Abstract:
Methods of joint repair employing sutures and attached fixation devices are discussed. For example, a bone block graft procedure (e.g., Latarjet) is discussed which employs fixation devices to secure contact between graft surfaces of two bones. A suture construct, including a continuous suture loop routed through a first fastener, is secured to a first bone. Looped ends of the suture loop are passed through passageways formed in the two bones. The looped suture ends are further routed through a second fastener. The second fastener is mounted to the second bone and a sliding knot, formed in the looped suture ends, is advanced into contact with the second fastener. The suture is further tensioned using a tensioner device to secure the two bones together.

Description:
CROSS-REFERENCE TO RELATED APPLICATION(S) 
       [0001]    This application claims the benefit of U.S. Provisional Application Number Application No. 61/794,212, entitled “Surgical Fastening,” filed on Mar. 15, 2013, the entirety of which is incorporated herein by reference. 
     
    
     BACKGROUND 
       [0002]    Joint and ligament injuries are common. One type of injury includes bone loss of the glenoid, resulting in anterior shoulder instability. One procedure to address this issue involves transfer of a resected portion of the coracoid to the area of glenoid bone loss to replace the missing bone. In some cases, the coracoid is transferred with its conjoined tendon. The coracoid and tendon increase stability, which may prevent dislocations. 
       SUMMARY 
       [0003]    In an embodiment, a tissue spreader is provided, including a first member and a second member. The first member includes a first distal end, a first proximal end, a first shaft portion connecting the first distal end and the first proximal end, the first shaft portion defining a lumen, and a first paddle portion located at the first distal end. The first paddle portion includes a first spreading member with a first spreading surface that has a longitudinal axis parallel to, but offset from, a central, longitudinal axis of the first shaft portion by a first distance greater than a radius of the first shaft portion. The second member includes a second distal end, a second proximal end, a second shaft portion connecting the second distal end and the second proximal end and disposed within the lumen of the first shaft portion, and a second paddle portion located at the distal end. The second paddle portion includes a second spreading member with a second spreading surface that has a longitudinal axis that is parallel to but offset from the central, longitudinal axis of the first shaft portion by a second distance greater than a radius of the first shaft portion. The first member and the second member are configured to rotate relative to each other about the central longitudinal axis between an open position and a closed position, where the first spreading surface and the second spreading surface are separated by the first distance plus the second distance when the first member and the second member are in the open position. 
         [0004]    In other embodiments, the tissue spreader may include one or more of the following, in any combination. The first spreading surface and the second spreading surface are substantially diametrically opposed relative to the central, longitudinal axis of the first shaft portion when the first member and the second member are in the open position. The first spreading surface and the second spreading surface are substantially overlapped when the first member and the second member are in the closed position. The second spreading member is nested in the first spreading member when the first member and the second member are in the closed position. The second shaft portion defines a second lumen concentric with the lumen defined by the first shaft portion. The tissue spreader further including a handle coupled to the first and second proximal ends such that rotation of the handle causes rotation of the second member relative to the first member. The tissue spreader further including a locking mechanism to stabilize the first and second members in the open position or the closed position. The locking mechanism including first and second saddle shaped notches on opposite sides of the first shaft portion and a post located on the second shaft portion, where the post rests in the first notch when the first and second members are in the open position and rests in the second notch when the first and second members are in the closed position. The locking mechanism including a spring that biases the second member along the central longitudinal axis of the first shaft portion towards the first proximal end. The first and second spreading members including lumens that align to form a single passage through the first and second spreading members when the first and second members are in the closed position. The first member including a first slot from the first distal end to the first proximal end, the second member including a second slot from the second distal end to the second proximal end, and the first and second members being configured such that the first and second slots are aligned when the first member and the second member are in the open position and the first and second slots are not aligned when the first member and the second member are in the second position. 
         [0005]    In an embodiment, a tissue spreader is provided, including a body member, an actuating member, at least one arm, and at least one jaw member. The body member defines a first lumen. The actuating member is disposed within the first lumen and defines a second lumen that extends from a proximal end of the actuating member to a distal end of the actuating member, where the actuating member is configured to move relative to the body member. The at least one arm is coupled to the body member and the actuating member. The at least one jaw member is coupled to the arm. The arm is further coupled to the body member and the actuating member such that movement of the actuating member relative to the body member causes the arm to move the jaw member away from the body member while maintaining a longitudinal axis of the jaw member parallel to a central, longitudinal axis of the tissue spreader. 
         [0006]    In other embodiments, the tissue spreader may include one or more of the following, in any combination. The at least one arm includes a first arm and a second arm, the first arm and the second arm coupled to the body member and the actuating member, the jaw member is coupled to the first arm and the second arm, and the first arm and the second arm are coupled to the body member and the actuating member such that movement of the actuating member relative to the body member causes the first arm and the second arm to move the jaw member away from the body member while maintaining a longitudinal axis of the jaw member parallel to a central, longitudinal axis of the tissue spreader. The at least one arm includes a first arm, a second arm, a third arm, and a fourth arm, where the first arm, the second arm, the third arm and the fourth arm are coupled to the body member and the actuating member. The at least one jaw member includes a first jaw member that is coupled to the first arm and the second arm and a second jaw member that is coupled to the third arm and the fourth arm. The first arm and the second arm are coupled to the body member and the actuating member such that movement of the actuating member relative to the body member causes the first arm and the second arm to move the first jaw member away from the body member while maintaining a longitudinal axis of the first jaw member parallel to a central, longitudinal axis of the tissue spreader, and the third arm and the fourth arm are coupled to the body member and the actuating member such that movement of the actuating member relative to the body member causes the third arm and the fourth arm to move the second jaw member away from the body member while maintaining a longitudinal axis of the second jaw member parallel to a central, longitudinal axis of the tissue spreader. The first arm, the second arm, the third arm, and the fourth arm are coupled to the body member and the actuating member such that movement of the actuating member relative to the body member causes the first arm and the second arm to move the first jaw member away from the body member in a first direction and causes the third arm and the fourth arm to move the second jaw member away from the body member in a second direction, the second direction being opposite to the first direction. A first end of the arm is coupled to the jaw member, a second end of the arm includes a first geared portion, the second end of the arm and the body member being coupled to one another by one or more arcuate grooves or flanges, and the actuating member includes a second geared portion that mates with the first gear portion such that movement of the actuating member results in movement of the second end of the arm along the grove or flange, which causes the arm to pivot relative to the central, longitudinal axis of the tissue spreader. The second lumen terminates in an opening at the proximal end of the actuating member. The actuating member is configured to move along the central, longitudinal axis of the tissue spreader. 
         [0007]    In an embodiment, a bone contouring device is provided, including a body portion and a head portion. The head portion is coupled to the body portion and includes a first surface, a second surface opposite the first surface and defining an opening, sidewalls connecting the first and second surfaces, a plurality of teeth and gaps positioned between the teeth, and a channel that extends from the opening to the plurality of teeth and gaps along an axis perpendicular to a longitudinal axis of the head portion. At least one of the opening, the channel, the teeth, and the gaps are dimensioned to permit passage of bone fragments through at least one of the gaps, the channel, and the opening. 
         [0008]    In other embodiments, the bone contouring device may include one or more of the following, in any combination. A handpiece connection portion coupled to the body portion at an end opposite the head portion, the handpiece connection portion configured to attach to a powered handpiece. The channel extends along the longitudinal axis of the head portion from a cutting surface of a first tooth to and past a cutting surface of a last tooth, the first tooth located at a distal end of the head portion and the last tooth located at a proximal end of the head portion. The head portion is angled upwards relative to the body portion. The head portion is angled downwards relative to the body portion. The head portion is aligned with the body portion such that a longitudinal axis of the head portion forms a straight line with a longitudinal axis of the body portion. 
         [0009]    In a further embodiment, a suture tensioning device is provided, including a shaft, a body, and a suture tensioning member. The shaft includes a distal end and a proximal end, the shaft defining a suture lumen that extends from the distal end to the proximal end, the suture lumen configured to have suture passed from the distal end to the proximal end and out of an opening at the proximal end. The body is coupled to the proximal end of the shaft. The suture tensioning member is coupled to the body and is configured to be coupled to the suture passed out the opening at the proximal end of the shaft and, when actuated, to exert a force on the suture in a direction away from the distal end of the shaft. 
