Abstract:
An arthroscopic method for reattaching a rotator cuff tendon to a humeral head may include creating a trough in the top of the humeral head, creating a cavity in the lateral portion of the humeral head, creating one or more tunnels between the cavity and the trough, retrieving sutures affixed to a loose end of the tendon through the trough, at least one tunnel, and the cavity; and passing the sutures through a tensioning and securing device, which is then implanted in the cavity, and the sutures are variously pulled or released to pull, tension, or release the sutures until the tendon is secured in the trough. The trough is preferably created using a unique extendable, angled surgical burr.

Description:
RELATED APPLICATIONS 
       [0001]    This application is a Divisional of U.S. patent Ser. No. 13/356,267, filed on Jan. 23, 2012. U.S. patent Ser. No. 13/356,267 is incorporated herein by reference and made a part hereof. 
     
    
     FEDERALLY SPONSORED RESEARCH OR DEVELOPMENT 
       [0002]    [Not Applicable] 
       MICROFICHE/COPYRIGHT REFERENCE 
       [0003]    [Not Applicable] 
       BACKGROUND OF THE INVENTION 
       [0004]    The present method and apparatus for rotator cuff repair generally relates to methods and devices for surgical repair of soft tissue damage. More specifically, the present method and apparatus for rotator cuff repair relates to methods and devices for reattaching tendons to bone. 
         [0005]    It has been estimated that over 15 million people in the United States alone are at risk from disability related to rotator cuff injuries. The rotator cuff is a group of four muscles in the shoulder: the supraspinatus; the infraspinatus; the teres minor; and the subscapularis. The supraspinatus extends over the top of the humerus, and is attached to the top of the humeral head by a tendon. This tendon can tear, and often tears away from the humeral head. These tears cause pain and limited mobility. Surgical repair of rotator cuff tears is common, but the surgical technique used to accomplish these repairs has changed significantly over time. 
         [0006]    Historically, rotator cuff repairs have been performed in an open fashion. The traditional open approach involved a relatively large incision, e.g. 5 cm, and splitting of the deltoid to “open” the affected area for repair. Once open, the humeral head was exposed, and a burr and rongeur were typically used to create a trough in the top of the humeral head, exposing bone marrow on all sides and the bottom of the trough. A transosseous bone tunnel or tunnels were also created between the trough and the lateral cortex. The tendon was sutured, and the sutures passed through transosseous tunnel(s). The tendon was then pulled into the trough, and the sutures were typically tied over the lateral cortex for fixation. 
         [0007]    The open approach is still described as the “gold standard” of rotator cuff repair because of the excellent functional results that rarely deteriorate over time. The trough provides excellent biological fixation between the tendon and the bone. Yet, a major disadvantage of the open technique is the required traumatic splitting of the deltoid. This often causes a long recovery time for patients, and can result in deltoid dehiscence and deltoid atrophy. 
         [0008]    Over time, rotator cuff repair has evolved to include less invasive and traumatic approaches. A “mini-open” approach was developed that still involved an open incision and splitting of the deltoid to fix the tendon to the humeral head, but took an arthroscopic approach to other aspects of the repair. For example, in the mini-open approach, an arthroscope can be used to inspect the tear and surrounding anatomy. The tendon can also be released arthroscopically, and a subacromial bursectomy and decortication of the greater tuberosity performed. The tendon is typically fixed, however, using anchors or transosseous tunnels through a traditional open incision. Decortication of the humeral head is intended to promote a biological healing response, but is inferior to the creation of a trough. 
         [0009]    Most recently, various techniques for purely arthroscopic rotator cuff repair have been developed. In these approaches, tendon fixation is also accomplished arthroscopically. These purely arthroscopic approaches rely on suture anchors implanted arthoscopically into the humeral head for fixation of the tendon. One disadvantage of the purely arthroscopic approaches is the technical complexity of such an operation. The most significant disadvantage of this approach, however, is that it lacks the biological healing associated with the tendon-to-trough healing of the open repair. Today&#39;s arthroscopic repair failures are commonly associated with bone, anchor, suture, or suture to tendon failure. Numerous refinements in suture techniques and anchor designs have been made in response, yet these refinements do not promote biological healing that may be crucial to obtaining lasting rotator cuff repairs. 
