Medical apparatus and method for attaching a suture to a bone

Abstract

A method of forming a channel in a bone, the method comprising: providing a first bore in the bone; and forming, a second bore in the bone at a predefined angle from said first bore, using said first bore as a reference point for defining the location of the second bore in the bone, wherein the first and second bores intersect in the bone.

Claims

1. A medical implement comprising: an arm that is formed with a bend having a distal end configured to engage a first bore in a bone; an elongate passageway for placement against a bone, the passageway configured to receive a drill for drilling a second bore in the bone, wherein an axis extending between the distal end of the arm and the first bore in the bone is substantially perpendicular to an axis of the elongate passageway; and a grasper adapted to be extended from the arm and grasp an end of a suture inserted through the second bore in the bone and pass it through the first bore in the bone.

2. A medical implement according to claim 1, wherein the grasper is movable to an extended position with respect to the arm where the grasper extends from the arm and to a retracted position where the grasper is positioned inside the arm.

3. An implement according to claim 2, wherein said implement includes a manually manipulatable member coupled to said grasper for moving the grasper to its extended and retracted positions.

4. The implement according to claim 3, wherein said manipulatable member includes a knob coupled to a stem slideable through a slot in said implement and coupled to said grasper.

5. The implement according to claim 4, wherein said stem is coupled to said grasper by a cable extending through a sleeve in said implement coupled to said arm.

6. The implement according to claim 4, wherein said knob is pivotable about a pivot axis perpendicular to a longitudinal axis of the implement.

7. The implement according to claim 1, wherein said grasper comprises a loop.

8. The implement according to claim 1, wherein said grasper is adapted to grasp a first end of a suture and pass it through a bore in the bone, while a second end of the suture is left outside the bone.

9. An implement according to claim 1, wherein said passageway extends longitudinally through the implement.

10. An implement according to claim 1, wherein said arm is formed as a single piece with bends.

11. An implement according to claim 1, wherein the passageway is urged in an axial direction of an elongate element toward the arm by extension of a resilient member.

12. An implement according to claim 11, wherein said resilient member comprises a spring.

13. A medical kit useful for attaching a suture to a bone in an arthroscopic surgical procedure, the medical kit comprising: a medical implement according to claim 1; and a drill receivable within said passageway for drilling a second bore in the bone; said drill including a stop engageable with a proximal end of the implement to fix a length of the second bore to extend for a slight distance past said first bore, to thereby permit a first end of the suture to traverse and extend past said first bore in order to facilitate its access and extraction via said first bore.

14. The kit according to claim 13, wherein said drill has a diameter of 2.5 mm.

15. The kit according to claim 13, wherein said kit further includes a suture loader sized and configured for reception in said passageway and for passing said suture through said second bore past said first bore in the bone.

16. The kit according to claim 15, wherein said suture loader includes a distal end formed with a notch for receiving said suture, and a proximal end formed with a shank having flat opposed sides parallel to said notch for orienting the suture loader with respect to the suture to be received within said notch.

17. The kit according to claim 13, wherein said kit further includes: a drill guide having a distal end engageable with said bone at a location of the first bore to be formed therein; and a proximal end opposite to said distal end; and a second drill receivable within said drill guide, said second drill including a distal end formed with cutting edges to drill said first bore in the bone, and a proximal end formed with a shoulder engageable with the proximal end of the drill guide for defining a depth of the first bore to be drilled by said second drill.

18. The kit according to claim 17, wherein said second drill has a diameter of 2.9 mm.

Description

BRIEF DESCRIPTION OF THE SEVERAL VIEWS OF THE DRAWINGS

(1) The invention is herein described, by way of example only, with reference to the accompanying drawings, wherein:

(2) FIGS. 1A, 1B and 1C illustrate the construction of the shoulder joint to be repaired according to an embodiment of the present invention, including the construction of the upper part of the humerus bone (FIG. 1A), a schematic section through the shoulder joint (FIG. 1B), and a damaged shoulder joint (FIG. 1C) to be repaired;

(3) FIG. 2 is a perspective view of one preferred embodiment of a medical bone-tunneling implement constructed according to the present invention for use in repairing a damaged shoulder joint;

(4) FIG. 3 is an enlarged detailed view of the distal end of the medical implement of FIG. 2, and particularly the loop projecting from the hook at the distal end;

(5) FIG. 4 is a top view of the implement of FIG. 2;

(6) FIG. 5 is a sectional view along line V-V of FIG. 4;

(7) FIGS. 6A and 6B are enlarged fragmentary views of the encircled portions of FIG. 5;

(8) FIG. 7 is a side view of the medical implement of FIG. 2;

(9) FIG. 8 is a sectional view along line VIII-VIII of FIG. 7;

(10) FIG. 9 is an enlarged detail view of the encircled portion of FIG. 8;

