Abstract:
An arthroscopic bone channel forming and suturing method including forming a first generally straight channel in a bone, forming a second generally straight channel in the bone, the second generally straight channel not intersecting the first generally straight channel, inserting a curved needle into the first generally straight channel, inserting a suture through the second generally straight channel in the bone to a suture pick-up location, manipulating the curved needle to form a curved junction between the first generally straight channel and the second generally straight channel; and pulling the suture by the curved needle from the suture pick-up location through the junction and though the first generally straight channel.

Description:
REFERENCE TO RELATED APPLICATIONS 
       [0001]    Reference is made to the following U.S. Provisional patent application which are believed to be related to the present application, the contents of which are hereby incorporated by reference herein and priority of which is hereby claimed under 37 CFR 1.78(a)(4) and (5)(i): 
         [0002]    U.S. Provisional Patent Application Ser. No. 61/802,958, entitled “Arthroscopic Surgical Device” and filed Mar. 18, 2013. 
         [0003]    U.S. Provisional Patent Application Ser. No. 61/887,561, entitled “Arthroscopic Surgical Device” and filed Oct. 7, 2013. 
         [0004]    Reference is also made to the following PCT Patent Applications and U.S. Provisional applications which are believed to be related to the present application, the contents of which are hereby incorporated by reference herein: 
         [0005]    PCT Patent Application No. PCT/IL2013/050030, entitled “Arthroscopic Surgical Device” and filed Jan. 15, 2013; 
         [0006]    PCT Patent Application No. PCT/IL2012/000318, entitled “Arthroscopic Surgical Device” and filed Aug. 23, 2012; 
         [0007]    PCT Patent Application No. PCT/IL2012/000319, entitled “Circular Bone Tunneling Device Employing a Stabilizing Element” and filed Aug. 23, 2012; 
         [0008]    Published PCT Patent Application No. WO 2012/007941, entitled “Circular Bone Tunneling Device” and filed Jul. 11, 2011; 
         [0009]    U.S. Provisional Patent Application Ser. No. 61/636,751, entitled “Circular Bone Tunneling Device Employing a Stabilizing Element” and filed Apr. 23, 2012; 
         [0010]    U.S. Provisional Patent Application Ser. No. 61/526,717, entitled “Circular Bone Tunneling Device” and filed Aug. 24, 2011; 
         [0011]    U.S. Provisional Patent Application Ser. No. 61/714,813, entitled “Arthroscopic Surgical Device” and filed Oct. 17, 2012; and 
         [0012]    U.S. Provisional Patent Application Ser. No. 61/584,267, entitled “Circular Bone Tunneling Device” and filed Jan. 8, 2012. 
     
    
     FIELD OF THE INVENTION 
       [0013]    The present invention relates generally to arthroscopic surgical devices and more particularly to arthroscopic bone tunneling devices. 
       BACKGROUND OF THE INVENTION 
       [0014]    Various types of arthroscopic surgical instruments are known for various applications including orthopedic surgery. 
       SUMMARY OF THE INVENTION 
       [0015]    It is appreciated that the terms ‘tunnel’ and ‘channel’ are used interchangeably in the description of the present invention and refer to a hollow bore, such as a cylindrically circular hollow bore, formed in a bone. It is also appreciated that the terms ‘tunneling’ and ‘channeling’ are used interchangeably in the description of the present invention and refer to a method of forming a hollow bore, such as a cylindrically circular hollow bore, in a bone. 
         [0016]    It is further appreciated that the term “suture” as used throughout the description of the present invention refers to any suitable suture and also refers to a transfer wire which is used to pull a suture through the bone. Typically, a transfer wire is used with the system and method of the present invention and is formed of Nitinol. Typically, a transfer wire used with the system and method of the present invention is folded over to form a loop at one end. 
         [0017]    The present invention seeks to provide an improved arthroscopic bone tunneling and suturing device. 
         [0018]    There is thus provided in accordance with a preferred embodiment of the present invention an arthroscopic bone channel forming and suturing method including forming a first generally straight channel in a bone, inserting a curved needle into the first generally straight channel, forming a second generally straight channel in the bone, the second generally straight channel not intersecting the first generally straight channel, inserting a suture through the second generally straight channel in the bone to a suture pick-up location, manipulating the curved needle to form a curved junction between the first generally straight channel and the second generally straight channel and pulling the suture by the curved needle from the suture pick-up location through the junction and though the first generally straight channel. 
         [0019]    Preferably, the inserting the suture includes locating a folded over end of the suture at the suture pick-up location. Additionally or alternatively, free ends of the suture extend outside of the second channel. 
         [0020]    In accordance with a preferred embodiment of the present invention the second generally straight channel is substantially longer than the first generally straight channel. 
         [0021]    Preferably, the curved needle has a radius of curvature which is generally equal to or greater than a length of the first generally straight channel. Additionally or alternatively, the geometry of the curved needle and the geometry of the first generally straight channel are such that the curved needle can pass through the first generally straight channel without changing the configuration of the first generally straight channel to add curvature thereto. Additionally, the geometry of the curved needle includes its width and its inner and outer radii of curvature and wherein the geometry of the first generally straight channel includes its width and its length. 
         [0022]    There is also provided in accordance with another preferred embodiment of the present invention an arthroscopic bone channel forming and suturing system including a punch configured to form a first generally straight channel in a bone, a drill configured to form a second generally straight channel in the bone, the second generally straight channel not intersecting the first generally straight channel, a curved needle configured to be insertable into the first generally straight channel, a needle driving assembly configured to manipulate the curved needle to form a curved junction between the first generally straight channel and the second generally straight channel and a suture assembly configured to insert a suture to a suture pick-up location via the second generally straight channel in the bone, the curved needle being configured to pull the suture from the suture pick up location and through the junction and the first generally straight channel. 
         [0023]    Preferably, the curved needle has a radius of curvature which is generally equal to or greater than a length of the first generally straight channel. 
         [0024]    There is further provided in accordance with yet another preferred embodiment of the present invention an arthroscopic bone channel forming and suturing method including forming a first channel in a bone, inserting a curved needle into the first channel, forming a second channel in the bone by using a straight drill extending through a straight working channel, removing the drill from the working channel, inserting a suture through the working channel extending through the second channel in the bone to a suture pick-up location and pulling the suture by the curved needle from the suture pick-up location though the first channel. 
         [0025]    Preferably, the method also includes forming a single incision in a patient&#39;s body for insertion and removal of the curved needle and the drill. Additionally, the inserting a suture includes locating a folded over portion of the suture at the suture pick-up location and free ends of the suture remain outside of the incision. 
