US20140025112A1 - Anchor and method for securing a suture - Google Patents
Anchor and method for securing a suture Download PDFInfo
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- US20140025112A1 US20140025112A1 US14/035,316 US201314035316A US2014025112A1 US 20140025112 A1 US20140025112 A1 US 20140025112A1 US 201314035316 A US201314035316 A US 201314035316A US 2014025112 A1 US2014025112 A1 US 2014025112A1
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- anchor
- body tissue
- suture
- anchors
- bone
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/04—Surgical instruments, devices or methods, e.g. tourniquets for suturing wounds; Holders or packages for needles or suture materials
- A61B17/0401—Suture anchors, buttons or pledgets, i.e. means for attaching sutures to bone, cartilage or soft tissue; Instruments for applying or removing suture anchors
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/04—Surgical instruments, devices or methods, e.g. tourniquets for suturing wounds; Holders or packages for needles or suture materials
- A61B17/0487—Suture clamps, clips or locks, e.g. for replacing suture knots; Instruments for applying or removing suture clamps, clips or locks
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/068—Surgical staplers, e.g. containing multiple staples or clamps
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/04—Surgical instruments, devices or methods, e.g. tourniquets for suturing wounds; Holders or packages for needles or suture materials
- A61B17/0469—Suturing instruments for use in minimally invasive surgery, e.g. endoscopic surgery
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/04—Surgical instruments, devices or methods, e.g. tourniquets for suturing wounds; Holders or packages for needles or suture materials
- A61B17/0401—Suture anchors, buttons or pledgets, i.e. means for attaching sutures to bone, cartilage or soft tissue; Instruments for applying or removing suture anchors
- A61B2017/0409—Instruments for applying suture anchors
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/04—Surgical instruments, devices or methods, e.g. tourniquets for suturing wounds; Holders or packages for needles or suture materials
- A61B17/0401—Suture anchors, buttons or pledgets, i.e. means for attaching sutures to bone, cartilage or soft tissue; Instruments for applying or removing suture anchors
- A61B2017/0414—Suture anchors, buttons or pledgets, i.e. means for attaching sutures to bone, cartilage or soft tissue; Instruments for applying or removing suture anchors having a suture-receiving opening, e.g. lateral opening
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/04—Surgical instruments, devices or methods, e.g. tourniquets for suturing wounds; Holders or packages for needles or suture materials
- A61B17/0401—Suture anchors, buttons or pledgets, i.e. means for attaching sutures to bone, cartilage or soft tissue; Instruments for applying or removing suture anchors
- A61B2017/044—Suture anchors, buttons or pledgets, i.e. means for attaching sutures to bone, cartilage or soft tissue; Instruments for applying or removing suture anchors with a threaded shaft, e.g. screws
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/04—Surgical instruments, devices or methods, e.g. tourniquets for suturing wounds; Holders or packages for needles or suture materials
- A61B17/0401—Suture anchors, buttons or pledgets, i.e. means for attaching sutures to bone, cartilage or soft tissue; Instruments for applying or removing suture anchors
- A61B2017/0445—Suture anchors, buttons or pledgets, i.e. means for attaching sutures to bone, cartilage or soft tissue; Instruments for applying or removing suture anchors cannulated, e.g. with a longitudinal through-hole for passage of an instrument
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/04—Surgical instruments, devices or methods, e.g. tourniquets for suturing wounds; Holders or packages for needles or suture materials
- A61B17/0401—Suture anchors, buttons or pledgets, i.e. means for attaching sutures to bone, cartilage or soft tissue; Instruments for applying or removing suture anchors
- A61B2017/0446—Means for attaching and blocking the suture in the suture anchor
- A61B2017/0454—Means for attaching and blocking the suture in the suture anchor the anchor being crimped or clamped on the suture
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/04—Surgical instruments, devices or methods, e.g. tourniquets for suturing wounds; Holders or packages for needles or suture materials
- A61B17/0401—Suture anchors, buttons or pledgets, i.e. means for attaching sutures to bone, cartilage or soft tissue; Instruments for applying or removing suture anchors
- A61B2017/0446—Means for attaching and blocking the suture in the suture anchor
- A61B2017/0458—Longitudinal through hole, e.g. suture blocked by a distal suture knot
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/04—Surgical instruments, devices or methods, e.g. tourniquets for suturing wounds; Holders or packages for needles or suture materials
- A61B17/0401—Suture anchors, buttons or pledgets, i.e. means for attaching sutures to bone, cartilage or soft tissue; Instruments for applying or removing suture anchors
- A61B2017/0446—Means for attaching and blocking the suture in the suture anchor
- A61B2017/0459—Multiple holes in the anchor through which the suture extends and locking the suture when tension is applied
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/04—Surgical instruments, devices or methods, e.g. tourniquets for suturing wounds; Holders or packages for needles or suture materials
- A61B17/0487—Suture clamps, clips or locks, e.g. for replacing suture knots; Instruments for applying or removing suture clamps, clips or locks
- A61B2017/0488—Instruments for applying suture clamps, clips or locks
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/04—Surgical instruments, devices or methods, e.g. tourniquets for suturing wounds; Holders or packages for needles or suture materials
- A61B2017/0496—Surgical instruments, devices or methods, e.g. tourniquets for suturing wounds; Holders or packages for needles or suture materials for tensioning sutures
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/04—Surgical instruments, devices or methods, e.g. tourniquets for suturing wounds; Holders or packages for needles or suture materials
- A61B17/06—Needles ; Sutures; Needle-suture combinations; Holders or packages for needles or suture materials
- A61B17/06166—Sutures
- A61B2017/0619—Sutures thermoplastic, e.g. for bonding, welding, fusing or cutting the suture by melting it
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- Health & Medical Sciences (AREA)
- Life Sciences & Earth Sciences (AREA)
- Surgery (AREA)
- Heart & Thoracic Surgery (AREA)
- Engineering & Computer Science (AREA)
- Biomedical Technology (AREA)
- Nuclear Medicine, Radiotherapy & Molecular Imaging (AREA)
- Medical Informatics (AREA)
- Molecular Biology (AREA)
- Animal Behavior & Ethology (AREA)
- General Health & Medical Sciences (AREA)
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- Veterinary Medicine (AREA)
- Rheumatology (AREA)
- Surgical Instruments (AREA)
Abstract
An improved anchor and device to secure a suture relative to bone. The anchor includes a generally cylindrical body portion with an opening extending from the leading end to the trailing end adapted to receive at least a portion of the suture and at least a portion of a tool therein. The anchor also includes at least two projections configured to extend from the anchor when the anchor is deployed in the bone. The anchor is configured to confine at least two suture portions between the body portion and the bone when the anchor is deployed in the bone. The anchor is also configured to have a first maximum dimension transverse to the central longitudinal axis of the body portion, and a greater second maximum dimension transverse to the central longitudinal axis when the anchor is deployed in the bone.
Description
- This application is a continuation of U.S. application Ser. No. 11/460,650 filed Jul. 28, 2006; which is a continuation of U.S. application Ser. No. 10/413,696 filed Apr. 14, 2003 (now U.S. Pat. No. 7,087,073); which is a division of U.S. application Ser. No. 09/789,621 filed Feb. 21, 2001 (now U.S. Pat. No. 6,635,073).
- The present invention relates to a method of securing tissue in a body of a patient. The method may be utilized to secure soft body tissues, hard body tissues, or to secure both soft and hard body tissues.
- Many different devices have previously been utilized to secure body tissues. Many of these devices have utilized anchors which engage either soft body tissue or hard body tissue to hold a suture in a desired location relative to the body tissue. Various methods and devices for use in positioning anchors relative to either soft or hard body tissues are disclosed in U.S. Pat. Nos. 5,403,348; 5,464,426; 5,534,012; 5,593,425; 5,718,717; and 5,948,002. The devices and methods disclosed in these patents have been generally satisfactory in securing either soft, hard, or hard and soft body tissues. Other devices and methods for securing body tissues are disclosed in U.S. Pat. Nos. 4,235,238; 4,448,194; 4,669,473; 5,085,661; and 5,372,146.
- The present invention relates to a new and improved method of securing a first body tissue with a second body tissue. The first body tissue may be a soft body tissue and the second body may be a hard body tissue. Alternatively, the first and second body tissues may both be soft body tissues. It is also contemplated that both the first and second body tissues could be hard body tissues.
- When the first and second body tissues are to be interconnected, a first anchor is moved into the second body tissue. If desired, the first anchor could be moved into and through the second body tissue. A second anchor is also moved into the second body tissue. If desired, the second anchor could be moved into and through the second body tissue. The first body tissue may be pressed against or otherwise secured with the second body tissue under the influence of force transmitted from the suture to the first body tissue.
- The suture which extends between the anchors may be tensioned by moving at least one of the anchors into the body tissue along a path which extends transverse to a path along which the other anchor is moved into the body tissue. The paths along which the anchors move into the body tissue may extend toward each other. The transverse paths of movement of the anchors into the body tissue promotes gripping of body tissue with the anchors and suture and promotes tensioning of the suture as the anchors move into the body tissue. Although it is believed that it may be desired to move the anchors into the body tissue along transverse paths, it is contemplated that the anchors could be moved into the body tissue along parallel paths if desired.
- A desired tension may be established in the suture by moving the anchors into the body tissue. Alternatively, a desired tension may be established in the suture by applying force to portions of the suture and then interconnecting the portions of the suture. A retainer or a knot may be utilized to interconnect portions of the suture.
- Regardless of how the tension is established in the suture, it may be desired to establish a predetermined tension in the suture. This may be done by determining the tension in the suture as the anchors are moved into the body tissue. Alternatively, the tension in the suture may be determined during movement of a retainer relative to portions of the suture prior to gripping of the suture with the retainer.
- The suture may be a continuous loop which extends between the two anchors. The tension in the loop may be determined as one or more of the anchors are moved into the body tissue. Alternatively, the suture may be formed by a pair of separate portions which are tensioned after the anchors are moved into the body tissue.
- One or more guides may be utilized to facilitate positioning of the anchors for movement along paths disposed in a desired spatial relationship with the body tissue. The guides may have tubular guide surfaces with central axes which extend transverse to each other.
- Leading end portions of the anchors may be utilized to initiate the formation of openings in the first and/or second body tissue. The leading end portion of each of the anchors may be utilized to pierce soft body tissue, a hard outer layers of bone, and/or cancellous bone as the anchor is moved into the body tissue. If either or both of the anchors are associated with body tissue which is bone, one or more of the anchors may be supported in a spaced apart relationship with a hard outer layer of bone by cancellous bone which is enclosed by the hard outer layer of bone. If desired, passages for the anchors may be formed with a drill or similar tool.
- The anchors may advantageously be interconnected while they are disposed in the body tissue. When this is done, the anchors may be moved along transverse paths which intersect in the body tissue. The anchors may be interconnected at the intersection between the two paths.
- There are a plurality of embodiments of the invention. Each embodiment of the invention has one or more features which may be advantageously utilized with one or more of the other embodiments of the invention. It is contemplated that the various features of the embodiments of the invention may be utilized separately or combined in any one of many different combinations.
- The foregoing and other features of the invention will become more apparent upon a consideration of the following description taken in connection with the accompanying drawings wherein:
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FIG. 1 is a fragmentary schematic illustration depicting the relationship between a plurality of anchors and body tissue prior to movement of the anchors into the body tissue; -
FIG. 2 is a fragmentary schematic illustration depicting the manner in which one of the anchors ofFIG. 1 is positioned relative to body tissue prior to initiation of formation of an opening in body tissue with a leading end portion of the anchor; -
FIG. 3 is a fragmentary schematic view illustrating the manner in which the anchor ofFIG. 2 is moved through first body tissue into second body tissue; -
FIG. 4 is a fragmentary schematic illustration illustrating the manner in which the anchor ofFIG. 3 is moved deeper into the second body tissue; -
FIG. 5 is a fragmentary schematic illustration depicting the manner in which the orientation of the anchor ofFIG. 4 is changed relative to the body tissue after the anchor has been moved to a desired depth in the body tissue; -
FIG. 6 is a schematic fragmentary illustration, generally similar toFIG. 3 , illustrating the manner in which a second one of the anchors ofFIG. 1 is moved through first body tissue into second body tissue; -
FIG. 7 is a fragmentary schematic illustration, generally similar toFIG. 4 , depicting the manner in which the anchor ofFIG. 6 is moved deeper into the body tissue; -
FIG. 8 is fragmentary schematic illustration, generally similar toFIG. 5 , depicting the manner in which the orientation of the anchor ofFIG. 7 is changed after the anchor has been moved to a desired depth in the body tissue; -
FIG. 9 is a fragmentary schematic illustration depicting the relationship between the anchors ofFIG. 1 and a suture extending between the anchors after the anchors have been moved into the body tissue; -
FIG. 10 is schematic illustration, generally similar toFIG. 9 , depicting the manner in which the suture extending between the anchors is tensioned with a predetermined force and in which a retainer is deformed to grip portions of the suture; -
FIG. 11 is a fragmentary schematic illustration, generally similar toFIGS. 1 and 9 , depicting the manner in which a pair of anchors interconnected by a continuous loop of suture are positioned relative to body tissue and the loop is tensioned during positioning of the anchors relative to the body tissue; -
FIG. 12 is a fragmentary schematic illustration, generally similar toFIG. 6 , illustrating the relationship between an anchor ofFIG. 11 and an apparatus which is utilized to effect movement of the anchor into body tissue and to measure tension in the continuous loop of suture extending between the anchors ofFIG. 11 ; -
FIG. 13 is a schematic illustration, generally similar toFIG. 11 , illustrating the manner in which a guide assembly is utilized to position anchors relative to body tissue; -
FIG. 14 is a schematic illustration depicting the manner in which a thin elongated member is utilized to guide movement of an anchor into body tissue; -
FIG. 15 is a fragmentary schematic illustration depicting the manner in which a second thin elongated member is utilized to guide movement of a second one of the anchors ofFIG. 14 into the body tissue; -
FIG. 16 is a fragmentary schematic illustration, similar toFIG. 13 , of another embodiment of a guide assembly which is utilized to position anchors relative to body tissue and depicting the manner in which tubular guide members extend through first body tissue into second body tissue; -
FIG. 17 is a fragmentary schematic illustration depicting the manner in which anchors are utilized to repair a fracture in a bone; -
FIG. 18 is a schematic illustration of another embodiment of the anchor; -
FIG. 19 is an illustration of still another embodiment of the anchor; -
FIG. 20 is a fragmentary schematic illustration, generally similar toFIG. 9 , illustrating the manner in which anchors are interconnected at an intersection between transverse paths along which the anchors are moved into body tissue; -
FIG. 21 is an enlarged fragmentary view of a portion ofFIG. 20 and illustrating how the anchors are interconnected at the intersection of the paths along which the anchors are moved into in the body tissue; -
FIG. 22 is a fragmentary schematic illustration, generally similar toFIG. 21 , illustrating the manner in which another embodiment of the anchors are interconnected at the intersection between the paths along which the anchors are moved into the body tissue; and -
FIG. 23 is a fragmentary sectional view, generally similar toFIG. 12 , illustrating the manner in which another embodiment of the anchors may be utilized to secure body tissues. - An apparatus 10 (
FIG. 1 ) is used to secure firsthuman body tissue 12 with secondhuman body tissue 14. In the illustration ofFIG. 1 , thefirst body tissue 12 is soft body tissue and thesecond body tissue 14 is hard body tissue. However, it should be understood that both thefirst body tissue 12 and thesecond body tissue 14 could be soft body tissue if desired. Alternatively, both thefirst body tissue 12 and thesecond body tissue 14 could be hard body tissue. - The
apparatus 10 includes a plurality of suture anchors 18 and 20. Although only two suture anchors 18 and 20 have been illustrated inFIG. 1 , it should be understood that a greater number of suture anchors could be provided if desired. For example, it is contemplated that three anchors could be provided if desired. - The
apparatus 10 also includes asuture 24 which extends between the suture anchors 18 and 20. Although the illustratedsuture 24 is integrally formed as one piece and extends between theanchors suture 24 could be formed by a plurality of separate portions each of which is connected with one of the anchors. Thus, a first segment of a suture could be connected with theleft suture anchor 18 and a second segment of a suture could be connected with theright suture anchor 20. - When the first and
second body tissues first body tissue 12 into thesecond body tissue 14. If desired, the suture anchors 18 and 20 could be moved into and through thesecond body tissue 14. - When the
anchor 18 is to be moved into thebody tissue 12, the anchor may be positioned in aninserter 28 and pressed against thebody tissue 12 by a pusher member 30 (FIG. 2 ). A trailingend portion 32 of theanchor 18 is positioned in theinserter 28 and is engaged by thepusher member 30. A pointed leadingend portion 34 of theanchor 18 extends from theinserter 28. - In the embodiment illustrated in
FIG. 2 , theinserter 28 has a tubular configuration and thepusher member 30 is telescopically inserted into the inserter. However, if desired, theinserter 28 could have a different configuration and could be constructed in such a manner as to perform the function of thepusher member 30. For example, theinserter 28 could be constructed could be a solid rod with a gripper at one end of the rod. This inserter would grip and apply axial force against a trailingend portion 32 of theanchor 18. - When the
anchor 18 is to be moved into thebody tissue 12, theleading end portion 34 of theanchor 18 initiates the formation of an opening in thebody tissue 12. Force applied against the trailingend portion 32 of theanchor 18 by thepusher member 30 causes the anchor to pierce thebody tissue 12. As theanchor 18 moves through thebody tissue 12, theleading end portion 34 of the anchor moves into engagement with thebody tissue 14. - The
leading end portion 34 of theanchor 18 initiates the formation of an opening in thebody tissue 14. Force applied against the trailingend portion 32 of theanchor 18 by thepusher member 30 moves the leading end portion of the anchor into the body tissue 14 (FIG. 3 ). Continued axial movement of thepusher member 30 relative to theinserter 28 moves theanchor 18 deeper into the body tissue 14 (FIG. 4 ). As theanchor 18 moves into thebody tissue 14, theleading end portion 34 of the anchor pierces the body tissue. Theanchor 18 may be moved along a linear or nonlinear path in thebody tissues - In the embodiment of the invention illustrated in
FIGS. 1-10 , theanchor 18 is utilized to form its own passage in thebody tissues anchor 18 in either thebody tissue - Once the
anchor 18 has moved into thebody tissue 14, the anchor may be toggled from the orientation shown inFIG. 4 to the orientation shown inFIG. 5 relative to thebody tissue 14. Changing the orientation of theanchor 18 relative to thebody tissue 14 increases the ability of the anchor to withstand pull out force applied against the anchor by thesuture 24. - The anchor 20 (
FIG. 1 ) is inserted into the body tissue in the same manner as previously described in conjunction with theanchor 18. Thus, theanchor 20 is positioned in an inserter 38 (FIG. 6 ) and is engaged by apusher member 40. Thepusher member 40 engages a trailingend portion 42 of theanchor 20. - The
pusher member 40 presses a pointed leadingend portion 44 of theanchor 20 against thebody tissue 12 to initiate the formation of an opening in the body tissue. Theanchor 20 then moves through thebody tissue 12 and moves into engagement with thebody tissue 14. The continued application of force against the trailingend portion 42 of theanchor 20 by thepusher member 40 causes theleading end portion 44 of the anchor to initiate the formation of an opening in thebody tissue 14. - As the
anchor 20 moves deeper into thebody tissue 14, the anchor pierces the body tissue in the manner illustrated inFIG. 7 . Theanchor 20 may be moved along a linear or nonlinear path in thebody tissue 14. - Once the
anchor 20 has moved into thebody tissue 14, the orientation of the anchor relative to the body tissue is changed with a toggling action. Thus, the orientation of theanchor 20 is changed from the orientation illustrated inFIG. 7 to the orientation illustrated inFIG. 8 . Changing the orientation of theanchor 20 relative to the body tissue increases the ability of the anchor to withstand pull out forces transmitted through thesuture 24. - Once both
anchors body tissue 12 into thebody tissue 14, thepusher members 30 and 40 (FIGS. 4 , 5, 7, and 8) are withdrawn from the body tissue. It is contemplated that theanchors body tissue body tissue anchors body tissue anchors body tissue separate inserters pusher members inserters pusher members - Although it is believed that it will be desired to pivot the
anchors FIGS. 4 and 7 to the orientations shown inFIGS. 5 and 8 , theanchors FIGS. 4 and 7 if desired. It is believed that pivoting theanchors FIGS. 5 and 8 will enable the anchors to remain stationary relative to thebody tissue 14 when relatively large tension forces are transmitted to the anchors through thesuture 24. - The suture 24 (
FIG. 9 ) is integrally formed as one piece and includes aconnector portion 48 which extends between the twoanchors suture 24 includes aleg portion 50 which extends from theanchor 18. Thesuture 24 also includes aleg portion 52 which extends from theanchor 20. A suture retainer (crimp) 54 is utilized to interconnect theleg portions suture 24. Alternatively, theleg portions leg portions - When the
leg portions suture 24 are to be interconnected with theretainer 54, thesuture 24 may be tensioned with a force application assembly 60 (FIG. 10 ). Theforce application assembly 60 applies a predetermined force, indicated schematically by anarrow 62 inFIG. 10 , to theleg portions suture 24. Thepredetermined force 62 has a magnitude which is a function of the size and strength of thesuture 24. - The
suture retainer 54 is pressed against thebody tissue 12 by aforce application member 66. Forces, indicated schematically at 70 and 72 inFIG. 10 , are transmitted through theforce application member 66 to thesuture retainer 54 to press the suture retainer against thebody tissue 12. The magnitude of the forces indicated by thearrows suture retainer 54 by theforce application member 66, are a function of the size and strength of thesuture 24. - While the