(11) FIGS. 10A-10D are enlarged views of the hook at the distal end of the medical implement of FIG. 2;

(12) FIG. 11 illustrates the contents of a medical kit including the implement of FIG. 2, together with other implements, particularly useful for performing an arthroscopic surgical procedure according a preferred embodiment of the invention described herein;

(13) FIG. 12 more particularly illustrates the construction of the suture loading needle in the medical kit of FIG. 11;

(14) FIGS. 13A and 13B are enlarged fragmentary views of the encircled portions of FIG. 12;

(15) FIG. 14 illustrates a suture hook which may be included in the medical kit of FIG. 11 for use in performing the arthroscopic surgical procedure according to another embodiment of the invention;

(16) FIG. 15 is an enlarged fragmentary view of the encircled portion of FIG. 14;

(17) FIG. 16 is a perspective view of a second preferred embodiment of a medical bone-tunneling implement constructed according to the present invention for use in repairing a damaged shoulder joint;

(18) FIGS. 17 and 18 are top and side views, respectively, of the medical implement of FIG. 16;

(19) FIG. 19 is a longitudinal sectional view along section line A-A of FIG. 17;

(20) FIG. 20 is an enlarged fragmentary view of encircled portion B of FIG. 19;

(21) FIG. 21 is an enlarged fragmentary view of the encircled portion C of FIG. 19;

(22) FIG. 22 is a flow diagram of a method of attaching a suture to a bone in accordance with an exemplary embodiment of the invention;

(23) FIGS. 23A-23J are schematic illustrations of phases of the method of FIG. 22; and

(24) FIG. 24 is a schematic illustration of an implement used for repairing a damaged shoulder joint in accordance with another exemplary embodiment of the invention.

(25) It is to be understood that the foregoing drawings, and the description below, are provided primarily for purposes of facilitating understanding the conceptual aspects of the invention and possible embodiments thereof, including what is presently considered to be a preferred embodiment. In the interest of clarity and brevity, no attempt is made to provide more details than necessary to enable one skilled in the art, using routine skill and design, to understand and practice the described invention. It is to be further understood that the embodiments described are for purposes of example only, and that the invention is capable of being embodied in other forms and applications than described herein.

DESCRIPTION OF SPECIFIC EMBODIMENTS OF THE INVENTION

(26) An aspect of some embodiments of the invention relates to attaching a tendon to a bone by threading a suture through a channel in the bone and through the tendon. In an exemplary embodiment of the invention, the channel comprises of a first and a second bore intersecting in the bone. In an exemplary embodiment of the invention, the intersection of the bores define a predetermined angle between them, suitable for attaching a tendon to the bone by threading a suture through the bores and the tendon. Preferably, the first and second bores are formed in an arthroscopic procedure.

(27) In an exemplary embodiment, the first bore is formed first and is then used to assist forming the second bore. Optionally, the first bore is used as a reference point for determining the location and/or alignment of the second bore in the bone. Alternatively or additionally, the reference point is used for determining the depth of the second bore such that the first and second bores intersect in the bone. Optionally, at least one of the first and second bore extends past the intersection of the bores in the bone such that a hook or loop may be inserted in one of the bores, crossing the intersection of the bores in the bone, to conveniently capture a suture inserted via the other bore.

(28) In an exemplary embodiment of the invention, a hook inserted into the first bore is used for clamping an implement, with which the second bore is formed, to the bone, thereby stabilizing the implement when drilling the second bore. Optionally, the hook extending from the implement is inserted into the first bore and is used as an arm for the clamp. The implement is then locked in a position clamped to the bone, with the first bore as both a reference and a holding point for the implement. The second bore is then formed by a tool preferably guided by a passageway in the implement. Optionally, the hook has a tip in the form of a rod, inserted in the first bore.

(29) An aspect of some embodiments of the invention relates to threading a suture though the second bore and extracting the suture through the first bore. In an exemplary embodiment of the invention an end of a suture is threaded through the second bore and grasped at the intersection of the bores in the bone by a loop extending from the hook inserted through the first bore. The loop with the suture is then extracted through the first bore. Optionally, said loop is replaced with any other suitable mechanism known in the art for grasping a suture, for example, a hook.

(30) In an exemplary embodiment of the invention there is provided an implement comprising a hook for insertion into a first bore. In an exemplary embodiment, the hook comprises a mechanism configured to grasp an end of a suture threaded through the second bore at the intersection of the bores in the bone. Optionally, the mechanism is further configured to thread the end of the suture through the first bore when extracting the hook from the bore. Optionally, said mechanism comprises a loop. Optionally, the loop is movable between an extracted position in which it is removed from the bore and an extended position in which it is extended into the intersection of the bores to grasp the end of the suture.