         [0026]    In accordance with a preferred embodiment of the present invention the second channel is substantially longer than the first channel. 
         [0027]    Preferably, the curved needle has a radius of curvature which is generally equal to or greater than a length of the first channel. Additionally or alternatively, the geometry of the curved needle and the geometry of the first channel are such that the curved needle can pass through the first channel without changing the configuration of the first channel to add curvature thereto. Additionally, the geometry of the curved needle includes its width and its inner and outer radii of curvature and wherein the geometry of the first channel includes its width and its length. 
         [0028]    There is even further provided in accordance with still another preferred embodiment of the present invention an arthroscopic bone channeling and suturing system including a punch configured to form a first channel in a bone, a straight drill extending through a straight working channel and being adapted to form a second channel and to insert the working channel in the straight channel in the bone, a needle driving assembly configured to insert a tunneling needle into the first channel and a suture assembly configured to insert a suture through the working channel and through the second channel in the bone to a suture pick-up location, the needle driving assembly being configured to retract the tunneling needle together with the suture from the suture pick-up location though the first channel. 
         [0029]    Preferably, the drill is removable from the working channel to allow insertion of the suture assembly into the working channel. Additionally or alternatively, the drill is formed with a drill bit configuration at a forward end thereof. 
         [0030]    In accordance with a preferred embodiment of the present invention the suture assembly includes a pair of forward arms and the suture looped over the pair of forward arms. 
         [0031]    In accordance with a preferred embodiment of the present invention the needle driving assembly is configured to drive the tunneling needle through the bone from the first channel to the suture pick-up location. 
         [0032]    Preferably, the tunneling needle includes a suture engagement groove configured to retain the suture and pull the suture from the suture pick-up location through the first channel. Additionally, the arthroscopic bone channeling and suturing device also includes a suture tensioning assembly and the suture is configured to slide into engagement with the suture engagement groove by tension provided by the tensioning assembly. 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         [0033]    The present invention will be understood and appreciated from the following detailed description, taken in conjunction with the drawings in which: 
           [0034]      FIGS. 1A &amp; 1B  are simplified pictorial illustrations of an arthroscopic surgical assembly constructed and operative in accordance with a preferred embodiment of the present invention, showing opposite views; 
           [0035]      FIGS. 2A &amp; 2B  are simplified pictorial illustrations of an arthroscopic surgical device forming part of the arthroscopic surgical assembly of  FIGS. 1A &amp; 1B , constructed and operative in accordance with a preferred embodiment the present invention, showing opposite views in a first operative orientation; 
           [0036]      FIGS. 3A &amp; 3B  are simplified pictorial illustrations of an arthroscopic surgical device constructed and operative in accordance with a preferred embodiment of the present invention, showing opposite views in a second operative orientation; 
           [0037]      FIGS. 4A &amp; 4B  are simplified pictorial illustrations of an arthroscopic surgical device constructed and operative in accordance with a preferred embodiment of the present invention, showing opposite views third operative orientation; 
           [0038]      FIGS. 5A &amp; 5B  are simplified pictorial illustrations of an arthroscopic surgical device constructed and operative in accordance with a preferred embodiment of the present invention, showing opposite views in a fourth operative orientation; 
           [0039]      FIGS. 6A &amp; 6B  are simplified pictorial illustrations of an arthroscopic surgical device constructed and operative in accordance with a preferred embodiment of the present invention, showing opposite views in a fifth operative orientation; 
           [0040]      FIGS. 7A &amp; 7B  are simplified pictorial illustrations of an arthroscopic surgical device constructed and operative in accordance with a preferred embodiment of the present invention, showing opposite views in a sixth operative orientation; 
           [0041]      FIGS. 8A &amp; 8B  are simplified pictorial illustrations of an arthroscopic surgical device constructed and operative in accordance with a preferred embodiment of the present invention, showing opposite views in a seventh operative orientation; 
           [0042]      FIGS. 9A &amp; 9B  are simplified pictorial illustrations of an arthroscopic surgical device constructed and operative in accordance with a preferred embodiment of the present invention, showing opposite views in an eighth operative orientation; 
           [0043]      FIGS. 10A &amp; 10B  are simplified pictorial illustrations of an arthroscopic surgical device constructed and operative in accordance with a preferred embodiment of the present invention, showing opposite views in a ninth operative orientation; 
           [0044]      FIGS. 11A &amp; 11B  are simplified pictorial illustrations of an arthroscopic surgical device constructed and operative in accordance with a preferred embodiment of the present invention, showing opposite views in a tenth operative orientation; 
           [0045]      FIGS. 12A &amp; 12B  are simplified pictorial illustrations of an arthroscopic surgical device constructed and operative in accordance with a preferred embodiment of the present invention, showing opposite views in an eleventh operative orientation; 
           [0046]      FIGS. 13A &amp; 13B  are simplified pictorial illustrations of an arthroscopic surgical device constructed and operative in accordance with a preferred embodiment of the present invention, showing opposite views in a twelfth operative orientation; 
           [0047]      FIGS. 14A &amp; 14B  are simplified pictorial illustrations of an arthroscopic surgical device constructed and operative in accordance with a preferred embodiment of the present invention, showing opposite views in an thirteenth operative orientation; 
           [0048]      FIGS. 15A &amp; 15B  are simplified pictorial illustrations of an arthroscopic surgical device constructed and operative in accordance with a preferred embodiment of the present invention, showing opposite views in a fourteenth operative orientation; 
           [0049]      FIGS. 16A &amp; 16B  are simplified pictorial illustrations of an arthroscopic surgical device constructed and operative in accordance with a preferred embodiment of the present invention, showing opposite views in a fifteenth operative orientation; 
           [0050]      FIGS. 17A &amp; 17B  are simplified pictorial illustrations of an arthroscopic surgical device constructed and operative in accordance with a preferred embodiment of the present invention, showing opposite views in a sixteenth operative orientation; 
           [0051]      FIGS. 18A &amp; 18B  are simplified pictorial illustrations of an arthroscopic surgical device constructed and operative in accordance with a preferred embodiment of the present invention, showing opposite views in a seventeenth operative orientation; 
           [0052]      FIGS. 19A and 19B  are respectively a simplified partially exploded view illustration of part of the arthroscopic surgical device of  FIGS. 1A-18B  in the first operative orientation and a fully exploded view illustration of a portion of the part of the device shown in  FIG. 19A ; 
           [0053]      FIG. 19C  is a simplified illustration of another part of the arthroscopic surgical device of  FIGS. 1A-19B ; 
           [0054]      FIGS. 19D and 19E  are simplified illustrations, from two different perspectives, of another part of the arthroscopic surgical device of  FIGS. 1A-19B ; 
           [0055]      FIG. 19F  is a simplified sectional view of a portion of the arthroscopic surgical device of  FIGS. 1A-19B . 
