion surgery. It should be noted that many patients do not receive this spinal assessment, for numerous reasons. Many school districts do not perform this assessment, and many children do not regularly visit a physician, so often, the curve progresses rapidly and severely. There is a large population of grown adults with untreated scoliosis, in extreme cases with a Cobb angle as high as or greater than 90°. Many of these adults, though, do not have pain associated with this deformity, and live relatively normal lives, though oftentimes with restricted mobility and motion. In AIS, the ratio of females to males for curves under 10° is about one to one, however, at angles above 30°, females outnumber males by as much as eight to one. Fusion surgery can be performed on the AIS patients or on adult scoliosis patients. In a typical posterior fusion surgery, an incision is made down the length of the back and Titanium or stainless steel straightening rods are placed along the curved portion. These rods are typically secured to the vertebral bodies, for example with bone screws, or more specifically pedicle screws, in a manner that allows the spine to be straightened. Usually, at the section desired for fusion, the intervertebral disks are removed and bone graft material is placed to create the fusion. If this is autologous material, the bone is harvested from a hip via a separate incision. 
     Alternatively, the fusion surgery may be performed anteriorly. A lateral and anterior incision is made for access. Usually, one of the lungs is deflated in order to allow access to the spine from this anterior approach. In a less-invasive version of the anterior procedure, instead of the single long incision, approximately five incisions, each about three to four cm long are made in several of the intercostal spaces (between the ribs) on one side of the patient. In one version of this minimally invasive surgery, tethers and bone screws are placed and are secured to the vertebra on the anterior convex portion of the curve. Currently, clinical trials are being performed which use staples in place of the tether/screw combination. One advantage of this surgery in comparison with the posterior approach is that the scars from the incisions are not as dramatic, though they are still located in a visible area, when a bathing suit, for example, is worn. The staples have had some difficulty in the clinical trials. The staples tend to pull out of the bone when a critical stress level is reached. 
     Commonly, after surgery, the patient will wear a brace for a few months as the fusing process occurs. Once the patient reaches spinal maturity, it is difficult to remove the rods and associated hardware in a subsequent surgery, because the fusion of the vertebra usually incorporates the rods themselves. Standard practice is to leave this implant in for life. With either of these two surgical methods, after fusion, the patient&#39;s spine is now straight, but depending on how many vertebra were fused, there are often limitations in the degree of flexibility, both in bending and twisting. As these fused patients mature, the fused section can impart large stresses on the adjacent non-fused vertebra, and often, other problems including pain can occur in these areas, sometimes necessitating further surgery. Many physicians are now interested in fusionless surgery for scoliosis, which may be able to eliminate some of the drawbacks of fusion. 
     One group of patients in which the spine is especially dynamic is the subset known as Early Onset Scoliosis (EOS), which typically occurs in children before the age of five. This is a more rare condition, occurring in only about one or two out of 10,000 children, but can be severe, sometimes affecting the normal development of organs. Because of the fact that the spines of these children will still grow a large amount after treatment, non-fusion distraction devices known as growing rods and a device known as the VEPTR—Vertical Expandable Prosthetic Titanium Rib (“Titanium Rib”) have been developed. These devices are typically adjusted approximately every six months, to match the child&#39;s growth, until the child is at least eight years old, sometimes until they are 15 years old. Each adjustment requires a surgical incision to access the adjustable portion of the device. Because the patients may receive the device at an age as early as six months old, this treatment requires a large number of surgeries. Because of the multiple surgeries, these patients have a rather high preponderance of infection and other complications. 
