Abstract:
Method and apparatus for reconstructing a ligament. A graft ligament support block comprises a body, a graft hole, and a transverse fixation pin hole extending through the body. An installation tool is provided for inserting the support block into a bone tunnel and forming a transverse tunnel aligned with the pin hole. In use, a graft ligament is looped through the graft hole, and the support block is mounted to the tool. The tool is used to advance the support block into the bone tunnel, with two free ends of the graft ligament extending out the bone tunnel. A transverse tunnel is formed aligned with the pin hole. The support block is secured in place by pinning the support block within the tunnel by advancing a fixation pin along the transverse tunnel and into the pin hole in the support block.

Description:
REFERENCE TO PENDING PRIOR PATENT APPLICATIONS 
     This is a continuation of prior U.S. patent application Ser. No. 10/123,434, filed Apr. 16, 2002 now U.S. Pat. No. 6,712,849 by Paul Re et al. for APPARATUS AND METHOD FOR RECONSTRUCTING A LIGAMENT, which in turn claims benefit of pending prior U.S. Provisional Patent Application Ser. No. 60/326,351, filed Oct. 1, 2001 by Paul Re et al. for APPARATUS AND METHOD FOR RECONSTRUCTING A LIGAMENT. The above-identified patent applications are hereby incorporated herein by reference. 
    
    
     FIELD OF THE INVENTION 
     This invention relates to surgical apparatus and procedures in general, and more particularly to surgical apparatus and procedures for reconstructing a ligament. 
     BACKGROUND OF THE INVENTION 
     A ligament is a piece of fibrous tissue which connects one bone to another. 
     Ligaments are frequently damaged (e.g., detached or torn or ruptured, etc.) as the result of injury and/or accident. A damaged ligament can cause instability, impede proper motion of a joint and cause pain. 
     Various procedures have been developed to repair or replace a damaged ligament. The specific procedure used depends on the particular ligament which is to be restored and on the extent of the damage. 
     One ligament which is frequently damaged as the result of injury and/or accident is the anterior cruciate ligament (i.e., the ACL). Looking first at  FIGS. 1 and 2 , it will be seen that the ACL  5  extends between the top of the tibia  10  and the bottom of the femur  15 . A damaged ACL can cause instability of the knee joint and cause substantial pain and arthritis. 
     Numerous procedures have been developed to restore a damaged ACL through a graft ligament replacement. In general, and looking next at  FIG. 3 , these ACL replacement procedures involve drilling a bone tunnel  20  up through tibia  10  and drilling a bone tunnel  25  up into femur  15 . In some cases the femoral tunnel  25  may be in the form of a blind hole and terminate in a distal end surface  30 ; in other cases the femoral tunnel  25 , or an extension of the femoral tunnel  25 , may pass completely through femur  15 . Once tibial tunnel  20  and femoral tunnel  25  have been formed, a graft ligament  35 , consisting of a harvested or artificial ligament or tendon(s), is passed up through tibial tunnel  20 , across the interior of the knee joint, and up into femoral tunnel  25 . Then a distal portion of graft ligament  35  is secured in femoral tunnel  25  and a proximal portion of graft ligament  35  is secured in tibial tunnel  20 . 
     There are currently a number of different ways to secure a graft ligament in a bone tunnel. One way is to use an interference screw  40  ( FIG. 4 ) to wedge the graft ligament against an opposing side wall of the bone tunnel. Another way is to suspend the graft ligament in the bone tunnel with a button  45  and a suture  50  ( FIG. 5 ) or with a crosspin  55  ( FIG. 6 ). Still another way is to pass the graft ligament completely through the bone tunnel and affix the graft ligament to the outside of the bone with a screw  60  and washer  65  ( FIG. 7 ) or with a staple (not shown). 