           [0056]      FIGS. 20A and 20B  are simplified exploded view illustrations of a portion of the arthroscopic surgical device of  FIGS. 1A-19F , showing opposite views; 
           [0057]      FIG. 20C  is a simplified partially assembled view of the portion of the arthroscopic surgical device of  FIGS. 20A and 20B ; 
           [0058]      FIGS. 20D and 20E  are simplified illustrations of the apparatus of  FIGS. 20A-20C  in two different operative orientations; 
           [0059]      FIGS. 21A and 21B  are simplified illustrations of another portion of the arthroscopic surgical device of  FIGS. 1A-19C , showing opposite views; 
           [0060]      FIGS. 22A and 22B  are simplified exploded view illustrations of the portion of the arthroscopic surgical device of  FIGS. 21A &amp; 21B , showing opposite views; 
           [0061]      FIGS. 23A and 23B  are simplified illustrations of part of the portion of the arthroscopic surgical device of  FIGS. 21A &amp; 21B ; 
           [0062]      FIGS. 24A and 24B  are simplified assembled view illustrations of a drill portion of the arthroscopic surgical device of  FIGS. 1A-19C , showing opposite views; 
           [0063]      FIGS. 25A and 25B  are simplified assembled view illustrations of a suture cartridge portion of the arthroscopic surgical device of  FIGS. 1A-24B , showing opposite views; 
           [0064]      FIG. 25C  is a simplified exploded view illustration of the suture cartridge portion of the arthroscopic surgical device shown in  FIGS. 25A and 25B ; 
           [0065]      FIG. 25D  is a simplified side view illustration of the suture cartridge portion of the arthroscopic surgical device shown in  FIGS. 25A-25C ; 
           [0066]      FIGS. 26A and 26B  are simplified assembled view illustrations of a working channel portion of the arthroscopic surgical device of  FIGS. 1A-25D , showing opposite views; 
           [0067]      FIG. 26C  is a simplified exploded view illustration of the working channel portion of the arthroscopic surgical device shown in  FIGS. 26A and 26B ; 
           [0068]      FIGS. 27A ,  27 B,  27 C,  27 D,  27 E,  27 F,  27 G,  27 H,  27 I,  27 J,  27 K,  27 L,  27 M,  27 N,  27 O,  27 P,  27 Q and  27 R are respective simplified illustrations of details of the operation of the arthroscopic surgical device of  FIGS. 1A-26C ; and 
           [0069]      FIGS. 28A ,  28 B,  28 C,  28 D,  28 E,  28 F,  28 G,  28 H,  28 I,  28 J,  28 K,  28 L,  28 M,  28 N,  28 O,  28 P,  28 Q,  28 R,  28 S,  28 T,  28 UI,  28 V,  28 W and  28 X are simplified illustrations of operation of the arthroscopic surgical device of  FIGS. 1A-27R  in a clinical context. 
       
    
    
     DETAILED DESCRIPTION OF PREFERRED EMBODIMENTS 
       [0070]    It is appreciated that the terms ‘tunnel’ and ‘channel’ are used interchangeably in the description of the present invention and refer to a hollow bore, such as a cylindrically circular hollow bore, formed in a bone. It is also appreciated that the terms ‘tunneling’ and ‘channeling’ are used interchangeably in the description of the present invention and refer to a method of forming a hollow bore, such as a cylindrically circular hollow bore, in a bone. 
         [0071]    It is further appreciated that the term “suture” as used throughout the description of the present invention refers to any suitable suture and also refers to a transfer wire which is used to pull a suture through the bone. Typically, a transfer wire is used with the system and method of the present invention and is formed of Nitinol. Typically, a transfer wire used with the system and method of the present invention is folded over to form a loop at one end. 
         [0072]    Reference is now made to  FIGS. 1A &amp; 1B , which are simplified pictorial illustrations of an arthroscopic surgical assembly, constructed and operative in accordance with a preferred embodiment of the present invention, showing opposite views, and to various additional drawings which are specifically referenced in parentheses hereinbelow. 
         [0073]    As seen in  FIG. 1B , there is provided a bone punch  10 , preferably including a handle portion  12 , an intermediate portion  14 , and a forward portion  16 , having a pointed tip  18 . A line  20  is preferably formed on forward portion  16  to indicate a desired extent of bone penetration to a surgeon using the punch. A generally concave impact surface  22  is preferably formed on a rearward end of punch  10 , for impact thereon by a surgical hammer. 
         [0074]    As seen in  FIGS. 1A &amp; 1B  and shown specifically in  FIGS. 2A &amp; 2B , an arthroscopic surgical device  100  according to a preferred embodiment of the present invention includes a housing portion, preferably formed of right and left housing elements  102  and  104 , and a multiple action driving assembly  106 , only part of which is seen in  FIGS. 1A &amp; 1B . The housing portion includes a handle portion, which is defined by respective right and left housing element handle portions  112  and  114 , respectively. 
         [0075]    The multiple action driving assembly  106  preferably includes a bone-engaging pin insertion assembly  120 , a bone-engaging needle driving assembly  122  and a selectable attachment assembly  123 . 
         [0076]    Bone-engaging pin insertion assembly  120  preferably includes a working channel assembly  124 , which is shown and described in detail hereinbelow with reference to  FIGS. 26A-26C , and a drill  126 , which is shown and described in detail hereinbelow with reference to  FIGS. 24A &amp; 24B . 
         [0077]    Referring now additionally to  FIGS. 26A-26C , it is seen that the working channel assembly  124  includes a main longitudinal rigid tube  128 , typically formed of stainless steel, and a hardened forward tube  130 , typically formed of hardened stainless steel, which fits into a forward end of main rigid tube  128 . Preferably, welded onto a rear end of main tube  128  is a driving socket element  132  having formed, at a rear end thereof, a recess  134 , typically having a hexagonal cross section. 
         [0078]    Driving socket element  132  is rotatably mounted within a collar member  136 , which is shown and described in detail hereinbelow, with reference to  FIGS. 19A &amp; 19B , and which is mounted onto the housing so as to have limited axial movement with respect thereto. Driving socket element  132  is restrained against axial movement relative to collar member  136 , preferably by a pair of retaining pins  138 , which extend through transverse apertures formed in collar member  136  and engage a groove  140  formed in driving socket element  132 . 