     Returning to the AIS patients, the treatment methodology for those with a Cobb angle between 20° and 40° is quite controversial. Many physicians prescribe a brace (for example, the Boston Brace), that the patient must wear on their body and under their clothes 18 to 23 hours a day until they become skeletally mature, for example to age 16. Because these patients are all passing through their socially demanding adolescent years, it is quite a serious prospect to be forced with the choice of either wearing a somewhat bulky brace that covers most of the upper body, having fusion surgery that may leave large scars and also limit motion, or doing nothing and running the risk of becoming disfigured and possibly disabled. It is commonly known that many patients have at times hidden their braces, for example, in a bush outside of school, in order to escape any related embarrassment. The patient compliance with brace wearing has been so problematic, that there have been special braces constructed which sense the body of the patient, and keep track of the amount of time per day that the brace is worn. Patients have even been known to place objects into unworn braces of this type in order to fool the sensor. Coupled with the inconsistent patient compliance with brace usage, is a feeling by many physicians that braces, even if used properly, are not at all effective at curing scoliosis. These physicians may agree that bracing can possibly slow down or even temporarily stop curve (Cobb angle) progression, but they have noted that as soon as the treatment period ends and the brace is no longer worn, often the scoliosis rapidly progresses, to a Cobb angle even more severe than it was at the beginning of treatment. Some say the reason for the supposed ineffectiveness of the brace is that it works only on a portion of the torso, and not on the entire spine. Currently a 500 patient clinical trial known as BrAIST (Bracing in Adolescent Idiopathic Scoliosis Trial) is enrolling patients, 50% of whom will be treated with the brace and 50% of who will simply be watched. The Cobb angle data will be measured continually up until skeletal maturity, or until a Cobb angle of 50° is reached, at which time the patient will likely undergo surgery. 
     Though this trial began as a randomized trial, it has since been changed to a “preference” trial, wherein the patients choose which treatment arm they will be in. This is partially because so many patients were rejecting the brace. Many physicians feel that the BrAIST trial will show that braces are completely ineffective. If this is the case, the quandary about what to do with AIS patients who have a Cobb angle of between 20° and 40° will only become more pronounced. It should be noted that the “20° to 40°” patient population is as much as ten times larger than the “40° and greater” patient population. 
     Currently, genetic scientists have found and continue to find multiple genes that may predispose scoliosis. Though gene tests have been developed, including a scoliosis score for risk of curve progression, some are still skeptical as to whether gene therapy would be possible to prevent scoliosis. However the existence of a scoliosis gene would no doubt allow for easier and earlier identification of probable surgical patients. 
     SUMMARY 
     In one aspect of the invention, a magnetic implant system includes an implantable device having a rotatable magnet therein; and a magnetic maintenance device comprising a base and a permanent magnet disposed on the base, the magnetic maintenance device configured to be placed on an external surface of a subject containing the implantable device. The magnetic maintenance device maintains the circumferential orientation of the implanted rotatable magnet despite bending and twisting forces being applied during physiological movement. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG. 1  illustrates the spine of a person with scoliosis. 
         FIG. 2  illustrates the Cobb angle of a scoliotic spine. 
         FIG. 3  illustrates the small incisions made during scoliosis non-fusion surgery of the inventive embodiments. 
         FIG. 4  illustrates an exemplary distraction device mounted on the spine of a subject. 
         FIG. 5A  is a cross-sectional view of a distraction rod and adjustable portion taken along a perpendicular axis to the longitudinal axis of the distraction rod. 
         FIG. 5B  illustrates a cross-sectional view of the distraction rod and the adjustable portion taken along the line B′-B of  FIG. 5A . 
         FIG. 5C  illustrates an enlarged cross-sectional view of detail C of  FIG. 5B . 
         FIG. 5D  illustrates a cross-sectional view of the magnet portion of the device, taken along the line D-D′ of  FIG. 5C . 
         FIG. 6  illustrates a distraction device being tested within a distraction loss tester. 
         FIG. 7A  illustrates a perspective view of one end of a distraction rod illustrating the splined tip. 
         FIG. 7B  is a side cross-sectional view of the tubular housing with the lead screw and magnetic assembly removed for clarity. 
         FIG. 7C  is a cross-sectional view of the tubular housing taken along the line C′-C in  FIG. 7B . 
         FIG. 7D  illustrates a magnified view of detail D of  FIG. 7C . 