     The “Gold Standard” of ACL repair is generally considered to be the so-called “Bone-Tendon-Bone” fixation. In this procedure, a graft of the patella tendon is used to replace the natural ACL. Attached to the opposing ends of the harvested tendon are bone grafts, one taken from the patient&#39;s knee cap (i.e., the patella) and one taken from the patient&#39;s tibia (i.e., at the location where the patella tendon normally attaches to the tibia). The graft ligament is then deployed in the bone tunnels, with one bone graft being secured in the femoral tunnel with an interference screw and the other bone graft being secured in the tibial tunnel with another interference screw. Over the years, this procedure has generally yielded a consistent, strong and reliable ligament repair. However, this procedure is also generally considered to be highly invasive and, in many cases, quite painful, and typically leaves unsightly scarring on the knee and a substantial void in the knee cap. 
     As a result, alternative procedures have recently been developed that incorporate the use of soft tissue grafts such as the hamstring tendon. However, soft tissue grafts such as the hamstring can be difficult to stabilize within a bone tunnel. More particularly, the use of an interference screw to aggressively wedge the hamstring against an opposing side wall of the bone tunnel can introduce issues such as graft slippage, tendon winding, tissue necrosis and tendon cutting. Furthermore, the use of a suture sling (e.g., such as that shown in  FIG. 5 ) and/or a crosspin (e.g., such as that shown in  FIG. 6 ) to suspend the hamstring within the bone tunnel can introduce a different set of issues, e.g., it has been found that the suture sling and/or crosspin tend to permit the graft ligament to move laterally within the bone tunnel, with a so-called “windshield wiper” effect, thereby impeding ingrowth between the graft ligament and the host bone and/or causing abrasion and/or other damage to the graft tissue. In addition, the use of a crosspin (e.g., such as that shown in  FIG. 6 ) to secure a hamstring within the bone tunnel can introduce still other issues, e.g., difficulties in looping the hamstring over the crosspin, or tearing of the hamstring along its length during tensioning if and where the crosspin passes through the body of the hamstring, etc. 
     SUMMARY OF THE INVENTION 
     As a result, one object of the present invention is to provide improved apparatus for reconstructing a ligament, wherein the apparatus is adapted to permit the graft ligament to be fashioned out of various soft tissue grafts, e.g., allografts, autografts, xenografts, bioengineered tissue grafts or synthetic grafts, and further wherein the graft is intended to be secured in place using a transverse fixation pin. 
     Another object of the present invention is to provide an improved method for reconstructing a ligament, wherein the method is adapted to permit the graft ligament to be fashioned out of various soft tissue grafts, e.g., allografts, autografts, xenografts, bioengineered tissue grafts or synthetic grafts, and further wherein the graft is intended to be secured in place using a transverse fixation pin. 
     These and other objects are addressed by the present invention which comprises, in one preferred form of the invention, the provision and use of a graft ligament support block which comprises a body, and a graft hole and a transverse fixation pin hole extending through the body, with both the graft hole and the transverse fixation pin hole preferably extending substantially perpendicular to the longitudinal axis of the body. In one preferred form of the invention, the invention also comprises an installation tool for inserting the graft ligament support block into the bone tunnel and, while supporting the graft ligament support block in the bone tunnel, forming a transverse tunnel in the host bone, with the transverse tunnel in the host bone being aligned with the transverse fixation pin hole in the graft ligament support block. 
