Adjustable self-locking loop constructs for tissue repairs and reconstructions

Abstract

Systems and methods for bone to bone, or soft tissue to bone, repairs without knot tying. The repair systems include self-cinching constructs which are tensionable and which include a flexible strand with a knotless, adjustable loop with at least one splice and a shuttle/pull device attached to the flexible strand. A final splice is formed by pulling on the shuttle/pull device subsequent to the knotless, adjustable loop being assembled with or secured to tissue (for example, a soft tissue graft or BTB graft), to allow desired tensioning of the graft to be fixated relative to the bone.

Claims

1. A fixation system for tissue reconstruction, comprising: a fixation device; a knotless tensionable loop construct attached to the fixation device and having two flexible loops and two splices, at least one of the two flexible loops having an adjustable length, wherein the two flexible loops are interlinked such that a first loop of the two flexible loops passes through an opening established by a second loop of the two flexible loops and the second loop passes through an opening established by the first loop wherein the two flexible loops and the two splices are formed from a same flexible strand; and a graft connected to the tensionable loop construct, wherein at least one of the two flexible loops is passed through a bone block of the graft wherein a region where the two flexible loops are interlinked is located within a hole of the bone block.

2. The fixation system of claim 1 wherein the fixation device is a button.

3. The fixation system of claim 1, wherein the graft includes soft tissue, synthetic material, bone, or a combination of such materials.

4. The fixation system of claim 3, wherein the soft tissue is tendon or ligament.

5. The fixation system of claim 1, wherein the graft is an autograft or an allograft.

6. The fixation system of claim 1, wherein the graft is a BTB graft.

7. The fixation system of claim 1, wherein the same flexible strand is a suture formed of ultrahigh molecular weight polyethylene.

8. The fixation system as recited in claim 1, wherein a strand of one of the two flexible loops is received through the other of the two flexible loops to interlink the two flexible loops.

9. The fixation system as recited in claim 1, wherein the first loop and the second loop of the two flexible loops are interlinked at a location that is separate from either of the two splices.

10. The fixation system as recited in claim 1, wherein the first loop and the second loop of the two flexible loops are interlinked at an opposite end of the first loop and the second loop from the two splices.

11. The fixation system as recited in claim 1, wherein the first loop and the second loop are interlinked to establish an adjustable closed loop that is larger than both the first loop and the second loop.

12. A surgical system, comprising: a fixation device; a loop construct connected to the fixation device and including a first adjustable loop, a first splice, a second adjustable loop, and a second splice, wherein the second adjustable loop is interlinked with the first adjustable loop such that the first adjustable loop passes through an opening established by the second adjustable loop and the second adjustable loop passes through an opening established by the first adjustable loop wherein the first adjustable loop, the first splice, the second adjustable loop, and the second splice are formed from a same flexible strand; and a graft connected to the loop construct such that at least one of the first adjustable loop and the second adjustable loop passes through a hole in a bone block of the graft wherein a region where the two flexible loops are interlinked is located within the hole of the bone block.

13. The surgical system as recited in claim 12, wherein a strand of the second adjustable loop is received through the first adjustable loop to interlink the first adjustable loop and the second adjustable loop.

14. The surgical system as recited in claim 13, wherein the strand is received through the first adjustable loop prior to forming the second adjustable loop.

15. The surgical system as recited in claim 13, wherein the strand is received through the first adjustable loop after the first adjustable loop is passed through the hole of the bone block.

16. The surgical system as recited in claim 12, comprising a splicing device spliced through one of the first adjustable loop and the second adjustable loop.

Description

BRIEF DESCRIPTION OF THE DRAWINGS

(1) FIG. 1 illustrates an exemplary knotless, self-locking, adjustable button/loop construct (pre-assembled tensionable construct) of the present invention.

(2) FIG. 1a illustrates a top view of the button of the tensionable construct of FIG. 1.

(3) FIGS. 2-6 illustrate starting materials and steps of assembling the knotless, self-locking, adjustable button/loop construct of FIG. 1, according to an exemplary embodiment of the present invention.

(4) FIGS. 7-16 illustrate subsequent steps of attaching the self-locking, adjustable button/loop construct of FIG. 6 to an exemplary graft (a BTB graft) to form an integrated system (implantable surgical system) according to an exemplary embodiment of the present invention.

