Abstract:
An anterior cruciate ligament (ACL) surgical repair technique involves the use of a single femoral and tibial tunnel and an implant that separates and positions two distinct bundles. This allows for the surgeon to create a more anatomic reconstruction with a procedure that is less technically demanding, can be performed using a transtibial or anteromedial approach, minimizes tunnel widening, and decreases operative time. The result is a strong fixation option for soft tissue grafts, with circumferential graft compression at the aperture, high pull-out strength, and ease of use. The graft bundles are positioned in a more anatomic orientation through the above noted single femoral and tibial tunnel.

Description:
This application is a continuation application under 35 U.S.C. 120 of commonly assigned U.S. patent application Ser. No. 12/721,319 entitled Methods and Systems for Material Fixation, filed Mar. 10, 2010, which in turn claims the benefit under 35 U.S.C. 119(e) of the filing date of Provisional U.S. Application Ser. No. 61/158,994, entitled Anterior Cruciate Ligament Surgical Reconstruction Technique, filed on Mar. 10, 2009 and of the filing date of Provisional U.S. Application Ser. No. 61/158,999, also entitled Anterior Cruciate Ligament Surgical Reconstruction Technique, filed on Mar. 10, 2009. 
     This application is also related to U.S. application Ser. No. 11/281,566 entitled Devices, Systems, and Methods for Material Fixation, filed on Nov. 18, 2005 and now issued as U.S. Pat. No. 7,651,528, to U.S. application Ser. No. 11/725,981, entitled Devices, Systems, and Methods for Material Fixation, filed on Mar. 20, 2007 and now issued as U.S. Pat. No. 7,967,861, to U.S. application Ser. No. 11/923,526, entitled Methods and Systems for Material Fixation, filed on Oct. 24, 2007 and now issued as U.S. Pat. No. 7,879,094, to U.S. application Ser. No. 12/437,020, entitled Manual Soft Tissue Tensioning Systems and Methods, filed on May 7, 2009 and now issued as U.S. Pat. No. 8,123,806, to co-pending U.S. application Ser. No. 12/437,007, entitled Inserter for Soft Tissue or Bone-to-Bone Fixation Device and Methods, filed on May 7, 2009, and to co-pending U.S. application Ser. No. 12/634,581, entitled Devices, Systems, and Methods for Material Fixation, filed on Dec. 9, 2009. 
     All of the above prior applications are commonly owned and herein expressly incorporated by reference, in their entirety. 
    
    
     BACKGROUND OF THE INVENTION 
     The present invention relates generally to devices, systems and methods for material fixation. More specifically, the present invention relates to techniques that can be used to firmly hold a soft tissue or graft against bone tissue within a bone tunnel. 
     It is known that the anterior cruciate ligament (ACL) is comprised of two bundles, the anteromedial (AM) bundle and the posterolateral (PL) bundle. However, the traditional transtibial ACL reconstruction re-creates only the AM bundle, and recent data has shown that this may not restore normal rotational knee kinematics. In order to address this deficiency in rotational stability, surgeons have developed techniques to reconstruct both the AM and PL bundles of the ACL, comparing the double bundle reconstruction. These techniques, which require the placement of two tibial and two femoral tunnels, increase the complexity of the operation, and this may result in increased complications and compromise revision surgery. In addition, the size of the tibial footprint may be prohibitively small in some patients, making it difficult to create two anatomic tunnels. 
     What is needed, therefore, are improved methods which do not require the creation of multiple tibial and/or femoral tunnels to achieve placement of a double bundle tendon graft. 
     SUMMARY OF THE INVENTION 
     The present invention comprises techniques which utilize a new implant system to reconstruct the ACL. The inventive techniques have been characterized as a “single-tunnel, double-bundle ACL reconstruction”. This technique involves the use of a single femoral and tibial tunnel and an implant that separates and positions two distinct bundles. This allows for the surgeon to create a more anatomic reconstruction with a procedure that is less technically demanding, can be performed using a transtibial or anteromedial approach, minimizes tunnel widening, and decreases operative time. The result is a strong fixation option for soft tissue grafts, with circumferential graft compression at the aperture, high pull-out strength, and ease of use. The graft bundles are positioned in a more anatomic orientation through the above noted single femoral and tibial tunnel. 
