# Patent

## Title
Transverse fixation technique for ACL reconstruction using bone-tendon-bone graft

## Abstract

A surgical method for transosseous fixation of a BTB graft into a joint is disclosed. A longitudinal tunnel formed in a bone is intersected by a transverse pin. A flexible strand is drawn with the pin through the bone. A looped portion of the strand is diverted so as to protrude out of the entrance to the longitudinal tunnel. The loop is severed so that one end of the strand is passed through a hole in the bone block of the BTB graft. The free ends of the loop are subsequently reattached using a knot to form a reformed loop. The strand with the reformed loop is retracted into the tunnel, drawing the attached BTB graft into the tunnel. The BTB graft is fixed in the tunnel using a transverse implant.

## Background
This application is a continuation-in-part (CIP) application of U.S. application Ser. No. 10/121,610, filed Apr. 15, 2002, now U.S. Pat. No. 6,537,319, which is a continuation of U.S. application Ser. No. 09/663,798, filed Sep. 18, 2000, now U.S. Pat. No. 6,371,124, which is a continuation of U.S. application Ser. No. 09/346,709, filed Jul. 2, 1999 now U.S. Pat. No. 6,132,433, which is a continuation of U.S. application Ser. No. 09/015,618, filed Jan. 29, 1998, now U.S. Pat. No. 5,918,604, which claims the benefit of U.S. Provisional Application Ser. No. 60/037,610, filed Feb. 12, 1997. This application also claims the benefit of U.S. Provisional Application Ser. No. 60/330,575, filed Oct. 25, 2001.


FIELD OF THE INVENTION
The present invention relates to surgical cross pin fixation of bone-tendon-bone (BTB) autografts and, more specifically, to reconstruction of the anterior cruciate ligament (ACL) using BTB graft fixation.
BACKGROUND OF THE INVENTION
Methods of ACL reconstruction using interference screw fixation are described in U.S. Pat. Nos. 5,211,647 and 5,320,626, the entire disclosures of which are incorporated herein by reference. In general, these methods of ACL reconstruction involve drilling a tunnel through the tibia, drilling a closed tunnel (socket) into the femur, inserting a substitute ACL graft into the tunnels, and securing the grafts to the walls of the tibial and femoral tunnels using interference screws. Although interference screw attachment is generally secure, it is sometimes neither possible nor desirable to provide such fixation, particularly in the femoral tunnel. In revision situations, for example, where a previous reconstruction has been performed, placing a second femoral tunnel close to the previous tunnel may not be indicated.
A fixation technique which provides strong attachment of a graft in the femoral tunnel using a transverse implant is disclosed in U.S. Pat. No. 5,601,562, of common assignment with the present application, and incorporated by reference herein. The transverse implant is inserted through a loop in a tendon graft. A threaded portion of the implant screws into the bone as the implant is advanced with rotation into the repair site. The technique is disadvantageous, however, because the graft can become wrapped around the implant as it is rotated. In addition, this technique requires a forked insertion tool to lift the tendon graft into the femoral socket, and large tibial and femoral tunnels are needed to accommodate the forked insertion tool. As a result of the large tunnels, the graft can slide laterally and “wipe” back and forth along the fixation implant.
An improved method for loading tendons into a femoral socket is disclosed in U.S. Pat. No. 5,918,604, the entire disclosure of which is incorporated by reference herein. In this technique, a strand of suture or nitenol wire is drawn transversely across the femoral socket, and a loop of the strand is pulled down from the socket and out of the tibial tunnel. The tendon graft is passed through the loop, and the strand loop with tendon attached is lifted back into the femoral socket. A transverse implant is then advanced under the tendon graft, preferably by impact insertion to avoid wrapping of the tendon graft during insertion.
Although the technique disclosed in U.S. Pat. No. 5,918,604 is much improved over prior techniques and has come into widespread use, it does not provide for the use of a closed loop graft, such as a bone-tendon-bone graft or construct. Accordingly, there is a need for an improved fixation technique, particularly in cruciate ligament reconstructions, utilizing a bone-tendon-bone (BTB) graft, or construct.
SUMMARY OF THE INVENTION
The present invention overcomes the disadvantages of the prior art, such as those noted above, by providing a surgical method for loading BTB grafts into a joint and fixating the grafts using a transverse, intraosseous implant passing through the bone block. The inventive technique advantageously uses narrow tibial and femoral tunnels, like the technique of U.S. Pat. No. 5,918,604 and can be similarly implemented using a transverse implant that is advanced by impaction into the femoral socket.
As applied to the knee, the method includes the use of standard techniques to drill a longitudinal tunnel in the tibia. Subsequently, a femoral tunnel (socket) is formed, preferably in the lateral femoral condyle. Advantageously, the diameters of the tibial and femoral tunnels are made just large enough to accommodate a BTB graft in a snug fit. A tunnel hook provided with a capture slot and mounted on a cross-pin drill guide is inserted through the tibial tunnel and into the femur. A drill pin directed by the drill guide is drilled through the femur to intersect the femoral tunnel. The drill pin passes through the capture slot of the tunnel hook. A channel is then formed in the femur, preferably using a cannulated drill placed over the guide pin, to accommodate a threaded section of the transtibial implant.
Next, a flexible strand, preferably a high strength suture, is attached to the guide pin and pulled through the femur. The tunnel hook is withdrawn once the strand is captured in the slot of the hook. The hook is retracted completely, through the femoral tunnel and out of the tibial tunnel, such that a loop of the flexible strand protrudes from the entrance to the tibial tunnel. The loop is subsequently severed and one of its free strands is passed through a 3 millimeter hole drilled through the bone block of a BTB graft. The flexible strand portions are then reattached using a knot to reform the loop. When tying the flexible suture strands back together, the knot remains on the medial side of the bone block of the BTB graft.
The reformed loop provided with the knot is retracted into the femoral tunnel by pulling evenly on the medial and lateral ends of the strand. Optionally, the strand may be lifted into place by a beath pin connected to a suture passed through the hole in the bone block, the beath pin passing longitudinally through the femoral tunnel to exit the anterior lateral thigh. As a result of either method, the BTB graft is drawn into the tibial tunnel. The flexible strand is then replaced with a length of guide wire by attaching the wire to the flexible strand and pulling the wire transversely across the femoral socket. A cannulated implant is placed over the wire and driven into the femur, preferably by impaction. The cannulated implant passes through the 3-millimeter hole of the BTB graft, thus securing the graft in the femoral tunnel.
Other features and advantages of the present invention will become apparent from the following description of the invention which refers to the accompanying drawings.