         [0010]    In other embodiments, the suture tensioning device may include one or more of the following, in any combination. The suture tensioning member includes a retractable screw member coupled to the body such that rotating the retractable screw member moves the screw member along a central axis of the tensioning device to exert the force on the suture in the direction away from the distal end of the shaft. The retractable screw member includes a distal end and a proximal end and a suture lumen that is arranged coaxial to the suture lumen of the shaft and extends from the distal end to the proximal end, where the suture lumen is further configured to have the suture passed from the distal end of the retractable screw member to the proximal end of the retractable screw member and out of an opening at the proximal end of the retractable screw member and where the retractable screw member includes an outer feature configured to be coupled to the suture passed out the opening at the proximal end of the retractable screw member. The suture tensioning member includes a tensioner barrel configured to be coupled to the suture passed out the opening at the proximal end of the shaft and a ratchet mechanism configured to move the tensioner barrel away from the distal end of the shaft along an axis parallel to a central axis of the tensioning device to exert the force on the suture in the direction away from the distal end of the shaft. The suture tensioning member includes a tensioning bar coupled to the body such that a longitudinal axis of the tensioning bar is oriented perpendicular to a central axis of the tensioning device, the tensioning bar configured to be coupled to the suture such that rotation of the tensioning bar exerts the force on the suture in the direction away from the distal end of the shaft. The distal end of the shaft is configured to engage the second fastener. 
         [0011]    In an embodiment, a drill guide is provided, including a body, a plurality of ports, a shaft, and a plurality of jaw members. The body is elongate and cannulated, having a distal end and a proximal end and defining a lumen extending along a longitudinal axis there-between, the body further including. The plurality of ports are formed in the distal end. The shaft is elongate and cannulated, positioned within the lumen and configured to slide within the lumen relative to the drill guide body. The shaft further includes a plurality of geared regions at a distal end, each geared region aligned with a respective one of the plurality of ports. The plurality of jaw members each including a gripping end and a geared end opposite the gripping end. Each of the geared ends are received within a respective port of the drill guide body and mesh with the geared region aligned therewith. Movement of the shaft along the longitudinal axis in a second direction urges movement of each of the plurality of jaw members into a closed position, where the gripping ends of each jaw member are distanced from the drill guide body by a first distance. Movement of the shaft along the longitudinal axis in a first direction urges movement of each of the plurality of jaw members into an open position, where the gripping ends of each jaw member are distanced from the drill guide body by a second distance, greater than the first distance. 
         [0012]    In other embodiments, the drill guide may include one or more of the following, in any combination. A pair of arcuate flanges formed upon opposing sidewalls of each of the plurality of ports and a pair of arcuate grooves formed on opposing lateral surfaces of the geared end of each of the plurality of jaw members, where the arcuate flanges configured to slide within the arcuate grooves allowing their respective jaw member to pivot relative to the longitudinal axis of the drill guide body and where, upon axial movement of the shaft relative to the drill guide body, the arcuate flanges slide within the arcuate grooves and urge their respective jaw member to pivot between the open and closed positions. Movement of the shaft towards the distal end of the anchor body results in pivoting of the gripping ends away from the drill guide body to the open position and movement of the shaft towards the proximal end of the anchor body results in pivoting of the gripping ends towards the drill guide body to the closed position. A handle coupled to the drill guide body and the shaft, the handle including a first elongate handle member and a second elongate handle member, where a first end of the first handle is coupled to the proximal end of the drill guide body, where a first end of the second handle is coupled to the proximal end of the drill guide body, where the first end of the second handle is further coupled to the proximal end of the shaft at a pivot point, and where pivoting the second handle member about the pivot point in a first rotational direction urges the shaft in a first axial direction and pivoting the second handle member about the pivot point in a second rotational direction moves the shaft in a second axial direction. The first rotational direction is towards the first handle member and the first axial direction is towards the distal end of the drill guide body. The drill guide further including a biasing mechanism in communication with the handle, where the second handle member is biased towards the second rotational direction. The drill guide further including a locking mechanism moveable between an engaged position and a disengaged position, where, in the engaged position, the locking mechanism permits pivoting of the second handle in the first rotational direction and inhibits pivoting of the second handle in the second rotational direction. 
         [0013]    In an embodiment, a suture construct is provided, including a surgical fastener and a continuous suture loop. The surgical fastener includes a body and a post. The body is generally circular, having opposed first and second surfaces, where the first surface is convex and the second surface is concave. A pair of first holes are formed within the body, extending from the convex first surface to the concave second surface. The post includes a first end and a second end, where the first end of the post is coupled to the concave second surface and extending along a longitudinal axis. A second hole is formed in the post, the second hole extending transverse to the longitudinal axis. The continuous suture loop is routed through either the pair of first holes or the second hole such that two suture loop ends extend from the surgical fastener. 
         [0014]    In other embodiments, the surgical fastener may include one or more of the following, in any combination. The post is axially coincident with a portion of the first pair of holes and each of the first pair of holes extend partially through the outer surface of opposing sides of the post, parallel to the longitudinal axis, forming arcuate surfaces on the opposing sides of the post. The post further includes a plurality of chamfered surfaces formed in the second end. The continuous suture loop is routed through one of the first pair of holes, along the first convex surface, and through the other of the first pair of holes. The continuous suture loop is routed through the second hole. The suture construct further including a length of pull suture threaded through the two loop ends. 
         [0015]    In an embodiment, a surgical repair method is provided, including preparing a first grafting surface on a glenoid bone, the first grafting surface positioned adjacent an area of bone loss within the glenoid bone, preparing a second grafting surface on an inferior surface of a coracoid process bone, drilling a first passage through the glenoid, drilling a second passage through the coracoid process, passing a guidewire through the first and second passages, wherein the guidewire is passed through the second passage and subsequently through the first passage, resecting a tip of the coracoid process, maneuvering the resected coracoid process along the guidewire such that at least a portion of the first and second grafting surfaces are in contact, and securing the resected coracoid process to the glenoid with two surgical fasteners and a suture extending there-between. 
         [0016]    In an embodiment, a surgical repair method may include spreading tissue interposed between an incision made in the patient&#39;s shoulder and at least one of the glenoid and the coracoid process with a tissue spreader including a first member, a second member. The first member includes a first distal end a first proximal end, a first shaft portion connecting the first distal end and the first proximal end, the first shaft portion defining a lumen, a first paddle portion located at the first distal end, the first paddle portion including a first spreading member with a first spreading surface that has a longitudinal axis parallel to, but offset from, a central, longitudinal axis of the first shaft portion by a first distance greater than a radius of the first shaft portion. The second member includes a second distal end, a second proximal end, a second shaft portion connecting the second distal end and the second proximal end and disposed within the lumen of the first shaft portion, and a second paddle portion located at the distal end, the second paddle portion including a second spreading member with a second spreading surface that has a longitudinal axis that is parallel to but offset from the central, longitudinal axis of the first shaft portion by a second distance greater than a radius of the first shaft portion. The first member and the second member are configured to rotate relative to each other about the central longitudinal axis between an open position and a closed position, the first spreading surface and the second spreading surface being separated by the first distance plus the second distance when the first member and the second member are in the open position. 
         [0017]    In other embodiments of the method, the tissue spreader may include one or more of the following, in any combination. The first spreading surface and the second spreading surface are substantially diametrically opposed relative to the central, longitudinal axis of the first shaft portion when the first member and the second member are in the open position. The first spreading surface and the second spreading surface are substantially overlapped when the first member and the second member are in the closed position. The second spreading member is nested in the first spreading member when the first member and the second member are in the closed position. The second shaft portion defines a second lumen concentric with the lumen defined by the first shaft portion. The tissue spreader further includes a handle coupled to the first and second proximal ends such that rotation of the handle causes rotation of the second member relative to the first member. The tissue spreader further includes a locking mechanism to stabilize the first and second members in the open position or the closed position. The locking mechanism includes first and second saddle shaped notches on opposite sides of the first shaft portion and a post located on the second shaft portion, where the post rests in the first notch when the first and second members are in the open position and rests in the second notch when the first and second members are in the closed position. The locking mechanism includes a spring that biases the second member along the central longitudinal axis of the first shaft portion towards the first proximal end. The first and second spreading members include lumens that align to form a single passage through the first and second spreading members when the first and second members are in the closed position. The first member includes a first slot from the first distal end to the first proximal end, the second member includes a second slot from the second distal end to the second proximal end, and the first and second members are configured such that the first and second slots are aligned when the first member and the second member are in the open position and the first and second slots are not aligned when the first member and the second member are in the second position. 