suture 24 is being tensioned under the influence offorce 62 and while thesuture retainer 54 is being pressed against thebody tissue 12 under the influence offorces suture retainer 54 is plastically deformed to firmly grip thesuture 24. To plastically deform thesuture retainer 54, a pair offorce application members suture retainer 54. The force with which theforce application members suture retainer 54 is indicated schematically byarrows 80 and 82 inFIG. 10 . The force applied against thesuture retainer 54 by theforce application members body tissue 12 by theforce application member 66 and while the suture is being tensioned by theforce application assembly 60. - In the embodiment of the invention illustrated in
FIGS. 1-10 , theanchors FIG. 10 ). However, theanchors body tissue 14 if desired. This would result in theanchors body tissue 14. - When the
body tissue soft body tissues anchors body tissue 12 into thebody tissue 14. If desired, theanchors body tissue 14. - In the embodiment of the invention illustrated in
FIGS. 1-10 , thebody tissue 12 is secured with thebody tissue 14 by thesuture 24. In this embodiment, thesuture 24 extends through thebody tissue 12 and presses thebody tissue 12 against thebody tissue 14. However, thebody tissue 12 could be secured with thebody tissue 14 in a different manner. For example, thesuture 24 could extend around thebody tissue 12 without extending through thebody tissue 12. Thebody tissue 12 could be spaced from thebody tissue 14 and secured with thebody tissue 14 by a portion of the suture extending between thebody tissue 12 and thebody tissue 14. - In the embodiment of the invention illustrated in
FIGS. 1-10 , thesuture 24 hasleg portions connector portion 48 which extends between the suture anchors. In the embodiment of the invention illustrated inFIG. 11 , the suture is formed as a continuous loop which extends between the two anchors. Since the embodiment of the invention illustrated inFIG. 11 is generally similar to the embodiment of the invention illustrated inFIGS. 1-10 , similar numerals will be utilized to designate similar components, the suffix letter “a” being associated with the numerals ofFIG. 11 to avoid confusion. - An
apparatus 10 a (FIG. 11 ) for use in securingfirst body tissue 12 a with second body tissue 14 a includes a plurality of suture anchors 18 a and 20 a. Asuture 24 a extends between theanchors 18 a and 20 a. Although thesuture 24 a has been illustrated inFIG. 11 as extending between only twoanchors 18 a and 20 a, a greater number of anchors could be provided if desired. - The
suture 24 a is forms a continuous flexible loop. Thus, thesuture 24 a includes afirst connector portion 48 a which extends between the suture anchors 18 a and 20 a and asecond connector portion 90 which extends between the suture anchors. Theconnector portions connector portions connector portions connector portions retainer 54 ofFIG. 9 , or a knot. - Since the
suture 24 a is a continuous closed loop without free ends, thesuture 24 a is tensioned whenever theanchors 18 a and 20 a are moved into the body tissue 14 a. The anchor 18 a is moved through thebody tissue 12 a into the body tissue 14 a in the same manner as previously described in conjunction with the embodiment of the invention illustrated inFIGS. 1-10 . Theanchor 20 a is then moved through thebody tissue 12 a into the body tissue 14 a. - As the
anchor 20 a moves into the body tissue 14 a, theanchor 20 a moves from the position illustrated in solid lines inFIG. 11 to the position illustrated in dashed lines inFIG. 11 . As theanchor 20 a moves into the body tissue 14 a, theconnector portions suture 24 a are both tensioned. The magnitude of the tension force in the continuous loop which is formed by thesuture 24 a will be a function of magnitude of the force which is utilized to move the suture anchors 18 a and 20 a into the body tissue 14 a. - The
anchors 18 a and 20 a may be moved either sequentially or simultaneously into the body tissue 14 a. Thus, the anchor 18 a may be moved through thebody tissue 12 a into the body tissue 14 a in the manner illustrated in solid lines inFIG. 11 . Theanchor 20 a may then be moved through thetissue 12 a into the tissue 14 a to the position illustrated in dashed lines inFIG. 11 . Alternatively, theanchors 18 a and 20 a may both be simultaneously moved through thebody tissue 12 a and into the body tissue 14 a. Theanchors 18 a and 20 a may be moved along either linear or nonlinear paths in thebody tissues 12 a and 14 a. - It is contemplated that an inserter, corresponding to the
inserter 18 ofFIGS. 2-5 , and a pusher member, corresponding to thepusher member 30 ofFIGS. 2-5 , will be utilized to position the anchor 18 a in the body tissue 14 a (FIG. 11 ). Similarly, an inserter, corresponding to theinserter 38 ofFIGS. 6-8 , and a pusher member, corresponding to thepusher member 40 ofFIGS. 6-8 , will be utilized to position theanchor 20 a in the body tissue 14 a (FIG. 11 ). - In the embodiment of the invention illustrated in
FIG. 11 , only twoanchors 18 a and 20 a are connected with the continuous loop formed by thesuture 24 a. However, a greater number of anchors, for example three, could be connected with the loop formed by thesuture 24 a. Upon insertion of the last anchor of the plurality of anchors, the loop formed by thesuture 24 a would probably slide in passages in at least one of the other anchors and the suture would be tensioned. - In the embodiment of the invention illustrated in
FIG. 12 , an apparatus is provided to measure tension in a suture which forms a continuous closed loop. Since the embodiment of the invention illustrated inFIG. 12 is generally similar to the embodiment of the invention illustrated inFIGS. 1-11 , similar numerals will be utilized to designate similar components, the suffix letter “b” being associated with the numerals ofFIG. 12 to avoid confusion. - An
anchor 20 b is positioned in an inserter 28 b and moved into body tissue under the influence of force applied against a trailing end portion 42 b of theanchor 20 b by apusher member 40 b. Atension measuring assembly 96 is provided in association with theinserter 38 b. Thetension measuring assembly 96 includes aforce transmitting member 100 having anend portion 102 which engagesconnector portions 48 b and 90 b of asuture 24 b. Although only asingle anchor 20 b is illustrated inFIG. 12 , it should be understood that thesuture 24 b forms a continuous loop connected with a second anchor, corresponding to the anchor 18 a ofFIG. 11 . - As the
anchor 20 b moves into thebody tissue 14 b, thesuture 24 b applies force against theend portion 102 of theforce transmitting member 100. A force measuring device 112 is connected with theforce transmitting member 100. The force measuring device 112 measures the tension force in the continuous closed loop formed by thesuture 24 b. The force measuring device 112 may be a load cell or other transducer. - During movement of the
anchor 20 b into thebody tissue 14 b, theinserter 38 b is pressed against thebody tissue 14 b by a remote inserter drive assembly 110 (FIG. 12 ). While theinserter 38 b is held stationary and pressed against thebody tissue 14 b, a pushermember drive assembly 114 moves thepusher member 40 b andanchor 20 b into thebody tissue 14 b in the manner previously described in conjunction with the embodiment of the invention illustrated inFIGS. 1-10 . Theanchor 20 b may be moved along either a linear path or a nonlinear path into thebody tissue 14 b. - The
force measuring assembly 96 is illustrated inFIG. 12 in association with asuture 24 b which is formed as a continuous loop. However, theforce measuring assembly 96 could be utilized with a suture having free end portions. Thus, theforce measuring assembly 96 could be used with thesuture 24 ofFIGS. 1-10 if desired. If this was done, theconnector portion 48 of thesuture 24 would engage theend portion 102 of theforce transmitting member 100. If desired, theleg portion 52 of thesuture 24 could also engage theend portion 102 of theforce transmitting member 100. - If desired, the force measuring device 112, pusher
member drive assembly 114, andinserter drive assembly 110 may be formed as part of a robotic tool which is associated with a console that gives a three dimensional view of an operating table in an operating room of a hospital. Controls at the console provide tactile feedback to a surgeon operating the controls. The controls effect operation of thedrive assemblies anchor 20 b into thebody tissue 14 b. - The robotic tool may include apparatus to move an anchor corresponding to the
anchors 18 or 18 a ofFIGS. 1 and 11 into thebody tissue inserter drive assembly 110 ofFIG. 12 , to position an inserter, corresponding to theinserter 28 ofFIG. 2 , relative to thebody tissue member drive assembly 114 ofFIG. 12 , to position a pusher member, corresponding to thepusher member 40 ofFIG. 2 , relative to thebody tissue - The robotic tool may be operated to effect simultaneous movement of two anchors, that is, an anchor corresponding to the anchor 18 (
FIG. 1 ) and an anchor corresponding to theanchor 20 b (FIG. 12 ), into thebody tissues anchors body tissue 14 b, the continuous loop formed by thesuture 24 b is tensioned. Theforce transmitting member 100 transmits a force which is a function of the tension in thesuture 24 b to the force measuring device 112. When the force measuring device 112 detects that the desired tension is present in thesuture 24 b, operation of the pusher member drive assemblies is interrupted with theanchors body tissue 14 b. - In the embodiment of the invention illustrated in
FIG. 13 , a guide assembly is utilized to position a suture anchor relative to the body tissue. Since the embodiment of the invention illustrated inFIG. 13 is generally similar to the embodiments of the invention illustrated inFIGS. 1-12 , similar numerals will be utilized to designate similar components, the suffix letter “c” being associated with the numerals ofFIG. 13 to avoid confusion. - A
guide assembly 120 is utilized in association with anapparatus 10 c. Theapparatus 10 c includes a plurality of suture anchors 18 c and 20 c. Although only twoanchors - A
suture 24 c extends from the suture anchors 18 c and 20 c. In the embodiment of the invention illustrated inFIG. 13 , thesuture 24 c is a continuous loop, in the same manner as thesuture 24 a ofFIG. 11 . However, thesuture 24 c could have free ends and leg portions corresponding to theleg portions suture 24 ofFIG. 1 . - The
guide assembly 120 includes a base 124 which positions guides 126 and 128 relative tobody tissue guides guides anchors - The
anchors guides inserters FIGS. 2-8 . Apusher member 132 is utilized to apply force against theanchors guides body tissue - The
guide 128 is movable along the base 124 to enable the distance between locations where theanchors body tissue guide 128 is moved along thebase 124 is indicated schematically byarrows 136 inFIG. 13 . Asuitable retainer 140 is provided to connect theguide 128 with the base 124 in a desired position relative to theguide 126. - If the
anchors body tissue 14 c, theguides guides pusher member 132 would be formed with an arcuate configuration corresponding to the arcuate configuration of theguides - In the embodiments of the invention illustrated in
FIGS. 1-13 , the anchors have pointed leading end portions which initiate the formation of openings in the body tissue. In the embodiment of the invention illustrated inFIGS. 14 and 15 , thin elongated members are provided to initiate the formation of openings in the body tissue. The thin elongated members are also be utilized to guide movement of the anchors into the body tissue. Since the embodiment of the invention illustrated inFIGS. 14 and 15 is generally similar to the embodiments of the invention illustrated inFIGS. 1-13 , similar numerals will be utilized to designate similar components, the suffix letter “d” being associated with the numerals ofFIGS. 14 and 15 to avoid confusion. - An
apparatus 10 d includes a plurality ofanchors suture 24 d. Thesuture 24 d is formed as a continuous flexible loop, in the same manner as is illustrated inFIG. 11 . However, thesuture 24 d could have legs with free end portions, in the manner illustrated inFIG. 1 . - A
tubular inserter 28 d (FIG. 14 ) cooperates with apusher member 30 d during movement of theanchor 18 d into body tissue. Similarly, atubular inserter 38 d (FIG. 15 ) cooperates with apusher member 40 d during movement of the anchor into body tissue. - When the
anchor 18 d (FIG. 14 ) is to be positioned relative to body tissue, a thinelongated member 146 is utilized to initiate formation of an opening in thebody tissue elongated member 146 may be a cylindrical rod similar to a K-wire. The thinelongated member 146 has apointed end portion 148. - When the
anchor 18 d is to be moved along a linear path in thebody tissue 14 b, the thinelongated member 146 will have the linear configuration illustrated inFIG. 14 . When theanchor 18 d is to be moved along an arcuate path, the thinelongated member 146 will have an arcuate configuration. - When the thin elongated member 146 (
FIG. 14 ) is to be moved into thebody tissue elongated member 146 is positioned in a desired orientation relative to the body tissue. The thin elongated member is then forced axially into thebody tissue elongated member 146 moves into thebody tissue 12 d, thepointed end portion 148 of the thin elongated member initiates the formation of an opening in thebody tissue 12 d. As the thinelongated member 146 moves through thebody tissue 12 d, thepointed end portion 148 engages thebody tissue 14 d and initiates the formation of an opening thebody tissue 14 d. - Once the thin
elongated member 146 has initiated the formation of an opening in thebody tissue 14 d, the thin elongated member is moved through the hardouter layer 278 d of bone into thecancellous bone 280 d. The thinelongated member 146 is moved to a desired depth in thecancellous bone 280 d. The depth to which theelongated member 146 is moved into thecancellous bone 280 d is somewhat greater than a depth to which theanchor 18 d is to be moved into the cancellous bone. - Once the thin
elongated member 146 ahs been moved to the desired depth in thecancellous bone 280 d, theanchor 18 d is telescopically positioned relative to the stationary thinelongated member 146. When this is done, the thinelongated member 146 will extend through acylindrical passage 152 in theanchor 18 d. Thepusher member 30 d is then positioned in a telescopic relationship with the stationary thinelongated member 146. When this is done, the thinelongated member 146 will extend through acylindrical passage 156 in thepusher member 30 d and the throughpassage 152 in theanchor 18 d. Thecylindrical inserter 28 d extends around thepusher member 30 d and a trailing end portion 32 d of theanchor 18 d. - The
pusher member 30 d (FIG. 14 ) is pressed axially against the trailing end portion of theanchor 18 d to slide the pusher member and the anchor along the stationary thinelongated member 146. As theanchor 18 d slides along the stationary thinelongated member 146, a pointed leadingend portion 34 d of theanchor 18 d pierces thebody tissue 12 d and thebody tissue 14 d. When theanchor 18 d has been moved to a desired position relative to thebody tissue 14 d, movement of the anchor along the thin elongated member is interrupted (FIG. 14 ). - The
anchor 20 d (FIG. 15 ) is positioned relative to the body tissue in the same manner as theanchor 18 d. When theanchor 20 d is to be positioned relative to thebody tissue FIG. 15 ) is positioned in a desired orientation relative to thebody tissue pointed end portion 162 of the thinelongated member 160 is then forced into the body tissue. The thinelongated member 160 may have a linear configuration or nonlinear configuration. - The
anchor 20 d is then telescopically positioned on the stationary thinelongated member 160. When this is done, the thinelongated member 160 will extend through a cylindrical passage 166 (FIG. 15 ) in theanchor 20 d. Theanchor 20 d is moved along the thinelongated member 160 until a pointed leading end portion 44 d of theanchor 20 d engages thebody tissue 12 d. Apusher member 40 d is then telescopically moved along the thin elongated member into engagement with a trailingend portion 42 d of theanchor 20 d. Thepusher member 40 d then applies force against the trailingend portion 42 d of theanchor 20 d to move the anchor into the body tissue to the position shown inFIG. 15 . - Once the
anchors body tissue 14 d, the thinelongated members anchors anchors FIG. 15 . - In the embodiment of the invention illustrated in
FIG. 13 , aguide assembly 120 is utilized to position theguides FIG. 16 . Since the embodiment of the guide assembly illustrated inFIG. 16 is generally similar to the embodiment of the guide assembly illustrated inFIG. 13 , similar numerals will be utilized to designate similar components, the suffix letter “e” being associated with the numeralsFIG. 16 to avoid confusion. - A
guide assembly 120 e includes a base 124 e. Tubular cylindrical guides 126 e and 128 e are provided on the base 124 e. Theguides anchors FIG. 13 . Theguides boy tissue body tissues - In the embodiment of the invention illustrated in
FIG. 16 , theguides body tissue 12 e and thebody tissue 14 e. Thebody tissue 14 e is soft body tissue which is easily penetrated by theguides body tissue 14 e could be hard body tissue which requires the application of a relatively large force against theguides guides slots - In the embodiment of the invention illustrated in
FIGS. 1-10 , the suture anchors 18 and 20 are utilized to connectsoft body tissue 12 withhard body tissue 14. In the embodiment of the invention illustrated inFIG. 17 , the anchors are utilized to connect hard body tissue with hard body tissue. Since the embodiment of the guide assembly illustrated inFIG. 17 is generally similar to the embodiment of the invention illustrated inFIGS. 1-16 , similar numerals will be utilized to designate similar components, the suffix letter “f” being associated with the numerals ofFIG. 17 to avoid confusion. -
First body tissue 12 f (FIG. 17 ) is connected with second body tissue 14 f withanchors suture 24 f extends between theanchors body tissue 12 f and 14 f are portions of abone 174. Afracture 178 extends across thebone 174. - The
anchors FIG. 17 ) are moved from one side of thebone 174 to the opposite side of the bone to interconnect thebody tissue 12 f and 14 f with thesuture 24 f. Aninserter 38 f andpusher member 40 f may be utilized to move theanchors bone 12 f and 14 f. Thepusher member 40 f is effective to apply sufficient force against theanchors body tissue 12 f and 14 f and to enable them to be moved from one side of thebone 174 to the opposite side of the bone. - If desired, passages could be drilled through the
bone 174 prior to movement of theanchors elongated members 146 and 160 (FIG. 15 ) are to be used to guide theanchors FIG. 17 ), the drilled passages would have a relatively small diameter. If theanchors bone 174 without thin elongated members, the drilled passages would have a larger diameter. - In the embodiment of the invention illustrated in
FIGS. 1-17 , theanchors anchor 186 illustrated inFIG. 18 . Theanchor 186 includes abody 190 from which a plurality ofbarbs anchor 186 is connected with a portion of asuture 200. Theanchor 186 has a known construction and is merely illustrative of any one of many different types of anchors which may have projections, corresponding tobarbs barbs - It should be understood that the anchor could have a construction which is different than the construction of the
anchors FIG. 19 ). Theanchor 204 has a threadedportion 206 which engages body tissue. - In the embodiments of the invention illustrated in
FIGS. 1-19 , the various anchors are connected with the body tissue in a spaced apart relationship. In the embodiment of the invention illustrated inFIGS. 20 and 21 , the anchors are interconnected while they are in the body tissue. Since the embodiment of the invention illustrated inFIGS. 20 and 21 is generally similar to the embodiments of the invention illustrated inFIGS. 1-19 , similar numerals will be utilized to designate similar components, the suffix letter “g” being associated with the numerals ofFIG. 20 to avoid confusion. - An
apparatus 10 g (FIG. 20 ) is utilized to securebody tissue 12 g to body tissue 14 g. Theapparatus 10 g includes ananchor 18 g and ananchor 20 g. Asuture 24 g extends between theanchors - The
suture 24 g includes afirst leg portion 50 g which extends from thesuture 18 g and asecond leg portion 52 g which extends from theanchor 20 g. The twoleg portions suture 24 g are interconnected by aretainer 54 g. In the embodiment of the invention illustrated inFIG. 20 , theleg portions suture 24 g are two separate pieces of suture. However, theleg portions - The
anchor 18 g and theanchor 20 g engage each other in the body tissue 14 g. Portions of theanchors anchor 18 g has projections 212 (FIG. 21 ) which engage projections 214 on theanchor 20 g. - The
projections 212 and 214 (FIG. 21 ) on theanchors leg portions suture 24 g. Althoughspecific projections 212 and 214 have been illustrated inFIG. 21 , it is contemplated that theprojections 212 and 214 could have a different configuration if desired. - In the embodiment of the invention illustrated in
FIGS. 20 and 21 , theanchors projections 212 and 214 on the anchors. In the embodiment of the invention illustrated inFIG. 22 , the anchors are interconnected by moving a portion of one anchor into an opening in the other anchor. Since the embodiment of the invention illustrated inFIG. 22 is generally similar to the embodiment of the invention illustrated inFIGS. 20 and 21 , similar numerals will be utilized to designate similar components, the suffix letter “h” being associated with the numerals ofFIG. 22 to avoid confusion. - An
anchor 18 h and ananchor 20 h are connected with a suture 24 h. The suture 24 h includes aleg portion 50 h which is connected to and extends from theanchor 18 h. The suture 24 h also includes aleg portion 52 h which is connected to and extends from theanchor 20 h. Theleg portions retainer 54 g ofFIG. 20 . Alternatively, theleg portions - In accordance with a feature of this embodiment of the invention, the
anchor 18 h is provided with an opening 220 (FIG. 22 ) through which a portion of theanchor 20 h extends. Theanchor 20 h hasretainers 224 which move through theopening 220 and engage theanchor 18 h when theanchors retainers 224 with theanchor 18 h interconnects theanchors - In the embodiments of the invention illustrated in
FIGS. 1-15 , the anchors are enclosed by thebody tissue 14. In the embodiment of the invention illustrated inFIG. 23 , the anchor is partially disposed outside ofbody tissue FIG. 23 is generally similar to the embodiments of the invention illustrated inFIGS. 1-22 , similar numerals will be utilized to designate similar components, the suffix letter “j” being associated with the numerals ofFIG. 23 to avoid confusion. - An apparatus 10 j (
FIG. 23 ) includes a plurality of anchors. The plurality of anchors includes theanchor 18 j and ananchor 20 j. Asuture 24 j extends between theanchors - The
anchor 18 j has ashank portion 230 which extends throughbody tissue 12 j into body tissue 14 j. If desired, theshank portion 230 of theanchor 18 j could extend through the body tissue 14 j. Ahead end portion 234 of theanchor 230 is pressed against thebody tissue 12 j and presses thebody tissue 12 j against the body tissue 14 j. - Similarly, the
anchor 20 j includes ashank portion 238 which extends through thebody tissue 12 j into the body tissue 14 j. If desired, theshank portion 238 of theanchor 20 j could extend through the body tissue 14 j. Theanchor 20 j has ahead end portion 242 which is pressed against thebody tissue 12 j. - The
suture 24 j extends around theshank portions anchors suture 24 j engages theshank portions anchors FIG. 23 ) thehead end portions anchors - The
suture 24 j is formed as a continuous loop. The loop extends around theshank portions anchors suture 24 j is generally similar to the loop formed by thesuture 24 a ofFIG. 11 . However, if desired, thesuture 24 j (FIG. 23 ) could be a single strand which extends between the twoanchors suture 24 j could be formed with two leg portions, corresponding to theleg portions 50 and 52 (FIG. 9 ) of thesuture 24. If thesuture 24 j (FIG. 23 ) is formed with a pair of leg portions, the leg portions could be interconnected with a retainer, similar to theretainer 54 ofFIG. 9 . - In the embodiment of the invention illustrated in
FIGS. 1-10 , the apparatus 10 (FIG. 1 ) includes a plurality of anchors which are interconnected by asuture 24. Although only twoanchors FIG. 1 , it should be understood that a greater number of anchors could be connected with thesuture 24. In the embodiment of the invention illustrated inFIG. 1 , theanchors anchor 18 could have a construction which is different than a construction of theanchor 20. - The
anchor 18 includes abody portion 250 from which the pointed leadingend portion 34 extends. Thespecific anchor 18 illustrated inFIG. 1 has acylindrical body portion 250 and a generally conical pointed leadingend portion 34 which are disposed in a coaxial relationship. - Although the pointed leading
end portion 34 of the anchor 18 (FIG. 1 ) has a conical configuration, the pointed leading end portion could have a different configuration if desired. For example the pointed leadingend portion 34 could be wedge-shaped. Alternatively, the pointed leadingend portion 34 could have a pyramidal configuration and be formed by the intersection three, four, or more surfaces. The surfaces could be flat or concave in configuration. - The