       BRIEF SUMMARY OF THE INVENTION 
       [0010]    One embodiment of the present method and apparatus for rotator cuff repair involves an arthroscopic method for reattachment of a rotator cuff tendon to its footprint. The method comprises: arthroscopically affixing sutures to a loose end of a rotator cuff tendon; arthroscopically creating a trough in the top portion of the humeral head, arthroscopically creating a cavity in the humeral head, the cavity located below the top portion of the humeral head, the cavity extending into the humeral head in a direction substantially perpendicular to a lateral surface of the humeral head, the cavity having an opening in the lateral surface of the humeral head; arthroscopically creating at least one tunnel between the cavity and the trough; arthroscopically passing the sutures through the at least one tunnel and the cavity; positioning the tendon in the trough; passing the sutures through an adjustable tensioning and securing device configured for implantation in the cavity; arthroscopically implanting the adjustable tensioning and securing device in the cavity; pulling and holding the free end of the sutures away from the tensioning and securing device in a first direction to tension the sutures; and pulling and holding the free end of the sutures away from the tensioning and securing device in a second direction, and then releasing the sutures to secure the sutures in the tensioning and securing device. 
         [0011]    In another embodiment, the present method and apparatus for rotator cuff repair involves a tensioning and securing device for tensioning and securing a rotator cuff tendon to a humeral head. The tensioning and securing device comprises: a body, the body having an outer diameter, a lateral end and a distal end, a mounting section, and a suture opening lateral of the mounting section, the body sized to fit in a cavity created in a lateral section of a humeral head; a face member attached to the lateral end, the face member extending beyond the outer diameter of the body; a first arm, the first arm having a base end and a securing end, the base end pivotally mounted to a first shaft attached to the mounting section; a second arm, the second arm having two side members and a center member, the second arm pivotally mounted at the side members to a second shaft attached to the first arm near the locking end; wherein rotating the second arm towards the lateral end of the body to contact the mounting section draws the securing end of the first arm into engagement with the center member of the second arm to prevent movement of a suture or sutures located therebetween. 
         [0012]    In another embodiment involving a tensioning and securing device for tensioning and securing a rotator cuff tendon to a humeral head, the tensioning and securing device comprises: a body, the body having an outer diameter, a lateral end and a distal end, body steps, and a suture opening distal of the body steps, the body sized to fit in a cavity created in a lateral section of a humeral head; a face member attached to the lateral end, the face member extending beyond the outer diameter of the body; a tensioning wheel, the tensioning wheel rotatably mounted on a shaft attached to the body; a securing wheel, the securing wheel configured to move along the body steps, the movement of the securing wheel in a proximal direction limited by at least one retention member, the movement of the securing wheel in a distal direction limited by the tensioning wheel and the body steps; wherein the tensioning and securing device is configured to prevent the distal movement of a suture passing through the tensioning and securing device by trapping the suture between the tensioning wheel and the securing wheel. 
         [0013]    Yet another embodiment of the present method and apparatus for rotator cuff repair involves a surgical burr useful for creating the trough in the humeral head. 
         [0014]    A surgical burr for creating a trough in the top of a humeral head may comprise: a handle; a power supply; a power control switch; a depth control switch; a sleeve, the sleeve having a proximal end and a distal end, the sleeve attached to the handle at the proximal end, and the sleeve having an angled bend at the distal end; a burr shaft, the burr shaft having a proximal end and a distal end; the burr shaft housed within the sleeve; a burr, the burr located on the distal end of the burr shaft; wherein the burr is extendable from the sleeve to a depth sufficient to create a trough in the top of a humeral head when the burr is extended from a position adjacent to the top of the humeral head. 
         [0015]    Additional objects and advantages of the invention are set forth in, or will be apparent to those of ordinary skill in the art from the detailed description herein. Also, it should be further appreciated that modifications and variations to the specifically illustrated and discussed features or materials hereof may be practiced in various embodiments and uses of this invention without departing from the spirit and scope thereof, by virtue of present reference thereto. Such variations may include, but are not limited to, substitution of equivalent means and features or materials for those shown or discussed, and the functional or positional reversal of various parts, features or the like. 
     
    
     
       BRIEF DESCRIPTION OF SEVERAL VIEWS OF THE DRAWINGS 
         [0016]    A full and enabling disclosure of the present invention, including the best mode thereof, directed to one of ordinary skill in the art, is set forth in the specification, which makes reference to the appended figures, in which: 
           [0017]      FIG. 1  illustrates a lateral view of the upper portion of a humerus, including the humeral head and a rotator cuff tendon, in partial cross section. 
           [0018]      FIG. 2 . illustrates sutures attached to the rotator cuff tendon depicted in  FIG. 1   
           [0019]      FIG. 3  illustrates a trough created in the humeral head depicted in  FIG. 2 . 
           [0020]      FIG. 4  illustrates a cross-sectional view of a telescoping right-angle burr 
           [0021]      FIG. 5  illustrates a pilot hole drilled in the humeral head depicted in  FIG. 3 . 