     In one preferred method of use, a graft ligament is looped through the graft hole in the graft ligament support block, and the graft ligament support block is mounted to the installation tool. The two free ends of the graft ligament are then preferably secured to a proximal portion of the installation tool under tension, whereby to tie down the two free ends of the graft ligament. In addition to controlling the two free ends of the graft ligament, this arrangement will also help hold the graft ligament support block to the installation tool. Then the installation tool is used to advance the graft ligament support block through the tibial tunnel, across the interior of the knee joint, and up into the femoral tunnel, with the two free ends of the looped graft ligament extending back out through the tibial tunnel. Next, a transverse tunnel is formed in the host bone, with the transverse tunnel being aligned with the transverse fixation pin hole in the graft ligament support block. Then the graft ligament support block is secured in place by pinning the graft ligament support block within the femoral tunnel, i.e., by advancing a transverse fixation pin along the transverse tunnel in the host bone and into the transverse fixation pin hole in the graft ligament support block. Then the two free ends of the looped graft ligament are released from the installation tool, the installation tool is detached from the graft ligament support block, and the installation tool is withdrawn from the surgical site. Finally, the two free ends of the looped graft ligament are secured to the tibia, thus completing the ACL repair. If desired, the tibial attachment can be effected using a second graft ligament support block. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       These and other objects and features of the present invention will be more fully disclosed or rendered obvious by the following detailed description of the preferred embodiments of the invention, which is to be considered together with the accompanying drawings wherein like numbers refer to like parts and further wherein: 
         FIG. 1  is a schematic view of a knee joint, as viewed from the anterior side; 
         FIG. 2  is a schematic view of a knee joint, as viewed from the posterior side; 
         FIG. 3  is a schematic view of a generic ACL reconstruction; 
         FIG. 4  is a schematic view of an ACL reconstruction effected using an interference screw; 
         FIG. 5  is a schematic view of an ACL reconstruction effected using a suture sling; 
         FIG. 6  is a schematic view of an ACL reconstruction effected using a crosspin; 
         FIG. 7  is a schematic view of an ACL reconstruction effected using a screw and washer; 
         FIG. 8  is a schematic view of a graft ligament support block formed in accordance with the present invention; 
         FIG. 9  is a partially exploded view showing the graft ligament support block of  FIG. 8  and an installation tool for deploying the same; 
         FIGS. 10–12  are various views showing the graft ligament support block of  FIG. 8  mounted to the distal end of the installation tool shown in  FIG. 9 ; 
         FIG. 13  is a partial perspective view showing details of the proximal end of the installation tool shown in  FIG. 9 ; 
         FIG. 14  is a side view, partially in section, showing further details of the construction of the installation tool shown in  FIG. 9 ; 
         FIG. 15  is a side sectional view of the installation tool&#39;s drill sleeve; 
         FIG. 16  is a perspective view of a transverse fixation pin which may be used in conjunction with the graft ligament support block of  FIG. 8  and the installation tool of  FIG. 9 ; 
         FIGS. 17–33  are a series of schematic views showing an ACL reconstruction being effected in accordance with the present invention; 
         FIG. 34  is a schematic view showing another form of graft ligament support block formed in accordance with the present invention; 
         FIG. 35  is an enlarged side view showing an alternative construction for a portion of the installation tool; 
         FIG. 36  is a sectional view taken along line  36 - 36  of  FIG. 35 ; 
         FIG. 37  is a schematic view showing a reamer drill guide formed in accordance with the present invention; 
         FIG. 38  is a schematic view showing the reamer element of the reamer drill guide shown in  FIG. 37 ; and 
         FIGS. 39–44  are a series of schematic views showing an ACL reconstruction being effected in accordance with the present invention. 
     
    
    
     DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENT 
     Looking next at  FIG. 8 , there is shown a graft ligament support block  100  which comprises one preferred form of the invention. Graft ligament support block  100  comprises a body  105 , and a graft hole  110  and a transverse fixation pin hole  115  extending through body  105 , with both graft hole  110  and transverse fixation pin hole  115  preferably extending substantially perpendicular to the longitudinal axis  120  of body  105 . In one preferred form of the invention, graft hole  110  and transverse fixation pin hole  115  extend diametrically across body  105 , with graft hole  110  and transverse fixation pin hole  115  extending substantially parallel to one another. Preferably graft hole  110  resides closer to the proximal end  125  of body  105  than transverse fixation pin hole  115 , and transverse fixation pin hole  115  resides closer to the distal end  130  of body  105  than graft hole  110 . In one preferred form of the invention, the distal end of body  105  has a circular cross-section, although it may also have an oval cross-section or a polygonal cross-section (e.g., square or rectangular or triangular, etc.). In one preferred construction, the distal end of body  105  has a cross-section sized just slightly smaller than the diameter of the bone tunnel, so as to provide a close interface between body  105  and the walls of the bone tunnel. In one preferred form of the invention, the distal end  130  of body  105  is tapered so as to facilitate advancement of graft ligament support block  100  through a bone tunnel. And in a preferred form of the invention, the proximal end of body  105  is sculpted away, e.g. such as shown at  135 , so as to provide more room for a graft ligament looped through graft hole  110  and extending distally therefrom. Body  105  also includes a pair of recesses  140  for mounting body  105  to an appropriate installation tool, as will hereinafter be discussed in further detail. 