anchor 18 is provided with a pair ofpassages suture 24 extends. Thepassages cylindrical body portion 250. Central axes of thepassages central axis 260 of the anchor. The central axes of thepassages central axis 260 of theanchor 18. - In the illustrated embodiment of the
anchor 18, twopassages body portion 250 of the anchor. However, it is contemplated that only a single passage may be provided through the anchor. This single passage could be skewed at an acute angle to thecentral axis 260 of theanchor 18. Alternatively, the passage could extend axially through the anchor. - The anchor 20 (
FIG. 1 ) is identical to theanchor 18. Theanchor 20 has acylindrical body portion 264 through whichpassages anchor 20 has aconical end portion 44 which is coaxial with thecylindrical body portion 264. - The
anchors anchors anchors - The
anchors anchors anchors - Although the
anchors anchors anchors anchors anchors anchors anchors - The
anchors anchors anchors - It is contemplated that the
anchors anchors anchors anchors - When the
anchors - The suture 24 (
FIG. 1 ) extends from theanchors suture 24 extends through thepassages anchor 18. Similarly, thesuture 24 extends through thepassages anchor 20. - The
suture 24 is freely movable relative to theanchors anchor passages anchors leg portions suture 24, the length of the connector portion 48 (FIG. 1 ) of thesuture 24 extending between the anchors can be shortened to accommodate positioning of the anchors in thebody tissue 14 at the locations which are relatively close together. Similarly, theanchors connector portion 48 of thesuture 24 to accommodate positioning of theanchors body tissue 14 at locations which are spaced a substantial distance apart. - Once the
anchors FIG. 9 , force applied to theleg portions connector portion 48 of thesuture 24. Any excess material in theconnector portion 48 of thesuture 24 will be pulled into theleg portions leg portions connector portion 48 of thesuture 24 being tensioned with substantially the same force by the force application assembly 60 (FIG. 10 ) prior to gripping of theleg portions suture 24 with thesuture retainer 54. - Since the
suture 24 is movable relative to theanchors FIG. 9 ) of thesuture 24 can be increased after theanchors body tissue 14. Thus, once theanchors FIG. 9 , pulling on theleg portions suture 24 causes the suture to slide in thepassages anchor 18 and to slide in thepassages anchor 20. As thesuture 24 moves in thepassages anchors connector portion 48 of thesuture 24 decreases. At the same time the length of theleg portions - Pulling on the
leg portions flexible suture 24 increases the tension in the leg portions. This increase in tension is transmitted from theleg portions suture 24 through thepassages anchors connector portion 48 of the suture. Therefore, pulling on theleg portions suture 24 eliminates any extra length in theconnector portion 48 of the suture and effects a corresponding increase in the combined lengths of the leg portions of the suture. As this occurs, tension in theconnector portion 48 of thesuture 24 increases to equal tension in theleg portions - The
suture 24 may be formed of a plastic material which is a biopolymer. Thus, thesuture 24 may be formed of polyglycolide which is commercially available under the trademark DEXON. Polyglycolide is a crystalline material that melts about 225° C.elsius. Although thesuture 24 is a monofilament suture having a continuous outer side surface, it is contemplated that the suture could be formed in a different manner. For example, thesuture 24 could be a cable having an interlaced structure formed by a plurality of filaments or strands which have been twisted, braided, twined, and/or threaded together. If desired, thesuture 24 and anchors 18 and 20 could be formed of the same polymeric material. - It is contemplated that the
suture 24 may be formed of a polyglycolide-based copolymer which is commercially available under the trademark VICRYL. Thesuture 24 may have a multifilament construction which is similar to the construction of the suture disclosed in U.S. Pat. No. 5,928,267. The disclosure in the aforementioned U.S. Pat. No. 5,928,267 is hereby incorporated herein by this reference thereto. - The strength of the
suture 24 will vary as a function of the size of the suture. It is contemplated that the specific strength of a particular suture size will vary depending upon the material from which the suture is constructed and whether the suture has a monofilament or multifilament construction. By consulting a chart, a surgeon can select asuture 24 of a size and strength suitable for a particular use. Thus, a relativelylarge size suture 24 having substantial strength may be selected when body tissue is to be connected with a bone or when portions of a bone are to be interconnected by the suture. On the other hand, a relativelysmall size suture 24 having a relatively small strength may be selected when delicate body tissue, such as stomach tissue or intestinal tissue, and/or mucosa are to be interconnected with the suture. - Once a suture of a size and strength suitable for retaining specific body tissue has been selected, the suture is threaded through the
passages anchor 18 through thepassages anchor 20. By moving theanchors connector section 48 can be increased. Alternatively, by tensioning theleg portions 50 and 52 (FIG. 1 ) of thesuture 24, the length of theconnector portion 48 can be decreased. - In the embodiment of the invention illustrated in
FIGS. 1-10 , thesuture 24 and anchors 18 and 20 are formed of different materials. Thus, theanchors suture 24 is a monofilament of polymeric material. However, it is contemplated that both thesuture 24 and theanchors suture 24 and anchors 18 and 20 could both be formed of polymers or copolymers which are biodegradable or bioerodible. Even when theanchors suture 24 of a biodegradable polymeric material. - The
anchors anchors FIGS. 18-23 herein. Alternatively, theanchors anchors - After the
anchors suture 24, in the manner illustrated inFIG. 1 , the anchors and suture are used to connectbody tissue 12 with thebody tissue 14. In the specific embodiment of the invention illustrated inFIGS. 1-10 , thebody tissue 12 is soft body tissue and thebody tissue 14 is hard body tissue. Thesoft body tissue 12 may be a tendon or a ligament. Thebody tissue 14 is a bone having a hard (cortical)outer layer 278 and relatively softcancellous bone 280 which is enclosed by the relatively hardouter layer 278. - It should be understood that many different kinds of soft tissue can be connected with bone at many different locations in a patient's body. For example, the
anchors suture 24 could be used to secure a meniscus to a bone in a knee joint of a patient. Alternatively, thesuture 24 and anchors 18 and 20 could be used to secure the rotator cuff in a shoulder of a patient. Thesoft tissue 12 may be mucosa. Thesoft tissue 12 may be musculofascial tissue. It should be understood that the foregoing specific locations for use of theapparatus 10 in the body of a patient have been set forth herein merely as examples and it is contemplated that theapparatus 10 may be used at any desired location in the body of a patient. - In the embodiment of the invention illustrated in
FIGS. 1-10 , thebody tissue 12 is pressed against thebody tissue 14 by force transmitted from thesuture 24 to thebody tissue 12. However, thebody tissue 12 could be spaced from thebody tissue 14. For example, thesuture 24 could extend at least part way around thebody tissue 12 with thebody tissue 12 spaced from thebody tissue 14. Thebody tissue 12 could be soft body tissue which has a range of movement, relative to thebody tissue 14, limited by thesuture 24. Thebody tissue 14 could be either hard body tissue (bone) or soft body tissue. Alternatively, theanchor 18 could be disposed in one bone and theanchor 20 disposed in another bone. If this was done, thesuture 24 could be utilized to limit the range of movement between the bones or to hold the bones in engagement with each other. - It is contemplated that the
suture 24 and anchors 18 and 20 may be used in vascular tissue. For example, theanchors suture 24 with body tissue which forms a portion of a blood vessel. Body tissue forming two sections of a blood vessel may be placed in a side-by-side relationship and interconnected with theanchors suture 24. - When the
body tissue 12 is to be secured to thebody tissue 14 with theapparatus 10, theanchor 18 is positioned in the inserter 28 (FIG. 2 ). The illustratedinserter 28 includes a cylindrical tubularouter member 284 which is connected with a suitable handle (not shown). Thepusher member 30 has a generally cylindrical configuration and is received in acylindrical passage 286 in the tubularouter member 284. - The
cylindrical passage 286 extends between an entrance opening adjacent to the handle and acircular exit opening 288. Thepusher member 30 extends along thepassage 286 through the opening adjacent to the handle of theouter member 284. Although the illustratedinserter 28 andpusher member 30 have linear central axes, they could have nonlinear central axes if desired. For example, theinserter 28 andpusher member 30 could have arcuate central axes. - A
slot 292 extends between the entrance opening adjacent to the handle of theinserter 28 and theexit opening 288. Theslot 292 facilitates positioning theanchor 18 in thepassage 286. This is because theanchor 18 is visible through theslot 292. In addition, theconnector portion 48 andleg portion 50 of thesuture 24 can be readily positioned in theslot 292. - The
slot 292 has a straight longitudinal central axis which extends parallel to the longitudinal central axis of thepassage 286 and to the longitudinal central axis of the tubularouter member 284. Theconnector portion 48 andleg portion 50 of thesuture 24 extend along theslot 292 away from theopening 288 toward the opposite end portion of the tubularouter member 284. Theslot 292 encloses theconnector portion 48 andleg portion 50 of thesuture 24 and protects theconnector portion 48 and leg portion of thesuture 24 against being snagged by objects in the environment around theinserter 28. - The
passage 286 has a circular cross sectional configuration with a diameter which is slightly greater than the diameter of thebody portion 250 of theanchor 18. Immediately adjacent to theexit opening 288, thepassage 286 tapers inwardly to a cross sectional size which is somewhat smaller than the cross sectional size of thebody portion 250 of theanchor 18. This enables theouter member 284 to firmly grip the trailingend portion 32 of theanchor 18. - The
slot 292 has a uniform width throughout the length of the slot until the slot approaches theexit opening 288. Immediately ahead of theexit opening 288, the width of theslot 292 decreases to reduce the cross sectional size of thepassage 286. - When the
anchor 18 is to be positioned in theinserter 28, the anchor is inserted through the opening to thepassage 286 adjacent to the handle with theend portion 34 of the anchor leading. Thepusher member 30 is moved into thepassage 286 and applies force against the trailingend portion 32 of theanchor 18 to move the anchor along thepassage 286. At this time, theconnector portion 48 andleg portion 50 of thesuture 24 are disposed in theslot 292. - When the
anchor 18 approaches theexit opening 288, the taperedleading end portion 34 of the anchor applies force against theouter member 284 to resiliently deflect the end portion of the outer member and expand theexit opening 288. At this time, the portion of theouter member 284 adjacent to theexit opening 288 resiliently grips thebody portion 250 of the anchor to hold the anchor in the position illustrated inFIG. 2 . - Although the
inserter 28 may have many different constructions, thespecific inserter 28 illustrated inFIG. 2 has the same construction as is disclosed in U.S. Pat. No. 5,948,002 issued Sep. 7, 1999 for “Apparatus and Method for Use in Positioning a Suture Anchor”. It should be understood that theinserter 28 may have a construction which is similar to any one of the constructions illustrated in the aforementioned U.S. Pat. No. 5,948,002. It is also contemplated that theinserter 28 could have a construction which is similar to the construction of any one of many other known inserters. However, it is believed that it may be desired to use an inserter having the construction disclosure in the aforementioned U.S. Pat. No. 5,948,002 to facilitate handling and positioning of theanchor 18 relative to thebody tissue - The
anchor 18 is held in theinserter 28 with theleading end portion 34 of the anchor extending from the inserter. Thepusher member 30 engages the trailingend portion 32 of theanchor 18 to block movement of the anchor along thepassage 286 in a direction away from theexit opening 288. - The longitudinal central axis of the
inserter 28 is then positioned in an orientation relative to thebody tissue 12 corresponding to the orientation of a path along which the anchor is to be moved into the body tissue. Thus, if theanchor 18 is to be moved straight downward (as viewed inFIG. 2 ) into thebody tissue 12 and into thebody tissue 14, theinserter 28 would be positioned with its longitudinal central axis extending generally perpendicular to anouter surface 300 of thebody tissue 12. However, in the embodiment of the invention illustrated inFIGS. 1-10 , it is desired to move theanchor 18 into thebody tissue outer surface 30 of thebody tissue 12. - In the specific instance illustrated in
FIG. 2 , theinserter 28 is positioned with its longitudinal axis extending at an angle of approximately 40° to theouter surface 300 of thebody tissue 12. However, it is contemplated that theinserter 28 could be positioned with its longitudinal axis extending at an angle of between 30° and 90° to theouter surface 300 of thebody tissue 12. The specific angle which is selected between theouter surface 300 of thebody tissue 12 and the longitudinal central axis of theinserter 28 will depend upon the desired path of movement of theanchor 18 into the body tissue. It is believed that it may be desired to have the path of movement of theanchor 18 into thebody tissue outer surface 300 of the body tissue. - It is believed that it will be desired to move the
anchor 18 for a predetermined distance into thebody tissue 14. It is also believed that it may be desired to limit the depth of movement of the anchor into thebody tissue 14. In order to enable the anchor to be moved through a substantial distance into thebody tissue 14 while minimizing the depth to which the anchor is moved into the body tissue, the path of movement of the anchor into the body tissue is skewed at an acute angle to theouter surface 300 of thebody tissue 12. When theanchor 18 is to be moved along a path which is skewed relative to theouter surface 300, it is believed that it may be desired to move the anchor into thebody tissue outer surface 300 of the body tissue. - Once a desired angle for the path of movement of the
anchor 18 through thebody tissue 12 and into thebody tissue 14 has been selected, theinserter 28 andpusher member 30 are moved toward theouter surface 300 of thebody tissue 12 with the anchor extending from the inserter, in the manner illustrated inFIG. 2 . The pointedleading end portion 34 of theanchor 18 is moved into engagement with an imperforate area on theouter surface 300 of thebody tissue 12. As theinserter 28 andpusher member 300 continue to move along their longitudinal central axes toward thebody tissue 12, the pointed leadingend portion 34 of theanchor 18 initiates the formation of an opening in theouter surface 300 of thebody tissue 12. - Continued movement of the
inserter 28 andpusher member 30 toward thebody tissue 12 causes theanchor 18 to piercebody tissue 12. As theanchor 18 moves through thebody tissue 12, the pointed leading end portion of the anchor moves into engagement with an imperforate area on anouter surface 304 of the hardouter layer 278 of thebone 14. It should be understood that thebody tissue 12 could have a thickness which is greater than the thickness illustrated schematically inFIG. 2 . It is contemplated that thebody tissue 12 could have a thickness which is substantially greater than the axial extent of theanchor 18. - The pointed
leading end portion 34 of theanchor 18 then initiates the formation of an opening in an imperforate area on thesurface 304 on the hardouter layer 278 of the bone. Continued movement of theinserter 28 along its path of movement moves theleading end portion 34 of the anchor into the hardouter layer 278 of the bone, in the manner illustrated schematically inFIG. 3 . As this occurs, theinserter 28 moves through thesoft tissue 12 into abutting engagement with theouter surface 304 on the hardouter layer 278 of thebone 14. - The axial force applied against the
inserter 28 is insufficient to cause the inserter to penetrate the hardouter layer 278 of thebone 14. Therefore, movement of theinserter 28 along its longitudinal central axis relative to thebody tissue outer surface 304 of the hardouter layer 278 of thebone 14. At this time, theleading end portion 34 of theanchor 18 will have initiated penetration of theouter layer 278 of the bone 14 (FIG. 3 ). - The movement of the inserter along the path of insertion of the
anchor 18 into thebody tissue FIG. 3 as being interrupted when the inserter engagesouter surface 304 of thebone 14. However, it is contemplated that movement of theinserter 28 along the path of insertion of theanchor 18 could be interrupted when the inserter engages theouter surface 300 on thebody tissue 12. If this was done, the inserter would be moved from the position illustrated inFIG. 2 along the path of movement of theanchor 18 into thebody tissue outer surface 300 of thebody tissue 12. At this time, theleading end portion 34 of theanchor 18 may or may not have moved into engagement with thebone 14. Whether or not the anchor has moved into engagement with thebone 14 when theinserter 28 engages theouter surface 300 of thebody tissue 12 will depend upon the thickness of thebody tissue 12, the angle of the path of movement of the anchor relative to thebody tissue 12, and the distance which theanchor 18 extends from theinserter 28. - When the
tissue 12 is soft tissue and thetissue 14 is bone or other hard body tissue, it is believed that it will be desirable to have the inserter move with theanchor 18 during initiation of penetration of the anchor into the hard body tissue. However, when thebody tissue 14 is soft body tissue, it may not be desired to have the inserter hold the trailingend portion 32 of the anchor during initiation of penetration of the anchor into thebody tissue 14. - It is contemplated that it may be desired to move the
inserter 28 into thebone 14. Thus, theinserter 28 could be moved through the hardouter layer 278 of thebone 14 into thecancellous bone 280. This would have the advantage of enabling theinserter 28 to at least partially support theanchor 18 as the anchor moves through the hardouter layer 278 of thebone 14. - In the embodiment of the invention illustrated in
FIGS. 1-10 , thebody tissue 14 is hard body tissue, that is, bone. It is believed that initiation of penetration of the anchor into the hardouter layer 278 of thebone 14 will be facilitated by having the anchor held in theinserter 28 as the pointed leadingend portion 34 begins to move through the imperforateouter surface 304 of theouter layer 278. Therefore, it is believed that it may be desired to move theinserter 28 through thesoft body tissue 12 into engagement with theouter surface 304 of thebone 14 during at least the initiation of formation of an opening in the hardouter layer 278 of thebone 14. - Once the
inserter 28 has moved into engagement with theouter surface 304 of thebone 14 and movement of the inserter relative to thebone 14 is interrupted, thepusher member 30 is moved relative to theinserter 28 to apply force against the trailingend portion 32 of the anchor and to move the anchor further into thebone 14, in the manner illustrated inFIG. 4 . Thus, theinserter 28 is held stationary relative to thebody tissue pusher member 30 is moved axially along the longitudinal central axis of theinserter 28. The pusher member is telescopically extended from theinserter 28 and moves theanchor 18 through the hardouter layer 278 of thebone 14 into the relatively soft cancellous bone 280 (FIG. 4 ). - As this occurs, the
suture 24 moves along theslot 292 in theinserter 28. As theanchor 18 moves into thebone 14, the anchor pulls thesuture 24 into the bone. This results in movement of thesuture 24 along theslot 292 in theinserter 28. As theanchor 18 moves into thecancellous bone 280, theleading end portion 34 of the anchor pierces the cancellous bone. - The
anchor 18 is moved into thebody tissue outer surface 300 of thebody tissue 12 and theouter surface 304 of thebody tissue 14. Therefore, the distance which theanchor 18 is moved into thebone 14 tends to be maximized while the depth, as measured perpendicular to theouter surfaces body tissue - If the
inserter 28 was positioned in engagement with theouter surface 304 of thebone 14 with the longitudinal central axis of the inserter extending perpendicular to the outer surface of the bone, and if thepusher member 300 was moved through the same distance relative to theinserter 28 from the retracted condition shown inFIG. 3 to the extended condition shown inFIG. 4 , theanchor 18 would be moved further into thebone 14 as measured along a path extending perpendicular to theouter surface 304 of the bone. It is believed that in at least some locations in a patient's body, it will be desired to have the distance which the anchor is moved into thebone 14 maximized while at the same time minimizing the depth of penetration of the anchor. This may be due to thebone 14 being relatively thin, the particular configuration of thebone 14, or other causes. - In order to increase the resistance of the anchor to pull out under the influence of tension forces in the
suture 24, the anchor is toggled or pivoted from the orientation illustrated inFIG. 4 to the orientation illustrated inFIG. 5 . This results in the anchor being moved from a position in which a longitudinal central axis of the anchor is aligned with the longitudinal central axis of a path of movement of the anchor into the bone 14 (FIG. 4 ) to a position in which the longitudinal central axis of the anchor is skewed relative to the path of movement of the anchor into the bone 14 (FIG. 5 ). - Once the
anchor 18 has been moved to the desired depth in the bone 14 (FIG. 4 ), toggling movement of the anchor is initiated by tensioning theconnector portion 48 andleg portion 50 of thesuture 24. A sloping orbevel surface 310 is provided on the leading end portion of thepusher member 30 to facilitate initiation of the pivotal movement of theanchor 18 relative to thepusher member 30. The force applied against theanchor 18 by thesuture 24 pulls the anchor back or upward (as viewed inFIG. 4 ) toward thesurface 310 on thepusher member 30. Therefore, the tension in thesuture 24 tends to rotate theanchor 18 in a counterclockwise direction from the position illustrated inFIG. 4 to the position illustrated inFIG. 5 relative to the softcancellous bone 280. - As the
anchor 18 is pivoted, the upper (as viewed inFIG. 5 ) portion of the anchor deflects the softcancellous bone tissue 280. The viscoelastic nature of the softcancellous bone tissue 280 causes the tissue to tend to close behind the anchor as it is pivoted upward to the position shown inFIG. 5 . The manner in which theanchor 18 is pivoted relative to the body tissue is similar to that disclosed in U.S. Pat. Nos. 5,948,002; 5,941,900; and 5,403,348. - Once the
anchor 18 has been moved to the position illustrated inFIG. 5 , thepusher member 30 is withdrawn from thebody tissue anchor 18 being supported in thebody tissue cancellous bone 280. Theanchor 18 is spaced from the hardouter layer 278 of thebone 14. Therefore, tension forces in thesuture 24 are transmitted from outer side surfaces of the anchor to thecancellous bone 280 while the anchor is maintained in a spaced apart relationship with the hardouter layer 278 of bone. The manner in which theanchor 18 is supported in thecancellous bone 280 in a spaced apart relationship with the hardouter layer 278 of bone is the same as is disclosed in U.S. Pat. No. 6,077,292. - Rotating the
anchor 18 relative to the path of movement of the anchor into thebody tissue suture 24 to the anchor. Theanchor 18 could remain in thebone 14 in the orientation shown inFIG. 4 in which the longitudinal central axis of the anchor is coincident with the longitudinal central axis of the path along which the anchor moves into the bone. However, by toggling or pivoting the anchor from the position shown inFIG. 4 to the position shown inFIG. 5 the resistance of the anchor to pull out forces tends to be increased. Of course, if the anchor is to be subjected to only relatively small pull out forces, the anchor could be left in the position shown inFIG. 4 relative to thebone 14 without being pivoted to the orientation illustrated inFIG. 5 . - In the embodiment of the invention illustrated in
FIGS. 1-10 , theanchor 18 is moved into thebody tissue FIG. 2 to the intermediate position ofFIG. 4 along a linear path. However, theanchor 18 could be moved from the initial position (FIG. 2 ) to the intermediate position (FIG. 4 ) along a nonlinear path if desired. For example, theanchor 18 could be moved along an arcuate path from the initial position to the intermediate position. - When the
anchor 18 is to be moved along an arcuate path from the initial position (FIG. 2 ) to the intermediate position (FIG. 4 ), theinserter 28 andpusher member 30 may be formed with an arcuate configuration. The arcuate configuration of theinserter 28 andpusher member 30 is would be the same as the arcuate configuration of the path along which theanchor 18 is to be moved into thebody tissue - When the