     More particularly, there is described a method for repairing a damaged ligament surgically, which comprises a step of preparing a ligament graft to be inserted in place of the damaged ligament, wherein the graft comprises an anteromedial (AM) bundle having a plurality of graft strands and a posterolateral (PL) bundle having a plurality of graft strands. The preparing step further includes a step of securing the end of each graft strand of both bundles using suture, and a step of doubling the graft over itself. This suture securing step preferably includes stitching the ends of each graft strand using a whip stitch. Another innovative feature of the invention is the preferred usage of a first suture color to secure the graft strands of the AM bundle and a second different suture color to secure the graft strands of the PL bundle. 
     A femoral implant, which comprises movable portions which may be deployed to expand outwardly to engage adjacent bone, is selected to have a size suitably compatible to the size of the prepared ligament graft. A tibial tunnel and a femoral socket are created, using well known prior art methods, for receiving the ligament graft. Advantageously, unlike in prior techniques for attempting to utilize double bundle grafts in a single tunnel approach, no additional steps of widening the tibial tunnel or femoral socket are required to accommodate either the bulk of the graft bundles or interference fixation devices are required. 
     Additional method steps include securing the graft strand bundles to the femoral implant so that they extend proximally from both sides of the implant, wherein the AM bundle extends along one side of the implant and the PL bundle extends along an opposing side of the implant, and securing ends of the suture used to secure the graft bundles to an insertion device in a manner as to ensure optimal anatomical placement of the AM and PL graft bundles. The femoral implant is inserted through the tibial tunnel and into the femoral socket to a desired depth, following which, the movable portions of the femoral implant are deployed to expand outwardly into adjacent bone. The suture securing ends are disengaged from the insertion device, the insertion device is released from the femoral implant and proximally withdrawn from the tibial tunnel. Then, the graft bundles are tensioned, and their proper positioning in the knee is ensured. 
     Advantageously, neither the femoral implant nor the tibial implant utilize interference fixation to secure the graft. The graft strand bundles are secured to the femoral implant by inserting them through an aperture extending through the implant. In a preferred approach, the step of securing the ends of the suture to an insertion device comprises securing the ends of the suture extending from the AM bundle to one side of the insertion device and the ends of the suture extending from the PL bundle the an opposing side of the insertion device. The step of securing the ends of the suture to the insertion device comprises wrapping the suture about suture cleats disposed on the insertion device. 
     Another advantageous feature of the inventive methods comprises a step of making a horizontal mark on the tendon bundles at an edge of the femoral implant to serve as a depth indicator. Marks are also made on the graft strands that represent the AM bundle on the both the implant end and the sutured end to assist in identification of the respective AM and PL bundles during the procedure. 
     Before the femoral implant is deployed, the grafts representing the AM bundle are positioned in a poster-superior position and the grafts representing the PL bundle in an antero-inferior position prior to deploying the femoral implant. 
     The step of tensioning the graft bundles preferably further comprises a step of securing the suture ends extending from the AM bundle to one side of a tensioning device and a further step of securing the suture ends from the PL bundle to an opposing side of the tensioning device, in order to ensure that equal tension is applied to each graft. 
     The inventive method additionally comprises a step of inserting and deploying a tibial anchor for securing the graft bundles in place within the tibial tunnel. 