           [0022]      FIG. 6  illustrates a burr reaming the pilot hole created in the humeral head depicted in  FIG. 5 . 
           [0023]      FIG. 7  illustrates an awl creating a tunnel between the reamed cavity and the trough in the humeral head depicted in  FIG. 6 . 
           [0024]      FIG. 8  illustrates a suture retriever passed through the tunnel in the humeral head depicted in  FIG. 7 . 
           [0025]      FIG. 9  illustrates sutures retrieved through the tunnel in the humeral head depicted in  FIG. 8 . 
           [0026]      FIG. 10  illustrates a combined awl and suture retriever deployment device, including an end portion in partial cross-section. 
           [0027]      FIG. 11  illustrates a partially cutaway side view of a preferred embodiment of the present combination suture tensioning and securing device. 
           [0028]      FIG. 12  illustrates a proximal end view of the combination suture tensioning and securing device of  FIG. 11 . 
           [0029]      FIG. 13  illustrates the combination suture tensioning and securing device positioned in the humeral head depicted in  FIG. 9 . 
           [0030]      FIG. 14  illustrates the rotator cuff tendon drawn into the trough in the humeral head depicted in  FIG. 13 . 
           [0031]      FIG. 15  illustrates the rotator cuff tendon in a secured position in the humeral head depicted in  FIG. 14 . 
           [0032]      FIG. 16  illustrates a partially cutaway side view of an embodiment of the present combination suture tensioning and securing device. 
           [0033]      FIG. 17  illustrates a proximal end view of the combination suture tensioning and securing device of  FIG. 16 . 
           [0034]      FIG. 18  illustrates the combination suture tensioning and securing device positioned in the humeral head depicted in  FIG. 9 . 
           [0035]      FIG. 19  illustrates the rotator cuff tendon drawn into the trough in the humeral head depicted in  FIG. 18 . 
           [0036]      FIG. 20  illustrates the rotator cuff tendon in a secured position in the humeral head depicted in  FIG. 19 . 
           [0037]      FIG. 21  illustrates a sagittal view of the upper portion of a humerus with a rotator cuff tendon affixed to the humerus using the present tensioning and securing device. 
           [0038]      FIG. 22  illustrates a sagittal view of the upper portion of a humerus with a rotator cuff tendon affixed to the humerus using two tensioning and securing devices. 
           [0039]      FIG. 23  illustrates a sagittal view of the upper portion of a humerus with a rotator cuff tendon affixed to the humerus using three tensioning and securing devices. 
       
    
    
       [0040]    Repeat use of reference characters throughout the present specification and appended drawings is intended to represent same or analogous features or elements of the invention. 
       DETAILED DESCRIPTION OF THE INVENTION 
       [0041]    Reference now will be made in detail to the embodiments of the invention, one or more examples of which are set forth below. Each example is provided by way of explanation of the invention, not limitation of the invention. In fact, it will be apparent to those skilled in the art that various modifications and variations can be made in the present invention without departing from the scope or spirit of the invention. For instance, features illustrated or described as part of one embodiment, can be used on or with another embodiment to yield a still further embodiment. Thus, it is intended that the present invention cover such modifications and variations. Other objects, features and aspects of the present invention are disclosed in or are apparent from the following detailed description. It is to be understood by one of ordinary skill in the art that the present discussion is a description of exemplary embodiments only, and is not intended as limiting the broader aspects of the present invention. 
         [0042]    With respect to rotator cuff repairs, the surgeon has a choice as to patient position, either the beach chair position or, more traditionally for the arthroscopic technique, a lateral decubitus position. Once positioning has been performed, the patient is prepped and draped in the usual sterile fashion, and standard portals are established. A diagnostic arthroscopy is done in the glenohumeral joint first and then attention is directed toward the subacromial space. Access portals (not shown) are made on demand and are usually localized well with a spinal needle. The main access portals for this procedure are lateral portals to access the lateral gutter inferiorly within the recess. These can be visualized through the posterior standard portal and the working portals are generally lateral working portals or anterior portals. It is up to the surgeon&#39;s discretion to address the acromio-clavicular (AC) joint or the coraco-acromial (CA) ligament, and to decide whether a subacromial decompression is to be performed. After that is performed, the procedure is started by localizing the lateral access portals. 
         [0043]      FIG. 1  depicts the upper portion of a humerus  10  and a torn rotator cuff tendon  20  lying on top of the humeral head  12 . The rotator cuff tendon  20  is detached from its footprint  15 , and therefore somewhat retracted from its normal, attached position, in which free end  17  would ordinarily extend near area  19 . A partial cutaway view of the humeral head shows the surface of the humeral head  14 , a layer of cortical bone  16 , and the inner cancellous bone marrow  18 . When repairing rotator cuff tendons that have torn or detached, it may be necessary to suture a frayed end of the tendon  20  back together, and remove scar tissue and bursa, as well as other material from previous repairs (not shown). 