inserter 28 andpusher member 30 have a rigid construction, it is believed that it may be desired to form thepassage 286 in the inserter and to form thepusher member 30 to have the same arc of curvature. This is done to facilitate movement of thepusher member 30 along thepassage 286 in theinserter 28. However, it is contemplated that theinserter 28 and/orpusher member 30 could have a flexible construction if desired. For example, theinserter 28 andpusher member 30 could have a construction similar to the construction disclosed in U.S. Pat. No. 5,897,574. The disclosure in U.S. Pat. No. 5,897,574 is hereby included herein in its entirety by this reference thereto. - The
anchor 20 is moved through thesoft body tissue 12 into thehard body tissue 14 in the same manner as in which theanchor 18 is moved through the soft body tissue into the hard body tissue. Thus, theanchor 20 is positioned in an inserter 38 (FIG. 6 ) having the same construction as theinserter 28 ofFIG. 3 . A pusher member 40 (FIG. 6 ) is telescopically moved along theinserter 38 into engagement with the trailingend portion 42 of theanchor 20 in the same manner as previously described in conjunction with theanchor 18,pusher member 30 andinserter 28 ofFIG. 3 . - The
leg portion 52 of thesuture 24 and theconnector portion 48 of the suture are at least partially received in aslot 316 in theinserter 38 in the same manner as in which the suture is received in theslot 292 in theinserter 28 ofFIG. 3 . Theinserter 38 andpusher member 40 have the same construction and cooperate in the same manner as is disclosed in U.S. Pat. No. 5,948,002 and have the same construction and mode of operation as theinserter 28 andpusher member 30 ofFIGS. 2-4 . - When the
anchor 20 is to be used in securing thebody tissue 12 to thebody tissue 14, theanchor 20 is positioned in theinserter 38 and thepusher member 40 is moved into engagement with the trailing end portion of the anchor. Theleading end portion 44 of the anchor is then moved from a position spaced from thebody tissue 12 to a position in which the leading end portion engages an imperforate area on theouter surface 300 of thebody tissue 12. At this time, theinserter 38 andpusher member 40 are positioned in an angular orientation relative to thesurface 300 of thebody tissue 12 corresponding to the angle of the desired path of insertion of theanchor 20 into thebody tissue - In the specific situation illustrated in
FIG. 6 , the path of insertion of theanchor 20 into thebody tissue surface 300 of thebody tissue 12. It is contemplated that the path of insertion of theanchor 20 into thebody tissue surface 300 of thebody tissue 12. In order to reduce the depth of insertion of theanchor 20 into thebone 14, it is believed that it may be desired to have the path of movement of theanchor 20 into thebody tissue surface 300 of thebody tissue 12. - When the
inserter 38 andpusher member 40 have been positioned with their longitudinal central axes coincident with the longitudinal central axis of the desired path of movement of theanchor 20 into thebody tissue pusher member 40 andinserter 38 are moved together toward thesurface 300 of thebody tissue 12. As this occurs, the pointed leadingend portion 44 of theanchor 20 initiates the formation of an opening in thesurface 300 of thebody tissue 12. - The
inserter 38,pusher member 40, andanchor 20 continue to move together relative to thebody tissue body tissue 12. When the pointed leadingend portion 44 of theanchor 20 engages an imperforate portion of theouter surface 304 of thebone 14, theleading end portion 44 of the anchor initiates formation of an opening in theouter surface 304 of thebone 14. - Continued movement of the
inserter 38,pusher member 40 andanchor 20 together along the path of insertion of the anchor into thebody tissue leading end portion 44 of the anchor moving into the hardouter layer 278 of thebone 14 in the manner illustrated inFIG. 6 . As this occurs, theinserter 38 moves into engagement with theouter surface 304 of thebone 14. Movement of theinserter 38 relative to thebone 14 is interrupted with the inserter in engagement with theouter surface 304 of the bone, in the manner illustrated schematically inFIG. 6 . - It may be desired to move the
inserter 38 through thebody tissue 12 into engagement with thebone 14, in the manner illustrated inFIG. 6 . This results in theanchor 20 being supported by theinserter 38 as the anchor initially penetrates the hardouter layer 278 of thebone 14. Theanchor 20,inserter 38 andpusher member 40 are moved together along the path of movement of the anchor into thebody tissue inserter 38 engages thesurface 304 on the hardouter layer 278 of the bone. By the time theinserter 38 engages thesurface 304 on the hardouter layer 278 of thebone 14, the leading end portion of the anchor has moved into the hard outer layer of the bone (FIG. 6 ). - When the
inserter 38 moves into engagement with theouter surface 304 of thebone 14, movement of the inserter relative to the bone is interrupted. Thepusher member 40 is then moved relative toinserter 38. Movement of thepusher member 40 relative to theinserter 38 applies force against the trailingend portion 42 of theanchor 20 and moves theanchor 20 into thebone 14. Theanchor 20 is moved into thebone 14 through the hardouter layer 278 and into thecancellous bone 280 as thepusher member 40 is telescopically extended from the inserter 38 (FIG. 7 ). As theanchor 20 moves into thebone 14, thesuture 24 moves along theslot 316 in theinserter 38. - Once the
anchor 20 has been moved to the desired depth in thecancellous bone 280, thepusher member 40 andinserter 38 may be withdrawn from thebody tissue FIG. 7 relative to the body tissue. Thus, the anchor may remain in thecancellous bone 280 with a longitudinalcentral axis 320 of the anchor aligned with the central axis of the path of movement of the anchor into thebody tissue body tissue suture 24. - When the orientation of the
anchor 20 is to be changed relative to thebone 14 from the orientation illustrated inFIG. 7 to the orientation illustrated inFIG. 8 , thesuture 24 is tensioned. Tensioning thesuture 24 tends to pivot theanchor 20 in a clockwise direction (as viewed inFIGS. 7 and 8 ) about a location where the trailingend portion 42 of the anchor engages thepusher member 40. Thepusher member 40 has abevel surface 324 which extends transversely to a longitudinal central axis of thepusher member 40. Thebevel surface 324 facilitates pivotal movement of theanchor 20 relative to thepusher member 40. - When the
anchor 20 has been pivoted to the orientation illustrated inFIG. 8 , thepusher member 40 is telescopically moved back into theinserter 38. Theinserter 38 andpusher member 40 are then withdrawn from thebody tissue 12. When theanchor 20 is in the orientation shown inFIG. 8 , thecentral axis 320 of the anchor extends transverse to the path of movement of the anchor into thebone 14. This increases the pull out force which is required to remove the anchor from the bone. - After the
anchors FIGS. 5 and 8 , the anchors are pointed toward each other (FIG. 9 ). Thus, theleading end portion 34 of theanchor 18 points toward theanchor 20 and theleading end portion 44 of theanchor 20 points toward theanchor 18. At this time, the longitudinalcentral axis 260 of theanchor 18 extends generally parallel to theouter surface 300 of thebody tissue 12 and to theouter surface 304 of thebone 14. Similarly, thecentral axis 320 of theanchor 20 extends parallel to theouter surface 300 of thebody tissue 12 and to theouter surface 304 of thebone 14. At this time, both theanchors cancellous bone 280 in a spaced apart relationship with the hardouter layer 278 of thebone 14. - In
FIG. 9 , thecentral axes anchors outer surface 300 of thebody tissue 12 and theouter surface 304 of thebody tissue 14. However, it is contemplated that theaxes anchors axes FIG. 9 is disposed. In addition, rather than being generally parallel to theouter surfaces body tissue axes anchors - The paths of movement of the
anchors body tissue outer surfaces body tissue anchor 18, into thebody tissue - Regardless of whether or not the central axes of the paths along which the
anchors body tissue anchor 18 moves into thebody tissue anchor 20 moves into the body tissue. Even though the central axes of the paths along which the anchors move into the body tissue are not disposed in a common plane, theanchor 18 moves toward the location where theanchor 20 enters thebody tissue anchor 18 is moved into the body tissue. Similarly, theanchor 20 moves toward locations where theanchor 18 moved into thebody tissue anchor 20 is moved into the body tissue. - By having the
anchors bone 14. This results in thesuture 24 being effective to press thebody tissue 12 against thebody tissue 14 with a clinching action. The clinching action with which thesuture 24 presses thebody tissue 12 against thebone 14 is similar to the clinching action which is obtained by the legs of a staple. This clinching action increases the force which is transmitted from thesuture 24 to thebody tissue 12 and increases the resistance of theanchors - Although it is believed that it may be desired to move the
anchors body tissue 14, the anchors could be moved along insertion paths which are either parallel or diverge. For example, the insertion path of theanchor 18 into thebody tissue anchor 20 into the body tissue. If this was done, the insertion paths of theanchors outer surfaces body tissue - Alternatively, it is contemplated that the
anchors body tissue anchor 18 could be moved along an insertion path which extends parallel to the illustrated insertion path of theanchor 20 inFIG. 7 . Similarly, theanchor 20 could be moved along an insertion path which extends parallel to the insertion path of theanchor 18 inFIG. 4 . It should be understood that the angular orientation of the insertion paths for theanchors - In the embodiment of the invention illustrated in
FIGS. 1-10 , theanchor 20 is moved into thebody tissue FIG. 7 along a linear path. However, theanchor 20 could be moved from the initial position to the intermediate position (FIG. 7 ) along a nonlinear path if desired. For example, theanchor 20 could be moved along an arcuate path from the initial position to the intermediate position. - When the
anchor 20 is to be moved along an arcuate path from the initial position to the intermediate position, theinserter 38 andpusher member 40 may be formed with an arcuate configuration. The arcuate configuration of theinserter 38 andpusher member 40 would be the same as the arcuate configuration of the path along which theanchor 20 is to be moved into thebody tissue - When the
inserter 38 andpusher member 40 have a rigid construction, it is believed that it may be desired to form the passage in the inserter and to form thepusher member 40 to have the same arc of curvature. This is done to facilitate movement of thepusher member 40 along the passage in theinserter 38. However, it is contemplated that theinserter 38 and/orpusher member 40 could have a flexible construction if desired. For example, theinserter 38 andpusher member 40 could have a construction similar to the construction disclosed in U.S. Pat. No. 5,897,574. - Once the
anchors FIG. 9 , ends of theleg portions leg portions retainer 54, as viewed inFIG. 9 , the retainer is moved downward toward thebody tissue 12. As theretainer 54 is moved downward toward thebody tissue 12, the tension in theconnector portion 48,leg portion 50 andleg portion 52 of the suture is increased. - By initially providing the
connector portion 48 of the suture with a length which is slightly less than the length illustrated inFIG. 9 , theconnector portion 48 of thesuture 24 is tensioned as theanchor 20 is moved into thebone 14. This is because as theanchor 20 moves into thebone 14, the anchor pulls thesuture 24 into the bone. If the connector portion of thesuture 48 is shorter than is required when theanchors FIG. 9 , the connector portion of thesuture 48 is tensioned as theanchor 20 moves into thebone 14. This tensioning of theconnector portion 48 of thesuture 24 causes the suture to move relative to theanchor 20 in thepassages leg portion 52 of thesuture 24 is decreased and the length of theconnector portion 48 of the suture is increased. - After the
anchors body tissue 14, the surgeon pulls on the free end of theleg portions retainer 54 toward thebody tissue 12. As this occurs, theleg portions suture 24 are tensioned. Any excess material in theconnector portion 48 of thesuture 24 is pulled from theconnector portion 48 by movement of the suture relative to theanchors leg portions suture 24 is movable in thepassages anchors connector portion 48 andleg portions suture 24. - When the
retainer 54 has been moved downward into engagement with theouter surface 300 of thebody tissue 12 and the desired tension is present in theconnector portion 48 andleg portions suture 24, the crimp is plastically deformed to grip the leg portions of the suture. Plastic deformation of the suture retainer results in cold flowing of the material of the suture retainer. If desired, energy, such as heat or vibrational energy, may be transmitted to theretainer 54 to facilitate plastic deformation of the material of the retainer under the influence of force applied against opposite sides of the retainer. - The
retainer 54 may be plastically deformed in the same manner as disclosed in U.S. patent application Ser. No. 09/685,795 filed Oct. 10, 2000 by Peter M. Bonutti et al. and entitled “Method and Apparatus for Securing a Suture”. The disclosure in the aforementioned application Ser. No. 09/685,795 is hereby incorporated herein in its entirety by this reference thereto. - It is contemplated that the
suture retainer 54 could be plastically deformed in other ways if desired. For example, ultrasonic vibratory energy may be transmitted to the material of thesuture retainer 54 to effect heating of at least some of the material of the suture retainer. The ultrasonic vibratory energy may be applied while thesuture 54 is being tensioned with a predetermined force and while a predetermined force is being transmitted from theconnector portion 48 andleg portions suture 24 to thebody tissue 12. It is contemplated that thesuture retainer 54 may be deformed by the use of ultrasonic vibratory energy in the manner disclosed in U.S. patent application Ser. No. 09/524,397 filed Mar. 13, 2000 by Peter M. Bonutti et al. and entitled “Method of Using Ultrasonic Vibration to Secure Body Tissue”. The disclosure in the aforementioned application Ser. No. 09/524,397 is hereby incorporated herein in its entirety by this reference thereto. - In the embodiment of the invention illustrated in
FIG. 9 , theconnector portion 48 andleg portions suture 24 are pressed against thebody tissue 12 by tension in the suture. If desired, a protective member, such as a pledget, may be positioned between thesuture 24 and thebody tissue 12. The protective member may be provided with openings through which thesuture 24 extends into thebody tissue 12. During tensioning of thesuture 24, theretainer 54 may be moved into engagement with the protective member. The protective member may have the same construction as any of the protective members disclosed in U.S. Pat. No. 4,823,794. - It is believed that it may be desired to tension the
suture 24 with a predetermined tension. It is also believed that it will be desired to transmit a predetermined force from theretainer 54 to thebody tissue 12 during tensioning of thesuture 24. This may be accomplished by utilizing the apparatus which is illustrated schematically inFIG. 10 . - The apparatus includes of
FIG. 10 theforce application assembly 60 which applies an upwardly (as viewed inFIG. 10 ) directedforce 62 to theleg portions suture 24. Contemporaneously with the application of thepredetermined tension force 62 to theleg portions suture 24, theforce application member 66 presses thesuture retainer 54 downward toward thebody tissue 12 with a predetermined force indicated by thearrows FIG. 10 . While thepredetermined tension force 62 is applied to thesuture 24 and thepredetermined forces retainer 54 by theforce application member 66, the retainer is plastically deformed under the influence offorces 80 and 82 applied against opposite sides of the retainer by theforce application members - Although the
leg portions suture 24 could extend straight through thesuture retainer 54, it is preferred to form a plurality of bends in theleg portions suture 24. In the illustrated embodiment of thesuture retainer 54, two bends are formed in theleg portion 50 of thesuture 24 as it is wrapped around thesuture retainer 54. Similarly, two bends are formed in theleg portion 52 of thesuture 24 as it is wrapped around thesuture retainer 54. - The
suture retainer 54 has a spherical configuration. Acylindrical passage 340 extends through the center of thespherical suture retainer 54. If desired, thesuture retainer 54 could have a different configuration. For example, thesuture retainer 54 could have an oval or elliptical configuration. Although thepassage 340 has a linear central axis, the passage could have a nonlinear central axis. If desired, a plurality of passages having the same or different configurations could be provided in thesuture retainer 54. Thesuture retainer 54 could have any one of the constructions disclosed in the aforementioned U.S. patent application Ser. Nos. 09/685,795 and 09/524,397. - After the
leg portions suture 24 have been inserted through thesuture retainer 54, in the manner indicated schematically inFIG. 10 , the suture retainer is moved along theleg sections suture 24. The downward forces 70 and 72 are then applied against thesuture retainer 54 by theforce application member 66. This downward force results in the transmission of a predetermined force from the suture retainer to thebody tissue 12 as theleg portions suture 24 are tensioned with a predetermined tension force. - While the predetermined tension is maintained in the
leg portions connector portion 48 of thesuture 24 and while thesuture retainer 54 is being pressed downward against thebody tissue 12 with a predetermined force, theforce application members suture retainer 54. The force applied against thesuture retainer member 54 by theforce application members suture retainer 54 by either or both of theforce application members - The force applied against the material of the
suture retainer 54 results in a collapsing of thepassage 340. In addition, cold flowing of the material of the suture retainer results in a flow of the material around theleg portions suture 24. - A transducer or
load cell 344 is provided to measure the amount of force, indicated by thearrow 62, which is utilized to tension theleg portions leg portions force application members force application members suture retainer 54, the application of downward (as viewed inFIG. 10 ) force against thesuture retainer 54 is also interrupted. The upward tensioning of theleg portions suture 24 is also interrupted. - The
suture retainer 54 may be formed of many different materials. However, it is believed that it will be preferred to form thesuture retainer 54 of a biodegradable polymer. One biodegradable polymer which may be utilized is polycaperlactone. Alternatively, the suture retainer could be formed of polyethylene oxide terephthalate or polybutylene terephthalate. It is also contemplated that other biodegradable or bioerodible copolymers could be utilized if desired. - Although it is preferred to form the
suture retainer 54 of a biodegradable material, the suture retainer could be formed of a material which is not biodegradable. For example, thesuture retainer 54 could be formed of an acetyl resin such as “Delrin” (trademark). Alternatively, thesuture retainer 54 could be formed of a para-dimethylamino-benzenediazo sodium sulfonated, such as “Dexon” (trademark). If desired, thesuture retainer 54 may be formed of the same material as thesuture 24. However, thesuture retainer 54 could be formed of a material which is different than the material of thesuture 24. The manner in which thesuture retainer 54 cooperates with thesuture 24 is the same as is disclosed in the aforementioned U.S. patent application Ser. No. 09/685,795 filed Oct. 10, 2000 by Peter M. Bonutti et al. and entitled “Method and Apparatus for Securing a Suture. - In the embodiment of the invention illustrated in
FIGS. 1-10 , thesuture 24 is tightened with a desired tension by pulling on theleg portions suture 24 by theretainer 54. However, if desired, thesuture 24 could be further tensioned by the application of heat to the suture. The application of heat to the polymeric material of the suture knotting together opposite ends of a length of suture. Alternatively, opposite ends of a length of suture material may be spliced or bonded together to form a continuous closed loop. If desired, a connector member formed of polymeric material could be utilized to interconnect opposite ends of a length of suture material to form the continuous closed loop. - The loop of the
suture 24 a forms a continuous flexible ring which extends throughpassages suture 24 a extends throughpassages anchor 20 a. The continuous loop or flexible ring formed by thesuture 24 a is freely movable in thepassages passages anchor 20 a. This enables the length of theconnector portion 48 a and theconnector portion 90 of thesuture 24 a to be varied as the suture anchors 18 a and 20 a are positioned relative to thebody tissue 12 a and 14 a. - The anchor 18 a has the same construction as the
suture anchor 18 ofFIGS. 1-10 . Similarly, theanchor 20 a has the same construction as thesuture anchor 20 ofFIGS. 1-10 . Although thesuture 24 a forms a continuous closed loop between the suture anchors 18 a and 20 a, thesuture 24 a is formed of the same material as thesuture 24 ofFIGS. 1-10 . - It should be understood that the
anchors 18 a and 20 a may be formed with any of many known configurations, 24 causes the suture to shrink and increase the tension in the suture. - Rather than using the
suture retainer 54 to interconnect theleg portions leg portions - In the embodiment of
FIG. 11 , theanchors 18 a and 20 a are interconnected by asuture 24 a which forms a continuous loop. By forming a continuous closed loop with thesuture 24 a, anchors 18 a and 20 a are interconnected when the anchors are moved into thebody tissue 12 a and 14 a. - In the illustrated embodiment of the invention, the
suture 24 a is formed into a continuous flexible ring by the application of ultrasonic energy to end portions of the suture. This may be accomplished in the manner disclosed in the aforementioned U.S. patent application Ser. No. 09/524,397 filed Mar. 13, 2000. The continuous loop of thesuture 24 a may be closed to form a flexible ring by including the configurations illustrated inFIGS. 18 and 19 herein. It should also be understood that theanchors 18 a and 20 a may be formed of any of many known materials, including the anchor materials mentioned herein in association with the embodiment ofFIGS. 1-10 . Thesuture 24 a may be formed with any known suture constructions mentioned herein in association with the embodiment ofFIGS. 1-10 . Thesuture 24 a may be formed of many known materials, including the suture materials mentioned herein in association with the embodiment ofFIGS. 1-10 . - The
apparatus 10 a ofFIG. 11 is associated withbody tissue 12 a and 14 a having arcuateouter surfaces 300 a and 304 a. In the illustration ofFIG. 11 , the body tissue 14 a is hard body tissue, that is bone, while thebody tissue 12 a is soft body tissue, such as a tendon or ligament. However, it should be understood that both thebody tissue 12 a and the body tissue 14 a could be soft body tissue. - If the
body tissue 12 a and 14 a are both soft body tissue, theapparatus 10 a would be utilized to connect thesoft body tissue 12 a with the soft body tissue 14 a in a manner similar to the disclosure in U.S. Pat. No. 5,464,426 to Peter M. Bonutti for “Method of Closing Discontinuity in Tissue”. In the event that both of thebody tissues 12 a and 14 a are soft body tissue, theanchors 18 a and 20 a may be embedded in the soft tissue forming the soft tissue 14 a in much the same manner as is illustrated inFIG. 11 . However, it is also contemplated that theanchors 18 a and 20 a could be moved into and through thesoft body tissue 12 a and into and through the soft body tissue 14 a. - In the illustration of
FIG. 11 , the body tissue 14 a is bone having a hard outer layer 278 a which encloses a relatively softcancellous bone 280 a. Thebody tissue 12 a and 14 a may be many different tissues in a patient's body. For example, thetissue 12 a could be a meniscus and the tissue 14 a could be a bone in a patient's leg. Alternatively, thetissue 12 a could be a rotor (musculotendinous) cuff and the tissue 14 a could be a bone in an upper portion of a patient's body. Thebody tissues 12 a and 14 a could be vascular tissue. - An inserter and pusher member corresponding to the
inserter 28 andpusher member 30 ofFIG. 2 are utilized to move the anchor 18 a into and through thebody tissue 12 a and into the body tissue 14 a. As the anchor 18 a moves into thebody tissue 12 a, a pointed leadingend portion 34 a of the anchor 18 a initiates the formation of an opening in an imperforate surface on theouter surface 300 a of thebody tissue 12 a. As the anchor 18 a moves into and through thesoft body tissue 12 a, theleading end portion 34 a is utilized to pierce thebody tissue 12 a. - As the anchor 18 a moves through the