         [0018]    In an alternative embodiment, the method may include spreading tissue interposed between an incision made in the patient&#39;s shoulder and at least one of the glenoid and the coracoid process with a tissue spreader, the tissue spreader including a body member, an actuating member, at least one arm, and at least one jaw member. The body member defines a first lumen. The actuating member is disposed within the first lumen and defines a second lumen that extends from a proximal end of the actuating member to a distal end of the actuating member, the actuating member configured to move relative to the body member. The at least one arm is coupled to the body member and the actuating member. The at least one jaw member is coupled to the arm. The arm is coupled to the body member and the actuating member such that movement of the actuating member relative to the body member causes the arm to move the jaw member away from the body member while maintaining a longitudinal axis of the jaw member parallel to a central, longitudinal axis of the tissue spreader. 
         [0019]    In other embodiments of the method, the tissue spreader may include one or more of the following, in any combination. The at least one arm includes a first arm and a second arm, the first arm and the second arm coupled to the body member and the actuating member, the jaw member is coupled to the first arm and the second arm, and the first arm and the second arm are coupled to the body member and the actuating member such that movement of the actuating member relative to the body member causes the first arm and the second arm to move the jaw member away from the body member while maintaining a longitudinal axis of the jaw member parallel to a central, longitudinal axis of the tissue spreader. The at least one arm includes a first arm, a second arm, a third arm, and a fourth arm, wherein the first arm, the second arm, the third arm and the fourth arm are coupled to the body member and the actuating member; the at least one jaw member includes a first jaw member that is coupled to the first arm and the second arm and a second jaw member that is coupled to the third arm and the fourth arm; the first arm and the second arm are coupled to the body member and the actuating member such that movement of the actuating member relative to the body member causes the first arm and the second arm to move the first jaw member away from the body member while maintaining a longitudinal axis of the first jaw member parallel to a central, longitudinal axis of the tissue spreader; and the third arm and the fourth arm are coupled to the body member and the actuating member such that movement of the actuating member relative to the body member causes the third arm and the fourth arm to move the second jaw member away from the body member while maintaining a longitudinal axis of the second jaw member parallel to a central, longitudinal axis of the tissue spreader. The first arm, the second arm, the third arm, and the fourth arm are coupled to the body member and the actuating member such that movement of the actuating member relative to the body member causes the first arm and the second arm to move the first jaw member away from the body member in a first direction and causes the third arm and the fourth arm to move the second jaw member away from the body member in a second direction, the second direction being opposite to the first direction. A first end of the arm is coupled to the jaw member; a second end of the arm includes a first geared portion, the second end of the arm and the body member being coupled to one another by one or more arcuate grooves or flanges; and the actuating member includes a second geared portion that mates with the first gear portion such that movement of the actuating member results in movement of the second end of the arm along the grove or flange, which causes the arm to pivot relative to the central, longitudinal axis of the tissue spreader. The second lumen terminates in an opening at the proximal end of the actuating member. The actuating member is configured to move along the central, longitudinal axis of the tissue spreader. 
         [0020]    In an embodiment of the method, preparing the first grafting surface may include forming a flat on an anterior surface of the glenoid adjacent the area of bone loss with a bone contouring device to prepare a flat and preparing the second grafting surface includes forming a flat on an inferior surface of the coracoid with the bone contouring device. The bone contouring device includes a body portion and a head portion coupled to the body portion. The head portion includes a first surface; a second surface opposite the first surface and defining an opening; sidewalls connecting the first and second surfaces; a plurality of teeth and gaps positioned between the teeth; and a channel that extends from the opening to the plurality of teeth and gaps along an axis perpendicular to a longitudinal axis of the head portion; where at least one of the opening, the channel, the teeth, and the gaps are dimensioned to permit passage of bone fragments through at least one of the gaps, the channel, and the opening. 
         [0021]    In other embodiments of the method, the bone contouring device may include one or more of the following, in any combination. The bone contouring device further includes a handpiece connection portion coupled to the body portion at an end opposite the head portion, the handpiece connection portion configured to attach to a powered handpiece. The channel extends along the longitudinal axis of the head portion from a cutting surface of a first tooth to and past a cutting surface of a last tooth, the first tooth located at a distal end of the head portion and the last tooth located at a proximal end of the head portion. The head portion is angled upwards relative to the body portion. The head portion is angled downwards relative to the body portion. The head portion is aligned with the body portion such that a longitudinal axis of the head portion forms a straight line with a longitudinal axis of the body portion. 
         [0022]    In an embodiment of the method, drilling the first passage through the glenoid may include securing a distal end of a glenoid drill guide to the glenoid; and distally advancing a drill bullet through the drill guide, wherein the drill bullet includes a sleeve and a drill; advancing the drill and sleeve from the posterior glenoid surface to the second grafting surface to form the first passageway; and removing the glenoid drill guide, the bullet, and the drill from the patient after forming the first passageway while retaining the sleeve in place. 
         [0023]    In an embodiment of the method, drilling the second passage through the coracoid may include grasping a superior surface of the coracoid process with a distal end of a coracoid drill guide; advancing a drill through the coracoid drill guide and the coracoid process, from the superior coracoid surface to the second grafting surface, to form the second passageway; and removing the coracoid drill guide and the drill from the patient after forming the second passageway. 
         [0024]    In other embodiments of the method, the coracoid drill guide may include an elongate, cannulated body having a distal end and a proximal end and defining a lumen extending along a longitudinal axis there-between. The body further includes a plurality of ports formed in the distal end; an elongate, cannulated shaft positioned within the lumen and configured to slide within the lumen relative to the drill guide body, the shaft including a plurality of geared regions at a distal end, each geared region aligned with a respective one of the plurality of ports; and a plurality of jaw members, each including a gripping end; and a geared end opposite the gripping end; where each of the geared ends are received within a respective port of the drill guide body and mesh with the geared region aligned therewith; and wherein movement of the shaft along the longitudinal axis in a second direction urges movement of each of the plurality of jaw members into a closed position, where the gripping ends of each jaw member are distanced from the drill guide body by a first distance; and where movement of the shaft along the longitudinal axis in a first direction urges movement of each of the plurality of jaw members into an open position, where the gripping ends of each jaw member are distanced from the drill guide body by a second distance, greater than the first distance. 
         [0025]    In further embodiments of the method, the coracoid drill guide may include one or more of the following, in any combination. A pair of arcuate flanges formed upon opposing sidewalls of each of the plurality of ports; and a pair of arcuate grooves formed on opposing lateral surfaces of the geared end of each of the plurality of jaw members; where the arcuate flanges configured to slide within the arcuate grooves allowing their respective jaw member to pivot relative to the longitudinal axis of the drill guide body; and where, upon axial movement of the shaft relative to the drill guide body, the arcuate flanges slide within the arcuate grooves and urge their respective jaw member to pivot between the open and closed positions. Movement of the shaft towards the distal end of the anchor body results in pivoting of the gripping ends away from the drill guide body to the open position and movement of the shaft towards the proximal end of the anchor body results in pivoting of the gripping ends towards the drill guide body to the closed position. A handle coupled to the drill guide body and the shaft, the handle including a first elongate handle member, wherein a first end of the first handle is coupled to the proximal end of the drill guide body; a second elongate handle member, wherein a first end of the second handle is coupled to the proximal end of the drill guide body and wherein the first end of the second handle is further coupled to the proximal end of the shaft at a pivot point; where pivoting the second handle member about the pivot point in a first rotational direction urges the shaft in a first axial direction and pivoting the second handle member about the pivot point in a second rotational direction moves the shaft in a second axial direction. The first rotational direction is towards the first handle member and the first axial direction is towards the distal end of the drill guide body. The coracoid drill guide further includes a biasing mechanism in communication with the handle, wherein the second handle member is biased towards the second rotational direction. The coracoid drill guide further includes a locking mechanism moveable between an engaged position and a disengaged position, wherein, in the engaged position, the locking mechanism permits pivoting of the second handle in the first rotational direction and inhibits pivoting of the second handle in the second rotational direction. 
         [0026]    In an embodiment, the method may further include, prior to resecting the tip of the coracoid process, securing the first surgical fastener to the superior coracoid surface by insertion of a portion of the first surgical fastener into the second passageway. 