     The invention, together with additional features and advantages thereof, may best be understood by reference to the following description taken in conjunction with the accompanying illustrative drawing. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG. 1  is an isometric view of an insertion device for inserting and deploying a femoral implant; 
         FIG. 2  is an enlarged view of a portion of the distal end of the inserter of  FIG. 1 , showing the graft bundles to be anchored using the inventive techniques; 
         FIG. 3  is an enlarged view of a different portion of the distal end of the inserter of  FIG. 1 , again showing the graft bundles to be anchored using the inventive techniques; 
         FIG. 4  is a representation of the implant system as described herein as it is installed in a human knee; 
         FIG. 5  is a view illustrating soft tissue grafts as prepared using the techniques of the present invention, after they have been passed through the orifices of the femoral implant; 
         FIG. 6  is an enlarged illustration of the femoral implant and graft as implanted, with the knee in a flexed orientation; 
         FIG. 7  is an isometric view of the handle portion of the inserter of  FIG. 1 ; 
         FIG. 8  is an illustration of a step of deploying the implant under the inventive technique; 
         FIG. 9  is an illustration of a step subsequent to the step shown in  FIG. 8 ; 
         FIG. 10  is an illustration showing the sutures disengaged from the suture cleats; 
         FIG. 11  is a view of the handle portion of the inserter of  FIG. 7 , showing a releasing step for releasing the inserter from the implant; 
         FIG. 12  is a view illustrating a first step in a sequence of orienting and tensioning the suture; 
         FIG. 13  is a view illustrating a second step in the sequence; 
         FIG. 14  is a view illustrating a third step in the sequence; 
         FIG. 15  is a view illustrating a fourth step in the sequence; 
         FIG. 16  is a view illustrating a step of inserting the tibial sheath into the knee; 
         FIG. 17  is a view showing a step of inserting the tibial screw into the sheaths and tightening the screw; and 
         FIGS. 18 and 19  are views showing the installed tibial sheath. 
     
    
    
     DETAILED DESCRIPTION OF THE INVENTION 
     The present inventive technique is indicated for primary and revision reconstruction of ACL deficient patients. The procedure should be considered for any patient with a pronounced pivot shift, and therefore, rotational instability. The inventive ACL reconstruction techniques afford surgeons a strong fixation option for soft tissue grafts, with circumferential graft compression at the aperture, high pull-out strength, and ease of use. The graft bundles are positioned in a more anatomic orientation through a single femoral and tibial tunnel. 
     Arthroscopy and Preparation 
     In accordance with the inventive techniques, the patient is positioned supine on the operating table in the ACL position preferred by the surgeon. A diagnostic arthroscopy is performed and concomitant pathology is addressed. Diagnosis of ACL rupture is confirmed and the ACL remnant is derided. The center of the both the tibial and femoral footprints of the ACL are identified and marked with a thermal device prior to complete removal. These locations will serve as the center for the femoral socket and tibial tunnel. 
     Graft Preparation 
     A hamstring autograft or allograft is recommended. Alternatively, if tibialis allograft (anterior or posterior) is used, one half of the graft must be divided into two segments, each with an approximate width of 6 mm. In the illustrated example, graft preparation is completed using the Gracilis and Semitendinosis tendons. 
     Referring particularly to  FIGS. 1-6 , in  FIG. 1  there is shown an insertion device  10  which comprises a handle portion  12  and a distal end portion  14 . A graft  16  is disposed about the distal end  14  of the device  10 . The graft  16  comprises an AM bundle  18  and a PL bundle  20 . Both ends of both graft strands are secured, preferably with a #2 non-absorbable suture in a whip-stitch fashion, as shown at  22  and  24 , respectively. In a preferred approach, different colored sutures are used to distinguish between the AM and PL bundles. For example, one end of the Semitendinosis Graft is stitched with a blue suture, and the other end with a green suture. The same process is completed with the Gracilis Graft. 
     Once the graft strands are stitched, the graft is doubled over itself and measured with a sizing guide, such as a graft sizing block (not shown), trough which the graft bundles are pulled. Using a graft sizing block, a diameter is selected through which the graft bundle fits tightly, but still passes through. An appropriately sized femoral implant  26  is then selected, and each graft strand is mounted onto the femoral implant  26 , by inserting the strands through the implant aperture  28  as shown particularly in  FIG. 5 . 