         FIG. 8  illustrates an embodiment of an external magnetic maintenance device. 
         FIG. 9  illustrates a sectional view of an external magnetic maintenance device in place on a patient who is implanted with a magnetic implant. 
         FIG. 10  illustrates a patient with an external magnetic maintenance device in place. 
         FIG. 11  illustrates and external adjustment device that is used with the distraction devices described herein. 
     
    
    
     DETAILED DESCRIPTION OF THE ILLUSTRATED EMBODIMENTS 
       FIG. 1  illustrates a patient  100  with scoliosis. The concave portion  102  of the spinal curve can be seen on the left side  104  of the patient  100 , and the convex portion  106  can be seen on the right side  108  of the patient  100 . Of course, in other patients, the concave portion  102  may appear on the right side  108  of the patient  100  while the convex portion  106  may be found on the left side  104  of the patient. In addition, as seen in  FIG. 1 , some rotation of the spine  110  is present, and unevenness between the left shoulder  112  and right shoulder  114  is seen. 
       FIG. 2  illustrates the Cobb angle  116  of a spine  110  of a patient with scoliosis. To determine the Cobb angle, lines  118  and  120  are drawn from vertebra  122  and  124 , respectively. Intersecting perpendicular lines  126  and  128  are drawn by creating 90° angles  130  and  132  from lines  118  and  120 . The angle  116  created from the crossing of the perpendicular lines  126  and  128  is defined as the Cobb angle. In a perfectly straight spine, this angle is 0°. 
     In many Adolescent Idiopathic Scoliosis (AIS) patients with a Cobb angle of 40° or greater, spinal fusion surgery is typically the first option. Alternatively, non-fusion surgery may be performed, for example with the distraction device  200  of  FIG. 4 .  FIG. 3  illustrates an upper incision  136  and a lower incision  138  formed in the patient  100  which is typically made during non-fusion scoliosis surgery. 
       FIG. 4  illustrates a distraction device  200  for treating scoliosis according to one embodiment of the invention. The distraction device  200 , which is an implantable device, is fixated at its upper end  202  and lower end  204  to the patient&#39;s spine  500 . The illustrated example of the spine  500  includes the particular thoracic and lumbar vertebrae that typically encompass a scoliotic curve, for example the curve of a patient with adolescent idiopathic scoliosis. The T 3  through T 12  thoracic vertebrae,  503 ,  504 ,  505 ,  506 ,  507 ,  508 ,  509 ,  510 ,  511 ,  512 , respectively and the L 1  through L 3  vertebrae,  513 ,  514 ,  515  are depicted in  FIG. 4 , not in a severe scoliotic condition, but in a very slight residual curve that represents a modest curve that has been partially or completely straightened during the implantation procedure. 
     Each vertebra is different from the other vertebra by its size and shape, with the upper vertebra generally being smaller than the lower vertebra. However, generally, the vertebrae have a similar structure and include a vertebral body  516 , a spinous process  518 ,  520 , laminae  526 , transverse processes  521 ,  522  and pedicles  524 . In this embodiment, the distraction device  200  includes a distraction rod  206  which is adjustable (lengthwise) via a coupled adjustable portion  208 . The distraction device  200  also includes a lower short rod  209 . The distraction device  200  is fixated to the spine  500  via hooks  600 ,  601  at the upper end  202  of the distraction rod  206 . Alternatively, a clamp may be secured around an adjacent rib (not shown) or rib facet. In still another alternative, a pedicle screw system may be used. 
     Referring back to  FIG. 4 , the distraction device  200  is illustrated as being fixated to the spine  500  with a pedicle screw system  531 , which attaches directly to the lower short rod  209 . The distraction rod  206  is shown after it has been bent into a kyphotic curve, and the lower short rod is shown after it has been bent into a lordotic curve. As explained in more detail below. The adjustable portion  208  preferably contains a magnetic assembly having a permanent magnet configured to drive a lead screw that, depending on the direction of rotation of the internal magnet, will extend or retract the distraction rod  206  using the adjustable portion  208 . Lengthening of the distraction rod  206 , for example, will impart a distraction force to the spine  500 . Retracting the distraction rod  206  will lower or remove the distraction force on the spine  500 , for example if too high a distraction force causes pain or complications. 