         [0044]    Turning now to  FIG. 2 , in accordance with one embodiment of the present arthroscopic method for rotator cuff repair, sutures  8  are arthroscopically attached to free end  17  of tendon  20 . These are preferably horizontal mattress sutures, which may be employed with whatever existing suturing device the surgeon feels most comfortable. Once sutures  8  are placed at the free end  17  of tendon  20 , sutures  8  are put aside through another accessory portal (not shown) to keep them out of the way. 
         [0045]    Turning now to  FIG. 3 , the next step in this embodiment of the present arthroscopic method for rotator cuff repair is to arthroscopically create trough  22  in humeral head  12 . Trough  22  is sized to accommodate a portion of the free end  17  of tendon  20 . Trough  22  preferably extends at a relatively shallow angle, fifteen degrees for example, into the inner cancellous bone marrow  18 . A sharp angle, ninety degrees for example, could present a sharp edge that could damage tendon  20 . However, the corner of trough  22  could be rounded if desired. 
         [0046]    Trough  22  is preferably created using a special surgical angle burr  50 , which may be similar to that depicted in  FIG. 4 . Surgical burr  50  may comprise a power supply (not shown), a handle  52 , power control  54 , depth control  56 , sleeve  58 , burr section  60 , extendable shaft  62 . Extendable right angle burr tool  50  also preferably comprises a suction mechanism (not shown) to remove fluid and debris from the burr area during operation. For example, the suction mechanisms may be similar to those employed on existing surgical burr tools. Suction may be controlled by operation of power control  54 , or by a separate control (not shown). Fluid and debris from the burr area during operation may be facilitated by a suction tube (not shown), or by sleeve  58 . Fluid and debris will travel through the tube or sleeve  58  when suction is activated during operation of surgical burr  50 . Surgical burr  50  may be constructed from a variety of suitable medical-grade materials as desired and/or required by law. 
         [0047]    Burr section  60  may be extended, for example, using an extendable shaft  62  that extends into sleeve  58 , where extendable shaft  62  is rigid enough to provide pressure on burr section  60  to create trough  22 , but flexible enough to pass through the angled section  64  of sleeve  58  as extendable shaft  62  extends burr section  60 . Burr section  60  could also be extended, for example, using an extendable shaft  62  having telescoping sections (not shown) near burr section  60  that telescope burr section  60 . 
         [0048]    Power control  54  may be an on-off switch, a variable speed switch or dial, or other type of steady or variable power sliding switch known to those of skill in the art. Similarly, depth control  56  may be an on-off switch or dial, wherein turning the switch on when burr section  60  is in position on the humeral head would create a trough of a pre-set depth. Depth control  56  may include a multiple position switch that would allow for multiple pre-set depth levels that the surgeon can choose from. The power source may be an electrical or pneumatic source, or other power source available in the operating room and suitable for operating a surgical instrument, such as surgical burr  50 . 
         [0049]    Depth control  56  may also be a variable depth sliding switch or dial, wherein right angle burr tool  50  may further comprise a depth indicator. Again, depth control  56  may employ various types of switches that can activate single or variable depth operation, as known to those of skill in the art. 
         [0050]    While it is preferable to use a right angle burr tool  50  to create the trough  22 , trough  22  may be formed by identifying the rotator cuff footprint and then using a conventional arthroscopic burr to create a trough. If the depth needs to be increased, then angled curretes can be used to deepen the trough with arthroscopic visualization. 
         [0051]    In this embodiment of the present arthroscopic method for rotator repair, surgical burr  50  is used through the anterior working portal while the arthroscope positioned in the posterior portal for superior visualization of trough  22  as it is created. Thus, the burr will not obstruct the view of the procedure. The exact position of trough  22  is approximate, not fixed, to give the surgeon flexibility once the actual physical situation is assessed arthroscopically. For example, the surgeon can medialize trough  22  in humeral head  12  if a retracted tear is encountered that does not have a great deal of movement. On the other hand, if the tear is not so retracted and/or has greater movement, the surgeon may place trough  22  in the more anatomic position shown in  FIG. 3 . 