         [0079]    Referring now additionally to  FIGS. 24A-24B , it is seen that drill  126  preferably comprises a solid rod  142  of circular cross section, having a drill bit configuration at a forward end  144  thereof and being formed at a widened rear end  146  thereof with a hexagonal cross section, such that rear end  146  is suitable for drivable engagement with a chuck of a conventional surgical drill (not shown). 
         [0080]    The bone-engaging needle driving assembly  122  preferably includes a hand-engageable ratchet handle  150  which is arranged for reciprocal motion about an axis  152  ( FIG. 19B ). A selectable direction ratchet shaft  156  ( FIG. 19B ) extends through slots  158  in respective right and left housing element handle portions  112  and  114 , and terminates in knobs  160 , whose positions in slots  158  govern the direction of motion of an arthroscopic arcuate tunneling needle  162  having a suture engagement groove  164  partially defined by a needle end portion  165 . 
         [0081]    As noted above, it is appreciated that the terms ‘tunneling’ and channeling′ are used interchangeably in the description of the present invention and refer to a method of forming a hollow bore, such as a cylindrically circular hollow bore, in a bone. 
         [0082]    A visible mechanical indicator  166  is preferably arranged on the top of respective housing portions  102  and  104 . Indicator  166  preferably provides a visible indication of the extent that arcuate tunneling needle  162  is displaced from its fully retracted position shown in  FIGS. 2A &amp; 2B . 
         [0083]    A suture cartridge assembly  170  is provided for selectable engagement with the housing and is illustrated in  FIGS. 25A-25D . Suture cartridge assembly  170  preferably includes a longitudinal tube  172  having a specially configured forward end  174 . As seen particularly in  FIG. 25C , the forward end  174  is configured to have a pair of mutually spaced forwardly extending arms  176  which are each formed with a suture retaining end notch  178  and a suture retaining side notch  180 . A transverse slot  182  is formed rearwardly of arms  176  to enable a folded over suture  184  which extends through a longitudinal bore in longitudinal tube  172  to be looped over arms  176  at notches  178  and  180  as shown in  FIG. 25A . 
         [0084]    As noted above, it is appreciated that the term “suture” as used throughout the description of the present invention refers to any suitable suture and also refers to a transfer wire which is used to pull a suture through the bone. Typically, a transfer wire is used with the system and method of the present invention and is formed of Nitinol. 
         [0085]    Mounted at a rearward end  185  of tube  172 , there is provided a selectable suture tensioning assembly  186 . Assembly  186  includes an assembly housing  187  onto which is pivotably mounted a user-operable suture release lever  188 , which, in turn, operates a pivotably mounted release element  189 . Release element  189  selectably retains the assembly housing  187  against rearward axial movement under the urging of a compression spring  190 . Frictional engagement between a screw  191 , threaded into engagement with a retaining member  192 , and a transversely extending rod  193  maintains tension on the suture  184  up to a predetermined threshold force beyond which the ends of the suture  184  become released from assembly  186 . Rod  193  engages a pair of slots  194  on opposite sides of assembly housing  187  and extends through a transverse aperture  195  in retaining member  192 . 
         [0086]    A pivot pin  196  pivotably mounts release lever  188  onto assembly housing  187 . A pusher pin  197 , mounted onto release lever  188 , engages release element  189  and produces pivoted movement thereof about a pivot pin  198 , fixed to housing  187 , in response to pressing on release lever  188 . A latch pin  199 , fixed onto assembly housing  187  selectably engages release element  189 . 
         [0087]    The operation of selectable suture tensioning assembly  186  may be summarized as follows. Insertion of the suture cartridge assembly  170  into engagement with collar member  136  causes release element  189  to be latched to collar member  136 . Downward pushing on release lever  188  produces pivotal motion of release element  189 , which pushes spring  190  rearwardly against retaining member  192 . This produces retraction of tube  172  and of arms  176  and tensions the forward folded over end of suture  184  and draws it tightly into engagement with arcuate tunneling needle  162 , which is adapted to selectably engage suture  184  at needle-suture engagement location located between arms  176 . The free ends of the suture  184  thereafter become released from the suture tensioning assembly  186  in response to retraction of the needle  162  along its arcuate path, which produces tensile force on the suture  184  which overcomes the grip between rod  193  and screw  191  produced by spring  190 . 
         [0088]    It is appreciated that free ends of suture  184  remain outside of an incision made in a patient&#39;s body before, during and after the insertion procedure described hereinbelow with reference to  FIGS. 27A-27R  and  28 A- 28 X. 
         [0089]    Reference is now made to  FIGS. 3A &amp; 3B , which are simplified pictorial illustrations of the arthroscopic surgical device of  FIGS. 1A-2B  in a second operative orientation. It is seen that the transition from the first operative orientation of  FIGS. 2A &amp; 2B  to the second operative orientation, which preferably occurs following insertion of a forward portion of the bone-engaging needle driving assembly  122  through an arthroscopic incision, as described hereinbelow with reference to  FIGS. 28E and 27B , involves shifting the position of knobs  160  from a lowered position to a raised position in slot  158 . 
         [0090]    Reference is now made to  FIGS. 4A &amp; 4B , which are simplified pictorial illustrations of the arthroscopic surgical device of  FIGS. 1A-3B  in a third operative orientation and which illustrate partial extension of arcuate tunneling needle  162 , as indicated by indicator  166 . This extension is produced by rotation of hand-engageable ratchet handle  150  about axis  152  ( FIG. 19B ) when knobs  160  are in the upper position in slots  158 . Needle  162  enters a channel earlier formed in a humerus, as will be described hereinbelow with reference to  FIGS. 27C &amp; 28H . 
         [0091]    Reference is now made to  FIGS. 5A &amp; 5B , which are simplified pictorial illustrations of the arthroscopic surgical device of  FIGS. 1A-4B  in a fourth operative orientation and which show insertion of the bone-engaging pin insertion assembly  120  through the housing of the arthroscopic surgical device  100  of  FIGS. 4A &amp; 4B  so that tip  144  extends nearly to the surface of the bone, as described hereinbelow with reference to  FIGS. 27D and 28I . 