BRIEF DESCRIPTION OF THE DRAWINGS
FIG. 1 is a schematic view of a BTB graft employed in a method according to the present invention.
FIG. 2 is a schematic view of a hook and a drill pin mounted on a drill guide and disposed within the femoral tunnel (socket) according to the present invention.
FIG. 3 is a schematic view of a step of forming a femoral channel for the transverse implant according to the present invention.
FIG. 4 illustrates a strand attached to a drill pin and being pulled through the femur according to the present invention.
FIG. 5 illustrates a loop of the strand being pulled by the hook and out through the femoral tunnel (socket) according to the present invention.
FIG. 6 illustrates the strand loop having been diverted through the tibial tunnel, capturing a ligament graft, and pulling the graft into the tibial tunnel according to the present invention.
FIG. 7 illustrates the BTB graft, having been loaded through the longitudinal tibial tunnel and into the femoral tunnel (socket), being fixated using a transverse implant according to the present invention.
FIG. 8 illustrates a completed BTB graft repair including tibial fixation with an interference screw.



DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS
Referring now to the drawings, where like elements are illustrated by like reference numerals, FIGS. 1–8 illustrate a transosseous fixation technique for bone-tendon-bone (BTB) graft according to a method of the present invention.
Referring to FIG. 1 and as applied to the knee, a bone-tendon-bone (BTB) graft 100 is harvested and measured as to length and diameter. A minimum diameter of 10 millimeters and a minimum length of 30 millimeters are preferred. The BTB graft 100 is fashioned so that a 3 millimeter hole 91 (FIG. 1) is drilled through femoral bone block 14 at a distance “D” of about 15 millimeters from the bone tendon junction 95 running from anterior to posterior. A second 1 millimeter hole 93 (FIG. 1) may be drilled through the superior aspect of the bone block 14 and furnished with a length of passing suture to assist in delivery of the BTB graft 100 into the femoral tunnel.
Referring now to FIG. 2, the method of the present invention includes the use of standard techniques to drill a longitudinal tunnel 56 in tibia 55 and a femoral tunnel 66 in femur 65. The femoral tunnel 66 is over-drilled by a minimum of 5 millimeters.
A tunnel marking hook 2 (FIG. 2) is placed into the femoral tunnel 66 through the tibial tunnel 56. A mark on the hook indicating appropriate alignment is brought flush with the joint opening of the femoral tunnel 66. The marking hook 2 is secured to a C-ring cross-pin drill guide 4 such as those disclosed in U.S. Pat. Nos. 5,350,383 and 5,918,604, the disclosures of which are incorporated by reference herein. In this manner, a drill pin guide sleeve 6 on the drill guide 4 is secured to the lateral thigh in routine fashion. A 3-millimeter guide pin 8 drilled from lateral to medial passes through a capture slot formed in the tunnel marking hook 2.
Referring now to FIG. 3, a 5 millimeter broach 10 is passed over the drill pin 8 and drilled through the medial cortex to create a pilot hole for the head of a transtibial implant 22 (FIGS. 7–8). In this manner, a channel 77 is formed in the lateral femoral cortex to accommodate the remainder of the implant, preferably using a dilator placed over the guide pin.
Next, and as illustrated in FIG. 4, a first flexible strand 12, which is preferably a strand of high strength suture sold by the present assignee under the tradename FiberWire, is attached to the guide pin 8 and passed through the femur 65. As shown in FIG. 5, withdrawing the marking hook 2 from the femoral and tibial tunnels 66 and 56, respectively, in the direction of arrow A pulls a loop 88 of the suture strand 12 captured in the capture slot 8 of the marking hook 2 out of the tibial tunnel 56.