(31) In an exemplary embodiment of the invention, the implement comprising a hook further comprises a passageway for receiving tools for forming of or inserting into a second bore. Optionally, the hook and the passageway are located such that when the hook is inserted into the first bore, a drill inserted through the passageway is configured to drill a second bore at a predefined angle from the first bore. Optionally, the predefined angle is 70°. Alternatively, the predefined angle is between 65° and 75°. Alternatively, the predefined angle is between 30° and 120°.

(32) Optionally. The drill is further configured to aid in determining the depth of the second bore to be drilled, by reference to the position of the hook which is inserted in the first bore. In an exemplary embodiment of the invention, the drill is configured such that the depth of the second bore to be drilled is suitable for different bones of a plurality of subjects and does not require adjustment for specific bones.

(33) Optionally, the implement further comprises a locking mechanism for clamping the implement to the bone when the hook is inserted into the first bore.

(34) In an exemplary embodiment, the first and second bores are formed with a same implement comprising of two channels for receiving tools such as a drill and a suture. In this embodiment the two bores are formed at the same side of the bone and the angle formed between the bores is preferably less than 45°.

(35) In the following description reference will be made to attaching a supraspinatus tendon to a humerus bone. However, it is understood that the invention may be adapted to attach any tendon or other soft tissue to any bone of a body.

(36) The Shoulder Joint and its Repair (FIGS. 1A-1C)

(37) FIG. 1A schematically illustrates the structure of the upper part of a humerus bone 2. It includes a spherical head 3 for reception in the glenoid socket 4, and an anatomical neck 5 joined to a greater tubercle 6 and a lesser tubercle 7. The juncture of the latter with the humerus bone 2 is a surgical neck 8.

(38) FIG. 1B is a schematic coronal section through the shoulder joint, showing: a supraspinatus tendon 10 of a supraspinatus muscle 11, the greater tubercle 6, and a shoulder blade (scapula) 12.

(39) FIG. 1C schematically shows the separation of the tendon 10 from the greater tubercle 6 in a damaged shoulder joint which is to be repaired by the reattachment of the tendon.

(40) As will be described below, this is accomplished, according to some embodiments of the present invention, by forming two bores B.sub.1 and B.sub.2 (FIG. 1C). The tendon is captured and drawn toward the left in the figure, so that it covers bore B.sub.2, as described below and a suture or sutures are passed through the two bores and through the tendon 10; and knotting the two ends of the suture or sutures, to thereby firmly attach the tendon to the bone. As will also be described below, the invention enables the two bores B.sub.1, B.sub.2 to be conveniently made in their required locations and at a predetermined angle to each other to achieve the reattachment of the torn tendon by sutures, rather than by bone anchors, in a manner similar to the open surgical procedures, thereby enabling an arthroscopic surgical procedure to be used for repairing a damaged shoulder joint.

(41) The Medical Implement of FIGS. 2-10D

(42) The medical implement illustrated in FIGS. 2-10D is a bone-tunneling implement according to an embodiment of the invention, designed for use in a medical procedure, particularly an arthroscopic surgical procedure for attaching a suture to a bone, utilizing the two-bore technique of FIG. 1C for receiving the suture through the two bores B.sub.1, B.sub.2, as briefly described above, and as to be described more particularly below.

(43) FIG. 2 illustrates the medical implement used for producing bore B.sub.2 (FIG. 1C) after bore B.sub.1 has been formed, so that the two bores are located to intersect each other at a preselected angle for receiving the suture. The implement illustrated in FIG. 2 includes a handle 20 having a proximal end 21 for manual grasping, and a distal end 22 for engagement with the bone to which the suture is to be attached after bore B.sub.1 has been formed in the bone. As shown in FIG. 2, the distal end 22 of the illustrated implement is optionally formed with a ribbed outer surface 23 to enable secure engagement with the bone.

(44) Handle 20 is further preferably formed with a passageway 20a therethrough extending from the proximal end toward its distal end (FIGS. 2 and 5). As will be described more particularly below, this passageway is located and configured first to receive a drill for making bore B.sub.2 (FIG. 1C), and then to receive one end of a suture to be attached to the bone.

(45) The proximal end 21 of the implement illustrated in FIG. 2 is optionally of an octagonal shape. It is further optionally formed with an elongated slot 24 longitudinally of its upper face terminating in a transversely extending slot formed through its two opposed side faces.

(46) The proximal end 21 of handle 20 further carries an optional manually manipulatable member 26 optionally including two opposed finger pieces 26a, 26b connected by a central stem 26c (FIG. 9) located within slots 24 and 25 and movable therealong preferably to the ends of the two slots 24 and 25. The distal end 21 of handle 20 further carries an optional lock nut 27 having internal threads threadedly received on threads 27a formed in the side walls in the proximal end 21 of handle 20. As will be described more particularly below, manipulatable member 26 is slidable within slot 25, and lock nut 27 is effective to lock member 26 in its moved position.