     Because a scoliotic spine is also rotated (usually the center section is rotated to the right in AIS patients), the non-fusion embodiment presented here allows de-rotation of the spine  500  to happen naturally, because there is no fixation at the middle portion of the distraction device  200 . 
     In order to further facilitate this de-rotation, the distraction device  200  may allow for free rotation at its ends. For example, the adjustable portion  208  may be coupled to the spine via an articulating joint. U.S. Patent Application Publication Nos. 20090112207 and 20100094302, both of which are incorporated by reference, describe various articulating interfaces and joints that may be utilized to couple the adjustable portion  208  to the connecting rods or the like. These Publications further describe various distraction rod embodiments and methods of use that may be used with inventions described herein. 
     As noted, the distraction rod  206  and the lower short rod  209  may be bent by the user (or supplied pre-curved) with the typical shape of a normal saggital spine, but it should also be noted that the curve may be slightly different than standard scoliosis fusion instrumentation, because in the non-fusion embodiment described herein, the distraction device  200  is not usually flush with the spine but rather is placed either subcutaneous or sub-fascial, and thus is not completely below the back muscles. In these less invasive methods, the only portions of the distraction device  200  that are designed to be placed below the muscles are the hooks  600 ,  601  and the portion of the distraction rod  206  immediately adjacent the hooks  600 ,  601 , the pedicle screw system  531  and the lower short rod  209 . Thus,  FIG. 4  illustrates an embodiment in which the bulk of the hardware associated with the distraction device  200  is placed over the muscle. It should be understood, however, that in alternative configurations, any other part of the entire implantable embodiment may be placed under the muscle (i.e., sub-muscular). It should be appreciated that a much smaller amount of muscle needs to be dissected during the procedure in comparison with current fusion procedures. This will allow for a much shorter procedure, much less blood loss, much quicker recovery, and less time in the hospital/less risk of infection. 
       FIGS. 5A-5C  illustrate cross-sectional views of the interface of the distraction rod  206  with the adjustable portion  208 .  FIG. 5A  is a cross-sectional view of the distraction rod  206  and adjustable portion  208  taken along a perpendicular axis to the longitudinal axis of the distraction rod  206 .  FIG. 5B  illustrates a cross-sectional view of the distraction rod  206  and the adjustable portion  208  taken along the line B′-B of  FIG. 5A .  FIG. 5C  illustrates an enlarged cross-sectional view of detail C of  FIG. 5B . As best seen in  FIG. 5C , an end  210  of the distraction rod  206  includes an elongate recess  212 . The elongate recess  212  may have a length of around 60 mm. The recess  212  is dimensioned to receive a lead screw  260 . The lead screw  260  may be made from a high strength material such as, for example, titanium. At least a portion of the lead screw  260  includes external threads  262  that are configured to engage with a nut  214  integrated into the recess  212 . The nut  214  provides a threaded portion on the recess  212  of the distraction rod  206 . The lead screw  260  may have, for example, 80 threads per inch although more or less could be used. The nut  214  may includes threads or a chamfered surface  216  on the outer diameter in order to better ensure a secure attachment to the inner diameter of the recess  212  of the distraction rod  206 . For example, the nut  214  may be bonded to the distraction rod  206  using an adhesive such as EPOTEK 353ND, available from EPDXY TECHNOLOGY, INC., 14 Fortune Drive, Billerica, Mass. This allows the distraction rod  206  to be fabricated from a single piece of stronger material. It also provides for clearance between the lead screw  260  and internal diameter of the distraction rod  206 . Alternatively, a threaded portion may be directly formed in the recess  212  without the aid of a separate nut  214 . A radially-poled cylindrical magnet  254  is part of a magnetic assembly  236  comprising a first cup  240  and a second cup  242 . The first and second cups  240 ,  242  are made from titanium. This entire magnetic assembly  236  is attached to the lead screw  260 , for example by a high strength pin  238  which is placed through a hole in the lead screw  260  and a receptacle  244  in the first cup  240 . This couples the cylindrical magnet  254  to the lead screw  260 . The cylindrical magnet  254  typically has two poles, a North and a South that are radially arrayed, as depicted in  FIG. 5D . The cylindrical magnet may comprise a rare