         [0092]    Reference is now made to  FIGS. 6A &amp; 6B , which are simplified pictorial illustrations of the arthroscopic surgical device of  FIGS. 1A-5B  in a fifth operative orientation. It is seen that the widened rear end  146  of bone-engaging pin insertion assembly  120  is engaged by the chuck of a surgical drill  200 , as described hereinbelow in detail with reference to  FIGS. 27E and 28J . 
         [0093]    Reference is now made to  FIGS. 7A &amp; 7B , which are simplified pictorial illustrations of the arthroscopic surgical device of  FIGS. 1A-6B  in a sixth operative orientation. It is seen that due to operation of surgical drill  200 , the forward tip  144  of the drill  126  is fully extended, as described hereinbelow in detail with reference to  FIGS. 27F and 28K . It is seen that concomitantly, due to the operation of surgical drill  200 , working channel assembly  124 , including collar member  136 , has moved to its full axially forward position with respect to the selectable attachment assembly  123 . It is noted, as will be described hereinbelow, that collar member  136  is automatically latched to selectable attachment assembly  123  at this stage. 
         [0094]    Reference is now made to  FIGS. 8A &amp; 8B , which are simplified pictorial illustrations of the arthroscopic surgical device of  FIGS. 1A-7B  in a seventh operative orientation. Here it is seen that the drill  126  is being retracted but that working channel assembly  124  remains in its full axially forward position, by virtue of latching of collar member  136  to selectable attachment assembly  123 . 
         [0095]    Reference is now made to  FIGS. 9A &amp; 9B , which are simplified pictorial illustrations of the arthroscopic surgical device of  FIGS. 1A-8B  in an eighth operative orientation and illustrate insertion of the suture cartridge assembly  170  through the working channel assembly  124 . It is noted that selectable suture tensioning assembly  186  is automatically latched to collar member  136 . 
         [0096]    Reference is now made to  FIGS. 10A &amp; 10B , which are simplified pictorial illustrations of the arthroscopic surgical device of  FIGS. 1A-9B  in a ninth operative orientation and which illustrate full extension of arcuate tunneling needle  162 , as indicated by indicator  166 . This extension is produced by rotation of hand-engageable ratchet handle  150  about axis  152  ( FIG. 19B ) when knobs  160  are in the upper position in slots  158 . 
         [0097]    It is seen that arcuate tunneling needle  162  extends between mutually spaced forwardly extending arms  176  of suture cartridge assembly  170 . As noted above, each of arms  176  is formed with a suture retaining end notch  178  and a suture retaining side notch  180 . A transverse slot  182  is formed rearwardly of arms  176  to enable a folded over suture  184  which extends through a longitudinal bore in longitudinal tube  172  to be looped over arms  176  at notches  178  and  180  as shown in  FIG. 25A . It is further seen that suture engagement groove  164  lies below mutually spaced forwardly extending arms  176  of suture cartridge assembly  170 . 
         [0098]    Reference is now made to  FIGS. 11A &amp; 11B , which are simplified pictorial illustrations of the arthroscopic surgical device of  FIGS. 1A-10B  in a tenth operative orientation. It is seen that lever  188  is manually depressed, thereby unlatching suture tensioning assembly  170  from collar member  136  and causing axially rearward displacement of suture tensioning assembly  170  relative to collar member  136  and concomitant axial retraction of arms  176  of suture cartridge assembly  170  relative to working channel  124 . It is seen that suture  184  is looped around needle  162  at a location on needle  162  lying above suture engagement groove  164 . 
         [0099]    Reference is now made to  FIGS. 12A &amp; 12B , which are simplified pictorial illustrations of the arthroscopic surgical device of  FIGS. 1A-11B  in an eleventh operative orientation. It is seen knobs  160  are lowered to their lower position in slots  158 . 
         [0100]    Reference is now made to  FIGS. 13A &amp; 13B , which are simplified pictorial illustrations of the arthroscopic surgical device of  FIGS. 1A-12B  in a twelfth operative orientation. It is seen that needle  162  is partially retracted so that it engages suture  184  at suture engagement groove  164 . 
         [0101]    Reference is now made to  FIGS. 14A &amp; 14B , which are simplified pictorial illustrations of the arthroscopic surgical device of  FIGS. 1A-13B  in a thirteenth operative orientation. It is seen that arcuate tunneling needle  162  is fully retracted, as indicated by indicator  166 , in engagement with the forward looped end of suture  184 , thus drawing the suture backwards along an arcuate path along with full retraction of the needle  162 . 
         [0102]    Reference is now made to  FIGS. 15A &amp; 15B , which are simplified pictorial illustrations of the arthroscopic surgical device of  FIGS. 1A-14B  in a fourteenth operative orientation. It is seen that suture cartridge assembly  170  is fully retracted and withdrawn from the working channel assembly  124 , leaving the suture  184  in the working channel assembly  124 . 
         [0103]    Reference is now made to  FIGS. 16A &amp; 16B , which are simplified pictorial illustrations of the arthroscopic surgical device of  FIGS. 1A-15B  in a fifteenth operative orientation. It is seen that the working channel assembly  124  is partially axially retracted by rotation of the selectable attachment assembly  123 , which forces collar member  136  axially rearwardly, thus drawing hardened forward tube  130  rearwardly out of tight engagement with the bone. 
         [0104]    Reference is now made to  FIGS. 17A &amp; 17B , which are simplified pictorial illustrations of the arthroscopic surgical device of  FIGS. 1A-16B  in a sixteenth operative orientation. It is seen that working channel assembly  124  is fully retracted and that the positions of knobs  160  in slots  158  are shifted upwardly, in order to provide extension of needle  162  in response to operation of ratchet handle  150 . The orientation of the needle  162  is shown by indicator  166 . 
         [0105]    Reference is now made to  FIGS. 18A &amp; 18B , which are simplified pictorial illustrations of the arthroscopic surgical device of  FIGS. 1A-17B  in a seventeenth operative orientation. It is seen that the arcuate tunneling needle  162  is now partially extended in order to permit manual disengagement of the looped forward end of suture  184  from suture engagement groove  164  of needle  162 . 
         [0106]    Reference is now made to  FIGS. 19A-24B  and initially specifically to  FIGS. 19A &amp; 19B  and to  FIGS. 20A and 20B , which are simplified exploded view illustrations of a portion of the arthroscopic surgical device of  FIGS. 1A-18B , showing opposite views, to  FIG. 20C , which is a simplified partially assembled view, and to  FIGS. 20D and 20E , which are simplified illustrations of the apparatus of  FIGS. 20A-20C  in two different operative orientations, all of which show details of some elements of multiple action driving assembly  106 . 