         [0052]    As seen in  FIG. 6 , a guide pin  27  is poised to arthroscopically create a pilot hole  24  (see  FIG. 5 ) in the lateral cortex. The guide pin  27  is introduced through the lateral working portal. The location for pilot hole  24  may be determined by positioning the guide pin  27  on the flair of the lateral cortex. A guide (not shown) may also be used, but is not required. The pilot hole  24  is placed on the flair of the lateral cortex such that it is not too low on the lateral margin for creation of the tunnel(s)  32  (see  FIG. 8 ), or too close to trough  22  such that the humeral head becomes unacceptably weakened, and thus presenting a risk of fracture. Pilot hole  24  preferably extends into the inner cancellous bone marrow  18  to a point beyond the lateral edge  23  of trough  22 . A depth stop or visual indicator on the guide pin  27  may be used to achieve the desired depth (not shown). 
         [0053]    In accordance with this preferred embodiment of the present arthroscopic method of rotator cuff repair, and as seen in  FIG. 6 , the surgeon then introduces a cannulated reamer  26  over the guide bit  27  (used to create the pilot hole) and through the lateral working portal to ream the lateral cortex and enlarge pilot hole  24 . Guide pin  27  extends into the pilot hole  24  and serves to guide reamer  26  as it creates cavity  28 . Cavity  28  preferably extends into the inner cancellous bone marrow  18  to a point near or slightly lateral of the lateral edge  23  of trough  22 . A depth stop or visual indicator on the reamer may be used to achieve the desired depth. During drilling and reaming, the arthroscope (not shown), may be positioned posterior to the operation so that direct visualization of cavity  28  will be noted. 
         [0054]    Once cavity  28  has been formed, an awl  30  is introduced through the lateral working portal and cavity  28 , and pushed through the inner cancellous bone marrow  18  and into trough  22  as seen in  FIG. 7 . Awl  30  has a built-in radius of curvature that will ensure that awl  30  emerges in trough  22 . Awl  30  is then withdrawn from humeral head  12  and the lateral working portal, which creates tunnel  32  (see  FIG. 8 ). Multiple tunnels may be created using multiple awls. 
         [0055]    Once tunnel  32  has been created, a suture retriever  34  is introduced through the lateral working portal and into cavity  28 , and then pushed through tunnel  32  and into trough  22  as seen in  FIG. 8 . Sutures  8  are then removed from the accessory portal and routed through loop  35  on suture retriever  34 . Suture retriever  34  and sutures  8  are then pulled back through tunnel  32  and cavity  28  as seen in  FIG. 9 . Suture retriever  34  and sutures  8  are then removed from the lateral access portal. 
         [0056]    Turning now to  FIG. 10 , it may be preferable to introduce suture retriever  34  and awl  30  to cavity  28  using a deployment device  70  to guide awl  30  and suture retriever  34  into tunnel  32 . The device  70  may deploy only one or multiple suture retrievers  34  and/or awls  30 . As depicted in  FIG. 10 , the device  70  is a combined awl and suture retriever that can deploy awl  30 , and then suture retriever  34  without the surgeon having to use separate devices. Such deployment devices  70  incorporate a depth stop formed either by configuring the length from the proximal end  82  of device  70  to the opening  84  or providing, for example, an external collar, tab or the like (not shown) to ensure that suture retriever  34  and/or awl  30  line-up with tunnel  32  when deployed. 
         [0057]    As depicted in  FIG. 10 , deployment device  70  includes a body  72 , which includes handle  74 , an awl  30 , and a suture retriever  34 . Deployment may be performed manually, using for example trigger  76 , a lever or the like (not shown), or automatically using for example, trigger  76 , a switch or button or the like and an electric motor and gears (not shown). Trigger guard  78  may be used to prevent accidental deployment of awl  30  and/or suture retriever  34 . Awl  30  and suture retriever  34  may be guided to opening  84  by deployment guide  80 . Multiple triggers  76  or a single trigger and a selector switch  75 , or a selector lever, levers, switches, etc. (not shown) may be employed to activate individual awls  30  and/or suture retrievers  34 . For example, positioning switch  75  to position A may configure the trigger  76  mechanism to operate an awl  30  while positioning switch  75  to position B configures the trigger  76  mechanism to operate suture retriever  34 . 
         [0058]    The combined awl and suture retriever  70  may serve to simplify and speed up the ordinarily complex arthroscopic procedure. For instance, rather than insert an awl  30  by hand to form a tunnel  32 , and then hand guide a suture retriever  34  through the tunnel  32 , the surgeon may simply insert the combined awl and suture retriever  70  into cavity  28  and activate the awl  30  by, for example, pressing and releasing a trigger  76  to create a tunnel  32 , and then, for example, pressing a second trigger  76  to deploy suture retriever  34 , threading sutures  8  through suture retriever  34 , and then releasing second trigger  76  and removing combined awl and suture retriever  70  from cavity  28  and the lateral access portal (not shown). 