     If desired, graft ligament support block  100  may also include suture hole  145  for receiving a tow suture, as will hereinafter be discussed in further detail. 
     Additionally, if desired, the proximal end of graft hole  110  may be tapered as shown at  150  so as to provide a less traumatic bearing surface for a graft ligament looped through graft hole  110 , and/or the entrance of transverse fixation pin hole  115  may be tapered as shown at  155  so as to facilitate entry of a transverse fixation pin into transverse fixation pin hole  115 . 
     Body  105  may be formed out of a polymer, a bioabsorbable or bioremodelable material, allograft bone, a metal, a ceramic, coral, a fiber composite, a composite including at least one of the foregoing, etc. By forming body  105  out of a relatively strong material, the graft ligament can be held under tension even where body  105  is relatively small, or where one or more of the holes  110 ,  115  and/or  145  is located fairly close to the periphery of body  105 . 
     Looking next at  FIGS. 9–15 , there is shown an installation tool  200  which may be used in conjunction with graft ligament support block  100 . Installation tool  200  generally comprises a holder  205  and an associated drill guide  210 . 
     Holder  205  comprises a shaft  215  having a pair of fingers  220  at its distal end and a handle  225  at its proximal end. Fingers  220  allow installation tool  200  to mate with, and releasably hold, graft ligament support block  100  by selectively fitting into the recesses  140  ( FIG. 8 ) formed on the proximal end of graft ligament support block  100 . See  FIGS. 9–12  and  14 . In essence, fingers  220  and recesses  140  comprise a male/female connection; if desired, the locations of the male and female members may be reversed (i.e., with the male portion on support block  100  and the female portion on holder  205 ); or an alternative type of connection (e.g., a grasper) may be used. Preferably one or more suture posts  227  are formed on the proximal end of shaft  215  adjacent to handle  225 . Suture posts  227  allow the two free ends of a graft ligament to be secured to the installation tool, as will hereinafter be discussed in further detail. Handle  225  allows installation tool  200  to be conveniently grasped by a user. Handle  225  includes a post hole  230 . Post hole  230  allows drill guide  210  to be releasably secured to holder  205 , as will hereinafter be discussed in further detail. 
     Drill guide  210  comprises an outrigger  235  having a threaded bore  240  ( FIG. 14 ) formed in its distal end  245 , and a slot  250  ( FIG. 9 ) and post  255  at its proximal end  260 . The end of post  255  is threaded, e.g., as shown at  265 . 
     The threaded bore  240  ( FIG. 14 ) in the outrigger&#39;s distal end  245  is sized to receive a drill sleeve  270  therein. Drill sleeve  270  has threads  275  along its length and terminates in a proximal head  280 . Head  280  can be used to manually rotate drill sleeve  270  within the outrigger&#39;s threaded bore  240 , whereby to move drill sleeve  270  relative to the distal end  245  of outrigger  235 . A lumen  285  extends through drill sleeve  270 . 