         [0107]    It is seen that ratchet handle  150  is typically formed with a lower aperture  210 , which accommodates a shaft  154 , and a slot  212 . A pin  214  is slidably movable in slot  212 , such that reciprocal arcuate motion of slot  212  is translated into reciprocal planar forward and rearward motion perpendicular to a longitudinal axis  216  of pin  214 . First and second reciprocal motion connection elements  220  and  222  are fixed to pin  214  at respective apertures  224  and  226  and move together therewith in reciprocal forward and rearward linear motion in response to rotational motion of ratchet handle  150 . 
         [0108]    Connection element  222  includes an elongate protrusion  228 , which moves reciprocally in a slot  230  formed in housing portion  102 . 
         [0109]    Connection element  220  includes a side extending shaft  240  which is formed with a circumferential groove  244  onto which is mounted one end of a tension spring  248 . An opposite end of tension spring  248  is mounted in a circumferential groove  250  formed in shaft  156 . Shaft  156  extends through an aperture  254  formed in a toggle element  256 , which communicates with a hollow shaft portion  258  of toggle element  256 . Shaft  156  extends through slots  158  formed on respective housing portions  102  and  104 . 
         [0110]    A double rack linear toothed element  270  is provided with an upper linear toothed ratchet rack  272  and a lower linear toothed gear rack  274 . A pointed corner  275  of connection element  220  selectably engages upper linear toothed rack  272 . Double rack linear toothed element  270  is preferably formed with a slot  276  which engages an elongate axial protrusion  277  formed in housing element  102 . 
         [0111]    An inward recessed portion  278  adjacent an inner end of a generally rigid flexible needle driving strip driving shaft  280  is fixedly mounted onto double rack linear toothed element  270  by means of a mounting element  282 , which is typically bolted onto element  270 . An indicator finger  284  is formed on mounting element  282  and forms part of indicator  166 . 
         [0112]    A second double rack linear toothed element  285  is provided with an upper linear toothed gear rack  286  and a lower linear toothed ratchet rack  287 . Double rack linear toothed element  285  is preferably formed with a slot  288 , which engages an elongate axial protrusion  289  formed in housing element  102 . 
         [0113]    A gear  290 , having a gear shaft  291 , engages lower linear toothed gear rack  274  of element  270  and also simultaneously engages upper linear toothed gear rack  286  of element  285 . Gear shaft  291  preferably is mounted at its opposite ends in apertures  292  in respective housing elements  102  and  104 . 
         [0114]    A pointed corner  293  of connection element  220  selectably engages lower linear toothed ratchet rack  287  of element  285 . 
         [0115]    Reference is now made specifically to  FIGS. 19A-19F  and  20 A- 20 E, which illustrate the structure of selectable attachment assembly  123 . As seen with particularity in  FIGS. 19A ,  19 C &amp;  19 F, the selectable attachment assembly  123  comprises a winged nut  294  having a threaded bore  295  extending therealong from a first end  296  of nut  294  to a circumferential recess  297  which is spaced from a second end  298  of nut  294  by a non-threaded bore portion  299 . 
         [0116]    As seen in FIGS.  19 A and  19 D- 19 F, a connection element  300  is arranged for threaded engagement with threaded bore  295  of winged nut  294 . Connection element  300  includes a first generally cylindrical portion  301  having a throughgoing axial bore  302  and a throughgoing bottom slit  303  formed therein. A threaded generally cylindrical collar portion  304  is located at an intermediate location along connection element  300  forwardly of first generally cylindrical portion  301  in the sense of  FIG. 19A . A second generally cylindrical portion  305  is located forwardly of collar portion  304  and has a cross sectional diameter which is greater than that of first cylindrical portion and less than that of collar portion  304 . 
         [0117]    Forward of second generally cylindrical portion  305  there are preferably provided a pair of spaced lugs  306  which are separated by a vertical recess  307 . Connection element  300  also includes an aperture  308 , formed in generally cylindrical portion  301 , in which is seated an axial guiding pin  309 . 
         [0118]    A latch element  310  includes a forward portion  311 , having a top transverse bore  312  through which extends a transverse pin  313  for pivotable attachment of latch element  310  to connection element  300  via lugs  306 . Latch element  310  also includes a rearwardly facing latch extension portion  314  which is seated in throughgoing bottom slit  303  and includes a depending latch protrusion  315 , at a rearward end thereof, for removable latched engagement with collar member  136  of working channel assembly  124 . 
         [0119]    Forward portion  311  also includes a bottom transverse bore  316  which accommodates a pin  317 , onto which is connected a first end of a tension spring  318 , whose opposite end is connected to a pin  319  which is mounted at opposite ends thereof at respective locations  320  in right and left housing elements  102  and  104 . 
         [0120]    Transverse pin  313  is mounted at opposite ends thereof at respective locations  321  in right and left housing elements  102  and  104 . 
         [0121]    Forward portion  311  is also formed with an aperture  322  for accommodating working channel assembly  124 , which extends therethrough. 
         [0122]    Returning now to the description of the working channel assembly  124  in greater detail and referring now additionally to  FIGS. 26A-26C , as mentioned above, working channel assembly  124  includes a main longitudinal rigid tube  128  and a hardened forward tube  130 . Driving socket element  132  is preferably welded onto a rear end of main tube  128  and is rotatably mounted within collar member  136 . Driving socket element  132  is restrained against axial movement relative to collar member  136 , preferably by a pair of retaining pins  138 , which extend through transverse apertures formed in collar member  136  and engage a groove  140  formed in driving socket element  132 . 
         [0123]    Turning specifically to  FIG. 26C , it is seen that socket element  132  is a generally cylindrical element which has a non-circular driving bore  134 , typically of hexagonal cross section, extending partially therethrough from a rear end  323  of socket element  132 . A narrow bore  324  extends forwardly of driving bore  134  and extends into a broadened bore  325  which terminates at a forward circumferential recess  326 . External circumferential recess  140  surrounds part of broadened bore  325 . 
         [0124]    Collar member  136  includes a generally cylindrical back portion  327  having a bore  328  which is intersected by pins  138  extending through transverse apertures  329  in cylindrical back portion  327 . A narrow bore  330  extends forwardly of bore  328  and communicates with a recess  332 . Cylindrical back portion  327  is also formed with an axial bottom groove  334  having side lobes  336  and communicating with a transverse aperture  337 . 