(5) FIG. 17 illustrates a surgical construct (implantable integrated system or surgical system) according to an exemplary embodiment of the present invention (with the self-locking, adjustable button/loop construct of FIG. 6 attached to an exemplary soft tissue graft).

(6) FIG. 18 illustrates a surgical construct (integrated system or a BTB TightRope) according to another exemplary embodiment of the present invention (the self-locking, adjustable button/loop construct of FIG. 6 attached to an exemplary BTB graft).

(7) FIGS. 19-30 illustrate steps of a method of ACL reconstruction with the integrated system of FIG. 18 (BTB TightRopeC).

(8) FIGS. 31-40 illustrate steps of a method of ACL reconstruction with another integrated system (surgical construct) of the present invention (a soft tissue graft attached to a self-locking, adjustable tensionable construct without a button).

(9) FIG. 41 illustrates an assembly board with a mounted self-locking, adjustable button/loop construct of the present invention used to assist in attaching a graft (for example, an exemplary BTB ACL graft).

(10) FIG. 42 illustrates an exemplary direction of use card to assist surgeon(s) in attaching the mounted self-locking, adjustable button/loop construct of FIG. 41 with a graft (soft tissue graft or BTB graft).

DETAILED DESCRIPTION OF THE INVENTION

(11) The present invention provides surgical constructs, systems and techniques for knotless tissue repairs and fixations. The surgical constructs comprise a tensionable construct with an adjustable, self-locking knotless flexible closed loop connected to tissue (such as soft tissue, graft, tendon, ligament, synthetic material, biological material, bone, or combinations of such materials, among others). The tissue may be directly looped over the flexible adjustable loop, or the flexible adjustable loop may be passed through tissue, for insertion and fixation into a bone tunnel or socket. The surgical constructs may also comprise a splicing device (a shuttle/pull device) adjacent the flexible, adjustable loop. The splicing device may be a suture passing instrument such as a closed loop, a FiberLink, a nitinol wire loop, a needle pre-inserted into a splice area, or any splicing device that aids in the formation of a final splice in the adjustable loop). The tensionable construct may optionally include a fixation device (for example, a button) securely attached to the adjustable loop. The splicing device (suture passing instrument or shuttle/pull device) aids in the formation of the final splice of the adjustable, self-locking knotless flexible closed loop. The tensionable construct is adjustable in length and allows the surgeon the ability to customize the device to each patient and seat the graft against the wall of the bone tunnel or socket. The adjustments are self-locking and the fixation device (implant) minimizes the compressive forces on the bone block.

(12) According to an exemplary embodiment, the tensionable construct is provided as a pre-assembled or pre-packaged construct on an assembly board upon which an adjustable flexible closed loop, a shuttle/pull device, a passing suture for fixation device, and a needle are mounted (in a kit, for example) and assembly instructions are provided. The pre-assembled tensionable construct may be assembled with BTB grafts or other tissue grafts (such as a ligament graft like an autograft, allograft or artificial graft), at the time of surgery, to form integrated systems for tissue repairs and reconstructions. During the assembly, the self-locking flexible adjustable closed loop is provided around tissue graft (for example, around a BTB block or a soft tissue strand) or through tissue. If a BTB construct is employed, the self-locking adjustable loop is provided around the BTB bone block without forming any knots or any crossing of the loop strands between the top of the bone block and the button. This minimizes the compressive forces on the bone block which, in turn, leads to a stronger reconstruction. The absence of any knots also limits the chances of the knot tightening down and restricting the adjustability of the implant.

(13) If an exemplary BTB graft is employed, the tensionable construct is assembled with the BTB graft by passing the self-locking adjustable loop of the tensionable construct through a hole in the bone block, and then passing the free strand of the construct through the looped end of the construct and through the loop of the shuttle/pull device (provided in the form of a splice loop of fixed diameter, for example). The flexible strand and the shuttle/pull device attached to it allow the formation of a final splice for the adjustable loop. The shuttle/pull device is provided within the strand (inside of the strand) and forms the final splice subsequent to the insertion of the self-locking adjustable loop through the hole in the bone block. The shuttle/pull device is removed subsequent to the formation of the final splice, and is not part of the final implantable construct (final assembled integrated system).

(14) The integrated systems of the present invention allow formation of the final fixation device with a knotless self-locking mechanism that allows the user (for example, the surgeon) to control the tension of the strand on the tissue to be attached to bone.