(47) The distal end 21 of handle 20 further includes another manipulatable member 28 having a stem 28a (FIG. 4) extending through the upper slot 24, and an optional knob 28b engageable by the user for moving member 28 to its forward position illustrated in FIG. 2, or to its rearward position at the end of slot 24.

(48) The distal end 22 of handle 20 is formed with a slot 29 (FIG. 2) for the reception of a hook, generally designated 30, coupled to manipulatable member 26 so as to be movable from an extended position, illustrated in FIG. 2, to a retracted position towards the ribbed distal outer surface 23 of the handle. Manipulatable member 26 is used for extending hook 30 to its illustrated extended position to facilitate reception of the hook into the first bore B.sub.1 (FIG. 1C) of the bone, and to its retracted position for clamping the handle to the bone such that the passageway 20a, which is used for making the second bore B.sub.2 (FIG. 1C), is at a predetermined angle (in this case 90°) with respect to, and in alignment with, the first bore B.sub.1. Optionally, the angle is 70°. Alternatively, the angle is between 65° and 75°. alternatively, the angle is between 30° and 120°. Thus, as shown in FIGS. 2 and 10B, hook 30 includes a first section 31 received within slot 29 of the handle, an upwardly-extending section 32 joined to a horizontal section 33, and a downwardly-extending end section 34 to be received within bore B.sub.1, as shown in FIG. 23.

(49) A loop 35 is optionally received within the downwardly-extending end section 34 of hook 30. It includes a pair of parallel legs 35a, 35b (FIGS. 3 and 10D) joined by a bridging section 35c. As will be described more particularly below, hook 35 is coupled to manipulatable member 28. Manipulatable member moves the hook to an extended position, as illustrated in FIGS. 2 and 3 or to a retracted position towards the tip of the downwardly-extending section 34 of hook 30. The position of the hook in the extended position enables a suture to pass between the two legs 35a, 35b. Optionally, the hook is then moved to a retracted position for extraction from bore B.sub.1 (FIG. 1C) of the bone to which the suture is to be attached.

(50) The manner in which the hook 30 is coupled to manipulatable member 26, in the preferred embodiment, for moving the hook to its illustrated extended position or to its retracted position, is more particularly seen in FIGS. 8 and 9. As shown particularly in FIG. 8, the central pin 26c of manipulatable member 26 is formed with a bore 26d into which is threaded a screw 26e for securing manipulatable member 26 to an elongated sleeve 40 (FIG. 9) integrally formed with or fixed to the hook 30.

(51) As shown in FIG. 5, and more particularly in FIGS. 2, 3 and 10A-10D, loop 35 is slidably received within hook 30. The two legs, 35a, 35b of the loop normally extend outwardly of the distal end of the hook and are joined at juncture 35d to a wire 35e passing through sleeve 40 of the hook. The proximal end of wire 35e is fixed to a connector 35f receiving the stem 28a of manipulatable member 28 (FIGS. 6A and 6B).

(52) In an exemplary embodiment of the invention, the arrangement is such that hook 30 and loop 35 are normally in their extended positions as illustrated in FIG. 2, wherein the leg 34 of loop 30 is spaced away from the distal end 22 of handle 20, and loop 35 is extended outwardly of the hook leg 34. In this condition, in accordance with this embodiment, the hook 30 is inserted within bore B.sub.1 (FIG. 1C) of the bone to which the suture is to be attached, with the loop 35 straddling bore B.sub.1 and spaced away from the distal tip of leg 34 of the hook in order to receive one end of the suture to be attached to the bone. This arrangement enables the loop to be positioned for receiving the suture from bore B2 and not to collide with residues from drilling bore B2. In this embodiment, bore B2 is narrower than bore B1 thereby enabling the drill forming bore B2 to pass through the loop which is inserted through bore B1.

(53) In another embodiment of the invention, hook 30 and loop 35 are in their retracted position, as shown in FIG. 5, when inserted into bore B1. The retracted position of hook 30 and loop 35 easies the insertion of the hook into the bore since the end of the hook is more rigid in its retracted position. Optionally, loop 35 is moved to its retracted position before forming bore B2 such that the drill forming bore B2 will pass through loop 35.

(54) After the hook has thus been inserted into bore B.sub.1 of the bone, in accordance with the above described embodiments, manipulatable member 26 is moved rearwardly and is locked in position for example by optional locking nut 27 to firmly clamp the hook to the bone, with the passageway 20a within handle 20 in alignment with bore B.sub.1 and at a predetermined angle therewith (in this case 90°). A drill is then passed through passageway 20a of handle 20 to drill bore B.sub.2 in the bone intersecting bore B.sub.1 and extending slightly past that bore. After the drill is removed, the loop is moved to its extracted position if necessary. One end of the suture to be attached to the bone is then passed through passageway 20a, and between legs 35a and 35b of loop 35 to the end of bore B.sub.2.