         [0125]    Forward of back portion  327  is a generally cylindrical forward portion  338  having an axial slot  340  which extends partially into cylindrical back portion  327  as shown at reference numeral  342 . Axial guiding pin  309  of connection element  300  engages axial slot  340  to ensure proper rotational alignment of working channel assembly  124  and to ensure proper alignment of suture cartridge assembly  170 . 
         [0126]    The assembly of socket element  132  inside collar member  136  and the mounting therein of main longitudinal rigid tube  128  is shown in an enlarged sectional portion of  FIG. 26A . 
         [0127]    Reference is now made specifically to  FIGS. 21A-24B , which illustrate bone-engaging needle driving assembly  122 . The bone-engaging needle driving assembly  122  includes linear gear rack element  270 , which is preferably driven along an elongate travel path responsive to reciprocal motion of ratchet handle  150 . 
         [0128]    Bone-engaging needle driving assembly  122  includes a static forward portion  400 , including a mounting base  402 , which extends forwardly of a forward end of the housing, which is fixed to an extension shaft  404  extending axially inwardly thereof and forwardly therefrom. Fixed to extension shaft  404  and extending forwardly thereof, there is preferably formed an arcuate needle storage and guiding portion  406 . 
         [0129]    Mounting base  402  is generally configured as a hollow cylinder to accommodate part of extension shaft  404  therewithin and is formed with matching side apertures  408  which accommodate mounting pins  410  ( FIG. 19B ), which serve to mount the mounting base  402  onto housing portions  102  and  104 , as seen in  FIG. 19B . 
         [0130]    Extension shaft  404  is preferably formed of two side by side pieces  411 . Side pieces  411  together define two mutually spaced axial mounting bores extending therethrough, which bores are designated by reference numerals  412  and  414 . Bore  412  slidably accommodates working channel assembly  124  and has a generally round cross-section. 
         [0131]    Bore  414  slidably accommodates parts of a flexible arcuate needle driving assembly, which preferably includes a flexible needle driving strip  418 , preferably formed of spring steel, and generally rigid flexible needle driving strip driving shaft  280 , which is mounted at the rear of flexible needle driving strip  418 , preferably as shown in enlargements A &amp; B in  FIG. 21A . This mounting is preferably by means of engagement of a protrusion  419  formed adjacent the forward end of rigid flexible needle driving strip driving shaft  280  with a corresponding aperture  420  formed adjacent a rearward end of flexible needle driving strip  418 . 
         [0132]    As seen in enlargement A of  FIG. 21A , bore  414  has a generally circular cross sectional central portion  422  to accommodate shaft  280 , from which portion extend a pair of symmetrical side cut outs  424  to accommodate the side edges of strip  418 . 
         [0133]    As seen particularly in enlargement D of  FIG. 21A , forward of extension shaft  404 , there is preferably formed an arcuate needle storage and guiding portion  450 , which is formed with an arcuate bore  452  including a portion  454  having a generally rectangular cross section, which slidably accommodates needle  162 . A pair of symmetrical side cut outs  456  extend outwardly from portion  454  and accommodate the side edges of flexible needle driving strip  418 . 
         [0134]    It is also seen in an enlargement of  FIG. 22A , that the forward end of flexible needle driving strip  418  is attached to arcuate needle  162 . This attachment is preferably by means of engagement of a protrusion  466  formed adjacent the rearward end of arcuate needle  162  with a corresponding aperture  467  formed adjacent a forward end of flexible needle driving strip  418 . 
         [0135]    Reference is now made to  FIGS. 27A ,  27 B,  27 C,  27 D,  27 E,  27 F,  27 G,  27 H,  27 I,  27 J,  27 K,  27 L,  27 M,  27 N,  27 O,  27 P,  27 Q and  27 R, which illustrate details of the operation of the arthroscopic surgical device of  FIGS. 1A-26C , and to  FIGS. 28A ,  28 B,  28 C,  28 D,  28 E,  28 F,  28 G,  28 H,  28 I,  28 J,  28 K,  28 L,  28 M,  28 N,  28 O,  28 P,  28 Q,  28 R,  28 S,  28 T,  28 U,  28 V,  28 W and  28 X, which are simplified illustrations of operation of the arthroscopic surgical device of  FIGS. 1A-27R  in a clinical context. 
         [0136]    Reference is initially made to  FIGS. 28A-28D , which show an initial step of using punch  10  ( FIG. 1B ) to form a channel  499  in a bone, such as a humerus. A surgeon positions punch  10  opposite an appropriate arthroscopic incision  500  in a patient, as shown in  FIGS. 28A and 28B . As seen in  FIG. 28C , using a surgical hammer which impacts on impact surface  22  of punch  10 , the surgeon forces the forward portion  16  of the punch  10  into the humerus up to line  20 . The punch is then withdrawn from the patient, leaving channel  499  in the humerus, as shown in  FIG. 28D .  FIG. 28E  illustrates initial insertion of the arthroscopic surgical device of  FIGS. 2A &amp; 2B , in a first operative orientation, as shown in  FIG. 27A , through an arthroscopic incision  501  adjacent to incision  500 . 
         [0137]    Reference is now made to  FIGS. 27B and 28F  which illustrate shifting of knobs  160  in slots  158  to their upward positions. 
         [0138]    Reference is now made to  FIG. 27C  and  FIG. 28G , which correspond to  FIGS. 4A &amp; 4B  and show extending of the needle  162 , by squeezing of handle  150  as indicated by an arrow  502  and positioning of the extended forward portion of needle  162  in channel  499  in the humerus.  FIG. 28H  shows the forward portion of needle  162  fully inserted in channel  499 . 
         [0139]    As seen in  FIG. 28C , needle  162  preferably has a radius of curvature which is generally equal to or greater than a length of channel  499 . Additionally, it is appreciated that the geometry of needle  162 , including its width and inner and outer radii of curvature, and the geometry of channel  499 , including its length and width, are such that needle  162  can pass through channel  499  without changing the configuration of channel  499  to add curvature thereto. 
         [0140]    Reference is now made to  FIGS. 27D and 28I , which show drill  126 , such as that described hereinabove with reference to  FIGS. 20A &amp; 20B , being mounted onto the arthroscopic surgical device  100  and being initially positioned, as indicated by an arrow  503 , to a position wherein the tip  144  touches the outside surface of the humerus. 
         [0141]      FIGS. 27E and 28J , which correspond generally to  FIGS. 6A &amp; 6B , show attachment of surgical drill  200  to widened rear end  146  of drill  126 . 