(15) At least one of the flexible strand and the splicing device (shuttle/pull device) may be made of any known suture material, such as ultrahigh molecular weight poly ethylene (UHMWPE) or the FiberWire suture (disclosed in U.S. Pat. No. 6,716,234 which is hereby incorporated by reference in its entirety). Typically the suture will be UHWMPE suture without a core to permit ease of splicing. The shuttle/pull device may be a suture passing instrument such as a splicing loop (for example, a loop of a flexible strand, or a FiberLink or a Nitinol loop) or a needle pre-inserted into the splice area or any device that allows formation of a final splice in the adjustable closed loop of the tensionable construct.

(16) The present invention also provides methods of fixation of bone to bone, or soft tissue to bone. An exemplary method of the present invention comprises the steps of: (i) providing a bone tunnel; (ii) providing a button/graft construct including a button and a loop of flexible material having an adjustable length, in the vicinity of the bone tunnel; (iii) attaching tissue to the button/graft construct by looping the tissue (graft) over the adjustable loop or, alternatively, by passing the loop of flexible material through the tissue (graft); (iv) advancing the button/graft construct with the attached tissue through the bone tunnel; and (v) securing the tissue within the bone tunnel by adjusting the length of the adjustable loop.

(17) The present invention also provides methods of tissue repair which do not require tying of knots and allow adjustment of both the tension of the suture and the location of the tissue with respect to the bone. An exemplary method of the present invention comprises inter alia the steps of: (i) providing a pre-assembled construct including an adjustable, self-locking knotless flexible closed loop with at least one splice in a flexible strand, the flexible closed loop being adjacent a shuttle/pull device (a splicing device or a suture passing instrument); (ii) assembling the pre-assembled construct with a tissue graft (BTB or other soft tissue graft) by passing the adjustable, self-locking knotless flexible closed loop through or around tissue, and then forming a final splice in the adjustable, self-locking knotless flexible closed loop with the shuttle/pull device to obtain a final implantable construct; (iii) securing the final implantable construct into a bone tunnel/socket; and (iv) pulling on the flexible strand to allow the tissue graft to achieve the desired location relative to the bone, and to allow proper tensioning of the final construct.

(18) Referring now to the drawings, where like elements are designated by like reference numerals, FIG. 1 illustrates an exemplary tensionable construct 99 (ACL TightRope 99) of the present invention employed for the formation of surgical integrated systems 100, 200, 200a (FIGS. 17, 18 and 35, respectively). In the particular exemplary embodiment illustrated in FIG. 1, tensionable construct 99 is formed of a knotless, closed, adjustable loop 50 formed of a flexible strand 5 or flexible material 5 and a shuttle/pull device 40 (a suture passing instrument or a splicing device such as a fixed loop 40, a FiberLink 40, a nitinol loop 40 or a needle 40, for example) attached to the flexible strand 5 (i.e., pre-loaded on the flexible strand). Optionally, tensionable construct 99 may include a fixation device 20 (for example, a button 20). A top view of an exemplary fixation device 20 is shown in FIG. 1a. Device 20 has a body 25 with an oblong configuration (when viewed along a longitudinal axis 25a of the device) and a plurality of holes, a tear drop hole 21 and a round hole 22 extending along the longitudinal axis 25a.

(19) As detailed below, the knotless, closed, adjustable loop 50 is formed by splicing an end 5a of flexible material 5 (for example, braided high strength (UHMWPE) suture strand 5 provided in a predetermined color, for example, white) to form splice 6. The splice 6 and loop 50 are secured to button 20 by sliding the button over the non-spliced strand 5b and passing the strand 5b through both button holes 21, 22 so that the splice 6 will rest on (abut) the thickness of the button 20.

(20) The knotless, closed, adjustable loop 50 has an adjustable perimeter and length, and is capable of adjusting tension. Details for the formation of adjustable closed loop constructs (similar to the loop 50) are set forth, for example, in U.S. Patent Application Publication Nos. 2010/025667 and 2010/0268273, the disclosures of which are incorporated herein in their entirety.

(21) Shuttle/pull device 40 (splicing device 40) of the tensionable construct 99 may be any suture passing device or splicing device configured to create a final splice in the knotless, closed, adjustable loop 50 after attachment to tissue to be reconstructed/repaired, and as detailed below. Shuttle/pull device 40 may be a suture passing instrument in the form of a pre-loaded flexible strand, a loop with a fixed perimeter, a FiberLink, a nitinol wire loop or a needle pre-attached to the flexible strand forming the knotless, closed, adjustable loop 50, for example.