body tissue 12 a, theleading end portion 34 a of theanchor 12 a moves into engagement with the outer surface 304 a on the hard outer layer 278 a of the bone 14 a. The force applied against the anchor 18 a by the pusher member causes theleading end portion 34 a of the anchor 18 a to initiate the formation of an opening at an imperforate area on the outer surface 304 a of the hard outer layer 278 a. As the anchor 18 a is moved into the hard outer layer 278 a, theleading end portion 34 a of the anchor pierces the outer layer ahead of the pusher member. As the anchor 18 a moves through the outer layer 278 a, theleading end portion 34 a of the anchor initiates the formation of an opening in the softcancellous bone 280 a. As the anchor 18 a is pushed into the softcancellous bone 280 a by the pusher member, theleading end portion 34 a of the anchor 18 a deforms the soft cancellous bone. - The anchor 18 a moves through the
soft body tissue 12 a and the hard outer layer 278 a of the bone 14 a into the softcancellous bone 280 a along an insertion path having a straight longitudinalcentral axis 350. However, the anchor 18 a could be moved along a nonlinear path if desired. As the suture anchor 18 a moves through thebody tissue 12 a into the body tissue 14 a, a longitudinalcentral axis 260 a of the anchor 18 a is coincident with the longitudinalcentral axis 350 of the path along which the anchor moves into the body tissue. - Once the anchor 18 a has been moved to a desired depth in the body tissue 14 a, the pusher member 30 (
FIG. 4 ) may be moved from the extended condition back to the retracted condition ofFIG. 3 . The inserter, corresponding to theinserter 28 ofFIGS. 3 and 4 , may then be withdrawn from thebody tissue 12 a. - Alternatively, the orientation of the anchor 18 a may be changed from an orientation in which the longitudinal central axis 360 a of the anchor 18 a is aligned with the longitudinal
central axis 350 of the path along which the anchor is inserted into thebody tissue 12 a and 14 a to an orientation in which thecentral axis 260 a of the anchor extends transverse to the longitudinalcentral axis 350 of the insertion path. It is believed that it may be desired to change the orientation of the anchor 18 a relative to the insertion path in order to increase the resistance of the anchor to tension forces transmitted through thesuture 24 a to the anchor 18 a. - In order to move the anchor 18 a from an orientation in which the longitudinal
central axis 260 a of the anchor is aligned with the longitudinalcentral axis 350 of the insertion path to the orientation illustrated inFIG. 11 , thesuture 24 a is tensioned. The tension forces initiate a toggling or pivoting action about the end portion of the pusher member which engages the anchor 18 a. This toggling action occurs in the same manner as was previously discussed in conjunction with the embodiment of the invention illustrated inFIGS. 4 and 5 . - Once the anchor 18 a has been pivoted to the desired orientation relative to the body tissue 14 a, the pusher member is telescopically withdrawn into the inserter and the inserter is removed from the
soft body tissue 12. The viscoelastic nature of thebody tissues 12 a and 14 a cause the passages formed by the anchor 18 a to constrict as the pusher member and inserter are withdrawn from thebody tissues 12 a and 14 a. - Once the anchor 18 a has been positioned in the body tissue 14 a, in the manner illustrated schematically in solid lines in
FIG. 11 , theanchor 20 a is positioned in the body tissue 14 a. To position theanchor 20 a in the body tissue 14 a, the anchor is moved from the position illustrated in solid lines inFIG. 11 along an insertion path having acentral axis 354. The insertion path along which theanchor 20 a is moved into thebody tissue 12 a and 14 a may be either linear or nonlinear. - An inserter and pusher member, corresponding to the
inserter 38 andpusher member 40 ofFIGS. 6 and 7 , are utilized to move thesuture anchor 20 a through thebody tissue 12 a and into the body tissue 14 a in the same manner as previously described in conjunction with the embodiment of the invention illustrated inFIGS. 1-10 . As theanchor 20 a is moved along the insertion path by the pusher member, the longitudinalcentral axis 320 a of the anchor is aligned with the longitudinalcentral axis 354 of the insertion path. - In the embodiment of the invention illustrated in
FIG. 11 , theanchors 18 a and 20 a are formed with pointed leadingend portions pointed end portions anchors 18 a and 20 a to form their own passages through thebody tissues 12 a and 14 a. However, it is contemplated that theanchors 12 a and 14 a could be provided with blunt leading end portions. If this was done, passages for theanchors 12 a and 14 a could be formed in the body tissues by a suitable tool, such as a drill. - As the
anchor 20 a moves along the insertion path, thesuture 24 a is tensioned by movement of theanchor 20 a. Thus, as theanchor 20 a moves along the insertion path, theconnector sections outer surface 300 a of thebody tissue 12 a. Theflexible suture 24 a conforms to any irregularities in theouter surface 300 a of thebody tissue 12 a and is effective to firmly press thebody tissue 12 a against the outer surface 304 a on the bone 14 a. - As the
suture 24 a moves from the initial loose condition, indicated schematically in solid lines inFIG. 11 , to the tensioned condition, indicated schematically in dashed lines inFIG. 11 , the suture may move in thepassages anchor 20 a to enable the length of theconnector sections suture 24 a to be adjusted. This shifting movement of thesuture 24 a relative to theanchor 20 a results in the same tension forces being present in bothconnector sections suture 24 a. - As the
anchor 20 a is moved along theinsertion path 354, the tension forces in bothconnector sections 48 a and 90 a of the suture increase. When a desired tension is present in both of theconnector sections suture 24 a, movement of thesuture anchor 20 a along the insertion path is interrupted. Thus, as theanchor 20 a is moved into thecancellous bone 280 a, thesuture 24 a is pulled taut between the twoanchors 18 a and 20 a. As theanchor 20 a moves along the insertion path, the tension in thesuture 24 a increases and the force which is transmitted from the suture to thebody tissue 12 a increases. The increase in force transmitted to thebody tissue 12 a firmly presses the body tissue against the bone 14 a. - In order to enhance the resistance of the
anchor 20 a to pull out forces applied to the anchor by thesuture 24 a, the anchor may be pivoted from an orientation in which the longitudinalcentral axis 320 a of the anchor is aligned with thecentral axis 354 of the insertion path to an orientation in which the central axis of theanchor 20 a extends transverse to the central axis of the insertion path. This toggling or pivotal movement of theanchor 20 a is initiated by tension in thesuture 24 a as the anchor is moved along the insertion path by the pusher member. A bevel surface on the leading end portion of the pusher member promotes pivoting or toggling of the anchor relative to the pusher member. - During movement of the
anchor 20 a along theinsertion path 354 by the pusher member, thesuture 24 a is pulled against the anchor 18 a which was initially inserted into the body tissue 14 a. As thesuture 24 a is pulled against the anchor 18 a and theanchor 20 a moves into the body tissue 14 a, a toggling action is automatically initiated by the resulting tension in thesuture 24 a. This toggling action results in pivotal movement of theanchor 20 a about a leading end portion of the pusher member. As theanchor 20 a pivots relative to the leading end portion of the pusher member, the anchor moves from an orientation in which the longitudinalcentral axis 320 a of the anchor is coincident with the longitudinalcentral axis 354 of the insertion path to the orientation illustrated schematically in dashed lines inFIG. 11 . As theanchor 20 a moves toward the position illustrated in dashed lines inFIG. 11 , thecentral axis 320 a of the anchor moves out of alignment with thecentral axis 354 of the insertion path. - In the embodiment of the invention illustrated in
FIG. 11 , thecentral axes anchors 18 a and 20 a are disposed in a plane which extends through a center of curvature of theouter surface 300 a of thebody tissue 12 a and a center of curvature of the outer surface 304 a of the body tissue 14 a. Thecentral axes anchors 18 a and 20 a are moved into thebody tissue 12 a and 14 a intersect at the center of curvature of theouter surface 300 a of thebody tissue 12 a and the outer surface 304 a of the body tissue 14 a. - Although the
central axes anchors 18 a and 20 a are moved into thebody tissue 12 a and 14 a are disposed in a single plane, it is contemplated that thecentral axes central axis 354 could be offset from thecentral axis 350 in a direction extending into the sheet of the drawing ofFIG. 11 . Although thecentral axes outer surface 300 a of thebody tissue 12 a and the outer surface 304 a of the body tissue 14 a, the angle of theaxes outer surfaces 300 a and 304 a of thebody tissue 12 a and 14 a could be such that theaxes surfaces 300 a and 304 a of thebody tissue 12 a and 14 a. - In the embodiment of the invention illustrated schematically in
FIG. 11 , thecentral axes anchors 18 a and 20 a extend generally perpendicular to a tangent to the arcuateouter surface 300 a of thebody tissue 12 a. It is contemplated that thecentral axes anchors 18 a and 20 a are moved into thebody tissue 12 a and 14 a could be skewed at an angle of between 30° and 90° relative to a tangent to theouter surface 300 a of thebody tissue 12 a. - In the embodiment of the invention illustrated in
FIG. 11 , the anchor 18 a is disposed deeper in the body tissue 14 a than is theanchor 20 a. Thus, the distance which the anchor 18 a was moved along its insertion path from the outer surface 304 a of the body tissue 14 a was greater than the distance which theanchor 20 a was moved along its insertion path from the outer surface of the body tissue 14 a. It is contemplated that theanchors 18 a and 20 a could be moved to substantially the same depth in the body tissue 14 a if desired. It is also contemplated that theanchor 20 a could be moved deeper into the body tissue 14 a than the anchor 18 a. - The
anchors 18 a and 20 a have been illustrated inFIG. 11 with their longitudinalcentral axes anchors 18 a and 20 a could be positioned in the body tissue 14 a with their longitudinalcentral axes FIG. 11 , the outer side surfaces 300 a and 304 a of thebody tissue 12 a and 14 a have been illustrated as having an arcuate configuration. However, it is contemplated that thebody tissues 12 a and 14 a could have outer surfaces which have an irregular arcuate configuration, or an irregular generally flat configuration, or a combination of irregular, arcuate and flat configurations. For example, the surface 304 a could be disposed on the end of a bone and thecentral axes anchors 18 a and 20 a could be offset so as to extend through the sides of the bone. - It is contemplated that the
apparatus 10 a will be utilized in many different environments to secure body tissue. Thus, theapparatus 10 a may be used to connect a meniscus with a bone in a knee joint of a patient. It is also contemplated that theapparatus 10 a may be utilized to connect a rotator cuff with the bone in a shoulder of a patient. Theapparatus 10 a may be used to interconnect sections of blood vessels. Theapparatus 10 a may be used to secure mucosa. It should be understood that these are only specific examples of many different locations in a patient's body in which theapparatus 10 a may be utilized to secure body tissues. - Although the
apparatus 10 a has been described inFIG. 11 in conjunction with the connection ofsoft body tissue 12 a with bone 14 a, it is contemplated that theapparatus 10 a may be utilized to connect one portion of soft body tissue in a patient's body with another portion of the soft body tissue in a patient's body. For example, layers of soft tissue may be positioned in a side-by-side relationship and interconnected using theapparatus 10 a. When relatively thin layers of soft tissue are placed in apposition, theanchors 18 a and 20 a may be moved through the both layers of tissue and disposed adjacent to a side of the tissue in a manner similar to that disclosed in the aforementioned U.S. Pat. No. 5,464,426. Alternatively, theanchors 18 a and 20 a may be moved through a relatively thin layer of soft body tissue into a relatively thick mass of soft body tissue. When this is done, it is believed that it may be desired to have the anchors embedded in the soft body tissue in the same manner as is illustrated schematically inFIG. 11 . - In the foregoing description, the anchor 18 a has been inserted into the body tissue 14 a before the
anchor 20 a is inserted into the body tissue 14 a. It should be understood that both anchors 18 a and 20 a could be inserted into the body tissue at the same time. Thus, a first pusher member and inserter, corresponding to thepusher member 30 andinserter 28 ofFIG. 2 could be used to move the anchor 18 a along a first insertion path into the body tissue 14 a at the same time that a second inserter and pusher member, corresponding to the inserter andpusher member FIG. 6 , are utilized to move theanchor 20 a into the body tissue 14 a. As this occurs, the rate of insertion of theanchors 18 a and 20 a could be coordinated so that they would be at the same depth in the body tissue 14 a at the same time. - As the
anchors 18 a and 20 a are moved together into the body tissue 14 a, thesuture 24 a is pulled into the body tissue 14 a by both of the anchors. This results in thesuture 24 a being tensioned between the two anchors as both of the anchors move relative to the body tissue 14 a. Since bothanchors 18 a and 20 a are being moved at the same time relative to the body tissue 14 a, there will be relative movement between thesuture 24 a and both of the anchors to obtain the required length of suture in theconnector portion connector portions suture 24 a is accommodated by the fact that the suture can move in thepassages passages anchor 20 a. - If desired, both anchors could be left in the body tissue 14 a with their longitudinal central axes coincident with the longitudinal central axes of their paths of insertion. Thus, the anchor 18 a could be left in the body tissue 14 a with its
central axis 260 a coincident with thecentral axis 350 of the insertion path of the anchor 18 a. Similarly, theanchor 20 a could be left in the body tissue 14 a with itscentral axis 320 a coincident with thecentral axis 354 of the insertion path of theanchor 20 a into the body tissue 14 a. If it is desired to leave the anchors in the body tissue 14 a with theircentral axes central axes surface 310 ofFIG. 4 and thesurface 324 ofFIG. 7 on the pusher members could be omitted. - Since the
central axes anchors 18 a and 20 a into the body tissue 14 a extend transverse to each other, theanchors 18 a and 20 a move toward each other as they move along their insertion paths. Thus, as the anchor 18 a is moved along the longitudinalcentral axis 350 of its insertion path into the body tissue 14 a, the anchor 18 a moves toward theaxis 354 of the insertion path for theanchor 20 a. Similarly, as theanchor 20 a moves along thecentral axis 354 of its insertion path, theanchor 20 a moves toward the insertion path for the anchor 18 a. By moving theanchors 18 a and 20 a toward each other along their insertion paths, thesuture 24 a grips thebody tissues 12 a and 14 a with a clinching action. This clinching action firmly presses thebody tissue 12 a against the body tissue 14 a. If theanchors 18 a and 20 a are toggled or pivoted to the orientation indicated in solid lines for the anchor 18 a and dashed lines for theanchor 20 a inFIG. 11 , the clinching action of thesuture 24 a against thebody tissues 12 a and 14 a is increased. This clinching action tends to maximize the tension forces which can be transmitted through thesuture 24 a without pulling theanchors 18 a and 20 a out of the body tissue 14 a. - The
anchors 18 a and 20 a are supported in thecancellous bone 280 a in a spaced apart relationship with the hard outer layer 278 a of the bone 14 a. Thus, the tension forces transmitted through thesuture 24 a are transmitted from theanchors 18 a and 20 a to thecancellous bone 280 a. - In the embodiment of the invention illustrated in
FIG. 8 , thesuture 24 a extends through both thebody tissue 12 a and the body tissue 14 a. Tension in thesuture 24 a presses thebody tissue 12 a against the body tissue 14 a. However, thesuture 24 a could extend across thebody tissue 12 a and theanchors 18 a and 20 a moved into the body tissue 14 a without passing through the body tissue. If this was done, thesuture 24 a would extend into the body tissue 14 a at locations offset from opposite edges of thebody tissue 12 a. Alternatively, thebody tissue 12 a could be spaced from the body tissue 14 a and an extension could extend from the continuous loop formed by thesuture 24 a to thebody tissue 12 a. - It is contemplated that it may be desired to increase the tension in the
suture 24 a after theanchors 18 a and 20 a have been positioned relative to thebody tissues 12 a and 14 a. This may be done by contracting thesuture 24 a under the influence of heat. If thesuture 24 a is to be heated, it may be desired to position a protective member between the suture and thetissue 12 a. The protective member may have any desired construction, including any of the constructions disclosed in U.S. Pat. No. 4,823,794. - In the embodiment of the invention illustrated in
FIG. 11 , aforce application assembly 60 is effective to apply tension force to thesuture 24 and to determine when a predetermined tension force is present in thesuture 24. In the embodiment of the invention illustrated inFIG. 12 , a tension measuring device 106 is associated with theinserter 38 b andpushrod 40 b for asuture anchor 20 b. Thesuture anchor 20 b is connected with a second suture anchor (not shown) corresponding to the suture anchor 18 a inFIG. 11 , by asuture 24 b. Thesuture 24 b is formed as a continuous closed loop which extends between thesuture anchor 20 b and another suture anchor, corresponding to the suture anchor 18 a ofFIG. 11 . - The suture anchor corresponding to the suture anchor 18 a of
FIG. 11 is moved into thebody tissue 14 b, to a position corresponding to the position illustrated in solid lines inFIG. 11 . Thesuture anchor 20 b is then moved through thebody tissue 12 b and into thebody tissue 14 b with aninserter 38 b andpusher member 40 b (FIG. 12 ). Thesuture anchor 20 b is moved through the hardouter layer 278 b of the bone forming thebody tissue 14 b into the relatively softcancellous bone 280 b. Theanchor 20 b is then pivoted or toggled to a position corresponding to the position illustrated in dashed lines inFIG. 11 for thesuture anchor 20 a. - As the
anchor 20 b is moved into thebody tissue 14 b, tension in theconnector portions 48 b and 90 b of thesuture 24 b is measured by the force measuring device 106. When a predetermined tension is present in theconnector portion 48 b and 90 b of thesuture 24 b, the output from the force measuring device 106 causes the pushermember drive assembly 114 to interrupt movement of the pusher member into thebody tissue 14 b. When this occurs, a longitudinalcentral axis 320 b of theanchor 20 b is coincident with a longitudinalcentral axis 354 b of the path along which theanchor 20 b is moved into thebody tissues connector portions 48 b and 90 b of thesuture 24 b extend through theslot 316 b in theinserter 38 b. - In the illustrated embodiment of the invention, the
force transmitting member 100 of thetension measuring device 96 is disposed in theslot 316 b in the side wall of thetubular inserter 38 b. Theconnector portions 48 b and 90 b of thesuture 24 b extend across theend portion 102 of theforce transmitting member 100. Although theforce transmitting member 100 has been illustrated inFIG. 12 as being disposed in theslot 316 b, it is contemplated that theforce transmitting member 100 could be disposed outside of the slot adjacent to an outer side surface of theinserter 38 b. - As the pusher
member drive assembly 114 is operated to move thepusher member 40 b axially relative to thestationary inserter 38 b, theanchor 20 b is moved from the position illustrated inFIG. 12 into thebody tissue 14 b. As thesuture anchor 20 b moves into thebody tissue 14 b, thesuture 24 b is pulled into the body tissue along with the suture anchor. As this occurs, a tension force is established in theconnector portions 48 b and 90 b of thesuture 24 b. - The tension force in the
connector portions 48 b and 90 b of thesuture 24 b results in the application of a downward (as viewed inFIG. 12 ) force against theend portion 102 of theforce transmitting member 100 by theconnector portions 48 b and 90 b of thesuture 24 b. This force is transmitted through theforce transmitting member 100 to the force measuring device 112. The force measuring device 112 includes a piezoelectric cell. When the force measuring device 112 detects that a predetermined tension force is present in theconnector portions 48 b and 90 b of thesuture 24 b, an output signal from the force measuring device is transmitted to a control apparatus, that is, a microprocessor, which interrupts operation of thepusher drive assembly 114. - At the time when operation of the
pusher drive assembly 114 is interrupted, the tension force in theconnector portions 48 b and 90 b of thesuture 24 b have initiated toggling or pivoting movement of thesuture anchor 20 b in thecancellous bone 280 b. This toggling or pivotal action moves the central axis of theanchor 20 b from an orientation in which it is aligned with thecentral axis 354 b of the path along which thesuture anchor 20 b is moved into thebody tissue 14 b to an orientation in which thecentral axis 320 b of thesuture anchor 20 b extends transverse to thecentral axis 354 b of the path along which the suture anchor moves into thebody tissue 14 b. When the operation of thepusher drive assembly 114 is interrupted, theanchor 20 b will have pivoted to a position corresponding to the position illustrated in dashed lines inFIG. 11 for theanchor 20 a. - Although it is believed that it will be preferred to utilize a tension measuring device, corresponding to the
tension measuring device 96, which is connected with theinserter 38 b, it is contemplated that the tension measuring device could be separate from theinserter 38 b. For example, thetension measuring device 96 could engage theconnector portions 48 b and 90 b of thesuture 24 b at a location which is approximately midway between theanchor 20 b and the another anchor connected with thesuture 24 b and corresponding to the anchor 18 a ofFIG. 11 . If desired, a tension measuring device could be substituted for the force application assembly ofFIG. 10 . - It is contemplated that a protective member, such as a pledget, could be provided between the
suture 24 b and thebody tissue 12 b. The protective member provided between thesuture 24 b and thebody tissue 12 b may be formed of a biodegradable or bioerodible polymer or copolymer if desired. The protective member may have any one of the constructions disclosed in U.S. Pat. No. 4,823,794. - It is contemplated that a robotic apparatus may be utilized to position suture anchors corresponding to the suture anchors 18 and 20 of
FIGS. 1-10 , the suture anchors 18 a and 20 a ofFIG. 11 , and thesuture anchor 20 b ofFIG. 12 relative to body tissue. The inserters 28 (FIGS. 2-4 ), 38 (FIGS. 6 and 7 ), and 38 b (FIG. 12 ) along with the pusher members 30 (FIGS. 2-4 ), 40 (FIGS. 6 and 7 ), and 40 b (FIG. 12 ) are connected with articulate arms of the robotic apparatus. Devices for effecting relative movement between the inserter members and the pusher members, similar to the pushermember drive assembly 114 andinserter drive assembly 110 ofFIG. 12 , are connected with the articulate arms of the robotic apparatus. - Operation of the pusher
member drive assembly 114 and theinserter drive assembly 110 is controlled by one or more computers in the robotic apparatus. Thetension measuring device 96 is also be associated with an articulate arm of the robotic apparatus. Thetension measuring device 96 is mounted on the articulate arm of the robotic apparatus in association with a slot, corresponding to theslot 316 b ofFIG. 12 , in theinserter 38 b. Alternatively, thetension measuring device 96 could be mounted on the articulate arm of the robotic apparatus in a spaced apart relationship with the inserter. - It is contemplated that the robotic apparatus will be utilized to position anchors, corresponding to the
anchors FIGS. 1-10 , theanchors 18 a and 20 a ofFIG. 11 , and the anchor 18 b ofFIG. 12 relative to body tissue at many different locations in a patient's body. The body tissue may be hard body tissue, soft body tissue, or a combination of hard and soft body tissue. If desired, a drill or similar tool could be associated with an articulate arm of the robotic apparatus to assist in the formation of an opening in the body tissue. The drill would form an opening extending through the hardouter layer 278 b into thecancellous bone 280 b. The opening formed by the drill could have a cross sectional area which is smaller than the cross sectional area of theanchor 20 b. - The robotic apparatus may have any one of many different constructions. It is contemplated that the robotic apparatus may have a construction similar to the construction illustrated in U.S. Pat. Nos. 6,063,095 and 6,102,850. The disclosures in the aforementioned U.S. Pat. Nos. 6,063,095 and 6,102,850 are hereby incorporated herein in their entirety by this reference thereto.