earth material, such as Neodymium-Iron-Boron. The cylindrical magnet  254  is attached to a thrust bearing  250  and a radial bearing  246 , which allow the low friction rotation of the cylindrical magnet  254 , and this aids the low friction rotation of the lead screw  260  within the nut  214 . This allows for the non-invasive coupling of an external moving magnetic field, in order to non-invasively distract the distraction device  200 , allowing the distraction rod  206  to telescopically extend from the adjustable portion  208 , and impart an increased distraction force on the spine  500 . The moving magnetic field may be supplied by one or more rotating magnets, for example as part of a motor-driven external device. Alternatively, the moving magnetic field may be produced by an electromagnetic coil. The lead screw  260  and nut  214  combination allows for a device that can be distracted or retracted. The device is retracted by making the external moving magnetic field move in the opposite rotational direction. This is an advantage, for example in the case of a patient that has accidentally been over distracted. The distraction device  200  may then be retracted somewhat, until the patient is at the preferred distraction amount. An elastomeric o-ring  234  creates a dynamic seal between the inner surface of the adjustable portion  208  and the distraction rod  206 . This o-ring resides inside a recess  232  of an o-ring gland  230  within the interior of the adjustable portion  208 . 
     The low friction lead screw  260  and nut  214  combination combined with the low friction bearings  250 ,  246  minimize the torque that needs to be applied on the cylindrical magnet  254 . Thus, they also minimize the required size of the cylindrical magnet  254 , because they minimize the magnetic force required to make the cylindrical magnet  254  turn. However, these same advantages also may make the assembly prone to lose some of the distraction length as the patient moves through daily activity. For example (returning to  FIG. 4 ), it may be possible for a patient&#39;s movement to create a “screw-like” motion which is capable of slowly retracting the distraction rod  206  in relation to the adjustable portion  208 , and thus shortening the distraction device  200  by multiples of very small movements. For example, in the process of walking, running, bending or other movements, a patient may place a compressive bending force (F) on the distraction device  200 . In these movements, the patient may also place a torque (T) between the two ends of the distraction device  200 , for example, the two ends at the portions that are secured to the spine  500 . In  FIG. 4 , a positive value of torque (T) denotes a right-hand mode, in which the distraction rod  206  is given energy to move in the direction of the arrow at torque (T) while the adjustable portion is given energy to move in the opposite circumferential direction. A negative value of torque (T) would represent the opposite, left hand motion. If there are no internal features in the distraction device  200  to limit the circumferential motion of the distraction rod  206  in relation to the adjustable portion  208 , the a positive value of torque (T) will cause the distraction rod  206  and adjustable portion  208  to circumferentially displace until, for example, the torsional movement in the patient stops, either willingly, or by the physical limitations in the spine or the rest of body. If the patient&#39;s movements cycle between bending and twisting, and therefore, between the force (F) and torque (T) depicted, they may do so in such a way as to cause a multiplicity of slight angular turns of the lead screw  260  in one direction in relation to the nut  214 , without compensatory turns in the opposite direction. For example, referring to  FIG. 6 , in laboratory testing, a distraction device  200  was secured with set screws  217 ,  219  in a distraction loss tester  211  having simulated vertebrae  213 ,  215  in order to place controlled axial compressive force (F) and a controlled twisting torque (T) on the distraction device  200 . One cycle of the program consisted of a  100  Newton compressive force (F), followed by a 0.81 Newton-meter torque (T), after which the compressive force (F) was completely released (0 Newton) and then an opposite torque (−0.81 Newton-meter) (−T) was placed. These parameters are considered extreme in relation to a typical patient&#39;s movements, but are effective in estimating “worst-case” operation, for example, if the distraction device  200  were being used as a single device within a very active patient. A distracted distraction device  200  tested under these parameters was able to lose several mm of distraction length after about 10,000 cycles, which is estimated be the equivalent of about one week in a patient (though actual patient movements are usually much more variable). 