(22) In an exemplary embodiment, shuttle/pull device 40 is a fixed closed loop with a fixed length and perimeter (i.e., non-adjustable). Fixed loop 40 may be formed by splicing another flexible strand 1 (for example, a #2 FiberWire suture 1 provided in a predetermined color, for example, blue) through strand 5b by first folding the blue strand and then passing both free ends 1a, 1b of the blue strand through the non-spliced strand 5b to form loop 40, eyesplice 7 and loop section 1c below eyesplice 7. Ends 1a, 1b are tied in a static knot 11.

(23) FIG. 1 also depicts a passing suture 3 (for example, a #5 FiberWire suture) for pulling the button 20 through a bone tunnel or socket (for example, the femoral tunnel). Like the shuttle/pull device 40, the passing suture 3 is removed at the end of the implantation of the final construct. Also shown in FIG. 1 a straight needle 4 is attached to adjustable, knotless suture loop 50 for passing the construct (the implant) through a graft, as detailed below. Another illustration of the adjustable, knotless button/loop construct 99 of the present invention is depicted in FIG. 6.

(24) FIG. 2 illustrates the button 20, flexible strand 5 (braid 5) and splicing suture 1, as starting materials used in configuring the construct 99.

(25) FIGS. 3-6 illustrate exemplary steps of assembling the knotless, self-locking, adjustable button/loop construct 99 (tensionable construct 99).

(26) FIG. 3 (creating eyesplice 6 and adjustable, closed loop 50): Step 1: start with a flexible strand 5 (for example, a white braided suture 5 such as a UHMWPE braid 5 of about 40-50 inches); fold the braid at midpoint to create two equal length braid strands 5a, 5b.

(27) Step 2: create an eyesplice 6 on one of the braid strands (for example, on strand 5a) by passing a blunt tip needle 4 through the center of the braid 5 and carrying the end 5a of the braid 5 through with it, in the nitinol loop 4a of the needle 4. The splice 6 should travel for a distance of about 16-18 mm through the braid, towards the midpoint created in step 1 to form adjustable, closed loop 50. Reduce the eyesplice loop 50 to about 80 mm.

(28) FIG. 4 (positioning the button 20): Step 3: slide a button 20 over the non-spliced strand 5b passing the strand through both button holes 21, 22 leading with the full round hole 22 of the button. Pass the free strand end 5a that results from the eyesplice 6 through the full round hole 22 and position the button 20 such that the exit point of the eyesplice 6 is resting within the thickness of the button 20.

(29) FIG. 5 (creating the second eyesplice 7 and the splicing loop 40): Step 4: prepare an eyesplice 7 in the same manner as Step 2 by employing another flexible strand 1 with two ends 1a, 1b (for example, a #2 blue suture braid 1). Fold the #2 blue braid 1 at the midpoint and pass both free ends 1a, 1b of the blue braid through the non-spliced strand 5b to form the second eyesplice 7.

(30) FIG. 6 (construct assembly): Step 5: position the blue braid and tie the two free ends 1a, 1b into a simple overhand knot 11 above the button 20 to form splicing loop 40 (with a fixed perimeter), and loop end 1c.

(31) Step 6: place a passing suture 3 (for example, a #5 FiberWire suture, not shown) through the tear drop button hole 21 and position the passing suture 3 so that the strands are about equal length. The passing suture 3 will pull/pass the button 20 through the bone (femur or tibia).

(32) Step 7: crimp the nitinol wire around a strand section 5c of adjustable loop 50 of the white braid; assemble the end of the nitinol wire into the needle capturing the white braid. The pre-assembled construct (tensionable construct 99) is then provided to medical personnel in the OR (for example, surgeon) who then completes the final assembly to create the final implantable construct with the graft. The graft may be a BTB graft or any other soft tissue grafts (for example, a soft tissue graft that cannot be folded over the adjustable, knotless loop) or a ligament, tendon graft or a synthetic graft.

(33) According to additional embodiments, just the loop construct (without fixation device/button 20) is provided to the surgeon. This embodiment could be used for soft tissue grafts that cannot be folded over the loop. In this no button/loop assembly, the implantation is conducted with an attachable button (as detailed below with reference to FIGS. 31-40).

(34) During the final assembly by the surgeon, the splicing loop 40 is removed after completing the splice. The passing suture 3 is also removed after the button 20 is implanted.