- In the embodiments of the invention illustrated in
FIGS. 1-12 , the suture anchors 18, 20, 18 a, 20 a, and 20 b are either positioned manually relative to body tissue or positioned relative to the body tissue by a robotic apparatus. Aguide assembly 120 which may be utilized with either the manual or robotic insertion of anchors into body tissue is illustrated inFIG. 13 . Theguide assembly 120 is utilized to be certain that the insertion paths along which the anchors are moved into the body tissue have a desired angular orientation relative to each other and to the body tissue. - The
guide assembly 120 includes the cylindrical guides 126 and 128 which are supported in a preselected angular relationship relative to each other by thebase 124. Theguide 128 may be moved toward and away from theguide 126, in the manner indicated by thearrow 136 inFIG. 13 , to vary the spacing between the guides. - In the embodiment of the invention illustrated in
FIG. 13 , theguides inserters FIGS. 2-8 . Thus, theguide 126 is provided with aslot 292 c through which a portion of thesuture 24 c extends away from theanchor 18 c. Similarly, theguide 128 is provided with aslot 316 c through which a portion of thesuture 24 c extends away from theanchor 20 c. - The
pusher member 132 has the same cylindrical construction as thepusher member 30 ofFIGS. 2-4 . However, thepusher member 132 is provided withindicia 360 which cooperates with theguide 126 to indicate the depth to which theanchor 18 c has moved intocancellous bone 280 c. Thus, as the pusher member is moved downward and toward the right (as viewed inFIG. 13 ), theindicia 360 moves to a location adjacent to acircular end surface 364 on theguide 126. - When the
pusher member 132 has moved into thebody tissue 14 c to a desired depth, a predetermined mark on theindicia 360 will have moved into alignment with theend surface 364 on theguide 126. This enables a surgeon to visually determine the depth to which theanchor 18 c has moved into the body tissue. Once theanchor 18 c has moved into the desired depth in the body tissue, movement of thepusher member 132 relative to theguide 126 is interrupted. Theanchor 18 c is then pivoted under the influence of tension in thesuture 24 c. During this pivotal movement of theanchor 18 c, thepusher member 132 may be moved further into thebody tissue 14 c through a relatively short predetermined distance to promote the pivoting or toggling action of the anchor. - The
pusher member 132 may be utilized to move theanchor 20 c into thebody tissue 14 c. If this is done, the depth to which theanchor 20 c is moved into thebody tissue 14 c will be clearly indicated by movement of theindicia 360 on thepusher member 132 relative to acircular end surface 368 on theguide 128. - It is contemplated that a pair of pusher members, having the same construction as the
pusher member 132, could be provided to move theanchors guides anchors body tissue 14 c. - When a robotic apparatus is utilized to move the
anchors body tissue 14 c, articulate arms of the robotic apparatus could be provided with fiber optic systems. These fiber optic systems would view the pusher members and endsurfaces 364 and 366 on theguides indicia 360 is in a desired position relative to the guides. Alternatively, the articulated arms of the robotic apparatus could be provided with drives, for examples, screw and nut drives, which would indicate the extent of operation of the drives and thereby the extent of movement of the pusher members, corresponding to thepusher member 132, relative to theguides anchors body tissue 14 c. - In the embodiment of the invention illustrated in
FIG. 13 , theguides inserters FIGS. 2-8 . However, it is contemplated that the guides could be constructed so as to receive inserters corresponding to theinserters - When the
guide assembly 120 is utilized in association with a robotic apparatus, it is contemplated that theguide 126, which is fixedly connected with thebase 124 of theguide assembly 120, could be connected with one articulate arm of the robotic apparatus. This would result in thebase 124 of the guide assembly being positioned relative to thebody tissue guide 126. The position of theretainer 140 along thebase 124 would be adjusted to position theguide 128 in a desired relationship with theguide 126. It is contemplated that theretainer 140 will be held against movement relative to the base by a suitable set screw which extends through a portion of the retainer into engagement with the base. When the set screw is loosened, theretainer 140 and guide 128 may be moved along thebase 124, in the manner indicated schematically by thearrow 136 inFIG. 13 . When the set screw is tightened, theretainer 140 and guide 128 are held against movement relative to thebase 124. - When the
guide 126 andbase 124 are connected with one articulate arm of a robotic apparatus, one or more pusher members, corresponding to thepusher member 132, can be moved relative to theguides anchors body tissue 14 c, a single robotic arm could be provided to move thepusher member 132 relative to theguide 126 to move theanchor 18 c into the body tissue. The same articulate arm could be utilized to move thesame pusher member 132 relative to theguide 128 to move theanchor 20 c into thebody tissue 14 c. Alternatively, a pair of pusher members, both of which have the construction of thepusher member 132, could be utilized to simultaneously move both of theanchors body tissue 14 c. If this is done, one of the pusher members could be associated with one articulate arm of the robotic apparatus and the second pusher member could be associated with another articulate arm of the robotic apparatus. - In the embodiment of the invention illustrated in
FIG. 13 , thesuture 24 c forms a continuous loop which extends between theanchors FIG. 11 . If theanchor 18 c is moved into thebody tissue 14 c before theanchor 20 c is moved into the body tissue, thesuture 24 c would be tensioned between the twoanchors anchor 20 c moves into the body tissue. As thesuture 24 c is tightened, it applies force against thebody tissue 12 c to firmly press thebody tissue 12 c against thebody tissue 14 c. If both of theanchors body tissue 14 c, movement of both anchors relative to thebody tissue 14 c will be effective to tension the suture. - The
tension measuring device 96 ofFIG. 12 may be associated with either theguide 126 or theguide 128. If desired, onetension measuring device 96 could be associated with theguide 126 and a second tension measuring device could be associated with theguide 128. Alternatively, atension measuring device 96 could be mounted on the base 124 in a spaced apart relationship with theguides - It is contemplated that, rather than being a continuous loop, the
suture 24 c could have the same construction as thesuture 24 ofFIGS. 1-10 . If this was done, a connector portion of the suture would extend between the twoanchors retainer 54 ofFIGS. 9 and 10 . - Of course, if the
suture 24 c has the same construction as thesuture 24 ofFIGS. 1-10 , only the connector portion of the suture extending between the twoanchors body tissue 14 c. The two leg portions of the suture would be tensioned after theanchors body tissue 14 c. This could be accomplished manually or by the use of a force application assembly, corresponding to theforce application assembly 60 ofFIG. 10 . In this situation, a force application member, corresponding to theforce application member 66 ofFIG. 10 may be utilized to press the retainer against the body tissue. While thesuture 24 c is being tensioned with a predetermined force and while the retainer is being pressed against the body tissue with a predetermined force, force application members, corresponding to forceapplication members FIG. 10 , would be utilized to effect deformation of the retainer. - In the embodiments of the invention illustrated in
FIGS. 1-13 , leading end portions of the anchors have been utilized to initiate the formation of openings in the soft body tissue and the hard body tissue. It is contemplated that it may be desired to initiate the formation of openings in either the soft body tissue or the hard body tissue or both with a tool other than the anchors. In the embodiment of the invention illustrated inFIGS. 14 and 15 , thinelongated members soft body tissue 12 d andhard body tissue 14 d. - In addition to initiating formation of openings in the
soft body tissue 12 d andhard body tissue 14 d, the thinelongated members anchors body tissues elongated members body tissues elongated members soft body tissue 12 d into thehard body tissue 14 d. - Movement of the thin
elongated members hard body tissue 14 d is interrupted after the thin elongated members have moved to a depth which is greater than the depth to which it is intended to subsequently move theanchors hard body tissue 14 d. The thinelongated members hard body tissue 14 d than the intended depth of theanchors hard body tissue 14 d to enable the thin elongated members to guide movement of the anchors to their intended depth in the hard body tissue. The thinelongated members body tissue 12 d into thebody tissue 14 d. -
Anchors elongated members 146 and 160 (FIG. 15 ) into thebody tissue anchors anchors FIGS. 1-10 . However, theanchors cylindrical passages elongated members anchors FIGS. 1-10 , theanchors FIGS. 14 and 15 ) are formed of bone. However, theanchors anchors FIGS. 1-10 . - When the
anchor 18 d (FIG. 14 ) is to be moved along the thinelongated member 146, theanchor 18 d is telescopically positioned on the stationary thinelongated member 146. Theanchor 18 d is moved along the thinelongated member 146 until theleading end portion 34 d of theanchor 18 d engages thesoft body tissue 12 d. At this time, the cylindrical thinelongated member 146 extends through thecylindrical passage 152 in theanchor 18 d and positions theanchor 18 d relative to thebody tissues - The
cylindrical pusher member 30 d is then telescopically positioned on the stationary thin elongated member 146 (FIG. 14 ). Thepusher member 30 d is moved along the thinelongated member 146 until a circularleading end surface 370 on thepusher member 30 d engages a trailing end of theanchor 18 d. At this time the cylindrical thinelongated member 146 extends through both thecylindrical passage 152 in theanchor 18 d and thecylindrical passage 156 in thepusher member 30 d. This enables the stationary thinelongated member 146 to position both theanchor 18 d andpusher member 30 d relative to thebody tissues - After the
pusher member 30 d andanchor 18 d have been positioned on the thinelongated member 146, thecylindrical inserter 28 d is positioned in a telescopic relationship with theanchor 18 d andpusher member 30 d. An axial force is applied to theinserter 28 d to slide the inserter along thestationary pusher member 30 d andanchor 18 d through thebody tissue 12 d into engagement with thebody tissue 14 d, as shown inFIG. 14 . At this time, the leading end portion of thepusher member 30 d andanchor 18 d are fully enclosed by theinserter 28 d. Theleading end portion 34 d of theanchor 18 d is disposed in engagement with thesurface 300 d on thebody tissue 12 d. - Movement of the
inserter 28 d through thebody tissue 12 d into engagement with thebody tissue 14 d is guided by thestationary pusher member 30 d andstationary anchor 18 d. Thepusher member 30 d andanchor 18 d are held in the desired orientation relative to the body tissue by the thinelongated member 146. When theinserter 28 d is moved to the position shown inFIG. 14 in engagement with thebody tissue 14 d, theleading end portion 34 d of theanchor 18 d is in engagement with thesurface 300 d of thebody tissue 12 d and is fully enclosed by theinserter 28 d. - An axial force is then applied to the
pusher member 30 d to move theanchor 18 d through thebody tissue 12 d into thebody tissue 14 d. During this movement of thepusher member 30 d andanchor 18 d, both theinserter 28 d and thinelongated member 146 are stationary relative to thebody tissues anchor 18 d has moved to the desired depth in thebody tissue 14 d, movement of thepusher member 30 d and anchor along the thinelongated member 146 is interrupted. - When the
anchor 18 d has been moved to the desired depth in thebody tissue 14 d, the anchor is in the position illustrated inFIG. 14 relative to the thinelongated member 146 and theinserter 28 d. Indicia corresponding to the indicia 360 (FIG. 13 ) is provided on thepusher member 30 d (FIG. 14 ) to indicate when theanchor 18 d has moved to the desired position relative to thebody tissues - The
anchor 20 d (FIG. 15 ) is positioned relative to thebody tissues anchor 18 d. The thinelongated member 160 is utilized to guide movement of theanchor 20 d and pusher member relative to thebody tissue 12 d in the same manner as previously explained in conjunction with theanchor 18 d. The thinelongated member 160 may be positioned relative to thebody tissue FIG. 15 ) simultaneously with the thinelongated member 146 or after the thinelongated member 146 has been positioned relative to thebody tissue - The
anchor 20 d andpusher member 40 d are positioned in a telescopic relationship with the thinelongated member 160. Theanchor 20 d is moved along the stationary thinelongated member 160 into engagement with thesurface 300 d on thebody tissue 12 d. Thepusher member 40 d is moved along the stationary thinelongated member 160 to a position in which a circularleading end surface 374 on thepusher member 40 d engages the trailing end of theanchor 20 d. - The
inserter 38 d is then positioned in a telescopic relationship with thestationary pusher member 40 d,anchor 20 d, andelongated member 160. Thecylindrical inserter 38 d is moved through thebody tissue 12 d into engagement with thesurface 304 d of thebody tissue 14 d. This movement of theinserter 38 d is guided by thestationary pusher member 40 d andanchor 20 d. - Once the
inserter 38 d has been moved to the position illustrated inFIG. 15 relative to thebody tissue pusher member 40 d is moved axially along the stationary thinelongated member 160. Force transmitted from thepusher member 38 d to theanchor 20 d moves the anchor through thebody tissue 12 d. Further movement of thepusher member 40 d along the stationary thinelongated member 160 moves theanchor 20 d to the position illustrated inFIG. 15 . Indicia on thepusher member 40 d cooperates with theinserter 38 d to indicate when theanchor 20 d has moved to a desired depth in thebody tissue 14 d. - The foregoing description has related to a process in which the thin
elongated members body tissue 14 d prior to movement of theanchors body tissue anchors body tissue 14 d involves movement of the thinelongated members body tissues - When the
anchor 18 d is to be moved through thebody tissue 12 d into thebody tissue 14 d in accordance with the aforementioned alternative method, the thinelongated member 146 is inserted through thepassage 156 in thepusher member 30 d (FIG. 14 ). The thinelongated member 146 is moved to a position in which thepointed end portion 148 of the thin elongated member extends past acircular end surface 370 on thepusher member 30 d. The portion of the thinelongated member 146 extending past theend surface 370 on thepusher member 30 d is then telescopically inserted through thepassage 152 in theanchor 18 d. - At this time during the alternative method, the
pointed end portion 148 on the thinelongated member 146 extends a short distance past a conicalleading end portion 34 d of theanchor 18 d. This results in thepointed end portion 148 on the thin elongated member forming a point for theleading end portion 34 d of theanchor 18 d at the location where thepassage 152 ends at theleading end portion 34 d of theanchor 18 d. - The
pusher member 30 d, thinelongated member 146, andanchor 18 d are then telescopically inserted into theinserter 28 d. Theanchor 18 d andpusher member 30 d are then moved to a position in which the anchor extends from theinserter 28 d. Thus, the anchor is moved to a position corresponding to the position of theanchor 18 inFIG. 2 . The portion of thesuture 24 d adjacent to theanchor 18 d is tensioned to press a trailing end portion 32 d of the anchor firmly against theend surface 370 on thepusher member 30 d. - At this time during the alternative method, the
pointed end portion 148 of the thinelongated member 146 extends from theleading end portion 34 d of theanchor 18 d. Therefore, thepointed end portion 148 of the thinelongated member 146 forms a point at a location where thepassage 152 intersects theend portion 34 d of theanchor 18 d. While thepusher member 30 d and thinelongated member 146 are held against movement relative to theinserter 28 d, the inserter, pusher member, thin elongated member, and anchor are moved as a unit relative to thebody tissue 12 d. As this occurs, thepointed end portion 148 of the thinelongated member 146 initiates the formation of an opening at an imperforate area on asurface 300 d of thebody tissue 12 d. - As the thin
elongated member 146,pusher member 30 d,anchor 18 d andinserter 28 d are moved together relative to thebody tissue 12 d, theleading end portion 34 d of theanchor 18 d moves into the opening in thebody tissue 12 d which was initiated by thepointed end portion 148 of the thin elongated member. Theanchor 18 d is pressed into thebody tissue 12 d under the influence of force applied against the trailing end portion 32 d of the anchor by theend surface 370 on thepusher member 30 d. At this time, there is no relative movement between the thinelongated member 146,pusher member 30 d,anchor 18 d, andinserter 28 d. During movement of theanchor 18 d into thebody tissue 12 d, theanchor 18 d remains in a position relative to theinserter 28 d corresponding to the position of theanchor 18 to theinserter 28 inFIGS. 2 and 3 . - As the thin elongated member,
pusher member 30 d,anchor 18 d, andinserter 28 d are moved together into thebody tissue 12 d during the alternative method, thepointed end portion 148 on the thin elongated member engages an imperforate area on anouter surface 304 d of thebone 14 d. Continued movement of the thinelongated member 146,pusher member 30 d,anchor 18 d andinserter 28 d together in a direction toward thebone 14 d results in initiation of the formation of an opening in theouter surface 304 d of the hardouter layer 278 d of thebone 14 d by the pointed end portion of the thinelongated member 146. Continued axial movement of the thinelongated member 146,pusher member 30 d,anchor 18 d andinserter 28 d together relative to thebone 14 d moves theleading end portion 34 d of theanchor 18 d into the hardouter layer 278 d in the same manner as is illustrated inFIG. 3 for theanchor 18. - As this occurs, the
inserter 28 d moves into abutting engagement with theouter surface 304 d on the hardouter layer 278 d of thebone 14 d (FIG. 14 ). At this time during the alternative method, theend surface 370 on thepusher member 30 d is disposed within theinserter 28 d. This, thepusher member 30 d andinserter 28 d are in the same relationship as is illustrated inFIG. 3 for thepusher member 30 andinserter 28. At this time, the trailing end portion 32 d of theanchor 18 d is enclosed by theinserter 28 d in the same manner as in which the trailingend portion 32 of theanchor 18 is enclosed by theinserter 28 inFIG. 3 . - The thin
elongated member 146 is then moved through the hardouter layer 278 d of thebone 14 d into thecancellous bone 280 d (FIG. 14 ). As the thinelongated member 146 moves into thecancellous bone 280 d, theinserter 28 d,pusher member 30 d andanchor 18 d remain stationary relative to thebone 14 d. Thus, as the thinelongated member 146 is axially advanced into thecancellous bone 280 d, theinserter 28 d,pusher member 30 d andanchor 18 d remain in the same relationship with thebone 14 d as is illustrated for theinserter 28,pusher member 30 andanchor 18 inFIG. 3 . - When the
pointed end portion 148 of the thinelongated member 146 has moved to a desired depth in thecancellous bone 280 d, thepusher member 30 d is moved axially along the thinelongated member 146. As this occurs, the leading end surface 370 (FIG. 14 ) on thepusher member 30 d applies force against the trailing end portion 32 d of theanchor 18 d. This force causes theanchor 18 d to slide along the thinelongated member 146. As thepusher member 30 d moves theanchor 18 d along the thinelongated member 146, theinserter 28 d and thin elongated member remain stationary in the position illustrated inFIG. 14 relative to the hardouter layer 278 d of bone. - Thus during performance of the alternative method, the
anchor 18 d,inserter 28 d,pusher member 30 d and thinelongated member 146 are all moved together from a position corresponding to a position illustrated inFIG. 2 for theanchor 18 to a position corresponding to the position illustrated inFIG. 3 for theanchor 18. The thinelongated member 146 is then telescopically extended from theanchor 18 d (FIG. 14 ) through the hardouter layer 278 d of bone into thecancellous bone 280 d while theanchor 18 d andpusher member 30 d remain stationary relative to thebone 14 d. - The thin
elongated member 146 is supported by theanchor 18 d andpusher member 30 d during the initial formation of an opening in the hardouter layer 278 d of thebone 14 d. After the thinelongated member 146 has initiated the formation of an opening in the hardouter layer 278 of thebone 14 d, theleading end portion 34 d of theanchor 18 d enlarges the opening. This positions the anchor in the desired orientation relative to the opening initiated by theelongated member 146. - After the thin
elongated member 146 has been moved to the desired depth in thebone 14 d during performance of the alternative method, theanchor 18 d is moved axially along the thinelongated member 146. As theanchor 18 d moves through the hardouter layer 278 d of bone and moves into thecancellous bone 280 d, the thinelongated member 146 cooperates with thepassage 152 in theanchor 18 d to guide movement of the anchor along an insertion path having a longitudinal central axis which is coincident with a longitudinal central axis of the thinelongated member 146. - Movement of the
pusher member 30 d andanchor 18 d along the stationary thin elongated member is interrupted when theanchor 18 d has moved to a desired depth in thecancellous bone 280 d. Indicia, corresponding to theindicia 360 ofFIG. 13 , is provided on thepusher member 30 d. This indicia cooperates with theinserter 28 d to indicate when theanchor 18 d has been moved to a desired position in thecancellous bone 280. If theanchor 18 d is being positioned in thecancellous bone 280 d by a robotic apparatus, in the manner previously discussed, the position of thepusher member 30 d relative to theinserter 28 d may be indicated by the position of a movable element in a drive assembly on an articulate arm of the robotic apparatus. - In the foregoing description of the alternative method, the thin
elongated member 146 and theleading end portion 34 d of theanchor 18 d are moved together through a short distance into the hardouter layer 278 d of bone, that is, to a position corresponding to the position of theanchor 18 inFIG. 3 . The thinelongated member 146 is then moved relative to theanchor 14 d (FIG. 14 ). However, the thinelongated member 156 could be moved through thesoft body tissue 12 d to a desired depth in thebone 14 d before theanchor 18 d is moved into engagement with the soft body tissue. However, if desired, the thinelongated member 146 andanchor 18 d could be moved together through thesoft body tissue 12 d to the desired depth in thebone 14 d without any relative movement between the anchor and thin elongated member. - The
anchor 20 d may be moved through thesoft body tissue 12 d into thehard body tissue 14 d simultaneously with movement of theanchor 18 d through the soft body tissue into the hard body tissue. However, if desired, theanchor 20 d may be moved through thesoft body tissue 12 d and into thehard body tissue 14 d after theanchor 18 d has been moved into the hard body tissue. - When the