         [0027]    In an embodiment of the method, passing the guidewire through the first and second passages may include advancing a first end of the guidewire through the second passage, from the superior coracoid surface to the second graft surface; guiding the first end of the guidewire towards the sleeve; capturing the first end of the guidewire at a distal end of a capture device extending through the sleeve; and retracting the first end of the guidewire through the sleeve to the posterior surface of the glenoid with the capture device. 
         [0028]    In an embodiment of the method, securing the resected coracoid process to the glenoid may include providing a suture construct, including a second surgical fastener, including a generally circular body having opposed first and second surfaces, wherein the first surface is convex and the second surface is concave; a pair of first holes formed within the body, extending from the convex first surface to the concave second surface; a post having a first end and a second end, wherein the first end of the post is coupled to the concave second surface and extending along a longitudinal axis; a second hole formed in the post, the second hole extending transverse to the longitudinal axis; and the suture, where the suture is formed in continuous suture loop; where the continuous suture loop is routed through either the pair of first holes or the second hole of the second fastener such that two suture loop ends extend from the concave second surface; attaching the suture loop ends to the guidewire; and advancing the suture loop through the first and second passageways, from the posterior glenoid surface to the superior coracoid surface, using the guidewire; where the second fastener is secured to the anterior glenoid surface by insertion of a portion of the second fastener into the first passageway during said suture advancement through the first and second passageways; and where the suture loop ends are passed through the first fastener. 
         [0029]    In other embodiments of the method, the suture construct may include one or more of the following, in any combination. The post is axially coincident with a portion of the first pair of holes; and each of the first pair of holes extend partially through the outer surface of opposing sides of the post, parallel to the longitudinal axis, forming arcuate surfaces on the opposing sides of the post. The post of the second fastener further includes a plurality of chamfered surfaces formed in the second end. The continuous suture loop is routed through one of the first pair of holes, along the first convex surface, and through the other of the first pair of holes. The continuous suture loop is routed through the second hole. 
         [0030]    In an embodiment of the method, securing the resected coracoid process to the glenoid may include forming a half-hitch knot in the suture loop ends extending through the superior coracoid surface and the first fastener; advancing the half-hitch knot into contact with the first fastener; coupling the suture loop ends of the suture to a suture tensioning device; and applying tension to the suture with the suture tensioning device. 
         [0031]    In other embodiments of the method, the suture tensioning device includes one or more of the following, in any combination. The suture tensioning device includes a shaft including a distal end and a proximal end, the shaft defining a suture lumen that extends from the distal end to the proximal end, the suture lumen configured to have suture passed from the distal end to the proximal end and out of an opening at the proximal end; a body coupled to the proximal end of the shaft; and a suture tensioning member coupled to the body, the suture tensioning member configured to be coupled to the suture passed out the opening at the proximal end of the shaft and, when actuated, to exert a force on the suture in a direction away from the distal end of the shaft. The suture tensioning member further includes a retractable screw member coupled to the body such that rotating the retractable screw member moves the screw member along a central axis of the tensioning device to exert the force on the suture in the direction away from the distal end of the shaft. The retractable screw member includes a distal end and a proximal end; and a suture lumen that is arranged coaxial to the suture lumen of the shaft and extends from the distal end to the proximal end; where the suture lumen is further configured to have the suture passed from the distal end of the retractable screw member to the proximal end of the retractable screw member and out of an opening at the proximal end of the retractable screw member, and where the retractable screw member includes an outer feature configured to be coupled to the suture passed out the opening at the proximal end of the retractable screw member. The suture tensioning member further includes a tensioner barrel configured to be coupled to the suture passed out the opening at the proximal end of the shaft; and a ratchet mechanism configured to move the tensioner barrel away from the distal end of the shaft along an axis parallel to a central axis of the tensioning device to exert the force on the suture in the direction away from the distal end of the shaft. The suture tensioning member further includes a tensioning bar coupled to the body such that a longitudinal axis of the tensioning bar is oriented perpendicular to a central axis of the tensioning device, the tensioning bar configured to be coupled to the suture such that rotation of the tensioning bar exerts the force on the suture in the direction away from the distal end of the shaft. The distal end of the shaft is configured to engage the second fastener. 
         [0032]    In an embodiment, a surgical repair method is provided, including preparing a first grafting surface on a glenoid bone, the first grafting surface positioned adjacent an area of bone loss within the glenoid bone; preparing a second grafting surface on an inferior surface of a coracoid process bone; drilling a first passage through the glenoid; drilling a second passage through the coracoid process; passing a guidewire through the first and second passages, wherein the guidewire is passed through the first passage and subsequently through the second passage; resecting a tip of the coracoid process; maneuvering the resected coracoid process along the guidewire such that at least a portion of the first and second grafting surfaces are in contact; and securing the resected coracoid process to the glenoid with two surgical fasteners and a suture extending there-between. 
         [0033]    In an embodiment, the method may include spreading tissue interposed between an incision made in the patient&#39;s shoulder and at least one of the glenoid and the coracoid process with a tissue spreader. The tissue spreader includes a first member and a second member. The first member includes a first distal end; a first proximal end; a first shaft portion connecting the first distal end and the first proximal end, the first shaft portion defining a lumen; and a first paddle portion located at the first distal end, the first paddle portion including a first spreading member with a first spreading surface that has a longitudinal axis parallel to, but offset from, a central, longitudinal axis of the first shaft portion by a first distance greater than a radius of the first shaft portion. The second member includes a second distal end; a second proximal end; a second shaft portion connecting the second distal end and the second proximal end and disposed within the lumen of the first shaft portion; and a second paddle portion located at the distal end, the second paddle portion including a second spreading member with a second spreading surface that has a longitudinal axis that is parallel to but offset from the central, longitudinal axis of the first shaft portion by a second distance greater than a radius of the first shaft portion; wherein the first member and the second member are configured to rotate relative to each other about the central longitudinal axis between an open position and a closed position, the first spreading surface and the second spreading surface being separated by the first distance plus the second distance when the first member and the second member are in the open position. 
         [0034]    In other embodiments of the method, the tissue spreader may include one or more of the following, in any combination. The first spreading surface and the second spreading surface are substantially diametrically opposed relative to the central, longitudinal axis of the first shaft portion when the first member and the second member are in the open position. The first spreading surface and the second spreading surface are substantially overlapped when the first member and the second member are in the closed position. the second spreading member is nested in the first spreading member when the first member and the second member are in the closed position. The second shaft portion defines a second lumen concentric with the lumen defined by the first shaft portion. The tissue spreader further includes a handle coupled to the first and second proximal ends such that rotation of the handle causes rotation of the second member relative to the first member. The tissue spreader further includes a locking mechanism to stabilize the first and second members in the open position or the closed position. The locking mechanism includes first and second saddle shaped notches on opposite sides of the first shaft portion and a post located on the second shaft portion, wherein the post rests in the first notch when the first and second members are in the open position and rests in the second notch when the first and second members are in the closed position. The locking mechanism includes a spring that biases the second member along the central longitudinal axis of the first shaft portion towards the first proximal end. The first and second spreading members include lumens that align to form a single passage through the first and second spreading members when the first and second members are in the closed position. The first member includes a first slot from the first distal end to the first proximal end; the second member includes a second slot from the second distal end to the second proximal end; and the first and second members are configured such that the first and second slots are aligned when the first member and the second member are in the open position and the first and second slots are not aligned when the first member and the second member are in the second position. 
         [0035]    In an embodiment, the method may further include spreading tissue interposed between an incision made in the patient&#39;s shoulder and at least one of the glenoid and the coracoid process with an alternative tissue spreader. The tissue spreader includes a body member defining a first lumen; an actuating member disposed within the first lumen and defining a second lumen that extends from a proximal end of the actuating member to a distal end of the actuating member, the actuating member configured to move relative to the body member; and at least one arm coupled to the body member and the actuating member; at least one jaw member coupled to the arm; where the arm is coupled to the body member and the actuating member such that movement of the actuating member relative to the body member causes the arm to move the jaw member away from the body member while maintaining a longitudinal axis of the jaw member parallel to a central, longitudinal axis of the tissue spreader. 