(35) Reference is now made to FIGS. 7-16 which illustrate subsequent, exemplary steps of a method of assembling (attaching) the tensionable construct 99 to tissue (for example, soft tissue or BTB graft) to be repaired and/or reconstructed. Tensionable construct 99 is provided as a pre-assembled construct that includes a suture passing device 40 (splicing loop) that aids in creating the final splice for the adjustable loop. As detailed below, the suture passing device may have an exemplary loop configuration and it is not part of the final assembled construct that is implanted; suture passing device 40 is just an aid for the final assembly and for the formation of the final splice (and spliced loop) of the assembly. The suture passing device 40 is not limited to a flexible strand or a suture, but it could be a needle pre-inserted into the splice area or a nitinol wire loop, among others.

(36) Details on assembling tissue 90 with the tensionable construct 99 to obtain integrated construct 100 of the present invention are set forth below with reference to FIGS. 7-16. The integrated construct 100 is a surgical implantable system consisting of tensionable construct 99 provided with knotless, adjustable loop 50 with a suture splicing device 40 attached to the knotless, adjustable loop 50 and tissue 90. During the final assembly by the surgeon, the suture passing device 40 (splicing loop 40) is removed after completing the splice and the formation of final closed loop 150. The passing suture 3 is also removed after the button 20 is implanted.

(37) The embodiments detailed below will be explained, for simplicity, with reference to tissue 90 as being an exemplary BTB graft 90; however, the invention is not limited to this exemplary embodiment and encompasses any tissue and/or tissue graft. BTB grafts and other soft tissue grafts are harvested and provided at the time of surgery so they cannot be assembled by the manufacturer with the fixation device. The partially-assembled construct 99 (tensionable construct 99) is attached to the graft by the surgeon, and during surgery, to complete the assembly of the final construct in the OR. The partially-assembled construct 99 (tensionable construct 99) may be attached to one or both ends of a BTB graft (for the femoral and tibial sides), as desired and depending on the particulars of each surgical repair.

(38) FIGS. 7 and 8: pass the straight needle 4 of Step 7 through a drill hole 91a formed within the bone block 91 of BTB graft 90 so that the loop 50 extends through the drill hole and a loop portion 50c is exposed. Once the implant 99 is passed, the needle 4 is cut off.

(39) FIGS. 9 and 10: pass the free strand 5b of the implant 99 through looped portion 50c of the knotless, adjustable loop 50 (implant 50) that has been passed through the bone block 91.

(40) FIG. 11: pass the free strand 5b through the pre-loaded passing suture loop 40.

(41) FIGS. 12 and 13: pull the tails 1a and 1b of the pre-loaded passing suture loop 40 through splice 7 of the implant 99 to advance the free strand 5b through the implant 99. The end of the free strand 5b is held tightly while pulling it through the implant 99.

(42) FIG. 14: the free strand 5b passes through the eyesplice 7, forming loop 55 which is interconnected (interlinked) with adjacent knotless, adjustable loop 50 through connecting region 59. The free strand 5b now becomes the shortening strand of the construct 99 (TightRope 99).

(43) FIG. 15: even out the implant 99 by pulling the shortening strands until the implant 99 is symmetric (i.e., interconnecting region 59 of the two interconnected loops 50, 55 is within hole 91a of the bone block 91). Final closed loop 150 is formed by the two interconnecting loops 50, 55 and two splices 6, 7.

(44) FIG. 16 shows the final construct 100 (integrated assembly 100) with the two shortening strands 5a, 5b of the TightRope 99 and the two strands of #5 FiberWire suture 3 for passing button 20. Closed loop 150 is attached to both the graft 90 and fixation device 20 (button 20).

(45) FIGS. 17 and 18 illustrate two exemplary integrated systems 100, 200. Integrated system 100 (BTB TightRope 100) includes tensionable construct 99 and BTB graft 90. Integrated system 200 (ACL TightRope 200) includes tensionable construct 99 and soft tissue 290. Integrated system 200 (ACL TightRope 200) is formed in a manner similar to that described above for the formation of integrated system 100, the difference being that the knotless adjustable loop 50 is passed not through tunnel 91 of the bone block 90 but rather passed around (and secured to) a mid portion 290a of folded soft tissue graft 290 (shown in FIG. 17, with the graft 290 being folded and looped over the interconnect region 59 formed by loops 50, 55).