         [0142]      FIGS. 27F and 28K , which correspond generally to  FIGS. 7A &amp; 7B , show linear forward displacement of drill  126  and working channel assembly  124  of bone-engaging pin insertion assembly  120  in the arthroscopic surgical device  100 , as indicated by an arrow  504 . This displacement is preferably achieved by operation of the surgical drill  200  in operative engagement with widened rear end  146  of drill  126 . As seen in  FIG. 28K , the tip  144  of drill  126  is in its most forward position and tube  130  is in its most forward position. 
         [0143]      FIGS. 27G and 28L , which correspond generally to  FIGS. 8A &amp; 8B , show retraction of the drill  126 , as indicated by an arrow  505 , while leaving the tube  130  in its most forward position. 
         [0144]    As seen in  FIG. 28L , a channel formed in the humerus by drill  126  is preferably longer, and more preferably, substantially longer, than channel  499  formed in the humerus by punch  10 . It is also seen in  FIG. 28L  that the channel formed in the humerus by drill  126  does not intersect channel  499 . 
         [0145]    Additionally, it is appreciated that the channel formed in the humerus by drill  126  and channel  499  formed in the humerus by punch  10  are not parallel channels. Preferably, an angle formed between the channel formed in the humerus by drill  126  and an extension of channel  499  formed in the humerus by punch  10  is generally a right angle or an acute angle greater than 45°. 
         [0146]    Reference is now made to  FIGS. 27H and 28M , which correspond generally to  FIGS. 9A and 9B  and which show insertion of the suture cartridge assembly  170 , including suture  184 , in engagement with the working channel assembly  124 , such that arms  176  of suture cartridge assembly  170  extend forwardly of a forward edge of tube  130 . 
         [0147]    Reference is now made to  FIGS. 27I and 28N , which correspond generally to  FIGS. 10A &amp; 10B  and show full extension of arcuate tunneling needle  162  through the bone, as indicated by indicator finger  284  of indicator  166 . This full extension is produced by squeezing of handle  150 , as indicated by an arrow  506 . It is seen that this squeezing of hand-engageable ratchet handle  150  produces rotation thereof, as indicated by arrow  506 , about a rotational axis defined by shaft  154  and, via pin  214 , displaces first reciprocal motion connection element  220  linearly forwardly, as indicated by an arrow  520 , with pointed corner  275  of connection element  220  in engagement with upper linear toothed rack  272  of double rack linear toothed element  270 , thereby driving element  270  and needle driving strip driving shaft  280  forwardly and causing arcuate needle  162 , driven thereby, to travel along an arcuate path through the portion  454  of arcuate bore  452  having a rectangular cross section and to extend outwardly into tunneling engagement with the bone, as indicated by an arrow  522 . 
         [0148]    As seen in  FIG. 28N , movement of needle  162  forms a curved junction between channel  499  and the channel formed by drill  126 . 
         [0149]    It is seen that suture engagement groove  164  of arcuate needle  162 , which is partially defined by end portion  165 , extends between arms  176  rearward of a forward end of suture  184 . 
         [0150]    Reference is now made to  FIGS. 27J and 28O , which correspond generally to  FIGS. 11A &amp; 11B  and show partial retraction of the suture cartridge assembly  170  relative to the working channel assembly  124 , as indicated by an arrow  530 , in response to manual depression of a user-operable suture release lever  188 . This retraction causes the forward folded over end of suture  184  to press rearwardly against needle  162 . 
         [0151]      FIGS. 27K and 28P , which correspond generally to  FIGS. 12A &amp; 12B , show downward repositioning of knob  160 , as indicated by an arrow  532 . 
         [0152]      FIGS. 27L and 28Q , which correspond generally to  FIGS. 13A &amp; 13B , show arcuate retraction of arcuate tunneling needle  162 , as indicated by an arrow  534 , through the bone, driven by further squeezing of handle  150  as indicated by an arrow  535 . The forward folded over end of suture  184  is seen to be in engagement with groove  164  of needle  162 , and to be retained therein by end portion  165  of needle  162 , such that retraction of the needle  162  pulls the suture  184  together with it along the arcuate travel path of the needle  162 . 
         [0153]      FIGS. 27M &amp; 28R , which correspond generally to  FIGS. 14A &amp; 14B , show full retraction of arcuate tunneling needle  162  in engagement with suture  184 , thereby pulling suture  184  through the arcuate passageway being traversed by arcuate needle  162 . This retraction is provided by further squeezing of handle  150 , as indicated by arrow  535 . The complete retraction of arcuate tunneling needle  162  is indicated by indicator finger  284  of indicator  166 . At this stage, suture  184 , in doubled-over configuration, extends entirely through the bone along the arcuate path tunneled by needle  162  through the curved junction formed in the bone by needle  162  and through channel  499 . At this stage, the suture  184  is securely retained in engagement with groove  164  of needle  162 . 
         [0154]      FIGS. 27N and 28S , which correspond generally to  FIGS. 15A &amp; 15B , show the arthroscopic surgical device of  FIGS. 1A-26C  following complete removal and disengagement of the suture cartridge assembly  170  and disengagement of the free ends of the suture  184  therefrom. 
         [0155]      FIGS. 27O and 28T , which correspond generally to  FIGS. 16A &amp; 16B , show partial retraction of tube  130  produced by rotation of winged nut  294 . 
         [0156]      FIGS. 27P and 28U , which correspond generally to  FIGS. 17A &amp; 17B , show complete retraction of tube  130 . 
         [0157]      FIG. 28V  shows removal of the arthroscopic surgical device from the body from the patient through incision  501 , leaving the suture  184  extending through the bone. 
         [0158]      FIGS. 27Q and 28W  show upward repositioning of knob  160 , as indicated by an arrow  536 . 
         [0159]      FIGS. 27R and 28X , which correspond generally to  FIGS. 18A &amp; 18B , show detachment of the suture  184  from arcuate tunneling needle  162  following extension thereof in response to further squeezing of handle  150 , as indicated by an arrow  538 . 
         [0160]    It is appreciated that following detachment of folded over portion of suture  184  from needle  162  free ends of suture  184  are pulled through working channel assembly  124 . As noted above, it is appreciated that free ends of suture  184  remain outside of incision  501  before, during and after the insertion procedure described above with reference to  FIGS. 27A-27R  and  28 A- 28 X. 
         [0161]    It will be appreciated by persons skilled in the art that the present invention is not limited by what has been particularly shown and described hereinabove. Rather the scope of the present invention includes both combinations and subcombinations of the various features described hereinabove as well as modifications thereof which would occur to persons skilled in the art upon reading the foregoing description and which are not in the prior art.