(55) Knob 28 is then moved rearwardly to move loop 35 to its retracted position, i.e, towards the end hook leg 34, to firmly grasp the suture. The arrangement is such that the two bores B.sub.1, B.sub.2 are located for attaching the suture to the bone, one end of the suture may be extracted via bore B.sub.1, and the other end of the suture may be extracted via bore B.sub.2.

(56) The Medical Kit of FIG. 11

(57) FIG. 11 illustrates the contents of a medical kit which may be supplied for use in performing the arthroscopic surgical procedure described above, and to include the medical implement as described above with respect to FIGS. 2-10D.

(58) Such a kit would include one or more of the following additional tools: a drill guide 51, an obturator 52, and a drill bit 53, for use in forming bore B.sub.1 (FIG. 1C) through the bone to which the suture is to be attached; a drill 54 for forming bore B.sub.2 via passageway 20a of implement 50; and a suture loader 55 for forcing the suture, via passageway 20a, into bore B.sub.2.

(59) As shown particularly in FIG. 11, drill 54 used for forming bore B.sub.2 includes a stop 54a at its proximal end to define the depth of bore B.sub.2 to be produced thereby. The depth of bore B2 should be coordinated with the length of bore B1 and with the distance between distal end 22 of implement 50 and hook 30 after the implement is extended and clamped to the bone. This distance is varies for different bodies depending on the bone structure of the treated body. Optionally, stop 54a is not fixed and can be moved to vary the depth of bore B2 for different bones. In some embodiments, markings are provided on the extended portion of implement 50 to indicate the distance of extension. Drill 54 also includes markings which coordinate with the markings on implement 50 and allows positioning of stop 54a according to the distance between distal end 22 and hook 30 of implement 50. Alternatively, stop 54a is fixed and such that the depth of bore B2 will suit any bone in a body.

(60) In an exemplary embodiment, drill 53 used for forming bore B1 also includes a stop 53a. In this embodiment, the position of stop 53a and stop 54a are coordinated so that the depth of bores B1 and B2 are defined and the bores intersect in the bone.

(61) In an exemplary embodiment, drill 54 is narrower than drill 53 such that drill 54 will pass through a loop inserted in bore B1 which was formed by drill 53. Alternatively, drill 54 is used for forming both bore B1 and bore B2.

(62) In an exemplary embodiment, suture loader 55, as more particularly illustrated in FIGS. 12 and 13A-13B, includes a shank 55a formed with a notch 55b at its distal end and handle 55c at its proximal end, which shank is formed with a pair of opposed flat surfaces 55d parallel to notch 55b, to facilitate aligning the suture received within notch 55b to bore B.sub.1 formed in the bone. Other designs of suture manipulators can also be used.

(63) In an exemplary embodiment, cannulated drill guide 51 is inserted into passageway 20a of implement 50 and is adapted to receive both obturator 52 and drill 53. The obturator 52 is inserted within drill guide 51 in order to locate the exact location of bore B.sub.1 and to clear a path through the soft tissue surrounding the bone for the drill to drill bore B1 in the bone. The obturator is then removed to enable drill 53 to drill bore B.sub.1 via guide 51. After bore B.sub.1 has been drilled, medical implement 50 is then used to drill bore B.sub.2 by inserting hook 30 into bore B.sub.1 to locate passageway 20a of implement 50 in precise alignment with bore B.sub.1 and at a predetermined optimum angle thereto. In some situations an obturator may not be required.

(64) Drill 54 is then passed through passageway 20a of implement 50 to drill bore B.sub.2. Drill 54 is then removed and knob 28 is moved to extend loop 35 from hook 30, if it was not already extended during the drilling of bore B.sub.2. The suture to be attached to the bone is then fed through passageway 20a by suture loader 55 traversing bore B.sub.1 between the two legs 35a, 35b of loop 35 to the end of bore B.sub.2. Optionally, drill 54 is cannulated and the suture is threaded through cannulated drill 54. In this option, the drill is removed after the thread is already in place or together with the entire implement. Loop 35 is then retracted within the end of hook 30 and to firmly clamp the suture to the end of hook 30. Hook 30 is removed from bore B.sub.1 to expose the clamped end of the suture, and handle 20 of implement 50 is also removed to expose the other end of the suture. Accordingly, with the suture passing through the two bores B.sub.1 and B.sub.2, and the two ends of the suture exposed outwardly of these bores, the sutures may now be used for attaching the bone tendon to the bone, or for any other purpose, instead of the anchor pins as previously used.