(46) FIGS. 19-30 illustrate steps of an ACL reconstruction with an exemplary BTB TightRope 100 (integrated system 100) of the present invention. The simplicity and strength of the ACL TightRope is used with bone-tendon ACL grafts. The BTB TightRope (tensionable construct 99) offers the same adjustable, four-point locking system as the ACL TightRope but allows placement through a small drill hole in the cortical bone block. The TightRope button 20 facilitates dependable, cortical fixation and the adjustable loop 50 allows the graft to be pulled into the femoral socket as deep as needed for ideal graft tunnel-matching. The BTB TightRope 99 also allows fixation of BTB grafts 90 into anatomic femoral sockets that can be difficult to reach with traditional interference screws.

(47) For graft preparation and implant loading, use the BTB TightRope for bone blocks of about 10 mm in diameter and about 20 mm in length. Use a 2 mm drill pin to place a hole about 10 mm from the end of the bone block, perpendicular to the cortical bone. The BTB TightRope 99 is packaged in a special card to facilitate assembly (as shown in FIG. 41). Step-by-step instructions (FIG. 42) may be also included on the card.

(48) FIG. 19: Use the attached needle 4 to pass the looped limb 50 of the TightRope 99 through the bone block 91 in the direction of arrow A. Once passed, cut the wire off the needle 4 and remove. Take care not to damage implant (loop 50) during cutting.

(49) FIG. 20: Pass the straight limb 5b of the TightRope 99 through the first loop 50c in the direction of arrow B.

(50) FIG. 21: Place 1 cm of the tip of the straight limb 5b into the blue passing suture loop 40 and fold over. Pull the tails of the passing suture loop to deliver the straight limb 5b through the suture splice 7 and button 20. Importantly, as the suture is passed through the splice (by pulling in the direction of arrow C), resistance will be encountered. A hemostat 85 may be used to pull the passing suture while holding firm counter tension on the straight suture.

(51) FIG. 22: Pull on the newly created shortening strand to even up loop lengths before implantation (by pulling in the direction of arrow D) and to form final construct 100. Final integrated construct 100 includes tensionable construct 99a (i.e., without the splicing device 40) and BTB graft 90 attached to it. Closed loop 150 of tensionable construct 99a is attached to both the graft 90 and the fixation device 20. Splices 6, 7 of loops 50, 55 forming closed loop 150 abut the fixation device 20. Final integrated construct 100 is implanted into a bone tunnel or socket, as detailed below.

(52) FIGS. 23 and 24: FEMORAL SOCKET PREPARATIONThe femoral socket 81 can be prepared in femur 80 in a retrograde fashion using the FlipCutter and the RetroConstruction Guide System, by a retrograde technique using an Arthrex FlipCutter, disclosed in U.S. Patent Application Publication No. 2009/0275950. Alternatively, the socket may be drilled transtibially through the medial portal or in an antegrade fashion with a ACL TightRope Drill Pin and Low Profile Reamers. In a Medial Portal Option, for medial portal and transtibial drilling, an Arthrex RetroButton Drill Pin may be used. Note the intraosseous length during tunnel preparation and mark that distance on the ACL TightRope RT implant. FIG. 23 shows the FlipCutter Option employing a FlipCutter 83. FIG. 24 shows the Medial Portal Option employing a drill/cutter 84.

(53) FIG. 25: Pass the blue passing suture 3 and white tensioning strands 50, 55 together through the femur 80. Pull even tension on both sets of sutures. Clamp sutures together and pull to advance button 20. Pull the button 20 through the femur 80. A line on the implant marked at the intraosseous length is helpful to signal that the button has exited the femur. The button 20 can also be viewed through the medial portal as it exits the femoral cortex. If tunnels are divergent, it may be helpful to use a probe through the lateral portal to facilitate implant and graft passage out of tibia 70 and into the femoral socket.

(54) FIG. 26: Hold slight tension on the tibial graft sutures during graft advancement. To advance the graft 90, pull on the tensioning strands one at a time, alternating approximately 2 cm on each side. Once the graft is fully seated, pull firmly back on the graft to check fixation. Once the graft is seated, do not continue to pull tensioning strands.