     In reality, the preferred design for a distraction device  200 , does not allow significant circumferential motion between the distraction rod  206  and the adjustable portion  208 .  FIG. 7A  illustrates a perspective view of the splined tip  220  of the distraction rod  206 . The splined tip  220  is illustrated with four (4) protrusions  222  that interface with four (4) corresponding longitudinal grooves  224  (two pairs in symmetric opposition) formed inside a tubular housing  226  (illustrated in  FIGS. 7B-D ) of adjustable portion  208 . The longitudinal grooves  224  may be formed by wire EDM machining or by broaching. While  FIGS. 7A-7D  illustrate an embodiment that uses four (4) protrusions  222  along with four (4) longitudinal grooves  224  there may be more or fewer. The tight tolerance of the splined tip  220  with the longitudinal grooves  224  keeps the distraction rod  206  centered within the tubular housing  226 . In addition, the combination of the splined tip  220  and corresponding grooves  224  act as an anti-rotation feature that prevents the distraction rod  206  from rotating relative to the tubular housing  226 . This may be necessary to allow the distraction device  200  to be “rigidized” in the event the device is used in fusion applications, instead of the non-fusion applications described. For example, in a fusion application, it is desired that the spine  500  not be able to flex or rotate much during the months that the fusion is taking place. In either the fusion applications or the non-fusion applications, the anti-rotation features are intended to limit inadvertent extension and/or retraction of the distraction rod  206  resulting from, for instance, patient movements. 
       FIG. 7C  is a cross-sectional view of the tubular housing  226  taken along the line C′-C in  FIG. 7B .  FIG. 7D  illustrates a magnified view of detail D of  FIG. 7C . In this illustrated embodiment, as best seen in the detailed view of  FIG. 7D , small reliefs  228  are incorporated into the sides or corners of the longitudinal grooves  224 . These reliefs  228  may be slight over cut wire EDM notches that prevent the corners of the protrusions  222  from contacting the inner wall of the tubular housing  226 . Less contact between the protrusions  222  and the longitudinal grooves  224  results in less frictional forces and reduces the likelihood of binding. Optionally, the tops of the protrusions  222  could be curved, for example, cut from a diameter instead of a square. This rounding of the protrusions  222  would keep the protrusions  222  from binding with the longitudinal grooves  224  when torsional stresses are imparted between the distraction rod  206  and the adjustable portion  208 . This optional modification makes the distraction rod  206  easier to manufacture and eliminates the need for the relief  228  overcuts. At the maximum amount of axial distraction length, the protrusions  222  butt up against a stop  231  (as seen in  FIG. 5C ), so that the distraction rod  206  terminates its axial movement in relation to the adjustable portion  208 . 
     The anti-rotation features of  FIGS. 7A-7D  are effective in severely minimizing distraction loss in a large variety of patient applications, however, under severe conditions, such as those described in  FIG. 6 , a distraction device  200  with these features may still lose as much as 1 mm over 10,000 cycles. An additional design improvement which takes advantage of the magnetic poles ( FIG. 5D ) of cylindrical magnet  254  will now be described, as a way to severely limit distraction loss, even in the most severe performance conditions. 