(65) It will thus be seen that the implement and kit described are particularly useful for arthroscopic medical procedures to attach a tendon to a bone, such as to repair a damaged shoulder joint. However, the invention could also be used in open surgical procedures, or for other procedures requiring the attachment of a suture to a bone instead of anchor pins heretofore used for such purposes.

(66) Variation in Use of Medical Kit

(67) FIGS. 14 and 15 illustrate a variation wherein one end of the suture is accessed and extracted via bore B.sub.1, not by the loop 35 as described above, but rather by a suture hook, generally designated 56 in FIGS. 14 and 15. Such a suture hook includes a shank 56a formed with a crochet notch 56b at its distal end, and an optional handle 56c at its proximal end. Such a suture hook enables the end of the suture received within bore B.sub.2 to be accessed and extracted via bore B.sub.1, thereby obviating the need for the loop 35 in implement 50 as described above with respect to FIGS. 2-10D. Suture hook 56 illustrated in FIGS. 14 and 15 may thus also be included in the tool kit illustrated in FIG. 11 to be used instead of the loop 35 of implement 50.

(68) The Medical Implement of FIGS. 16-21

(69) FIGS. 16-21 illustrate another bone-tunneling implement constructed in accordance with an embodiment of the present invention, generally corresponding to the implement described above with respect to FIGS. 2-10D, but incorporating a number of modifications.

(70) In the bone-tunneling implement illustrated in FIGS. 2-10D, the hook 30 is the movable element movable with respect to the distal end of the handle 20 in order to facilitate the reception of the hook into the first bore B.sub.1, and for clamping the handle to the bone at a predetermined angle with respect to the first bore. In the medical implement of FIGS. 16-21 this arrangement in reversed; that is, in the medical implement of FIGS. 16-21, the movable member is the distal end of the handle, which is movable towards and away from the hook. Such an arrangement has the advantage of simplifying the mechanism for moving the movable element.

(71) Another difference in the structure of the medical implement of FIGS. 16-21, over that of FIGS. 2-10D, is that the manipulatable member or knob 28 in FIGS. 2-10D is not slidable along an axis parallel to the longitudinal axis of the handle, but rather is pivotal along a pivot axis perpendicular to the longitudinal axis of the handle. In addition, the lock nut 27 used in the medical implement of FIGS. 2-10D to lock the manually-manipulatable member 26, is omitted. Such features not only simplify the structure, but also facilitate its use by the surgeon.

(72) The medical implement illustrated in FIGS. 16-21 is generally designated 100. It includes a handle 120 having a proximal end 121 for manual grasping, and a distal end for engagement with a bone in which a suture is to be attached. As in the previously—described embodiment, the bone would be pre—formed with a first bore B1 (FIG. 1C). The medical implement of FIGS. 16-21 also includes a hook 130 at the distal end of the handle, and a loop 135 movable to an extended position with respect to the hook for facilitating entry of one end of the suture through the loop, and to a retracted position for clamping the respective end of the suture, as described above with respect to FIGS. 2-10D.

(73) In the implement of FIGS. 2-10D, the hook (30) is the movable element with respect to the distal end (22) of the handle; the construction of FIGS. 16-21 reverses these parts. That is, in the construction of FIGS. 16-21, the hook 130 is fixed, and the distal end of the handle is movable towards and away from the hook in order to facilitate the entry and removal of the hook into the first bore B1.

(74) This feature can be best seen in FIG. 19, wherein it will be seen that the handle 120 is hollow, and slidably receives a core 123 having a distal end 122 movable towards and away from the hook 130.

(75) As clearly seen in FIG. 19, core 123 is urged by a spring 124 in the direction of bringing the distal end 122 into engagement with the hook 130, but may be manually moved rearwardly by means of manipulatable member 126 having a stem passing through longitudinal slots 127 (FIG. 18) in handle 120 so as to permit the distal end 122 to be retracted rearwardly of hook 130 against the bias of spring 124. As further seen particularly in FIG. 19, the core 123 is formed with passageway 120a (corresponding to passageway 20a in FIGS. 2-10D) used for making a second bore B.sub.2 shown in FIG. 1C. At the distal end 122, passageway 120a is a slot in core 123.

(76) Loop 135 received within hook 130 is basically of the same construction as described above with respect to loop 35 in FIGS. 2-10D, in that it is coupled to knob 128 to move the hook to its extended and retracted positions in order to grasp a suture passed between the two legs of the hook for extraction from bore B.sub.1, as described above with respect to FIGS. 2-10D. The coupling of the loop 135 to knob 128 is also effected by means a wire 135e passing through the distal end of handle 120.