(55) FIGS. 27-20: Fix the tibial side of the graft (in tibial tunnel 71 of tibia 70) and cut shortening strands. BTB TightRope 99 is also ideal for All-Inside ACL Reconstruction with RetroScrew (FIG. 28) or for tibial fixation (FIG. 29). For RetroScrew fixation, the graft is secured in the tibia 70 employing interference screw 77 (FIG. 27) or an interference screw 77 and a button 20a (FIG. 28). Tibial fixation may be also achieved by attaching tensionable construct 99 to the remaining bone block of the BTB graft 90 (in a manner similar to the formation of integrated system 100 for the femoral fixation), to form integrated system 100a for tibial fixation of a final reconstruction construct 300, as shown in FIG. 29.

(56) FIG. 30: Shows an enlarged view of the final construct 300 (ACL BTB TightRope) of FIG. 29, with two integrated systems 100, 100a for the fixation of a BTB graft 90 within femoral socket 81 and tibial socket 71.

(57) FIGS. 31-40 show an example of an Open Tightrope ABS 199 which is passed through a soft tissue graft 390 that has been stitched together (with stiches 322), not allowing loading over a traditional closed loop device. This exemplary embodiment employs a tensionable construct 199 which is similar to the tensionable construct 99 described above in that it also contains an adjustable knotless loop 50 and a splicing device 40 (a suture passing instrument or any shuttle/pull device to form a final splice in the construct); however, tensionable construct 199 differs from the tensionable construct 99 in that it does not include a fixation device 20 (button 20). As in the previously-described embodiments, loop 50 is passed through soft tissue graft 390 and then the free strand 5b of the construct 199 is passed through looped portion 50c of the knotless, adjustable loop 50 and through the pre-loaded passing suture loop 40 (splicing device 40). A second splice is formed in the flexible strand 5 and a second loop 55 is interconnected to loop 50 (through interconnecting region 59) forming close loop 150 having an adjustable, knotless configuration. Upon fixation of the graft 390 in a bone tunnel (for example, the tibial tunnel), a slotted button (having a dog bone configuration, for example) may be employed to secure the construct to the tibial cortex.

(58) FIGS. 31 and 32: The looped side 50 of the tensionable construct 199 is passed through the graft 390 with a passing suture 33 (FIG. 31) to form loop portion 50c extending out of the tissue graft (FIG. 32).

(59) FIGS. 33-35: The free end 5b is passed through the loop 50c (FIG. 33), and then placed in the passing suture 40 (FIG. 34) where it is pulled through the splice 7 to create the tightrope closed loop 150 (FIG. 35) of integrated assembly 200a including tensionable construct 199a (without the splicing suture 40). In this manner, by pulling the passing suture 40, end 5b passes through splice 7 and forms another closed loop 55 which is interconnected with loop 50 by interconnecting region 59. The overall construct is an adjustable, knotless, closed loop 150 formed of two interconnected loops 50, 55 and two splices 6, 7 (all formed from a single, same suture strand 5).

(60) FIG. 36: TightRope loop is assembled and ready to be passed into socket, for example tibial socket 71 in tibia 70. The TightRope 199a and graft 290 are passed into the tibia 70.

(61) FIGS. 37-40: A slotted button 120 (FIGS. 37-39) is loaded onto the tightrope loop and tensioned against bone which tensions and fixates the graft. The final construct 400 is shown in FIG. 40 with integrated system 200a implanted into tibia and secured to the tibial cortex with button 120.

(62) The tensionable constructs of the present invention (which are employed for further attachment to a graft and for subsequent implantation into a surgical site) may be provided in a pre-assembled state, on an assembly board which may be part of a surgical kit. The assembly board may contain the tensionable construct with the flexible closed loop (adjustable, self-locking knotless flexible closed loop), the splicing device (shuttle/pull device), any passing suture for the fixation device (if a fixation device is employed), and a needle, all pre-assembled and ready for use by medical personnel. Instructions may be also provided.

(63) FIG. 41 illustrates an exemplary sterilizable assembly board 500 with an exemplary adjustable tensionable construct 99 of the invention (pre-assembled tensionable construct 99), a needle, and any other necessary components. The assembly board may be folded, and will be supplied with mounted components, as a sterilized product, e.g., a kit. In use, while the suture construct of the invention is maintained in position by a plurality of flexible holding tabs 510, the needle 4 with the threaded loop 50 are lifted from the board and passed through an opening in the BTB graft block. After the threaded loop 50 emerges from the bone block opening, the needle 4 is cut off. A free end 5b of the suture is then removed from the board tabs and is passed through the emerged threaded loop section 50c. Then the blue splicing loop 40 is lifted from the board tabs and the free end 5b is passed through the lifted loop 40. The free suture strand is then pinched against an adjacent section of the free suture strand to form a temporary loop that captures splicing loop section 50c. The knotted end 11 of the splicing loop 40 is pulled until the temporary loop is in vicinity of the button 20. Then the free suture strand end is pulled through the button hole. The BTB graft 90 is held while the free end is pulled to even out the loops holding the BTB graft 90. The assembled BTB graft construct and passing suture are then removed from the assembly board.