anchor 20 d is to be positioned relative to thebody tissue FIG. 15 ) is moved through thepusher member 40 d while thepusher member 40 d,inserter 38 d, andanchor 20 d are spaced from thebody tissue elongated member 160 extending past theend surface 374 on thepusher member 40 d is inserted through thepassage 166 in theanchor 20 d. When this has been done, thepointed end portion 162 of the thinelongated member 160 will extend a short distance past the pointed leading end portion 44 d of theanchor 20 d. This will result in thepointed end portion 162 of the thinelongated member 160 forming a continuation of the pointed leading end portion 44 d of theanchor 20 d. - The portion of the
suture 24 d adjacent to theanchor 20 d is tensioned to press theanchor 20 d against theend surface 374 on thepusher member 40 d. While thepusher member 40 d, thinelongated member 160 andanchor 20 d are held against movement relative to each other, the thin elongated member, pusher member and anchor are telescopically inserted into theinserter 38 d. The thinelongated member 160,pusher member 40 d andanchor 20 d are moved to a position in which theend surface 374 of thepusher member 40 d is enclosed by theinserter 38 d. At this time, theanchor 20 d will be in the same position relative to theinserter 38 d as is theanchor 20 relative to theinserter 38 ofFIG. 6 . However, the thinelongated member 160,pusher member 40 d,inserter 38 d, andanchor 20 d (FIG. 15 ) will all be spaced from thebody tissue - While the thin
elongated member 160,pusher member 40 d andanchor 20 d are held against movement relative to theinserter 38 d and only thepointed end 162 of the thin elongated member extends from the anchor, the inserter is moved to a desired position relative to thebody tissue FIG. 15 , theinserter 28 d is moved to a position offset from the position in which theinserter 28 d andpusher member 30 d have been used to move theanchor 18 d along the thinelongated member 146 into thebone 14. Thus, as viewed inFIG. 15 , the thinelongated member 160,pusher member 40 d,inserter 38 d, andanchor 20 d are offset in a direction which is out of the sheet of drawings on whichFIG. 15 is disposed from the location of theanchor 18 d relative to the sheet of drawings. - While the
anchor 20 d is in the same orientation relative to theinserter 38 d as is theanchor 20 relative to theinserter 38 ofFIG. 6 , thepointed end portion 162 of the thinelongated member 160 is moved into engagement with an imperforate area on theouter surface 300 d of thebody tissue 12 d. At this time, the trailingend portion 42 d of theanchor 20 d is disposed within theinserter 38 d and is engaged by thepusher member 40 d, in the same manner as is illustrated inFIG. 6 for theanchor 20 andpusher member 40. The thin elongated member (FIG. 15 ) extends through thepusher member 40 d and through thepassage 166 in theanchor 20 d. Thepointed end portion 162 of the thin elongated member is disposed adjacent to and forms a continuation of the pointed leading end portion 44 d of theanchor 20 d. - The
pointed end portion 162 of the thinelongated member 160 engages the imperforateouter surface 300 d of thebody tissue 12 d at the location where theanchor 20 d is to be inserted into thebody tissue elongated member 160,pusher member 40 d,inserter 38 d andanchor 20 d are held against movement relative to each other, they are pressed into thebody tissue 12 d. As this occurs, thepointed end portion 162 of the thin elongated member initiates the formation of an opening in thesurface 300 d of thebody tissue 12 d. Continued movement of the thinelongated member 160,inserter 38 d,pusher member 40 d andanchor 20 d together into thebody tissue 12 d results in the opening which was initially formed by thepointed end portion 162 of the thinelongated member 160 being enlarged by the pointed leading end portion 44 d of theanchor 20 d. - As the thin
elongated member 160,pusher member 40 d,inserter 38 d andanchor 20 d continue to be moved together toward thebone 14 d, thepointed end portion 162 of the thinelongated member 160 moves into engagement with an imperforate area on thesurface 304 d of thebone 14 d. At this time, the pointed leading end portion of theanchor 20 d will have moved into thebody tissue 12 d. The right (as viewed inFIG. 15 ) side of theinserter 38 d will have just begun moving into thebody tissue 12 d while the left (as viewed inFIG. 15 ) side of theinserter 38 d will be disposed adjacent to and outside of thebody tissue 12 d. Of course, the position of the left side of theinserter 38 d relative to thebody tissue 12 d will depend upon the thickness of the body tissue. At this time, the trailingend portion 42 d of theanchor 20 d is enclosed by theinserter 38 d. - Continued axial movement of the thin
elongated member 160,pusher member 40,inserter 38 d andanchor 20 d together, that is without relative movement between them, along the insertion path results in thepointed end portion 162 of the thin elongated member initiating the formation of an opening in theouter surface 304 d of thehard layer 278 d of bone. Continued movement of the thinelongated member 160,pusher member 40 d,inserter 38 d, andanchor 20 d along the insertion path results in the opening which was initiated by the pointed leading end portion 162 d of the thinelongated member 160 being expanded by the pointed leading end portion 44 d of theanchor 20 d. - The thin
elongated member 160,pusher member 40 d,inserter 38 d andanchor 20 d are held against movement relative to each other until theinserter 38 d engages theouter surface 304 d on the hardouter layer 278 d of bone. At this time, thepusher member 40 d,inserter 38 d andanchor 20 d will be in the same position relative to each as is illustrated inFIG. 6 for theinserter 38,pusher member 40 andanchor 20. At this time, thepointed end portion 162 of the thinelongated member 160 is disposed adjacent to and forms a continuation of the leading end portion 44 d of theanchor 20 d. - While the
anchor 20 d,inserter 38 d, andpusher member 40 d are stationary relative to the hardouter layer 278 d of thebone 14 d, the thinelongated member 160 is moved along the path of insertion into thebone 14 d. As this occurs, the thinelongated member 160 moves through the hardouter layer 278 d into thecancellous bone 280 d. When the thin elongated member has been moved to a desired depth into the softcancellous bone 280 d, that is, to the position illustrated inFIG. 15 , movement of the thin elongated member into the cancellous bone is interrupted. - The
pusher member 40 d is then moved axially along the thinelongated member 160 to push theanchor 20 d through the hardouter layer 278 d into thecancellous bone 280 d. As this occurs, the thinelongated member 160 andinserter 38 d are stationary relative to the hardouter layer 278 d of thebone 14 d. Thepassage 166 in theanchor 20 d slides along the thinelongated member 160 under the influence of force applied against the trailingend portion 42 d of the anchor by theend surface 374 on thepusher member 40 d. - When the
pusher member 40 d has moved theanchor 20 d to the desired depth into thecancellous bone 280 d, movement of thepusher member 40 d andanchor 20 d along the thin elongated member is interrupted. Thepusher member 40 d may advantageously be provided with indicia, corresponding to theindicia 360 ofFIG. 13 , which cooperates with theinserter 38 d to indicate the position of the pusher member and theanchor 20 d relative to thebody tissue 14 d. It is contemplated that indicia may be provided on the thinelongated members elongated members inserters body tissue 14 d. - In the foregoing description of the alternative method, the thin
elongated member 160 and the leading end portion 44 d of theanchor 20 d are moved together through a short distance into the hardouter layer 278 d of bone, that is, to a position corresponding to the position of theanchor 20 inFIG. 6 . The thinelongated member 160 is then moved relative to theanchor 20 d (FIG. 15 ). However, the thinelongated member 160 could be moved through the soft body tissue to a desired depth in thebone 14 d before theanchor 20 d is moved into engagement with the soft body tissue. However, if desired, the thinelongated member 160 andanchor 20 d could be moved together through thesoft body tissue 12 d to the desired depth into thebone 14 d without any relative movement between the anchor and the thin elongated member. - As the
anchor 20 d is moved into thecancellous bone 280 d with any of the foregoing methods related toFIGS. 14 and 15 , thesuture 24 d is tensioned. In the embodiment of the invention illustrated inFIG. 15 , thesuture 24 d forms a continuous closed loop which extends through theanchors FIG. 11 for thesuture 24 a. Therefore, as theanchor 20 d is moved into thecancellous bone 280 d,connector portions suture 24 d are tensioned between theanchors tension measuring device 96 ofFIG. 12 , may be provided to measure the tension in thesuture 24 d. If a tension measuring device, corresponding to thetension measuring device 96 ofFIG. 12 , is utilized to measure the tension in thesuture 24 d (FIG. 15 ), the movement of theanchor 20 d into thecancellous bone 280 d is interrupted when there is a desired tension in theconnector portions suture 24 d. - It should be understood that the
suture 24 d could have a pair of leg portions, corresponding to theleg portions suture 24 ofFIG. 9 , which are interconnected by a suture retainer or crimp, corresponding to the suture retainer or crimp 54 ofFIG. 9 . If this was done, a force application assembly, corresponding to theforce application assembly 60 ofFIG. 10 , could be utilized to determine when the desired tension force was present in thesuture 24 d (FIG. 15 ). - If the
anchor 18 d is moved into thecancellous bone 280 d prior to movement of theanchor 20 d into the cancellous bone, thesuture 24 d will be tightened with a desired tension force during insertion of theanchor 20 d into thecancellous bone 280 d. However, if both anchors 18 d and 20 d are inserted at the same time into thecancellous bone 280 d, thesuture 24 d will be tightened to the desired tension during movement of both anchors into thecancellous bone 280 d. - If desired, the step of measuring the tension in the
suture 24 d could be omitted. If this was done, theanchors cancellous bone 280 d. By properly sizing the loop formed by thesuture 24 d and selecting the locations of the insertion paths for theanchors suture 24 d when theanchors cancellous bone 280 d. However, it is believed that it may be desired to actually measure the tension in thesuture 24 d to be certain that a desired tension is obtained when theanchors cancellous bone 280 d. - If desired, the
anchors FIG. 15 relative to thecancellous bone 280 d and the hardouter layer 278 d. Alternatively, theanchors cancellous bone 280 d. In either situation, theanchors cancellous bone 280 d in a spaced apart relationship with the hardouter layer 278 d. - When the
anchor 18 d is to be pivoted relative to thecancellous bone 280, the thinelongated member 146 is first completely withdrawn from theanchor 18 d. While thepusher member 30 d is pressed against the trailing end portion of theanchor 18 d, thesuture 24 d is tensioned to cause a pivoting movement of theanchor 18 d relative to thepusher member 30 d in the manner illustrated schematically inFIGS. 4 and 5 of theanchor 18. - Similarly, if the orientation of the
anchor 20 d is to be changed relative to thecancellous bone 280 d, the thinelongated member 160 is completely withdrawn from theanchor 20 d. While thepusher member 40 d is pressed against the trailing end portion of theanchor 20 d, the tension in thesuture 24 d causes the anchor to pivot from the orientation shown inFIG. 7 for theanchor 20 to the orientation shown inFIG. 8 for theanchor 20. - In the embodiment of the invention illustrated in
FIG. 15 , thesuture 24 d extends in a continuous closed loop between the twoanchors suture 24 d is not tensioned until both anchors 18 d and 20 d have been moved into thebody tissue 14 d. Therefore, if the orientation of theanchors FIG. 15 to the orientation illustrated inFIG. 9 of theanchors cancellous bone 280 d. - To effect simultaneous pivotal movement of the
anchors cancellous bone 280 d, the thinelongated member 146 is withdrawn from theanchor 18 d and the thinelongated member 160 is withdrawn from theanchor 20 d while the anchors are disposed in the orientation illustrated inFIG. 15 in thebody tissue 280 d. Bothpusher members anchors suture 24 d causes theanchor 18 d to pivot in a counterclockwise direction about the end portion of thepusher member 30 d. At the same time, the tension in thesuture 24 d causes theanchor 20 d to pivot in a clockwise direction about the end portion of thepusher member 40 d. Of course, theanchors cancellous bone 280 d if desired. - In the specific embodiment of the invention illustrated in
FIGS. 14 and 15 , theanchors body tissues elongated members anchors - When the
anchors elongated members - For example, if the
anchors body tissues elongated members anchors body tissues - It is contemplated that the desired anchor insertion paths into the
body tissues elongated members elongated members - After the arcuate thin
elongated members body tissues anchors anchors passages elongated members pusher members elongated members anchor passages pusher members - If desired, the
pusher members elongated members pusher members elongated members pusher members - It is contemplated that it may be desired to move the
anchors body tissues elongated members elongated members body tissues anchors elongated members pusher members pusher members elongated members - In the embodiment of the invention illustrated in
FIGS. 14 and 15 , the thin elongated members are offset from each other in the direction of the sheet on whichFIG. 15 of the drawings is disposed. However, it is contemplated that the thinelongated members FIG. 14 ) of the thinelongated member 146 and thepointed end portion 162 of the thinelongated member 160 would be disposed in engagement when the thin elongated members have been inserted into thebody tissue 12 d and thebody tissue 14 d. This would facilitate positioning of theanchors FIG. 20 for theanchors - A
guide assembly 120 e for guiding movement of suture anchors into body tissue is illustrated schematically inFIG. 16 . Theguide assembly 120 e has the same general construction and mode of operation as theguide assembly 120 ofFIG. 13 . Theguide assembly 120 e is illustrated inFIG. 16 in association withsoft body tissue soft body tissue 12 e is formed as a relatively thin layer. Thebody tissue 14 e is formed as a relatively thick mass. - The
guide assembly 120 e is utilized to guide movement of suture anchors corresponding to the suture anchors 18 and 20 ofFIG. 1 along insertion paths into thebody tissue 14 d with a suture, corresponding to thesuture 24 ofFIG. 1 extending between the suture anchors. However, theguide assembly 120 e could be used in association with a suture which extends in a continuous loop between a pair of suture anchors. The continuous suture loop would be utilized in the same manner as described in conjunction withFIG. 11 . - The
guide assembly 120 e includes alinear base 124 e which is positioned in abutting engagement with anouter surface 300 e of thelayer 12 e of body tissue. At this time, theguides guide assembly 120 e. The slide blocks are then moved alongslots - The
guide 126 e is then positioned in the opening in theslide block 380. Theguide 126 e is pressed axially into thebody tissue 12 e and thebody tissue 14 e to the position illustrated schematically inFIG. 16 . Theguide 128 e is then pressed axially into thebody tissue 124 e and 114 e to the position illustrated schematically inFIG. 16 . - Once the
guides soft body tissue anchors FIG. 1 , are positioned incylindrical passages guides pusher members FIGS. 2-8 , are then utilized to move theanchors guides layer 124 e of soft body tissue into the mass 14 e of soft body tissue. As this occurs, the suture extending between the anchors moves alongslots suture 24 ofFIG. 1 , the leg portions of the suture are tensioned after the anchors have been moved into the mass 14 e of soft body tissue. However, if the suture has the loop construction illustrated inFIG. 11 , the suture is tensioned as the anchors are moved into thesoft body tissue 14 e. - The slotted guides 126 e and 128 e are positioned with their longitudinal central axes extending transverse to each other. This results in the anchor which is moved along the
guide 126 e, that is the anchor corresponding to theanchor 18 inFIG. 1 , moving toward theguide 128 e as the anchor is moved into the body tissue. Similarly, the anchor which is moved along theguide 128 e, that is, theanchor 20 inFIG. 1 , moves toward theguide 126 e as the anchor is moved into thebody tissue 14 e. The anchors may be left in thebody tissue 14 e with their longitudinal central axes extending parallel to longitudinal central axes of theguides anchors FIG. 10 . - Once the anchors have been positioned in the body tissue with the suture extending between the anchors, the
guides body tissue layer 124 e of body tissue firmly against the relatively large mass 14 e of body tissue. - In the embodiment of
FIG. 17 , theanchors suture 24 f are utilized to pressbone 12 f on one side of afracture 178 against bone 14 f on the other side of the fracture. Theanchors suture 24 f have the same construction as theanchors suture 24 ofFIGS. 1-10 . To secure the body tissue orportion 12 f of thebone 174 to the body tissue or portion 14 f of the bone, the two portions of the bone are firmly pressed together at thefracture 178. - When the
anchor 18 f is to be positioned relative to thebone 174, the anchor is positioned in an inserter, corresponding to theinserter 28 ofFIG. 2 . A pusher member, corresponding to thepusher member 30 ofFIG. 2 , is positioned in the inserter and engages a trailing end portion of theanchor 18 f. Theanchor 24 f is held in the inserter with aleading end portion 34 f (FIG. 17 ) of the anchor extending from the inserter in the same manner as is illustrated inFIG. 2 . At this time, thesuture 18 f extends along a slot in the inserter. Thus, thesuture 24 f extends along a slot corresponding to theslot 292 in theinserter 28 ofFIG. 2 . - The longitudinal central axis of the inserter is then positioned in a desired orientation relative to the
portion 12 f and the portion 14 f of thebone 174. The orientation of the inserter corresponds to the path along which theanchor 18 f is to be moved into and through theportion 12 f of thebone 174 and into and through the portion 14 f of the bone. If theanchor 18 f is to be moved straight downward (as viewed inFIG. 17 ) through theportions 12 f and 14 f of thebone 174, the inserter would be positioned with its longitudinal central axis extending generally perpendicular to theouter surface 300 f of the portion 14 f of thebone 174. However, in the embodiment of the invention illustrated inFIG. 17 it is preferred to move the anchor along a path which is skewed relative to theouter surface 300 f of thebone 174. The inserter may be positioned with its longitudinal axis extending at an angle of between 30° and 90° to theouter surface 300 f of the bone. - With the inserter in the desired orientation relative to the
surface 300 f of thebone 174, the pointed leadingend portion 34 f of theanchor 18 f is pressed against an imperforate area on theouter surface 300 f of thebone 174. The pointedleading end portion 34 f of theanchor 18 f then initiates formation of an opening in theportion 12 f of thebone 174. However, if desired, a drill or similar tool could be utilized to form a passage extending through theportion 12 f and the portion 14 f of the bone at the desired angle relative to thesurface 300 f of the bone. This passage could have a diameter which is either slightly smaller or slightly greater than the outside diameter of theanchor 18 f. If the diameter of the passage which is drilled through thebone 174 is less than the outside diameter of the anchor, the anchor would be effective to expand the passage as the anchor moves into theportion 12 f of the bone. - Assuming that the
anchor 18 f is utilized to form a passage in thebone 174, the pointed leading end portion of the anchor penetrates a hardouter layer 278 f of thebone 174 and moves intocancellous bone 280 f which is enclosed by the hardouter layer 278 f. As this occurs, the pusher member, corresponding to thepusher member 30 is telescopically extended from the inserter, in the manner illustrated schematically inFIG. 4 for thepusher member 30 andinserter 28. This moves theanchor 18 f through theportion 12 f of thebone 174 and through the portion 14 f of the bone. - Immediately after the
anchor 18 f emerges from the lower (as viewed inFIG. 17 ) side of thebone 174, thesuture 24 f is tensioned and the anchor is pivoted or toggled to the position illustrated inFIG. 17 . After theanchor 18 f has been toggled to the position illustrated inFIG. 17 , the pusher member is withdrawn from the bone. - The
anchor 20 f is moved through theportion 12 f of thebone 174 into the portion 14 f of thebone 174, in the manner indicated schematically in solid lines inFIG. 17 . Theanchor 20 f is moved through the portion 14 f of thebone 174 and toggled to the position illustrated in dashed lines inFIG. 17 . - When the
anchor 20 f is to be moved through thebone 174, the anchor is positioned in theinserter 38 f which has the same construction as theinserters FIGS. 2-8 . Thepusher member 40 f is telescopically moved along theinserter 38 f into engagement with the trailing end portion of theanchor 20 f. Thesuture 24 f has the same construction as thesuture 24 ofFIG. 1 . Therefore, aleg portion 52 f and aconnector portion 48 f may be received in a slot in theinserter 38 f in the same manner as previously described in conjunction with the embodiment of the invention illustrated inFIGS. 2-8 . - The
inserter 38 f andpusher member 40 f are positioned in an angular orientation relative to thesurface 300 f of thebone 174 corresponding to the angle of the desired path of insertion of theanchor 20 f into thebody tissue FIG. 17 , the path of insertion of theanchor 20 f into thebone 174 is skewed at an angle of between 55° and 60° relative to the surface 30 f. It is contemplated that the path of insertion of theanchor 20 f into thebone 174 may be located at an angle between 30° and 90° relative to thesurface 300 of thebone 174. As was previously mentioned in conjunction with theanchor 18 f, a passage extending through thebone 174 may be preformed by a drill or other tool. - Assuming that the
anchor 20 f is to be utilized to form its own passage through thebone 174, when a leading end portion 44 f of theanchor 20 f engages an imperforate surface on theouter surface 300 f of theportion 12 f of thebone 174, the leading end portion of the anchor initiates formation of an opening in the outer surface of theportion 12 f of thebone 174. Continued movement of thepusher member 40 f along the path, of insertion of the anchor into thebone 174 results in the anchor moving into the hardouter layer 278 f of the bone. Continued movement of thepusher member 40 f relative to theinserter 38 f results in the anchor moving into thecancellous bone 280 f in theportion 12 f of thebone 174. As thepusher member 40 f continues to move theanchor 20 f into thebone 174, the anchor moves across thefracture 178 in the manner illustrated schematically inFIG. 17 , as theanchor 20 f moves through thecancellous bone 280 f. - The
anchor 20 f then moves through the hardouter layer 278 f of theportion 14 of thebone 174. Once the anchor has moved out of the bone 14 f at the lowest (as viewed inFIG. 17 ) side of the bone, thesuture 24 is tensioned and the anchor is toggled to the position illustrated in dashed lines inFIG. 17 . - Once the