         [0059]    Once suture retriever  34  and sutures  8  are removed from the lateral access portal, sutures  8  are inserted through a tensioning and securing device  100  (see, e.g.,  FIGS. 12 and 13 ). Tensioning and securing device is then implanted into cavity  28 , and tendon  20  is positioned in trough  22  and sutures  8  are tensioned and secured. Alternatively, tendon  20  may be pulled manually into trough  22  using sutures  8  before inserting sutures  8  through the tensioning and securing device. The structure and operation of tensioning and securing device is illustrated in  FIGS. 11-21 . 
         [0060]    As its name implies, tensioning and securing device  100  tensions and secures the rotator cuff tendon  20  in trough  22 . It protects the bone from any sawing action of the sutures  8  through the lateral cortex. Moreover, it functions to distribute the forces applied to the surface of the lateral cortex. 
         [0061]      FIG. 11  depicts a cutaway side view of tensioning and securing device  100  in accordance with a preferred embodiment of the present arthroscopic method of rotator cuff repair. Tensioning and securing device  100  comprises circular body  102 , face member  104 , first shaft  106 , first arm  108 , second shaft  110 , and second arm  112 . Tensioning and securing device  100  is shown in an unsecured or tensioning position. 
         [0062]    Body  102  further comprises a suture opening  107  and a mounting section  105 . Body  102  has an outer diameter  114 , a proximal end  101 , and a distal end  103 . Outer diameter  114  of body  102  is sized to fit within cavity  28 , with face member  104  abutting the lateral surface of humeral head  12  (see  FIG. 14 ). Body  102  may be made from a relatively strong material that is also compatible for use in a medical implant, such as medical grade stainless steel. Other parts of tensioning and securing device  100  may also be made from similar materials. It should be understood that, while body  102  is preferably circular in cross-section (see, e.g.,  FIGS. 12 and 13 ), other cross-sectional body shapes that are sized to fit within cavity  28  are also envisioned, including, but not limited to, triangular, square, hexagonal, octagonal, etc. 
         [0063]    Face member  104  extends beyond the outer diameter  114  of body  102 , and thus serves to limit the depth of insertion of tensioning and securing device  100  in cavity  28 . Further, face member  104  prevents movement of tensioning and securing device  100  as tendon  20  is tensioned in trough  22  (see, e.g.,  FIG. 15 ). It should be understood that, while face member  104  is depicted as flange-like, other configurations of face member that limit the depth and movement of tensioning and securing device  100  in cavity  28  are also within the scope of the present tensioning and securing device  100 . For example, face member  104  could be comprised of an arm or arms extending from a portion of the circumference of the body  102  (not shown) rather than a flange-like face member extending from the entire circumference of the body  102 . However, a face member that distributes over a relatively large area the lateral force on humeral head  12  resulting from tensioning tendon  20  in trough  22  is preferred, such as flange-like face member  104 . 
         [0064]      FIG. 12  shows tensioning and securing device  100  looking into the device from proximal end  101 . First arm  108  is pivotally attached to first shaft  106 , which is in turn attached to mounting section  105 . Second arm  112  is pivotally attached to second shaft  110 , which is in turn attached to first arm  108 . In this embodiment, body  102  has a mostly circular inner wall configuration  109 . However, inner wall configuration  109  may be one of a variety of configurations that will accommodate the tensioning and securing mechanism, including non-circular configurations. The operation of tensioning and securing device  100  is illustrated in  FIGS. 13-15 . 
         [0065]    Turning now to  FIG. 13 , tensioning and securing device  100  has been arthroscopically inserted into cavity  28  such that face member  104  abuts the lateral surface of humeral head  12 . The free ends of sutures  8  were threaded through suture opening  107  lateral of mounting section  105 , and then through second arm  112  and out the lateral end  101  of body  102  while sutures  8  and tensioning and securing device  100  were outside of the body. Once tensioning and securing device  100  is in place in the humeral head, sutures  8  are pulled in a direction lateral and downwards in relation to the humeral head, i.e. in the direction of the arrow. Pulling sutures  8  in this direction releases arms  108  and  112  (if tensioning and securing device  100  is in a secured position) or does not engage second arm  112 . The surgeon may then continue to pull sutures  8  in the direction of the arrow to draw tendon  20  into trough  22 . As mentioned previously, however, tendon  20  may be pre-positioned in trough  22  by pulling on sutures  8  before tensioning and securing device  100  has been inserted into cavity  28 . 