       FIGS. 8 and 9  illustrate an externally-located magnetic maintenance device  320  which is placed over the skin of a patient in order to maintain the circumferential orientation of an implanted cylindrical magnet  254  of a magnetic implant  350 , for example, a distraction device  200  such as that illustrated in  FIGS. 4 ,  5 C,  5 D, and  6 . The patient is depicted in  FIG. 9  by skin  352 , fat  354  and muscle  356 . The magnetic implant  350  is shown implanted subfascial, but it can also be implanted submuscular, intramuscular, etc. In the case of a spinal distraction device, it would more likely be implanted substantially submuscular. The magnetic maintenance device  320  includes a magnet  322  and a base  324 . The base has a central magnet holder  328  ( FIG. 8 ) and pair of wings  326  or flanges. The lower surface  334  ( FIG. 8 ) of the base  324  is configured for contacting the patient&#39;s skin  352  and should be constructed of an appropriate biocompatible skin contact material, for example polyurethane. The magnet  322  is held within the magnet holder  328  by snaps, by adhesive, molded in place, or simply held by the attractive force from the magnetic field between the magnet  322  and the cylindrical magnet  254  of the magnetic implant  350 . During use, the magnetic maintenance device  320  is placed on the correct location over the magnetic implant  350 , the inward pole of the magnet  322  (in this case the south pole  332 ) will attract the opposite pole (in this case the north pole  358 ) of the cylindrical magnet  254 , aligning it as pictured. Of course, the inward pole of the magnet  322  may include the north pole in an alternative configuration. In  FIG. 9 , the attraction between the south pole  360  of the cylindrical magnet  254  and the north pole  330  of the magnet are not dominant, because they are located further apart. 
     Any torque applied on the cylindrical magnet  254  of the magnetic implant  350  would have to overcome the strong attraction of the north pole of the cylindrical magnet  254  to the south pole of the magnet  322 . In the severe cycling scenario presented, a magnet  322  made from nickel-plated Neodymium-Iron-Boron having a diameter of 38 mm and a thickness of 6.35 mm can keep a cylindrical magnet  254  having a diameter of less than 9 mm from being continually turned, and thus maintain distraction length throughout continued cycling. An indentation  336  ( FIG. 8 ) located in the base  324  at the point directly adjacent the magnetic implant  350  helps to keep the magnetic maintenance device  320  from pinching the patient&#39;s soft tissue, as the attraction forces are instead applied to the wings  326 , which also have a large surface area, to lower the local stress on the soft tissue. 
       FIG. 10  shows a patient  380  with a magnetic maintenance device  320  in place over the implanted magnet of an implant, in this case a magnetically distractable spinal rod. The magnetic maintenance device  320  may be more securely attached to the patient using medical tape, a band, adhesive or a belt, but as mentioned, the magnetic force will often be sufficient to keep it in place. The magnetic maintenance device  320  may be worn under a brace, if a brace is being used, or may be worn through a hole cut in the brace. The magnetic maintenance device  320  may be worn over clothes or under clothes. The magnetic maintenance  320  device may be worn during showering or may be removed prior to showering. The magnetic maintenance device  320  may be removed prior to sleeping or worn during sleeping, however, because of the drastically reduced activity while sleeping for most patients, the magnetic maintenance device  320  is not likely needed during sleeping. 
       FIG. 11  illustrates an external adjustment device  400  according to one embodiment that is used to drive the cylindrical magnet  254  of the magnetic implant  350 . The external adjustment device  400  includes two permanent magnets  402 ,  404  contained within respective covers  406 . Each permanent magnet  402 ,  404  is rotatable within its respective cover  406  and provides a moving magnetic field. A motor  408  is mechanically engaged to the permanent magnets  402 ,  404  via a transmission (not shown) contained within a housing  410  of the external adjustment device  400 . Particular details on the nature of the external adjustment devices that can be used in connection with the distraction devices described herein are disclosed, for example, in U.S. Patent Application Publication Nos. 2009/0112207, 2010/0094302, 2010/0121323, and U.S. patent application No. 13/172,598, all of which are incorporated by reference herein. 
     While embodiments have been shown and described, various modifications may be made without departing from the scope of the inventive concepts disclosed herein. The invention(s), therefore, should not be limited, except to the following claims, and their equivalents.