         [0036]    In other embodiments of the method, the tissue spreader may include one or more of the following, in any combination. The at least one arm includes a first arm and a second arm, the first arm and the second arm coupled to the body member and the actuating member; the jaw member is coupled to the first arm and the second arm; and the first arm and the second arm are coupled to the body member and the actuating member such that movement of the actuating member relative to the body member causes the first arm and the second arm to move the jaw member away from the body member while maintaining a longitudinal axis of the jaw member parallel to a central, longitudinal axis of the tissue spreader. The at least one arm includes a first arm, a second arm, a third arm, and a fourth arm, wherein the first arm, the second arm, the third arm and the fourth arm are coupled to the body member and the actuating member; the at least one jaw member includes a first jaw member that is coupled to the first arm and the second arm and a second jaw member that is coupled to the third arm and the fourth arm; the first arm and the second arm are coupled to the body member and the actuating member such that movement of the actuating member relative to the body member causes the first arm and the second arm to move the first jaw member away from the body member while maintaining a longitudinal axis of the first jaw member parallel to a central, longitudinal axis of the tissue spreader; and the third arm and the fourth arm are coupled to the body member and the actuating member such that movement of the actuating member relative to the body member causes the third arm and the fourth arm to move the second jaw member away from the body member while maintaining a longitudinal axis of the second jaw member parallel to a central, longitudinal axis of the tissue spreader. The first arm, the second arm, the third arm, and the fourth arm are coupled to the body member and the actuating member such that movement of the actuating member relative to the body member causes the first arm and the second arm to move the first jaw member away from the body member in a first direction and causes the third arm and the fourth arm to move the second jaw member away from the body member in a second direction, the second direction being opposite to the first direction. The first end of the arm is coupled to the jaw member; a second end of the arm includes a first geared portion, the second end of the arm and the body member being coupled to one another by one or more arcuate grooves or flanges; and the actuating member includes a second geared portion that mates with the first gear portion such that movement of the actuating member results in movement of the second end of the arm along the grove or flange, which causes the arm to pivot relative to the central, longitudinal axis of the tissue spreader. The second lumen terminates in an opening at the proximal end of the actuating member. The actuating member is configured to move along the central, longitudinal axis of the tissue spreader. 
         [0037]    In an embodiment of the method, preparing the first grafting surface may include forming a flat on an anterior surface of the glenoid adjacent the area of bone loss with a bone contouring device to prepare a flat; and preparing the second grafting surface includes forming a flat on an inferior surface of the coracoid with the bone contouring device. The bone contouring device includes a body portion and a head portion coupled to the body portion. The head portion includes a first surface; a second surface opposite the first surface and defining an opening; sidewalls connecting the first and second surfaces; a plurality of teeth and gaps positioned between the teeth; and a channel that extends from the opening to the plurality of teeth and gaps along an axis perpendicular to a longitudinal axis of the head portion, where at least one of the opening, the channel, the teeth, and the gaps are dimensioned to permit passage of bone fragments through at least one of the gaps, the channel, and the opening. 
         [0038]    In other embodiments of the method, the bone contouring device may include one or more of the following, in any combination. The bone contouring device further includes a handpiece connection portion coupled to the body portion at an end opposite the head portion, the handpiece connection portion configured to attach to a powered handpiece. The channel extends along the longitudinal axis of the head portion from a cutting surface of a first tooth to and past a cutting surface of a last tooth, the first tooth located at a distal end of the head portion and the last tooth located at a proximal end of the head portion. The head portion is angled upwards relative to the body portion. The head portion is angled downwards relative to the body portion. The head portion is aligned with the body portion such that a longitudinal axis of the head portion forms a straight line with a longitudinal axis of the body portion. 
         [0039]    In an embodiment of the method, drilling the first passage through the glenoid may include securing a distal end of a glenoid drill guide to the glenoid; and distally advancing a drill bullet through the drill guide, wherein the drill bullet includes a sleeve and a drill; advancing the drill and sleeve from the posterior glenoid surface to the second grafting surface to form the first passageway; and removing the glenoid drill guide, the bullet, and the drill from the patient after forming the first passageway while retaining the glenoid sleeve in place. 
         [0040]    In an embodiment of the method, drilling the second passage through the coracoid may include grasping a superior surface of the coracoid process with a distal end of a coracoid drill guide; advancing a drill through the coracoid drill guide and the coracoid process, from the superior coracoid surface to the second grafting surface, to form the second passageway; and removing the coracoid drill guide and the drill from the patient after forming the second passageway while retaining the coracoid sleeve in place. 
         [0041]    In further embodiments of the method, the coracoid drill guide may include an elongate, cannulated body having a distal end and a proximal end and defining a lumen extending along a longitudinal axis there-between, the body further including a plurality of ports formed in the distal end; an elongate, cannulated shaft positioned within the lumen and configured to slide within the lumen relative to the drill guide body, the shaft including a plurality of geared regions at a distal end, each geared region aligned with a respective one of the plurality of ports; and a plurality of jaw members, each including a gripping end; and a geared end opposite the gripping end; where each of the geared ends are received within a respective port of the drill guide body and mesh with the geared region aligned therewith; and where movement of the shaft along the longitudinal axis in a second direction urges movement of each of the plurality of jaw members into a closed position, where the gripping ends of each jaw member are distanced from the drill guide body by a first distance; and where movement of the shaft along the longitudinal axis in a first direction urges movement of each of the plurality of jaw members into an open position, where the gripping ends of each jaw member are distanced from the drill guide body by a second distance, greater than the first distance. 
         [0042]    In embodiments of the method, the coracoid drill guide may include a pair of arcuate flanges formed upon opposing sidewalls of each of the plurality of ports; and a pair of arcuate grooves formed on opposing lateral surfaces of the geared end of each of the plurality of jaw members; where the arcuate flanges configured to slide within the arcuate grooves allowing their respective jaw member to pivot relative to the longitudinal axis of the drill guide body; and where, upon axial movement of the shaft relative to the drill guide body, the arcuate flanges slide within the arcuate grooves and urge their respective jaw member to pivot between the open and closed positions. 
         [0043]    In other embodiments of the method, the coracoid drill guide may include one or more of the following, in any combination. Movement of the shaft towards the distal end of the anchor body results in pivoting of the gripping ends away from the drill guide body to the open position and movement of the shaft towards the proximal end of the anchor body results in pivoting of the gripping ends towards the drill guide body to the closed position. The coracoid drill guide further includes a handle coupled to the drill guide body and the shaft, the handle including a first elongate handle member, wherein a first end of the first handle is coupled to the proximal end of the drill guide body; a second elongate handle member, where a first end of the second handle is coupled to the proximal end of the drill guide body and wherein the first end of the second handle is further coupled to the proximal end of the shaft at a pivot point; where pivoting the second handle member about the pivot point in a first rotational direction urges the shaft in a first axial direction and pivoting the second handle member about the pivot point in a second rotational direction moves the shaft in a second axial direction. The first rotational direction is towards the first handle member and the first axial direction is towards the distal end of the drill guide body. The coracoid drill guide further includes a biasing mechanism in communication with the handle, where the second handle member is biased towards the second rotational direction. The coracoid drill guide further includes a locking mechanism moveable between an engaged position and a disengaged position, where, in the engaged position, the locking mechanism permits pivoting of the second handle in the first rotational direction and inhibits pivoting of the second handle in the second rotational direction. 
         [0044]    In an embodiment of the method, passing the guidewire through the first and second passages may include advancing a first end of the guidewire through the glenoid sleeve, from the posterior glenoid surface to the first graft surface; guiding the first end of the guidewire towards the coracoid sleeve; capturing the first end of the guidewire at a distal end of a capture device extending through the coracoid sleeve; retracting the first end of the guidewire through the coracoid sleeve to the superior surface of the coracoid with the capture device; and removing the coracoid and glenoid sleeves while retaining the guidewire in place. 
         [0045]    In an embodiment of the method, securing the resected coracoid process to the glenoid may include providing a suture construct, including a first surgical fastener and a suture. The first surgical fastener includes a generally circular body having opposed first and second surfaces, where the first surface is convex and the second surface is concave; a pair of first holes formed within the body, extending from the convex first surface to the concave second surface; a post having a first end and a second end, where the first end of the post is coupled to the concave second surface and extending along a longitudinal axis; a second hole formed in the post, the second hole extending transverse to the longitudinal axis; the suture is formed in continuous suture loop, where the continuous suture loop is routed through either the pair of first holes or the second hole of the first fastener such that two suture loop ends extend from the concave second surface; attaching the suture loop ends to the guidewire; and advancing the suture loop through the first and second passageways, from the superior coracoid surface to the anterior glenoid surface, using the guidewire; where the first fastener is secured to the superior coracoid surface by insertion of a portion of the first fastener into the second passageway during said suture advancement through the first and second passageways; and wherein the suture loop ends are passed through anterior glenoid surface. 