     Slot  250  and post  255  permit outrigger  235  to be releasably mounted to holder  205 . More particularly, outrigger  235  may be mounted to holder  205  by fitting the holder&#39;s shaft  215  in the outrigger&#39;s slot  250  ( FIGS. 13 and 14 ), fitting the outrigger&#39;s post  255  in the holder&#39;s post hole  230 , and then tightening nut  290  onto the threaded end  265  of post  255 . 
     As will hereinafter be described, graft ligament support block  100  and installation tool  200  are intended to be used in conjunction with a transverse fixation pin. One preferred transverse fixation pin  300  is shown in  FIG. 16 . Transverse fixation pin  300  generally comprises a solid shaft  305  terminating in a tapered distal end  310 , and a ribbed (or barbed or threaded) section  315 . A non-circular socket  320  is formed in the proximal end of transverse fixation pin  300 , whereby transverse fixation pin  300  may be engaged by a driver. 
     An ACL reconstruction effected in accordance with the present invention will now be described. 
     First, the surgical site is prepared for the graft ligament, e.g., by clearing away the damaged ACL, etc. Then a guidewire  400  ( FIG. 17 ) is drilled up through tibia  10  and into the interior of the knee joint. Preferably guidewire  400  is stopped short of engaging the bottom of femur  15  ( FIG. 18 ). Then a cannulated tibial drill  500  ( FIG. 19 ) is loaded onto guidewire  400  and drilled up through tibia  10  and into the interior of the knee joint ( FIG. 20 ). Then cannulated tibial drill  500  is withdrawn back down the guidewire ( FIG. 21 ), leaving a tibial tunnel  20 . 
     Next, guidewire  400  is drilled an appropriate distance into the interior of femur  15 . If desired, guidewire  400  may be drilled all the way through femur  15  ( FIG. 22 ), for reasons which will hereinafter be described. Then a cannulated femoral drill  600  (e.g., an acorn drill) is loaded onto guidewire  400  ( FIG. 22 ), passed through tibial tunnel  20 , across the interior of the knee joint, and then drilled up into femur  15 , stopping within the interior of femur  15  ( FIG. 23 ). Then cannulated femoral drill  600  is withdrawn back down the guidewire, leaving a femoral tunnel  25  ( FIG. 24 ). 
     Next, a graft ligament  35  is mounted to graft ligament support block  100  by threading one end of the graft ligament through graft hole  110 , and then graft ligament support block  100  is mounted to the distal end of shaft  215 , i.e., by seating fingers  220  in recesses  140 . The two free ends of graft ligament  35  are preferably held taut, e.g., by passing sutures  70  through the two free ends of graft ligament  35  and then securing those sutures (e.g., by winding) to suture posts  227 . This arrangement will help control the two free ends of graft ligament  35  and will help hold graft ligament support block  100  to holder  205 . Then installation tool  200  is used to push graft ligament support block  100 , and hence graft ligament  35 , up through tibial tunnel  20  ( FIG. 25 ), across the interior of the knee joint, and up into femoral tunnel  25  ( FIG. 26 ). 
     If desired, all of the force required to advance graft ligament support block  100  and graft ligament  35  through tibial tunnel  20 , across the interior of the knee joint, and up into femoral tunnel  25  may be supplied by pushing distally on installation tool  200 . Alternatively, if guidewire  400  has been drilled completely through femur  15  (e.g., such as is shown in  FIG. 22 ), and if the proximal end of guidewire  400  includes a suture eyelet (e.g., such as the suture eyelet  405  shown in  FIGS. 23 and 24 ), a suture may be used to help tow graft ligament support block  100  and graft ligament  35  up into position. More particularly, a suture  700  ( FIG. 25 ) may be looped through the suture hole  145  in graft ligament support block  100  and through suture eyelet  405  on guidewire  400 ; then, by pulling distally on the portion of guidewire  400  extending out of the top end of femur  15 , suture  700  can be used to help tow graft ligament support block  100  and graft ligament  35  up into position ( FIG. 26 ). Such an arrangement will help reduce the amount of force which needs to be delivered by installation tool  200  to push graft ligament support block  100  and graft ligament  35  up into position. 