Referring to FIG. 6, the flexible strand 12, having been severed at the loop 88 outside the tibial tunnel 56, is secured to the femoral bone block 14 of the BTB graft 100 by passing one portion of the severed flexible strand through the 3 millimeter hole 91 preformed in the superior, femoral bone block 14, as described above. The flexible strand portions are then reattached using a knot 18 to reform the loop. When tying the flexible suture strands back together, the knot 18 remains on the medial side of the bone block. Knot 18 is cleared out of the medial side of the thigh.
Once the BTB graft 100 is secured to the reformed flexible strand loop, the BTB graft 100 is drawn into the tibial tunnel 56 by drawing on the ends of the strand on the medial and lateral sides of the femur in the direction of arrows B and C, as illustrated in FIG. 6. In lieu of or in addition to this technique, the BTB graft 100 may be drawn into the tibial tunnel 56 using a beath pin (not shown), connected to a suture passing through hole 91 of superior bone block 14, the beath pin being passed through the femoral tunnel 66 to exit the anterior lateral thigh. The passing suture attached to the superior bone block 14 can then be delivered out through the skin.
After bone block 14 of the BTB graft 100 is delivered into the femoral tunnel 66, proper positioning of the BTB graft 100 is checked by confirming that the bone tendon junction 95 (FIG. 1) of the BTB graft 100 is flush to opening 61 of the femoral tunnel 66, the cancellous portion of the bone block 14 is flush with lateral wall 62 of the femoral tunnel 66, and the tendon is flush with the medial side of the tunnel 66.
The flexible strand 12 is then attached a length of nitinol guide wire 20 (FIG. 7). The nitinol wire is delivered laterally through the graft 100 and the femoral tunnel 66 by pulling the medial side of flexible suture strand 12, such that the wire 20 passes through both the medial and lateral sides of the femur. A guide wire introducer (Arthrex Part No. AR-4069) can be inserted over the lateral nitinol guide wire 20 to insure proper alignment of the BTB graft 100 and guide wire.
Referring to FIG. 8, femoral fixation is provided by a transosseous cannulated implant 22. The transosseous cannulated implant 22 is fed onto the guide wire 20 followed by an impactor. The implant 22 is gently impacted into position. Implant position and femoral fixation are confirmed prior to removing the guide wire 20.
Tibial fixation of the BTB graft 100 may be performed by various known methods, including interference screw fixation 24, which provides the most secure post-operative result; distal fixation with a cancellous screw using a post and washer technique; and a belt buckle staple technique utilizing a pair of ligament staples.
Various endoscopic techniques and instruments relating to graft fixation are known in the prior art and can be used in the practice of the present invention. U.S. Pat. No. 5,320,636 to Schmieding discusses an endoscopic drill guide for graft tunnel location. U.S. Pat. No. Des. 378,780 illustrates a cannulated headed reamer, which can be used in femoral socket formation. Similarly, U.S. Pat. Nos. 5,269,786 and 5,350,383 disclose drill guides for location of bone tunnels.
Although the present invention has been described in relation to particular embodiments thereof, many other variations and modifications and other uses will become apparent to those skilled in the art. It is preferred, therefore, that the present invention be limited not by the specific disclosure herein, but only by the appended claims.