         [0046]    In further embodiments of the method, the suture construct may include one or more of the following, in any combination. The post is axially coincident with a portion of the first pair of holes; and each of the first pair of holes extend partially through the outer surface of opposing sides of the post, parallel to the longitudinal axis, forming arcuate surfaces on the opposing sides of the post. The post of the first fastener further includes a plurality of chamfered surfaces formed in the second end. The continuous suture loop is routed through one of the first pair of holes, along the first convex surface, and through the other of the first pair of holes. The continuous suture loop is routed through the second hole. 
         [0047]    In an embodiment of the method, securing the resected coracoid process to the glenoid may include providing a second fastener, the second fastener including a generally circular body having opposed first and second surfaces, wherein the first surface is convex and the second surface is concave; a pair of holes formed within the body, extending from the convex first surface to the concave second surface; a post having a first end and a second end, wherein the first end of the post is coupled to the concave second surface and extending along a longitudinal axis; passing a first end loop of the suture through one of the pair of holes of the second fastener; passing a second end loop of the suture through the other hole of the pair of holes of the second fastener; forming a half-hitch knot using the suture loop ends extending through the second fastener; advancing the half-hitch knot into contact with the second fastener; and further advancing the half-hitch knot so as to urge the second fastener post into the first passageway. 
         [0048]    In an embodiment of the method, securing the resected coracoid process to the glenoid may include coupling the suture ends to a suture tensioning device; and applying tension to the suture with the suture tensioning device. 
         [0049]    In embodiments of the method, the suture tensioning device may include one or more of the following, in any combination. A shaft including a distal end and a proximal end, the shaft defining a suture lumen that extends from the distal end to the proximal end, the suture lumen configured to have suture passed from the distal end to the proximal end and out of an opening at the proximal end; a body coupled to the proximal end of the shaft; and a suture tensioning member coupled to the body, the suture tensioning member configured to be coupled to the suture passed out the opening at the proximal end of the shaft and, when actuated, to exert a force on the suture in a direction away from the distal end of the shaft. 
         [0050]    In an embodiment, the suture tensioning member may include a retractable screw member coupled to the body such that rotating the retractable screw member moves the screw member along a central axis of the tensioning device to exert the force on the suture in the direction away from the distal end of the shaft. The retractable screw member includes a distal end and a proximal end; and a suture lumen that is arranged coaxial to the suture lumen of the shaft and extends from the distal end to the proximal end; where the suture lumen is further configured to have the suture passed from the distal end of the retractable screw member to the proximal end of the retractable screw member and out of an opening at the proximal end of the retractable screw member, where the retractable screw member includes an outer feature configured to be coupled to the suture passed out the opening at the proximal end of the retractable screw member. 
         [0051]    In an embodiment of the method, the suture tensioning member may include a tensioner barrel configured to be coupled to the suture passed out the opening at the proximal end of the shaft; and a ratchet mechanism configured to move the tensioner barrel away from the distal end of the shaft along an axis parallel to a central axis of the tensioning device to exert the force on the suture in the direction away from the distal end of the shaft. 
         [0052]    In an embodiment of the method, the suture tensioning member may further include a tensioning bar coupled to the body such that a longitudinal axis of the tensioning bar is oriented perpendicular to a central axis of the tensioning device, the tensioning bar configured to be coupled to the suture such that rotation of the tensioning bar exerts the force on the suture in the direction away from the distal end of the shaft. 
         [0053]    In an embodiment of the method, the distal end of the shaft is configured to engage the second fastener. 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         [0054]    The foregoing and other objects, features and advantages will be apparent from the following more particular description of the embodiments, as illustrated in the accompanying drawings in which like reference characters refer to the same parts throughout the different views. The drawings are not necessarily to scale, emphasis instead being placed upon illustrating the principles of the embodiments. 
           [0055]      FIGS. 1A-1N  illustrate embodiments of a procedure for repairing an area of glenoid bone loss in a patient&#39;s shoulder; 
           [0056]      FIGS. 2A-2B  are schematic illustrations of an embodiment of a radial opening tissue spreader; (A) open position; (B) closed position; 
           [0057]      FIGS. 3A-3C  are schematic illustrations of an embodiment of a locking mechanism for the radial opening spreader of  FIGS. 2A-2B ; (A) open position; (B) closed position; (C) spring of locking mechanism; 
           [0058]      FIGS. 4A-4D  are schematic illustrations of a half-cannulated radial opening tissue spreader; (A) closed position; (B) open position; (C) open position, cutaway; (D) open position, cutaway with inserted secondary tool; 
           [0059]      FIG. 5  is a schematic illustration of an embodiment of a parallel tissue spreader; 
           [0060]      FIG. 6  is a schematic illustration of an embodiment of a pin-less joint of the parallel tissue spreader of  FIG. 5 ; 
           [0061]      FIGS. 7A-7B  are schematic illustrations of an embodiment of a bone contouring device; (A) perspective view; (B) cutaway view; 
           [0062]      FIGS. 8A-8C  are schematic illustrations of alternative embodiments of the bone contouring device of  FIGS. 7A-7B  having varied orientation of a head portion with respect to a body portion; (A) positive angle; (B) straight line; (C) negative angle; 
           [0063]      FIGS. 9A-9D  are schematic illustrations of embodiments of a drill guide (e.g., a glenoid drill guide); (A) side view; (B, C) perspective views, distal end; (D) perspective view, proximal end; 
           [0064]      FIGS. 10A-10D  are schematic illustrations of an embodiment of another drill guide (e.g., a coracoid drill guide) in a closed position; (A); top-down view; (B); side view of jaw members, cutaway; (C) perspective view; (D) perspective view of jaw members; 
           [0065]      FIGS. 11A-11D  are schematic illustrations of an embodiment of the drill guide of  FIGS. 10A-10D  in a closed position; (A); side view; (B); top-down view; (C) side view of jaw members, cutaway; (D) perspective view of jaw members; 
           [0066]      FIG. 12  is a schematic illustration of an embodiment of a self-retaining driver system; 
           [0067]      FIGS. 13A-13C  are schematic illustrations of a screw button; (A) side view; (B) perspective view of proximal end; (C) perspective view of distal end; 
           [0068]      FIGS. 14A-14D  are further schematic illustrations of the self-retaining driver system of  FIG. 12 ; (A) handle portion; (B, C) distal end of external shaft; (D) end-on view; 
           [0069]      FIGS. 15A-15C  are schematic illustrations of a progression of operations for engaging an active self-retaining mechanism; 
           [0070]      FIG. 16  is a schematic illustration of an alternative embodiment of a screw button; 
           [0071]      FIG. 17  is a schematic illustration of an embodiment of a surgical saw; 
           [0072]      FIG. 18  is a photograph illustrating an embodiment of the surgical saw of  FIG. 17  in use; 
           [0073]      FIGS. 19A-19C  are schematic illustrations of a surgical fastener; (A) side view; (B) view of first surface; (C) perspective view of second surface; 
           [0074]      FIG. 20A  is a photograph of the surgical fastener of  FIGS. 19A-19C  engaged with a suture loop according to a first manner of suture routing; 
           [0075]      FIGS. 20B-20C  illustrate the surgical fastener of  FIGS. 19A-19C  engaged with a suture loop according to a second manner of suture routing; (A) photograph; (B) schematic illustration; 
           [0076]      FIGS. 21A-21C  are schematic illustrations of an embodiment of a suture tensioner; (A) perspective view, overall; (B) perspective view, proximal end; (C) perspective view, distal end; 
           [0077]      FIG. 22  is a schematic illustration of an embodiment of a suture tensioner having a transverse suture tensioning member; 
           [0078]      FIGS. 23A-23C  illustrate an embodiment of a ratcheting tensioner; (A) photograph, perspective; (B) schematic illustration, cutaway; (C) photo, magnified view of ratcheting mechanism; and 
           [0079]      FIGS. 24A-24T  illustrate an alternative embodiment of a procedure for repairing an area of glenoid bone loss in a patient&#39;s shoulder. 