(77) In the implement of FIGS. 16-21, however, manipulatable knob 128 for loop 135 is pivotal about an axis 128a extending perpendicularly to the longitudinal axis of the handle 120 and located slightly above that longitudinal axis, as can be seen particularly in FIG. 19. Thus, as shown in FIG. 19, loop 135 would normally be urged, by spring 124 to its retracted position within hook 130 (FIG. 19), but is conveniently movable to its extended position, shown in FIG. 18, by merely pivoting knob 128 forwardly, whenever it is desired to extend the loop for receiving the end of the suture. Releasing the knob will then effect the retraction of the loop to firmly grasp the suture, as described above with respect to the implement of FIGS. 2-10D.

(78) In addition, whereas hook 30 shown in FIG. 2 formed an angle of about 90° between horizontal section 33 and end section 34, in the embodiment shown in FIGS. 16-21, hook 130 forms a larger angle of about 110°-115° between horizontal section 33 and end section 34. Accordingly, with this embodiment, the angle between bores B1 and B2 formed using implement 100 is about 65°-70°.

(79) In substantially all other respects, the bone-tunneling implement illustrated in FIGS. 16-21 is constructed, and operates, in the same manner as described above.

(80) It is to be understood that, where applicable, implements according to various embodiments of the invention can include features taken from both described embodiments of the bone-tunneling implements. Furthermore, it should be clear that other methodologies to provide the functions performed by the two above embodiments can also be used.

(81) Method of Attaching a Suture to a Bone (FIGS. 22 and 23A-G)

(82) FIG. 22 is a block diagram of a method 220 of attaching a suture to a bone in accordance with an exemplary embodiment of the invention. FIGS. 23A-G are illustrations of stages of method 220. the illustrations and description below refers to implement 100 shown in FIGS. 16-21. It is noted that method 220 with appropriate changes may be applied with implement 50 shown in FIGS. 2-10D or other variations of the implement.

(83) A first bore B1 is formed in the humerus bone at 222. Preferably, bore B1 is formed near the greater tubercle 6 shown in FIG. 23A and FIGS. 1A-1C and is not long enough to exit the bone. Optionally, as shown in FIG. 23A, bore B1 is drilled with a drill bit 53 inserted through drill guide 51. Optionally, an obturator is first inserted through drill guide 51 in order to clear a path through the soft tissue surrounding the bone. Alternatively, bore B1 is formed by any other method known in the art.

(84) Hook 130 is then inserted into bore B1 at 224. Optionally, the hook is inserted through drill guide 51, as indicated in FIG. 23B, in order to ease locating bore B1 and the drill guide is removed after insertion.

(85) Optionally, the insertion of the hook into bore B1 is used as a reference point for forming bore B2, such that bores B1 and B2 intersect at a predetermined angle. Alternatively or additionally, hook 130 is used as an arm clamping implement 100 to the bone. Before inserting hook 130 to bore B1, manipulatable member 126 is moved rearwardly so as permit distal end 122 of the core to be retracted rearwardly of hook 130. After insertion of hook 130 in bore B1, manipulatable member 126 is released and distal end 122 is clamped to the bone by bias of spring 124 as shown in FIG. 19, or otherwise.

(86) FIG. 23C depicts the hook inserted into the first hole and distal end 122 clamped to the bone. As further shown in FIG. 23C, manipulatable knob 128 is moved to shift loop 135 to its extended position.

(87) At 226 a second bore B2 is formed through the bone (FIG. 23D) at a predetermined angle from bore B1. Bore B2 is drilled to a depth such that bore B2 meets bore B1 in the humerus bone thereby enabling a suture to be threaded through the two bores. Preferably, bores B1 and B2 extend past the intersection of the bores in the bone such that drill 54 passes through loop 135 in bore B1. Preferably, bore B2 is not long enough to exit the bone. Optionally, bores B1 and B2 define a 70° angle in the bone. Preferably, bores B1 and B2 define an angle of between 65° and 75° in the bone.

(88) Optionally, before drilling bore B2, an obturator, such as the obturator 52 shown in FIG. 11, is used to clear the path and locate the exact location of bore B2. Bore B2 is then drilled at the location indicated by the obturator, using a drill such as drill 54 shown in FIG. 11.

(89) After forming bore B2 a first end of a suture 57 is threaded through bore B2 at 228. As shown in FIG. 23E, a suture loader such as suture loader 55 depicted in FIG. 12 is optionally used for threading suture 57 through bore B2 and through loop 135 extending from hook 130. Suture loader 55 is then removed, leaving suture 57 in the bore.

(90) At 230 the first end of the suture is caught at the intersection of bores B2 and B1 by loop 135. Manipulatable knob 128 is moved to shift loop 135 to its retracted position inside hook 130. Suture 57 which was threaded through loop 135 is now caught inside hook 130.