anchor 18 f has been moved to the position illustrated in solid lines inFIG. 17 and theanchor 20 f has been moved to the position illustrated in dashed lines inFIG. 17 , ends ofleg portions suture 24 f are tensioned. As this occurs, thesuture 24 f slides into passages formed in theanchors leg portions suture 24 f are tensioned, theconnector portion 48 f of the suture is tensioned. Any excess material in theconnector portion 48 f of thesuture 24 f is pulled from theconnector portion 48 f into either one or both of theleg portions suture 24 f. A retainer, corresponding to theretainer 54 ofFIG. 9 , may be utilized to interconnect theleg portions suture 24 f. Alternatively, a knot may be utilized to interconnect theleg portions - A force application assembly, corresponding to the
force application assembly 60 ofFIG. 10 may be utilized to apply a predetermined tension force to theleg portions suture 24 f. In addition, a force application member, similar to theforce application member 66 ofFIG. 10 , may be utilized to press a crimp against thebone 174 as thesuture 24 f is tensioned. While the desired tension force is being applied to the suture and while the crimp is being pressed against the bone with the desired force, force application members, corresponding to forceapplication members FIG. 10 , may be utilized to plastically deform the suture retainer. - It is believed that a guide assembly, similar to the
guide assembly 120 ofFIG. 13 , may advantageously be utilized when theanchors guides FIG. 13 , which engage theanchors pusher members FIGS. 1-8 . Alternatively, the guides could be utilized to position inserters, corresponding to theinserters FIGS. 2-8 . - When the
anchors FIG. 17 are being moved into thebone 174, it is believed that the use of thin elongated members, corresponding to the thinelongated members FIG. 15 , may advantageously be utilized to guide movement of theanchors bone 174. One of the thin elongated members would be moved through thebone 174 along an insertion path to be followed by theanchor 18 f. The other thin elongated member would be moved through thebone 174 through an insertion path to be followed by theanchor 20 f. - Small passages may be predrilled in the
bone 174 to receive the thin elongated members. The predrilled holes for the thin elongated members may have a diameter which is slightly less than the diameter of the thin elongated members. Once the thin elongated members have been moved through thebone 174, theanchors bone 174. - The anchors of
FIGS. 1-17 all have the same general construction. However, it is contemplated that the anchors could have a different construction if desired. For example, the anchors could be constructed in the manner generally similar to the construction of theanchor 186 ofFIG. 18 . Theanchor 186 has a plurality of barbs, that isbarbs barbs anchor 186 against movement relative to the body tissue. Of course, the anchor could be provided with barbs or projections having a construction which is different than the construction of the barbs orprojections - The
anchor 186 has a known construction. The construction of theanchor 186 is the same as is disclosed in U.S. Pat. No. 5,725,557. However, it should be understood that theanchor 186 is typical of many different known anchor constructions having projections or barbs which engage either soft or hard body tissue to retain the anchor against movement relative to the body tissue. Any one of these known anchors could be utilized in place of theanchor 186 if desired. Theanchor 204 ofFIG. 19 has a threadedportion 206 which engages body tissue to hold the anchor against movement relative to the body tissue. Although it is believed that the threadedportion 206 may be most effective to hold theanchor 204 against movement relative to bone, the anchor could be utilized in association with soft body tissue if desired. - The
anchor 204 has a known construction. The construction of theanchor 204 is the same as is disclosed in U.S. Pat. No. 5,443,482. However, it should be understood that theanchor 204 could have a different construction if desired. - In the embodiment of the invention illustrated in
FIGS. 20 and 21 , theanchors body tissue 12 g and 14 g along insertion paths which intersect in the body tissue 14 g. InFIG. 20 , the longitudinal central axes of the insertion paths along which theanchors body tissue 12 g and 14 g are disposed in a single flat plane. - The
anchors body tissue 12 g and 14 g intersect. It is believed that movement of theanchors body tissue 12 g and 14 g may be facilitated by the utilization of a guide assembly, corresponding to theguide assembly 120 ofFIG. 13 . In addition, thin elongated members, corresponding to the thinelongated members FIG. 15 , may be utilized to further guide movement of theanchors - Although the
anchors FIG. 20 in association withsoft body tissue 12 g having an arcuateouter surface 300 g and hard body tissue or bone 14 g having an arcuateouter surface 304 g, it is contemplated that theanchors anchors anchors body tissue 12 g ofFIG. 20 , with another piece of soft body tissue, corresponding to the body tissue 14 g ofFIG. 20 . - The
anchors body tissue 12 g and into the body tissue 14 g or may be simultaneously moved through thebody tissue 12 g into the body tissue 14 g. Assuming that theanchors body tissue 12 g and into the body tissue 14 g, theanchor 18 g is first moved through thebody tissue 12 g into the body tissue 14 g. An inserter member and a pusher member, corresponding to theinserter 28 andpusher member 30 ofFIG. 2 , are utilized to move theanchor 18 g into the body tissue 14 g. If a guide assembly, similar to theguide assembly 120 ofFIG. 13 , is utilized to facilitate movement of theanchor 18 g along a desired insertion path, the inserter, corresponding to theinserter 28 ofFIG. 1 , may be omitted and the anchor moved along a guide, corresponding to theguide 126 ofFIG. 13 . - The pusher member which is utilized to move the
anchor 18 g through thebody tissue 12 g and into the body tissue 14 g may advantageously be provided with indicia, corresponding to theindicia 360 on thepusher member 132 ofFIG. 13 . When theindicia 360 on the pusher member indicates that theanchor 18 g has been moved to the desired depth in the body tissue 14 g, movement of the anchor into the body tissue is interrupted. - The
anchor 20 g is then moved through thebody tissue 12 g into the body tissue 14 g. The path of movement of theanchor 20 g through thebody tissue 12 g into the body tissue 14 g intersects the path of movement of theanchor 18 g. It is contemplated that the use of a guide assembly, corresponding to theguide assembly 120 ofFIG. 13 , will facilitate movement of theanchor 20 g along an insertion path which intersects the insertion path of theanchor 18 g. However, if desired, theanchor 20 g could be moved along its insertion path without the benefit of a guide assembly corresponding to theguide assembly 120 ofFIG. 13 . - It is believed that it may be desired to utilize thin elongated members, corresponding to the thin
elongated members FIG. 15 , to position theanchors body tissue 12 g and 14 g. Of course, if this was done, passages, corresponding to thepassages anchors FIG. 15 , would be provided in theanchors - In the embodiment of the invention illustrated in
FIG. 20 , theanchors suture 24 g extending from the anchors. Thus, aleg portion 50 g of suture material is secured to theanchor 18 g and extends from the anchor to theretainer 54 g. Similarly, aleg portion 52 g of the suture material is fixedly connected to theanchor 20 g and extends to theretainer 54 g. In the embodiment of the invention illustrated inFIG. 20 , there is no connector portion, corresponding to theconnector portion 48 ofFIGS. 1 and 9 , of thesuture 24 g extending between the twoanchors leg portions suture 24 g are formed as separate segments. Of course, thesuture 24 g could be provided with a connector portion, corresponding to theconnector portion 48 ofFIGS. 1 and 9 if desired. - The
anchors body tissue 12 g into the body tissue 14 g intersect. The manner in which theanchors FIG. 21 . - The
anchor 18 g has a leading end portion 34 g which engages a leading end portion 44 g of theanchor 20 g. Although the leading end portions 34 g and 44 g of theanchors portions anchors 18 and 20 (FIG. 1 ). It is contemplated that the leading end portions 34 g and 44 g of theanchors anchors - In the illustrated embodiment of the invention, the leading end portion 34 g of the
anchor 18 g is formed with annular projections 212 (FIG. 21 ) which engage annular projections 214 on the leading end portion 44 g of theanchor 20 g. Theannular projections 212 on theanchor 18 g extend around the end portion 34 g of the anchor. Similarly, the annular projections 214 on theanchor 20 g extend around the end portion 44 g of the anchor. - The
projections 212 and 214 on theanchors anchor 20 g moves along its insertion path into engagement with theanchor 18 g. Theprojections 212 and 214 become interconnected in such a manner as to interconnect theanchors projections 212 and 214 become intermeshed to prevent separation of theanchors - It is contemplated that the leading end portions 34 g and 44 g of the
anchors projections 212 and 214. Thus, one of the anchors, for example, theanchor 18 g, could be provided with a plurality of hooks which would engage a plurality of loops on the other anchor, that is, theanchor 20 g. If desired, theanchors anchors anchors anchors anchors anchor 18 g with another portion of a mechanical connection on theanchor 20 g. - If desired, fiberoptics could be positioned along the paths of movement of the
anchors anchor anchors anchors - The embodiment of the invention illustrated in
FIG. 22 is similar to the embodiment of the invention illustrated inFIGS. 20 and 21 . However, in the embodiment of the invention illustrated inFIG. 22 , theanchors - In the embodiment of the invention illustrated in
FIG. 22 , theanchor 18 h is provided with anopening 220 into which theanchor 20 h moves. Theanchor 20 h has a plurality ofretainers 224 which engage the portion of theanchor 18 h forming theopening 220 to interconnect the two anchors. - If desired, the
anchor 18 h could be provided with a flexible mesh, a series of hooks, and/or a series of loops which are engaged by theanchor 20 h to interconnect theanchors retainers 224, could be provided at axially spaced apart locations along the body of theanchor 20 h to engage openings formed by loops or a mesh connected with theanchor 18 h. It should be understood that the openings or mesh provided by theanchor 18 h could be formed by one or more extensions from theanchor 18 h. - It is believed that accurate movement of the
anchors anchor 18 h in the body tissue 14 h and a second articulate arm of the robotic apparatus could be utilized to position theanchor 20 h in the body tissue 14 h. If desired, a guide assembly, corresponding to theguide assembly 120 ofFIG. 13 , could be utilized in association with the robotic arms. If this was done, the guide assembly could be connected with one of the robotic arms for movement therewith relative to the other robotic arm. Accurate placement of theanchors - In the embodiments of the invention illustrated in
FIGS. 1-22 , anchors have been completely enclosed by the body tissue into which they are inserted. Thus, theanchors FIG. 9 ) into which the anchors are inserted. In the embodiment of the invention illustrated inFIG. 23 , anchors 18 j and 20 j are only partially enclosed by the body tissue into which they are inserted. Portions of theanchors - In the embodiment of the invention illustrated in
FIG. 23 , a portion of theanchor 18 j is inserted through thebody tissue 12 j into the body tissue 14 j. Thus, theshank portion 230 of theanchor 18 j is inserted through thebody tissue 12 j into the body tissue 14 j. Similarly, theanchor 20 j is provided with a shank portion which is inserted through thebody tissue 12 j into the body tissue 14 j. - In the embodiment of the invention illustrated in
FIG. 23 , thesuture 24 j is connected with theshank portions anchors head end portions suture 24 j could be connected with theshank portions anchors head end portions - For example, the
shank portion 230 of theanchor 18 j could be provided by an opening which is engaged by thesuture 24 j and which moves into the body tissue 14 j when theanchor 18 j moves into the body tissue. This opening could be formed as a recess which functions as a hook to engage a bend in thesuture 24 j. The hook in theshank portion 230 of theanchor 18 j could be formed adjacent to a pointed leading end portion 34 j of theshank portion 230. Alternatively, a hole could extend diametrically through theshank portion 230 of theanchor 18 j. The opening through which thesuture 24 j extends could be formed adjacent to the leading end portion 34 j of theanchor 18 j or at any desired location along theshank portion 230 of theanchor 18 j. - The
anchor 20 j may be provided with a series of generally hook-shaped recesses in the shank portion 238 j of the anchor. These recesses may be provided at axially spaced apart locations along theshank portion 238 of theanchor 20 j. The suture 234 j may be formed as a loop, in the manner indicated schematically inFIG. 11 for thesuture 20 a. If this is done, the suture loop could be moved into engagement with a recess in theshank portion 238 of theanchor 20 j which would result in a desired amount of tension being removed from thesuture 24 j as theshank portion 238 of theanchor 20 j moves through thebody tissue 12 j into the body tissue 14 j. - For example, if there is a relatively large amount of slack in the
suture 24 j, the suture would engage a recess adjacent to a pointed leading end portion 44 j of theanchor 20 j. However, if there was relatively little slack in thesuture 24 j, the suture would be disposed in engagement with a recess spaced along theshank portion 238 at a distance from the pointed leading end portion 44 j of theanchor 20 j. It is contemplated that a series of recesses could be provided along theshank portion 238 of theanchor 20 j to engage thesuture 24 j even if the suture is positioned beneath thehead end portion 234 of theanchor 18 j, in the manner illustrated inFIG. 23 , rather than being disposed in engagement with a recess or opening in theshank portion 230 of theanchor 18 j. - The
head end portions anchors body tissue 12 j to limit the extent of movement of the anchors into the body tissue 14 j. In addition, thehead end portions anchors suture 24 j against thebody tissue 12 j to facilitate locating thesuture 24 j in a desired orientation relative to the body tissue. If thesuture 24 j engages a hole or a recess in ashank portion anchor head end portions head end portions anchors head end portion 234 of theanchor 18 j would be provided on a side of theanchor 18 j opposite from theanchor 20 j. Thesuture 24 j would extend from an opening or recess in theshank portion 230 of theanchor 18 j into the slot. Thesuture 24 j would then extend across thehead end portion 234 of theanchor 18 j to theanchor 20 j. By having thesuture 24 j extend across thehead end portion 234 of theanchor 18 j, any tendency for the suture to cut thesoft body tissue 12 j would be minimized. - The loop forming the
suture 24 j would then be moved across thehead end portion 242 of theanchor 20 j into a notch or slot inside of thehead end portion 242 of theanchor 20 j opposite from theanchor 18 j. Thesuture 24 j would then be pulled downward (as viewed inFIG. 23 ) along theshank portion 238 of theanchor 20 j and engaged with a selected recess of a series of recesses in theshank portion 238 of theanchor 20 j. Once this has been done, theanchor 20 j would be moved through thebody tissue 12 j into the body tissue 14 j. Since the path of movement of theanchor 20 j through thebody tissue 12 j into the body tissue 14 j extends transverse to the path of movement of theanchor 18 j through thebody tissue 12 j and into the body tissue 14 j, the tension in thesuture 24 j would be increased as theanchor 20 j moves into the body tissue 14 j. - The present invention relates to a new and improved method of securing a
first body tissue 12 with asecond body tissue 14. Thefirst body tissue 12 may be a soft body tissue and thesecond body tissue 14 may be a hard body tissue. Alternatively, the first andsecond body tissues second body tissues - When the first and second body tissues are to be interconnected, a
first anchor 18 is moved into thesecond body tissue 14. If desired, thefirst anchor 18 could be moved into and through thesecond body tissue 14. Asecond anchor 20 is also moved into thesecond body tissue 14. If desired, thesecond anchor 20 could be moved into and through thesecond body tissue 14. Thefirst body tissue 12 may be pressed against or otherwise secured with thesecond body tissue 14 under the influence of force transmitted from thesuture 24 to thefirst body tissue 12. - The
suture 24 which extends between theanchors anchors anchors body tissue 14 may extend toward each other. The transverse paths of movement of theanchors body tissue 14 promote gripping of body tissue with the anchors andsuture 24 and promotes tensioning of the suture as the anchors move into the body tissue. Although it is believed that it may be desired to move theanchors - A desired tension may be established in the
suture 24 by moving theanchors FIGS. 11 , 13-15, and 23). Alternatively, a desired tension may be established in thesuture 24 by applying force to portions of the suture and then interconnecting the portions of the suture (FIGS. 1-10 , 12, 17, and 20-22). Aretainer 54 or a knot may be utilized to interconnect portions of thesuture 24. - Regardless of how the tension is established in the
suture 24, it may be desired to establish a predetermined tension in the suture. This may be done by determining the tension in thesuture 24 as the anchors are moved into the body tissue (FIG. 12 ). Alternatively, the tension in thesuture 24 may be determined during movement of a retainer relative to portions of the suture prior to gripping of the suture with the retainer (FIG. 10 ). - The
suture 24 may be a continuous loop (FIGS. 11 , 13-15, and 23) which extends between the twoanchors anchors body tissue 14. Alternatively, thesuture 24 may be formed by a pair of separate portions (FIGS. 1-10 , 12, 17 and 20-22) which are tensioned after theanchors - One or
more guides guides - Leading
end portions anchors second body tissue anchors anchors outer layer 278 of bone bycancellous bone 280 which is enclosed by the hard outer layer of bone. If desired, passages for the anchors may be formed with a drill or similar tool. - The
anchors FIGS. 20-22 ). When this is done, theanchors anchors - There are a plurality of embodiments of the invention. Each embodiment of the invention has one or more features which may be advantageously utilized with one or more of the other embodiments of the invention. It is contemplated that the various features of the embodiments of the invention may be utilized separately or combined in any one of many different combinations.
Claims (18)
1. An anchor configured to secure a suture relative to bone, the anchor comprising:
a generally cylindrical body portion having a leading end, a trailing end, a central longitudinal axis, and an opening extending from the leading end to the trailing end configured to receive at least a portion of the suture and at least a portion of a tool therein;
at least two projections configured to extend from the anchor when the anchor is deployed in the bone, the projections configured to engage the bone and secure the anchor in the bone;
the anchor being configured to confine at least two suture portions between the body portion and the bone when the anchor is deployed in the bone; and
the anchor being configured to have a first maximum dimension transverse to the central longitudinal axis of the body portion and a second maximum dimension transverse to the central longitudinal axis of the body portion, the second maximum dimension configured to be greater than the first maximum dimension when the anchor is deployed in the bone.
2. The anchor of claim 1 , wherein the tool is configured to be withdrawn from the body portion.
3. The anchor of claim 1 , wherein the anchor is formed of a polymeric material.
4. The anchor of claim 3 , wherein the polymeric material is hydrophilic.
5. The anchor of claim 3 , wherein the polymeric material is one selected from the group consisting of cellulose, petroylglutamic acid, high purity carboxymethylcellulose, a collagen, and a polylactide.
6. The anchor of claim 1 , wherein the anchor is made of one from the group consisting of autogenic bone, allogenic bone, xenogenic bone, a biodegradable material, a non-biodegradable material, polycaperlactone, metal, a biodegradable copolymer, and a bioerodible copolymer.
7. The anchor of claim 1 , wherein the trailing end includes a generally flat surface transverse to the central longitudinal axis adapted to bear an insertion force.
8. The anchor of claim 1 , wherein the trailing end is configured to releasably receive the at least a portion of the tool therein.
9. The anchor of claim 1 , wherein the leading end has a tapered configuration.
10. A method of securing a suture with respect to bone, the method comprising:
utilizing an anchor comprising a generally cylindrical body portion having a leading end, a trailing end, a central longitudinal axis, and an opening extending from the leading end to the trailing end configured to receive at least a portion of the suture therein, and at least two bone engaging projections extending from the body portion configured to engage the bone and secure the anchor in a desired position in the bone;
applying pressure to the anchor with a pusher member to move the anchor into the bone with at least two suture portions extending out of the opening;
moving an elongate member within the pusher member and the opening of the body portion; and
expanding the anchor from a first maximum dimension transverse to the central longitudinal axis to a second maximum dimension transverse to the central longitudinal axis after the insertion of the anchor in the bone.
11. The method of claim 10 , further comprising withdrawing the elongate member from the opening.
12. The method of claim 10 , wherein the anchor is formed of a polymeric material.
13. The method of claim 12 , wherein the polymeric material is hydrophilic.
14. The method of claim 12 , wherein the polymeric material is one selected from the group consisting of cellulose, petroylglutamic acid, high purity carboxymethylcellulose, a collagen, and a polylactide.
15. The method of claim 10 , further comprising applying force to tension the at least two suture portions extending out of the opening.
16. The method of claim 15 , further comprising tying the at least two suture portions extending out of the opening.
17. The method of claim 10 , further comprising utilizing at least one additional anchor, and applying pressure through an additional pusher member to the at least one additional anchor to move it into another desired position in the bone, and having at least two additional suture portions extending from an opening therein.
18. The method of claim 17 , further comprising tying the at least two additional suture portions extending from the opening of the at least one additional anchor.
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US14/035,316 Abandoned US20140025112A1 (en) | 2001-02-21 | 2013-09-24 | Anchor and method for securing a suture |
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US11/460,650 Abandoned US20060265009A1 (en) | 2000-05-03 | 2006-07-28 | Method of securing body tissue |
US11/461,110 Expired - Fee Related US8814902B2 (en) | 2000-05-03 | 2006-07-31 | Method of securing body tissue |
US11/930,621 Abandoned US20080114399A1 (en) | 2000-05-03 | 2007-10-31 | Method of securing body tissue |
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Cited By (26)
Publication number | Priority date | Publication date | Assignee | Title |
---|---|---|---|---|
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Also Published As
Publication number | Publication date |
---|---|
US20010041916A1 (en) | 2001-11-15 |
US7087073B2 (en) | 2006-08-08 |
US20060265009A1 (en) | 2006-11-23 |
US6635073B2 (en) | 2003-10-21 |
US20060265011A1 (en) | 2006-11-23 |
US8814902B2 (en) | 2014-08-26 |
US20080114399A1 (en) | 2008-05-15 |
US20030204204A1 (en) | 2003-10-30 |
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