     Tibial Tunnel Placement 
     A tibial tunnel  30  and femoral socket  32  ( FIG. 4 ) are created in the tibia  33   a  and femur  33   b , respectively, in the usual fashion. A particular advantage of the present invention, in contrast to prior approaches, is that little or no modification, such as widening or notching, of the otherwise usual tunnels need be performed. Thus, the tibial tunnel  30  is placed in the center of the tibial footprint. This is medial to the posterior aspect of the anterior horn of the lateral meniscus. The guide pin for the tibial tunnel is placed immediately anterior to the MCL with the tibial guide set at 50 degrees, at a minimum of 3 cm distal to the joint. This medial starting point creates a more horizontal tibial tunnel, allowing placement of a femoral socket lower down the notch wall. The guide pin is drilled from this point to the center of the ACL tibial footprint, on the medial third of the intercondylar plateau, in line with the posterior border of the anterior horn of the lateral meniscus. This guide pin is then over-drilled with the appropriate sized cannulated reamer, typically 9 or 10 mm, as previously determined by the size of the graft. 
     Femoral Socket Placement 
     The femoral socket  32  is positioned in the center of the femoral footprint, low on the femoral notch (two o&#39;clock in a left knee, ten o&#39;clock position in a right knee). This location is typically accessible with an ACL over-the-top guide through the tibial tunnel. Alternatively, if this point is not accessible through the tibial tunnel, a low antero-medial portal is employed. The guide pin for the femoral fixation device should be inserted to the cortex of the femur. Depth marks on the guide pin indicate the length of the femoral tunnel. After insertion of the guide pin, the pin is over-reamed with the appropriately sized reamer, usually 9 or 10 mm, to a depth that permits femoral implant placement (minimum 30 mm). 
     Graft Placement and Fixation 
     The distal end portion  14  of the insertion device  10  comprises a shaft  34 , to the distal end of which is secured the femoral implant  26 , as shown in  FIG. 5 . The next step in the inventive procedure is to pass the prepared soft tissue double bundle grafts  16  through the orifice or aperture  28 , as also shown in  FIG. 5 . Then, the sutures  36  of the prepared tendons  16  are wrapped around suture cleats  38  on the inserter handle portion  12  ( FIG. 1 ). To achieve optimal anatomical placement of the bundles, it is preferred that the like-colored, sutured graft ends representing the AM bundle be wrapped on one suture cleat. The sutured ends representing the PL bundle are wrapped on the opposite suture cleat. A horizontal mark  40  ( FIG. 1 ) is made on the tendon bundles at the inferior edge of the implant  26  to serve as the aperture depth indicator. By turning the inserter handle  12  over, with the safety pin  42  facing down, additional marks  44  ( FIG. 3 ) are made on the grafts that represent the AM bundle at both the implant end and the sutured end. This helps with intra-articular and extra-articular identification of the bundles once inserted into the femoral tunnel. 
     The femoral fixation device  26  with the graft  16  properly positioned is inserted through the tibial tunnel  30  (or the AM portal if this was used to create the femoral tunnel) into the femoral socket  32 . This insertion step is preferably done while holding the implant inserter handle portion  12  with the safety pin  42  in an upward facing orientation, and the insertion step continues until the implant is moved distally into the femoral socket to the marked depth location  40 . This step is illustrated in  FIG. 6 . The device should be oriented so that one graft is positioned postero-superior (ten o&#39;clock position in the left knee flexed to 90 degrees) and one graft is antero-inferior (four o&#39;clock position in the left knee flexed to 90 degrees) to approximate anatomic orientation until the implant is seated. For the illustrated device, this is accomplished particularly, for the purpose of achieving optimal anatomic femoral placement of the graft bundles, by rotating the inserter, with the knee flexed to 90 degrees, until the marked grafts representing the AM bundle are placed in the postero-superior position and the PL bundles are placed in the antero-inferior position. Orientation of the suture cleats  38 , located on the inserter handle  12 , will be approximately 10 and 4 o&#39;clock for a left knee. 
     The device is then deployed, providing for aperture femoral fixation. This is done by ensuring the implant is in proper position and the safety pin  42  is completely pulled out of the handle  12 , by pulling upwardly ( FIG. 7 ). The release of the safety pin  42  permits a deployment knob  46  to rotate. 