       
    
    
     DETAILED DESCRIPTION 
       [0080]      FIGS. 1A-1N  illustrate an embodiment of a procedure for repairing an area of glenoid bone loss in a patient&#39;s shoulder.  FIGS. 1A-1N  show a scapula  100  with a glenoid  104 , including a region of glenoid bone loss  102 , and a coracoid process  106 . As discussed in detail below, the procedure includes preparing grafting surfaces on the glenoid  104  near the area of bone loss  102  and on an inferior surface of the coracoid process  106 . Passages are then drilled through the glenoid  104  and coracoid process  106 . A guidewire is then passed through the passages in the coracoid process  106  and the glenoid  104  to serve as a guide for a portion of the coracoid process  106  which will be grafted onto the glenoid  104  in the area of bone loss  102 . The tip of the coracoid process  106  is then resected and maneuvered along the guidewire to bring at least a portion of the prepared grafting surfaces of the glenoid  104  and the coracoid process  106  (see. e.g.,  FIGS. 1C ,  1 E,  1 J,  110 ,  124 ) into contact. Once positioned, the resected tip is secured in place using a suture construct that includes at least two surgical fasteners (e.g., an endobutton and a screw button) and suture extending there-between. 
         [0081]    Embodiments of the procedure are described in more detail and illustrated in  FIGS. 1A-1N  using an artificial scapula  100 . However, in practice, the procedure is a minimally invasive arthroscopic procedure. Initially a patient is prepared for surgery and a plurality of anterior and posterior incisions are made in the patient&#39;s shoulder. Tissue spreaders (e.g. as shown in  FIGS. 2-6 ) are used to gain access the glenoid and coracoid process by spreading muscle and/or tissue, as necessary, throughout the procedure. 
         [0082]      FIG. 1A  shows a rasp  108  (e.g. as shown in  FIGS. 7 and 8 ) being used to prepare a grafting surface  110  on the glenoid&#39;s  104  anterior surface adjacent to an area of bone loss  102 . The rasp  108  is used to form a clean, flat mating surface  110  for the bone graft. In certain embodiments, not shown, the rasp may be attached to a powered reciprocating handle. 
         [0083]    Next, as shown in  FIGS. 1B-C , a glenoid drill guide  112  (e.g. as shown in  FIG. 9 ) is positioned on the glenoid  104 . The glenoid drill guide  112  is inserted through a posterior portal in the patient&#39;s shoulder along a half cannula (not shown) to protect the articular cartilage. An engagement member on the distal end of the glenoid drill guide  112  (e.g., a hook  114 ) is placed at a selected position on the glenoid  104  (e.g., the “five o&#39;clock” position) and the drill guide  112  is visually aligned perpendicular to the prepared grafting surface  110  ( FIG. 1C ). Properly aligning the drill guide  112  to the prepared grafting surface  110  helps to prevent misalignment or post-operative graft movement. In certain embodiments, not shown, visual alignment of the drill guide may be accomplished through one of the incisions. 
         [0084]    Next, as shown in  FIG. 1D , a passage is drilled through the glenoid  104  in a direction from the posterior surface to the prepared graft surface  110  on the glenoid&#39;s anterior side. A drill bullet  116  is advanced through the drill guide  112 . Inside the bullet  116  is a sleeve  117  and a drill  118 . The drill  118  and sleeve  117  are advanced through the glenoid  104  until the sleeve  117  is barely exposed visibly on the anterior surface of the glenoid  104 . The drill  118 , bullet  116 , and guide  112  are then removed, leaving the sleeve  117  in place to provide a cannula for passing a guidewire and suture. 
         [0085]    Once the glenoid  104  passage has been drilled through the glenoid  104 , cortical bone on the inferior coracoid is removed with the rasp  108  to prepare a flat grafting surface  124  on the coracoid process ( FIG. 1E ). Removing the cortical bone exposes bleeding, cancellous bone which will be mated to the grafting surface  110  on the anterior  30  glenoid  104 . 
         [0086]    Next, as shown in  FIG. 1F , the superior aspect of the coracoid process  106  is grasped with a coracoid drill guide  126  (e.g. as shown in  FIGS. 10 and 11 ). Coracoid drill guide  126  includes a cannulated body  128  and a plurality of jaw members (e.g., three jaw members  130 ). The coracoid drill guide  126  is positioned on the superior aspect of the coracoid process  106  and the jaw members  130  are closed around the coracoid process  106  securing the drill guide  126  in position. A drill (e.g., a 1.9 mm drill, not shown) is passed down the cannula in the drill guide body  128  and a passage is drilled through the coracoid process  106  from the superior surface through the prepared grafting surface  124  on the inferior side. 
         [0087]    Once the passage is drilled in the coracoid process  106 , the coracoid drill guide  126  is removed and a first fastener (e.g. cannulated screw button  132  as shown in  FIGS. 13A-13C  and  16 ) is inserted in the passage on the superior aspect of the coracoid process  106  ( FIG. 1G ). A driver (e.g., as shown in FIGS.  12  and  14 A- 14 D) is used to capture the screw button  132  (e.g., as shown in  FIGS. 15A-15D ), pass the screw button  132  over the drill (by passing the drill through the central cannula of the screw button), and screw the screw button  132  into the passage drilled into the coracoid process. After the screw button  132  is in place a looped guidewire  134  is passed through the screw button  132 , coracoid process  106 , and out of the graft surface  124  on the coracoid&#39;s  106  inferior surface. In alternative embodiments, the drill may be removed and the guidewire passed through the passages before inserting the screw button  132 . The guidewire  134  may then be used to guide the screw button  132  into position. 
         [0088]    As shown in  FIG. 1H , the looped guidewire  134  is then guided towards the sleeve  118  in the anterior glenoid  104  using a grasper  136 . A capture device (e.g., hook  138 ) placed through the sleeve  118  is used to capture the looped end  134   a  of the guidewire  134  and pull the guidewire  134  through the sleeve  118  to the posterior side of the glenoid  104 . The sleeve  118  is then removed from the glenoid passage. 
         [0089]    As shown in  FIG. 1I , the tip of the coracoid process  106  is subsequently resected, at a length determined by the surgeon using a (e.g., a reciprocating saw  140  as shown in  FIGS. 17 and 18 ). Next ( FIG. 1J ), the resected coracoid  142 , also referred to herein as a graft, is transferred along the guidewire  134  through a tunnel in the subscapularis muscle to the grafting surface  110  on the anterior glenoid  104 . The conjoined tendon remains attached to the resected coracoid  142  and provides a sling effect and dynamic tensioning of the inferior part of the subscapularis when the arm is abducted. The resected coracoid  142  with the attached conjoined tendon maintains the subscapularis split open, and it may be desirable to not attempt to close the split because doing so may limit rotation. 
         [0090]    With the resected coracoid  142  positioned on the anterior glenoid  104  graft surface  110 , a suture construct  144  including an attached surgical fastener  146  (e.g. as shown in  FIGS. 19 and 20 ) is pulled through the glenoid and coracoid passages to secure the graft in place ( FIGS. 1J-1L ). A pull suture  144   a  is threaded through two looped ends (not shown) in the suture construct  144  and attached to the looped end  134   a  of the guidewire  134 . As the guidewire  134  is withdrawn from the anterior side of the glenoid  104 , the suture construct  144  is pulled with the guidewire  134 , from the glenoid&#39;s  104  posterior side, through the glenoid and coracoid passages, and out of the screw button  132 . The surgical fastener  146  includes a post with a hole through the post through which a looped portion  144   b  of the suture construct  144  is threaded. When the surgical construct  144  is pulled through the glenoid  104  the post on the surgical fastener  146  is drawn into the passage on the posterior glenoid  104 , the body of the fastener  146  resting on the glenoid&#39;s  104  posterior surface and forming an anchor point (e.g. similar to a washer). 
         [0091]    Once the suture construct  144  has been passed through the glenoid and coracoid passages, tension is applied to suture construct  144  and the resected coracoid  142  is secured in place. The two looped ends of the suture bundle, which will be extending out of the screw button  132 , are tied into a half-hitch knot  152 , also known as a Nice knot, while the surgical fastener  146  rests on the posterior glenoid surface. The sliding Nice knot  152  is transported down the suture by pulling one of the two loops until the knot arrives at the screw button  132 . 