(64) FIG. 42 shows an exemplary instruction card 550 that may be part of the kit of the present invention together with the assembly board 500.

(65) The tensionable, self-locking adjustable constructs of the present invention are provided around a BTB bone block without forming any knots or any crossing of the loop strands between the top of the bone block and the button. This minimizes the compressive forces on the bone block which, in turn, leads to a stronger reconstruction. The absence of any knots also limits the chances of the knot tightening down and restricting the adjustability of the implant.

(66) The present invention also provides methods of tissue repair/reconstruction by inter alia: (i) providing a surgical reconstruction system comprising an adjustable, self-locking, knotless loop construct including an adjustable loop formed of two interconnected loops and two splices and, optionally, a button attached to the adjustable loop; and (ii) securing tissue (for example, soft tissue or BTB graft) with the reconstruction system.

(67) An exemplary method of BTB ACL reconstruction comprises inter alia the steps of: (i) providing a flexible, adjustable, knotless button/loop construct 99 with a fixation device (button) 20 attached to the button/loop construct that is capable of adjusting tension, the button/loop construct 99 including an adjustable loop 50 and a non-adjustable, fixed loop 40 and two corresponding eyesplices 6, 7; (ii) passing the adjustable loop 50 through a hole 91a formed in a bone block 91 of a BTB graft 90; (iii) passing the free strand 5b through the looped end 50 of the construct; (iv) passing the free strand 5b through the fixed loop 40 (of the pre-loaded passing suture 1); (v) pulling the tails of the pre-loaded passing suture 1 through the construct to shorten the construct, as desired; and (vi) securing the BTB graft 90 within a femoral tunnel/socket by pulling on button 20. The construct is adjustable in length and allows the surgeon the ability to customize the device to each patient and seat the bone block fully against the back wall of the femoral socket. The adjustments are self-locking and the fixation device (implant) minimizes the compressive forces on the bone block.

(68) Button 20 of the reconstruction integrated assembly 100 may be formed, for example, of metal, PEEK or PLLA. As detailed above, the button is provided with openings that allow the passage of the flexible materials to pass thereto. The flexible materials may be a high strength braid construct such as an ultrahigh molecular weight (UHMWPE) braid. As detailed above, the flexible materials may be provided with optional colored strands (for example, white and blue) to assist surgeons in distinguishing between suture lengths with the trace and suture lengths without the trace.

(69) The flexible strands employed for the constructs of the present invention may be formed of a high-strength suture, such as an ultrahigh molecular weight polyethylene (UHMWPE) suture which is the preferred material as this material allows easy splicing. Alternatively, the high strength suture may be a FiberWire suture, which is disclosed and claimed in U.S. Pat. No. 6,716,234, the entire disclosure of which is incorporated herein by reference. FiberWire suture is formed of an advanced, high-strength fiber material, namely ultrahigh molecular weight polyethylene (UHMWPE), sold under the tradenames Spectra (Honeywell) and Dyneema (DSM), braided with at least one other fiber, natural or synthetic, to form lengths of suture material. The preferred FiberWire suture includes a core within a hollow braided construct, the core being a twisted yarn of UHMWPE.

(70) The strands may also be formed of a stiff material, or combination of stiff and flexible materials, depending on the intended application. The strands may be also coated and/or provided in different colors. The knotless constructs of the present invention can be used with any type of flexible material or suture that forms a splice and a loop.

(71) The knotless suture constructs also include sutures that are splicedat least in partin a manner similar to an Arthrex ACL TightRope, such as disclosed in U.S. Patent Application Publication Nos. 2010/0256677 and 2010/0268273, the disclosures of which are incorporated by reference herein.

(72) While the present invention is described herein with reference to illustrative embodiments for particular applications, it should be understood that the invention is not limited thereto. Those having ordinary skill in the art and access to the teachings provided herein will recognize additional modifications, applications, embodiments and substitution of equivalents all fall within the scope of the invention. Accordingly, the invention is not to be considered as limited by the foregoing description.