     With the inserter handle  12  held firmly in place, the implant deployment knob  46  may be rotated ( FIG. 8 ) in the direction of arrow  48 , clockwise, until the deployment knob can no longer be turned, advancing distally to the point that it comes into contact with the remaining portion of the inserter handle  12 . This advanced position is shown in  FIG. 9 , wherein the femoral implant is fully deployed, to engage expanded portions of the implant, which have been moved outwardly during the deployment sequence, as shown, with adjacent bone. 
     Once the implant  26  is deployed, the sutures  36  are disengaged from the suture cleats  38 , as shown in  FIG. 10 . The inserter  10  is then released from the implant  26  by pulling proximally an implant release knob  50  from the deployment knob  46 , as illustrated in  FIG. 11 , and holding it in the retracted position. Next, the inserter handle  12  is drawn back. The inserter  12  is removed from the operative site and discarded. 
     A tendon expander or suture tensioning device  52  is held in an orientation generally perpendicular to the tibial tunnel ( FIG. 12 ), and the sutured ends  36  of the tendon bundles are wrapped around suture cleats  54  on either end of the tensioning device  52 . This is done in such a way that the sutures are first inserted into lateral slits  56  ( FIG. 13 ), and then wrapped around the vertical cleats  54 . This procedure is disclosed more fully in U.S. application Ser. No. 12/487,020, already expressly incorporated herein by reference. By anchoring the AM and PL bundles to opposite sides of the tensioner, equal tension is applied to each graft using this convenient one-handed device. 
     As shown sequentially in  FIGS. 13-15 , for proper orientation of the graft bundles at the tibial aperture, the tensioner  52  is positioned, as noted above, until the tendons representing the AM bundle are positioned in the anteromedial portion of the tunnel, and the PL bundle is positioned in the posterolateral portion. Rotation occurs by holding the T-handle of the tensioner, with visualization of the tibial footprint, so that one graft limb is positioned in the anteromedial portion of the tunnel and one in the posterolateral portion. This process of positioning the bundles can be facilitated by inserting a flat device, such as a Freer elevator, into the tibial tunnel between the bundles to rotate the graft at the internal aperture. Holding the bundles in the desired orientation, the knee is then cycled with tension applied to the graft. 
     Once this tensioning procedure has been completed, it is time to insert the tibial sheaths and screw, with the sheaths being oriented so that one bundle sits at the PL aspect of the tunnel and the other sits on the AM border. The knee is placed in full extension, and with the graft under tension, the tibial sheaths  58  are inserted into the tibial tunnel, between the tendon bundles, such that cortical engagement tabs  61  ( FIGS. 18 and 19 ) on the sheaths are in the 9 o&#39;clock position for a left knee and 3 o&#39;clock for a right knee. The sheaths should be positioned so that the tabs  61  are fully seated against the tibia. Care is taken throughout this final procedure to maintain tension on the graft with the tensioner  52  to prevent loss of graft tension. At this point, the sheath inserter  60  ( FIG. 16 ) is snapped off, disengaged from the sheaths, and discarded. 
     At this juncture, a tibial screw  62 , selected to be of a size to match the diameter of the tibial tunnel, is securely placed onto a distal end of a tibial inserter  64  ( FIG. 17 ). The screw and inserter are inserted into the tibial tunnel, through an aperture in the tensioning device  52 , as shown in  FIG. 17 , so that the tibial screw is positioned in the center of the sheaths, with the tip of the screw engaging the sheaths. The inserter  64  is then turned clockwise until the screw head is flush with the superior rim of the cortical wall. Because tibial screw threads are designed to match those of the sheaths, excess torque is not needed to engage and insert the screw. As shown in  FIGS. 18 and 19 , once the tibial screw has been completely seated to the cortical wall, the inserter  64  is removed by pulling the handle straight back. The integrity of the repair is then checked, after which the excess suture  36  and tendon is trimmed flush with the tibial tunnel. 
     Accordingly, although exemplary embodiments of the invention has been shown and described, it is to be understood that all the terms used herein are descriptive rather than limiting, and that many changes, modifications, and substitutions may be made by one having ordinary skill in the art without departing from the spirit and scope of the invention.