     Once graft ligament support block  100  and graft ligament  35  have been advanced into position ( FIG. 26 ), drill sleeve  270  is advanced into tight engagement with femur  15  ( FIG. 27 ). This action will help stabilize installation tool  200  relative to femur  15 . Then a transverse tunnel drill  800  ( FIG. 28 ) is used to drill a transverse tunnel  75  through the lateral portion of femur  15 , through transverse fixation pin hole  115  in graft ligament support block  100 , and into the medial portion of femur  15 . In this respect it will be appreciated that transverse tunnel drill  800  will be accurately and consistently directed through transverse fixation pin hole  115  in graft ligament support block  100  ( FIG. 28 ) due to the fact that the orientation of graft ligament support block  100  and installation tool  200  (and hence drill sleeve  270 ) is regulated by the engagement of fingers  220  in recesses  140 . 
     Once transverse tunnel drill  800  has been used to drill transverse tunnel  75 , transverse tunnel drill  800  is removed ( FIG. 29 ). Then drill sleeve  270  is loosened and outrigger  235  dismounted from holder  205 . Then transverse fixation pin  300 , mounted on a driver  325  ( FIG. 30 ), is advanced into transverse tunnel  75  and across transverse fixation pin hole  115  in graft ligament support block  100  ( FIG. 31 ), whereby to secure graft ligament support block  100  (and hence graft ligament  35 ) in femoral tunnel  25 . Depending on whether section  315  of transverse fixation pin  300  is ribbed or barbed or threaded, the transverse fixation pin may be advanced by driver  325  by tapping on the proximal end of the driver with a mallet or by rotating the driver and/or both. The driver  325  is then removed ( FIG. 32 ). Next, the two free ends of graft ligament  35  are detached from the handle&#39;s suture posts  227 , and holder  205  is withdrawn ( FIG. 33 ). In this respect it will be appreciated that graft ligament support block  100  will be held in position in femoral tunnel  25  when holder  205  is withdrawn due to the presence of transverse fixation pin  300  in transverse tunnel  75  and transverse fixation pin hole  115 . Finally, the two free ends of graft ligament  35  are secured to tibia  10 , thereby completing the ACL reconstruction procedure. 
     In the embodiment disclosed above, transverse fixation,pin hole  115  ( FIG. 8 ) is pre-formed in body  105 . Such a construction is generally advantageous, since it eliminates the need to drill through body  105  after graft ligament support block  100  has been positioned in the femoral tunnel and before transverse fixation pin  300  has been passed through body  105 . In addition, by pre-forming transverse fixation pin hole  115  in body  105 , transverse fixation pin hole  115  can be given a desired geometry, e.g., it permits the entrance to crosspin hole  115  to be tapered, such as is shown at  155  in  FIG. 8 , whereby to help center transverse fixation pin  300  in transverse fixation pin hole  115 . However, it should also be appreciated that, if desired, transverse fixation pin hole  115  may not be pre-formed in body  105 . Instead, transverse fixation pin hole  115  may be formed in situ, at the time of surgery, e.g., by drilling across body  105  when forming transverse tunnel  75  with transverse tunnel drill  800 . Where transverse fixation pin hole  115  is to be formed in situ, it is of course necessary for body  105  to be formed out of a drillable material. In addition, where transverse fixation pin hole  115  is to be formed in situ, it is preferred that body  105  be formed out of a relatively strong material, since then any misplacement (i.e., any off-center placement) of transverse fixation pin hole  115  will be well tolerated by body  105 . 