(91) At 232 manipulatable member 126 is moved to release distal end 122 from being clamped to the bone. Hook 130 is removed from bore B1 and suture 57 which is clamped in hook 130 is thereby threaded through bore B1. The end of the suture is then extracted from the bone by threading through bore B1 at 232. As shown in the magnified section of FIG. 23G, suture 57 is now threaded through a channel in the bone consisting of bores B1 and B2.

(92) In an alternative embodiment, the suture is first threaded into bore B1 and caught through bore B2.

(93) At 233 the suture is threaded through the tendon according to any procedure known in the art. The tendon is then pulled into place by means known in the art. At 234 the two ends of the suture, the first end extending from bore B1 and the second end extending from bore B2 and tendon 10 may be knotted together thereby attaching the tendon to the humerus bone. FIG. 23H is a coronal section view of a humerus bone illustrating a suture knotted through the bone and tendon. The suture, threaded through a into bore B1 is exited bore B2 at b, retrieved through tendon 10 at c and is knotted at d. FIG. 23I is a lateral view of a row of sutures tied over tendon 10 in accordance with an exemplary embodiment of the invention. A first suture is passed through the bone at a1 to b1 and retrieved through the tendon at c1 and then knotted at d1. A second suture is passed through a channel in the bone from a2 to b2 and passed through the tendon at c2 to be knotted at d2, etc.

(94) FIG. 23J illustrates a lateral view of another embodiment of the invention where two sutures are passed through a single bone channel and are tied over different locations through the tendon. For example, a first and a second suture are threaded through a bone channel from a1 to b1. The first suture is retrieved through the tendon at c11 and knotted at d11. The second suture is retrieved through the tendon at c12 and knotted at d12.

(95) It is noted that a plurality of ways of tying the sutures are known in the art. FIGS. 23I-J are provided an example and other methods such as for example crossing the sutures over the tissue, to increase the area of the tendon held against the bone, are also covered by the present invention.

(96) The Medical Implement of FIG. 24

(97) In another embodiment of the invention, bores B1 and B2 are formed with a same implement 240 as shown in FIG. 24.

(98) Implement 240 includes two channels 242 and 244 for receiving tools such as drills, holders, etc. Instrument 240 is brought close to the bone at the greater tubercle 6. A drill, such as drill 53 shown in FIG. 11, is inserted into channel 242 for forming a first bore B1. Optionally, an obturator, such as obturator 52 shown in FIG. 11, is first inserted into channel 242 for clearing the path through the soft tissue and indicating the location of bore B1.

(99) A pin or hook is then inserted into channel 242 and bore B1 for positioning implement 240 to the bone in order to stabilize the implement when forming a second bore B2. optionally, the drill used for forming bore B1 is kept in the bore for stabilization of implement 240 and a second drill is used for forming bore B2.

(100) A drill is then inserted through channel 244 and second bore B2 is formed. Channels 242 and 244 are located in implement 240 such that bores B1 and B2 formed with drills inserted through the channels, intersect in the bone. Preferably, bores B1 and B2 are not long enough to exit the bone. Optionally, a stop on the drill forming bores B1 and B2 causes the bores to be formed to a certain depth such that the bores will intersect in the bone and will not cross the bone.

(101) In the embodiment shown in FIG. 24, the angles formed between the bores is preferable less than 90° so as to allow the two bores to be formed from the same side of the bone. Optionally, the bores define an angle of less than 45° in the bone. Optionally, the bores define an angle of less than 30° in the bone.

(102) Implement 240 further comprises two channels 246 and 248 for receiving a suture. Channels 246 and 248 join with channels 242 and 248 at intersection points 250 and 252 respectively. After bores B1 and B2 are formed, a suture is inserted through channel 246 and bore B1 and is retrieved through bore B2 and channel 248 in a manner similar to that described with respect to the embodiments shown in FIGS. 2 and 16 above.

(103) It will be appreciated that other variations, modifications and applications of the invention may be made. For example, other means may be used for extracting the end of the suture via bore B.sub.1 than those described above. In addition, other constructions of the slidable manipulatable members 26 and 28 may be used for removing the hook and/or the loop. The couplings of manual manipulatable member 26 may include a slip or yielding coupling in order to prevent excessive force from being applied by hook 30 to the bone, and thereby reduce the possibility of breakage of the bone.

(104) Many other variations, modifications and applications of the invention will be apparent.

(105) All publications, patents and patent applications mentioned in this specification are herein incorporated in their entirety by reference into the specification, to the same extent as if each individual publication, patent or patent application was specifically and individually indicated to be incorporated herein by reference. In addition, citation or identification of any reference in this application shall not be construed as an admission that such reference is available as prior art to the present invention. To the extent that section headings are used, they should not be construed as necessarily limiting. In addition, any priority document(s) of this application is/are hereby incorporated herein by reference in its/their entirety.