         [0066]    Once tendon  20  is in trough  22 , the surgeon may continue to pull sutures  8  in the direction lateral and downwards in relation to the humeral head, i.e. in the direction of the arrow in  FIG. 13 . This will apply the desired final amount of tension to sutures  8 . The surgeon then pulls sutures  8  in a lateral and upwards direction as depicted in  FIG. 15 . 
         [0067]    Pulling sutures  8  in this direction engages second arm  112  and draws second arm  112  into contact with mounting section  105 . At the same time, the pivotal connection between first arm  108  and second arm  112  draws first arm  108  over second arm  112 , and traps sutures  8  between first arm  108  and second arm  112 . 
         [0068]      FIG. 15  shows tensioning and securing device  100  in this secured position. Tendon  20  will thus be held in place in trough  22  until biological healing between bone and tendon occurs. Excess suture material may be cut or trimmed back inside tensioning and securing device  100 . A cap  114  (see  FIGS. 21-23 ) may be arthroscopically affixed over the lateral opening of tensioning and securing device  100  before closing the surgical portals. This cap  114  may be affixed in a variety of ways, including use of a threaded cap that engages threads in the lateral opening of body  102  (not shown), an interference fit, such as a snap fit, inside the lateral opening of body  102 , cementing the cap  114  in place, etc. 
         [0069]    Alternatively, cap  114  may be affixed over the lateral opening of tensioning and securing device  100  during manufacture or before tensioning and securing device is arthroscopically inserted into the patient. The cap  114  may also form a second securing point for sutures  8 , employing any number of known methods of securing sutures or similar materials. For example, sutures  8  may be pulled under a prong on the cap  114  (not shown), or simply trapped between the cap  114  and body  102  if the cap  114  is snap fit or cemented in place (see  FIG. 21 ), or threaded through a slit  116  in the cap  114  and secured by positioning the sutures  8  in a narrow portion of the slit  116  (see  FIG. 22 ). The face of the cap may be comprised of a flexible material, including, but not limited to, surgical grade rubber for example. The flexibility of the face of cap  114  allows for movement of the sutures  8  to operate tensioning and securing device  100 , for instance, while maintaining the lateral opening of tensioning and securing device  100  effectively closed off. 
         [0070]      FIG. 16  depicts an alternate tensioning and securing device  200  in accordance with the present arthroscopic method of rotator cuff repair. Tensioning and securing device  200  comprises a body  202 , face member  204 , tensioning wheel  206 , shaft  208 , securing wheel  210 , and retention bars  212 . 
         [0071]    Body  202  has a proximal end  201  and a distal end  203 . Body  202  has an outer diameter  214  sized to fit within cavity  28 , with face member  204  abutting the lateral surface of humeral head  12  (see  FIG. 18 ). Body  202  may be made from a strong material that is also compatible for use in a medical implant, such as medical grade stainless steel. Other parts of tensioning and securing device  200  may also be made from stainless steel. Body  202  further comprises a suture opening  207  and body steps  205 . It should be understood that, while body  202  is preferably circular in cross-section (see, e.g.,  FIGS. 17 and 18 ), other cross-sectional body shapes that are sized to fit closely within cavity  28  are also envisioned, including, but not limited to, triangular, square, hexagonal, octagonal, etc. 
         [0072]    Face member  204  extends beyond the outer diameter  214  of body  202  and serves to limit the depth of insertion of tensioning and securing device  200  in cavity  28 . Further, face member  204  prevents movement of tensioning and securing device  200  as tendon  20  is tensioned in trough  22  (see, e.g.,  FIGS. 20 and 21 ). It should be understood that, while face member  204  is depicted as flange-like, other configurations of face member that limit the depth and movement of tensioning and securing device  200  in cavity  28  are also within the scope of the present tensioning and securing device  200 . For example, face member  204  could be comprised of an arm or arms extending from a portion of the circumference of the body  202  (not shown) rather than a flange-like face member extending from the entire circumference of the body  202 . However, a face member that distributes over a large area the lateral force on humeral head  12  resulting from tensioning tendon  20  in trough  22  is preferred, such as flange-like face member  204 . 
         [0073]    Tensioning wheel  206  is rotatably mounted on shaft  208 . Securing wheel  210  is not mounted to a shaft, but is prevented from excess lateral movement in one direction by retention bars  212  (see  FIG. 17 ), and movement in the opposite direction by contact with the body steps  205  and tensioning wheel  206 . Tensioning wheel  206  and securing wheel  210  are preferably rough or toothed to facilitate friction between sutures  8  and wheels  206  and  210 . 