     Additionally, in the embodiment disclosed above, the outer surface of body  105  is sculpted away proximal to graft hole  110 , such as is shown at  135  in  FIG. 8 , so as to help accommodate the graft ligament in femoral tunnel  25 . In  FIG. 8 , sculpting is effected so as to produce a substantially planar surface at  135 . However, if desired, sculpting can be effected so as to provide alternative geometries, e.g., a surface groove, etc. Thus, for example, in  FIG. 34  body  105  is shown with a pair of surface grooves  165  communicating with, and extending proximally from, graft hole  110 . Surface grooves  165  are sized so as to provide a recess for seating portions of the graft ligament as the graft ligament extends proximally from graft hole  110 . 
     Also, in the embodiment disclosed above, body  105  is shown (see, for example,  FIG. 8 ) as having a relatively smooth outer surface. However, if desired, body  105  may have spikes or ribs, etc. formed on a side wall thereof so as to help stabilize body  105  within the bone tunnel. 
     Furthermore, in the embodiment disclosed above, drill sleeve  270  is movably connected to outrigger  235  via a screw connection (i.e., screw threads  275  on the exterior of drill sleeve  270  and threaded bore  240  in outrigger  235 ). This arrangement provides a simple and cost-effective way to movably secure drill sleeve  270  to outrigger  235 . However, if desired, other types of arrangements could also be used. For example, and looking now at  FIGS. 35 and 36 , drill sleeve  270  could have a smooth or ribbed or roughed (e.g. knurled) exterior  275 A that slides through a non-threaded bore  240 A in outrigger  235 , with a locking pin  235 A being selectively advanceable (through a threaded bore  235 B) into engagement with drill sleeve  270 , whereby to selectively lock the drill sleeve to the outrigger. Still other possible arrangements for selectively locking drill sleeve  270  to outrigger  235  will be apparent to those skilled in the art of drilling and drill sleeves. 
     Also, in the embodiment disclosed above, drill guide  210  is shown (see, for example,  FIG. 14 ) as being releasably secured to holder  205  via a post  255  and tightening nut  290 . However, it should be appreciated that other types of connections (e.g., a “quick release” clamping mechanism) may also be used to releasably secure drill guide  210  to holder  205 . 
     It is also possible to form transverse tunnel  75  before graft ligament support block  100  and graft ligament  35  are positioned in femoral tunnel  25 . More particularly, in one possible arrangement, a reamer drill guide  200 A ( FIG. 37 ) may be used. Reamer drill guide  200 A is substantially identical to the installation tool  200  described above, except as will hereinafter be described. More particularly, reamer drill guide  200 A comprises a reamer  205 A and the drill guide  210 . Reamer  205 A is substantially identical to the holder  205  described above, except that it has a cylindrical element  220 A ( FIGS. 37 and 38 ) at its distal end having a transverse hole  220 B extending therethrough, and it omits the suture posts  227  which are preferably provided on holder  205 . Reamer  205 A is configured so that (i) its cylindrical element  220 A has a diameter approximately equal to the diameter of femoral tunnel  25 , and (ii) when drill guide  210  is attached to reamer  205 A, the lumen  285  in drill sleeve  270  will be aligned with transverse hole  220 B in reamer  205 A. 
     Graft ligament support block  100 , holder  205  and reamer drill guide  200 A may be used to effect an ACL reconstruction as follows. 
     First, the surgical site is prepared for the graft ligament, e.g., by clearing away the damaged ACL, etc. Then a guidewire  400  ( FIG. 17 ) is drilled up through tibia  10 , across the interior of the knee joint. Preferably guidewire  400  is stopped short of engaging the bottom of femur  15  ( FIG. 18 ). Then a cannulated tibial drill  500  ( FIG. 19 ) is loaded onto guidewire  400  and drilled up through tibia  10  and into the interior of the knee joint ( FIG. 20 ). Then cannulated tibial drill  500  is withdrawn back down the guidewire ( FIG. 21 ), leaving a tibial tunnel  20 . 