## Claims

1. A method of anterior cruciate ligament reconstruction, comprising the steps of:
forming a tibial tunnel between an anterior tibial surface and the tibial plateau;
forming a femoral tunnel having an opening and a sidewall;
introducing a first strand into the femoral tunnel through said sidewall;
pulling said first strand through said opening of said femoral tunnel and down through said tibial tunnel;
severing said first strand to obtain at least two severed strands;
attaching one of said severed strands to a bone block of a bone-tendon-bone graft;
subsequently reattaching said severed strands to form a reformed first strand; and
pulling said reformed first strand attached to said bone block of said bone-tendon-bone graft into said femoral tunnel.

2. The method of claim 1 further comprising the step of supporting said bone-tendon-bone graft in said femoral tunnel.

3. The method of claim 2, wherein said step of supporting said bone-tendon-bone graft in said femoral tunnel is conducted using a transosseous implant.

4. The method of claim 1 further comprising the step of forming a loop in said first strand after said step of pulling said first strand through said opening of said femoral tunnel and down through said tibial tunnel.

5. The method of claim 1, wherein said step of pulling said first strand through said opening of said femoral tunnel and down through said tibial tunnel is performed by engaging said first strand with a hook.

6. The method of claim 5 further comprising the step of inserting said hook into said femoral tunnel and retracting said hook and said first strand engaged thereto from said femoral tunnel.

7. The method of claim 1 further comprising the step of attaching a second strand to said bone-tendon-bone graft and pulling an upper portion of said bone-tendon-bone graft into said femoral tunnel by pulling longitudinally on said second strand.

8. The method of claim 7, wherein said first and second strands are formed of suture.

9. The method of claim 8, wherein a wire is attached to said first strand and pulled through said bone-tendon-bone graft after said upper portion of said bone-tendon-bone is pulled into said femoral tunnel.

10. The method of claim 1, wherein said step of attaching one of said severed strands through said bone-tendon-bone graft further comprises providing at least one hole through said bone-tendon-bone graft and passing said one of said severed strands through said hole.

11. The method of claim 10, further comprising the step of supporting said bone-tendon-bone graft in said femoral tunnel by advancing a cannulated implant along the wire such that at least a portion of the implant passes through the hole in the bone block of the bone-tendon-bone graft.

12. A method of anterior cruciate ligament reconstruction, the method comprising the steps of:
forming a tibial tunnel between an anterior tibial surface and the tibial plateau;
forming a femoral tunnel having an opening and a sidewall;
introducing a suture into the femoral tunnel through said sidewall;
pulling said suture through said opening of said femoral tunnel and down through said tibial tunnel;
severing said suture to obtain at least two severed strands;
passing one of said severed strands through a hole in a bone block of a bone-tendon-bone graft;
subsequently reattaching said severed strands to form a reformed suture;
lifting said bone block of said bone-tendon-bone graft into said femoral tunnel; and
supporting said bone-tendon-bone graft into said femoral tunnel by using a transosseous implant.

13. The method of claim 12 further comprising the step of introducing a nitinol wire through said hole of said bone block of said bone-tendon-bone graft after the bone block of the bone-tendon-bone graft has been lifted into the femoral tunnel, and advancing a cannulated along the wire and through the bone block to support the graft in the femoral tunnel.