         [0074]      FIG. 17  shows tensioning and securing device  200  looking into the device from proximal end  201 . Here, two retention bars  212  are shown. Retention bars  212  may serve to separate multiple sutures  8  routed through tensioning and securing device  200 . Securing wheel  210  is shown in a secured position near the top of body steps  205  to trap suture  8  (not shown) between tensioning wheel  206  and securing wheel  210 . In this embodiment, circular body  202  has a non-circular inner wall configuration  209 . However, inner wall configuration  209  may be one of a variety of configurations that will accommodate the tensioning and securing mechanism, including a circular configuration. The operation of tensioning and securing device  200  is illustrated in  FIGS. 18-20 . 
         [0075]    In  FIG. 18 , tensioning and securing device  200  has been arthroscopically inserted into cavity  28  such that flange  204  abuts the lateral surface of humeral head  12 . The free ends of sutures  8  were threaded through suture opening  207  distal of tensioning wheel  206 , and then between tensioning wheel  206  and securing wheel  210  and out the lateral end of body  202  while sutures  8  and tensioning and securing device  200  were outside of the body. Once tensioning and securing device  200  is in place in the humeral head, sutures  8  are pulled in a direction lateral and upwards in relation to the humeral head, i.e. in the direction of the arrow. Pulling sutures  8  in this direction engages tensioning wheel  206 , but releases (if tensioning and securing device  200  is in a secured position) or does not engage securing wheel  210 . The surgeon may then continue to pull sutures  8  in the direction of the arrow to draw tendon  20  into trough  22 . As mentioned previously, however, tendon  20  may be pre-positioned in trough  22  by pulling on sutures  8  before tensioning and securing device  100  has been inserted into cavity  28 . 
         [0076]    Once tendon  20  is in trough  22 , the surgeon may pull sutures  8  in a direction lateral and downwards in relation to the humeral head, i.e. in the direction of the arrow in  FIG. 19 . This will pull sutures  8  into engagement with securing wheel  210  and apply slightly more than the desired final amount of tension to sutures  8 . The surgeon then releases sutures  8 , which will draw securing wheel  210  up body steps  205  and trap sutures  8  between tensioning wheel  206  and securing wheel  210 . 
         [0077]      FIG. 20  shows tensioning and securing device  200  in this secured position. Tendon  20  will thus be held in place in trough  22  until biological healing between bone and tendon occurs. Excess suture material may be trimmed back inside tensioning and securing device  200 . A cap  114  (see  FIGS. 21-23 ) may be arthroscopically affixed over the lateral opening of tensioning and securing device  200  before closing the surgical portals. This cap  114  may be affixed in a variety of ways, including use of a threaded cap that engages threads in the lateral opening of body  102  (not shown), an interference fit, such as a snap fit, inside the lateral opening of body  102 , cementing the cap  114  in place, etc. The cap  114  may also form a second securing point for sutures  8 , employing any number of known methods of securing sutures or similar materials. For example, sutures  8  may be pulled under a prong on the cap  114  (not shown), or simply trapped between the cap  114  and body  202  if the cap  114  is snap fit or cemented in place (see  FIG. 21 ), or threaded through a slit  116  in the cap  114  and secured by positioning the sutures  8  in a narrow portion of the slit  116  (see  FIG. 22 ). The face of the cap may be comprised of a flexible material, including, but not limited to, surgical grade rubber for example. The flexibility of the face of cap  114  allows for movement of the sutures  8  to operate tensioning and securing device  200 , for instance, while maintaining the lateral opening of tensioning and securing device  200  effectively closed off. 
         [0078]      FIGS. 21-23  illustrate exemplary locations for tensioning and securing devices  101  or  201  on the surface of the humeral head  14 .  FIG. 21  depicts a single tunnel  32  and corresponding tensioning and securing device  100 . In  FIG. 23 , a second tunnel  32  and corresponding tensioning and securing device  100  is added. Second tensioning and securing device  100  is shown positioned on the same plane as first tensioning and securing device  100 . However, the devices may be on staggered planes as well. The surgeon can make this decision based upon an analysis of the bone structure and quality in order to minimize compromises in bone integrity.  FIG. 23  adds yet another tunnel  32  and corresponding tensioning and securing device  100 . Preferably the bone bridge between tensioning and securing devices will be equal to or greater than one centimeter. 
         [0079]    Although preferred embodiments of the invention have been described using specific terms, devices, and methods, such description is for illustrative purposes only. The words used are words of description rather than of limitation. It is to be understood that changes and variations may be made by those of ordinary skill in the art without departing from the spirit or the scope of the present invention, which is set forth in the following claims. In addition, it should be understood that aspects of the various embodiments may be interchanged either in whole or in part. Therefore, the spirit and scope of the appended claims should not be limited to the description of the preferred versions contained therein.