     Next, guidewire  400  is drilled an appropriate distance into the interior of femur  15 . Then a cannulated femoral drill  600  (e.g., an acorn drill of the type shown in  FIG. 22 ) is loaded onto guidewire  400 , passed through tibial tunnel  20 , across the interior of the knee joint, and then drilled up into femur  15 , stopping within the interior of femur  15 . Then cannulated femoral drill  600  is withdrawn back down the guidewire, leaving a femoral tunnel  25 , and then guidewire  400  is withdrawn (see  FIG. 39 ). 
     Next, reamer drill guide  200 A is advanced so that its cylindrical element  220 A is advanced through tibial tunnel  20 , across the interior of the knee, and up into femoral tunnel  25 . In this respect it should be appreciated that as reamer drill guide  200 A is advanced through tibial tunnel  20  and femoral tunnel  25 , its cylindrical element  220 A will ream both bone tunnels, clearing out any intervening debris. 
     Once reamer drill guide  200 A has been advanced into position, drill sleeve  270  is advanced into tight engagement with femur  15 . This action will help stabilize reamer drill guide  200 A relative to femur  15 . Then a transverse tunnel drill  800  ( FIG. 40 ) is used to drill a transverse tunnel  75  through the lateral portion of femur  15 , through transverse hole  220 B in cylindrical element  220 A, and into the medial portion of femur  15 . In this respect it will be appreciated that transverse tunnel drill  800  will be accurately and consistently directed through transverse hole  220 B in cylindrical element  220 A ( FIG. 40 ) due to the fact that the relative orientation of cylindrical element  220 A and drill sleeve  270  is regulated by the pre-defined engagement of drill guide  210  with reamer  205 A. 
     Once transverse tunnel drill  800  has been used to drill transverse tunnel  75 , transverse tunnel drill  800  is removed. Then drill sleeve  270  is loosened and reamer drill guide  200 A is withdrawn from the surgical site ( FIG. 41 ). 
     Next, a graft ligament  35  is mounted to graft ligament support block  100  by threading one end of the graft ligament through graft hole  110 , and then graft ligament support block  100  is mounted to the distal end of shaft  215 , i.e., by seating fingers  220  in recesses  140 . The two free ends of graft ligament  35  are preferably held taut, e.g., by passing sutures  70  through the two free ends of graft ligament  35  and then securing these sutures (e.g., by winding) to suture posts  227 . This arrangement will help control the two free ends of graft ligament  35  and will help hold graft ligament support block  100  to holder  205 . Then holder  205  is used to push graft ligament support block  100 , and hence graft ligament  35 , up through tibial tunnel  20 , across the interior of the knee joint, and up into femoral tunnel  25  ( FIG. 42 ). As graft ligament support block is advanced in femoral tunnel  25 , or after it has been advanced an appropriate distance into femoral tunnel  25 , it is rotated as necessary, by turning handle  225  as necessary, so as to align the transverse fixation pin hole  115  with transverse tunnel  75 . Such alignment may be facilitated by providing an alignment marker (e.g., such as the alignment marker  225 A shown in  FIG. 43 ) on handle  225 . 
     Then transverse fixation pin  300 , mounted on a driver  325 , is advanced into transverse tunnel  75  and across transverse fixation pin hole  115  in graft ligament support block  100  ( FIG. 44 ), whereby to secure graft ligament support block  100  (and hence graft ligament  35 ) in femoral tunnel  25 . Then driver  325  is removed. Next, the two free ends of graft ligament  35  are detached from the handle&#39;s suture posts  227 , and holder  205  is withdrawn. In this respect it will be appreciated that graft ligament support block  100  will be held in position in femoral tunnel  25  when holder  205  is withdrawn due to the presence of transverse fixation pin  300  in transverse tunnel  75  and transverse fixation pin hole  115 . Finally, the two free ends of graft ligament  35  are then secured to tibia  10 , thereby completing the ACL reconstruction procedure. 
     In the preceding discussion, the present invention has been discussed on the context of an ACL reconstruction. However, it should be appreciated that the present invention may also be used in connection with the other types of ligament reconstructions and/or other types of anatomical reconstructions.