         [0092]    As shown in  FIG. 1M , a suture tensioner  148  (e.g. as shown in  FIGS. 21-23 ) is used to compress the resected coracoid  142  against the glenoid  104 . The suture loop is wrapped around a tensioning member  150  on the suture tensioner  148 . In operation, the suture tensioner  148  draws tension on the suture knot and compresses the graft. Once in tension, several throws of a surgeon&#39;s knot or several half-hitches are tied to secure the Nice knot  152  and the graft  142 . Finally ( FIG. 1N ), any extra length of suture is cut and the coracoid graft  142  onto the anterior glenoid  104  can heal. 
         [0093]      FIGS. 24A-24T  illustrate an alternative embodiment of a procedure for repairing an area of glenoid bone loss in a patient&#39;s shoulder.  FIGS. 24A-24T  show a scapula  100  with a glenoid  104 , including a region of glenoid bone loss  102 , and a coracoid process  106 . 
         [0094]      FIGS. 24A-24B  show a rasp  108  (e.g. as shown in  FIGS. 7 and 8 ) being used to prepare the grafting surface  110  on the anterior surface of the glenoid  104 , adjacent to an area of bone loss  102 , and the grafting surface  124  on the inferior surface of the coracoid  106 . In certain embodiments, not shown, the rasp may be attached to a powered reciprocating handle. 
         [0095]    Next, as shown in  FIG. 24C , a glenoid drill guide  112  (e.g. as shown in  FIG. 9 ) is positioned on the glenoid  104 . The glenoid drill guide  112  is inserted through a posterior portal in the patient&#39;s shoulder along a half cannula (not shown) to protect the articular cartilage. An engagement member on the distal end of the glenoid drill guide  112  (e.g., hook  114 ) is placed at a selected position on the glenoid  104  (e.g., the “five o&#39;clock” position) and the drill guide  112  is visually aligned perpendicular to the prepared grafting surface  110  ( FIG. 1C ). Properly aligning the drill guide  112  to the prepared grafting surface  110  helps to prevent misalignment or post-operative graft movement. In certain embodiments, not shown, visual alignment of the drill guide may be accomplished through one of the incisions. 
         [0096]    Next, as shown in  FIGS. 24D-24F , a passage is drilled through the glenoid  104  in a direction from the posterior surface to the prepared graft surface  110  on the anterior glenoid surface. The drill bullet  116 , including glenoid sleeve  117  and the drill  118 , is advanced through the drill guide  112  the sleeve  117  is barely exposed visibly on the anterior surface of the glenoid  104  ( FIG. 24E ). The drill  118 , bullet  116 , and guide  112  are then removed leaving the glenoid sleeve  117  in place to provide a cannula for passing the guidewire ( FIG. 24F ). 
         [0097]    Next, as shown in  FIG. 24G , another passage is drilled through the coracoid process. As discussed above, the superior aspect of the coracoid process is grasped with a coracoid drill guide (e.g.,  126  as shown in  FIGS. 10 and 11 ). Coracoid drill guide includes a cannulated body and a plurality of jaw members. The coracoid drill guide is positioned on the superior aspect of the coracoid process and the jaw members are closed around the coracoid process  106  securing the drill guide in position. A drill (e.g., a 1.9 mm drill, not shown) is passed down the cannula in the drill guide body and a passage is drilled through the coracoid process from the superior surface through the prepared grafting surface on the inferior side. A glenoid sleeve  117 ′ is further guided through the coracoid passageway using the drill as a guide. Once the passage is drilled in the coracoid process  106 , the coracoid drill guide and drill  126  are removed, retaining the coracoid sleeve  117 ′ in place. 
         [0098]    As shown in  FIG. 24H-24K , a looped guidewire (e.g.,  134 ) is then advanced from the anterior surface of the glenoid  104  to the superior surface of the coracoid, through the glenoid and coracoid passages. For example, the guidewire  134  is passed through the glenoid sleeve  117 , from the posterior surface of the glenoid  104  to the glenoid graft surface  110  ( FIG. 24H ). A capture device (e.g., hook  138 ) is also placed through the coracoid sleeve  117 ′ to capture the looped end  134   a  of the guidewire  134 . A grasper  136  is employed to guide the looped end  134   a  of the guidewire  134  towards the coracoid sleeve  117 ′ to facilitate such capture ( FIG. 24I ). Using the hook  138 , the guidewire is further retracted through the coracoid sleeve  117  to the superior surface of the coracoid  106  ( FIG. 24J ). Subsequently, the coracoid sleeve  117 ′ and the glenoid sleeve  117  are removed ( FIG. 24K ). 
         [0099]    As shown in  FIGS. 24L-24P , the tip of the coracoid process  106  is subsequently resected and transferred into contact with the glenoid  104 . For example, as illustrated in  FIG. 24L , a saw (e.g., reciprocating saw  140 ) may be employed to resect the coracoid  106  at a length determined by the surgeon. Next the resected coracoid  142 , also referred to herein as a graft, is transferred along the guidewire  134  through a tunnel in the subscapularis muscle to the grafting surface  110  on the anterior glenoid  104 . For example, a device such as grasper  136  may be employed to facilitate the transfer ( FIG. 24M ). The conjoined tendon remains attached to the resected coracoid  142  and provides a sling effect and dynamic tensioning of the inferior part of the subscapularis when the arm is abducted. The resected coracoid  142  with the attached conjoined tendon maintains the subscapularis split open, and it may be desirable to not attempt to close the split because doing so may limit rotation. 
         [0100]    With further reference to  FIGS. 24N-24O , the resected coracoid  142  is positioned on the anterior glenoid  104  graft surface  110 . For example, a suture construct  144  including a suture  145  and an attached surgical fastener  146  (e.g. as shown in  FIGS. 19 and 20 ) is attached to the guidewire  134  extending through the superior surface of the glenoid  106  ( FIG. 24N ). For example, a pull suture  144   a  is threaded through two looped ends (not shown) in the suture construct  144  and attached to the looped end  134   a  of the guidewire  134 . As the guidewire  134  is withdrawn from the coracoid passage, a portion of the suture  145 , including the suture ends, is pulled with the guidewire  134 , through the coracoid and glenoid passages, and out of posterior surface of the glenoid  104 . 
         [0101]    The surgical fastener  146  includes a post with a hole through the post through which a looped portion  144   b  of the suture construct  144  is threaded. When the suture  145  is pulled through the glenoid  104 , the post on the surgical fastener  146  is drawn into the coracoid passage, with the body of the fastener  146  resting on the formerly superior coracoid surface ( FIG. 24O ,  24 P). In this manner, the surgical fastener  146  can urge the resected coracoid  142  towards the glenoid  104 , facilitating transfer of the resected coracoid  142 . 
         [0102]    With reference to  FIGS. 24Q-24T , the resected coracoid  142  is secured in place. Once the ends of the suture  145  have been passed through the glenoid and coracoid passages, the suture ends are routed through a second surgical fastener  146   b  ( FIGS. 24Q ,  24 R). In certain embodiments, the second surgical fastener  146   b  may be the same as surgical fastener  146  (e.g. as shown in  FIG. 19 ), including a body, a pair of holes extending through the body, and a post extending from a surface of the body. One of the ends of the suture  145  is passed through one of the pair of holes and another end of the suture  145  is passed through the other of the pair of holes. The two looped ends of the suture  145 , which will be extending out of the second fastener  146   b , are tied into a half-hitch knot  152 , also known as a Nice knot. The half-hitch knot is subsequently advanced into contact with the second fastener  146   b  and then further advanced so as to urge the post of the second fastener  146   b  into the glenoid passageway ( FIG. 24S ). 
         [0103]    As shown in  FIG. 24T , a suture tensioner  148  (e.g. as shown in  FIGS. 21-23 ) is used to compress the resected coracoid  142  against the glenoid  104 . The suture loop is wrapped around a tensioning member  150  on the suture tensioner  148  and the suture tensioner  148  draws tension on the suture knot and compresses the graft. Once in tension, several throws of a surgeon&#39;s knot or several half-hitches are tied to secure the Nice knot  152  and the graft  142 . Finally, any extra length of suture is cut and the coracoid graft  142  onto the anterior glenoid  104  can heal. 
         [0104]      FIGS. 2A and 2B  illustrate an example of a radial opening tissue spreader  200  used, for example, to spread muscle tissue during a surgical procedure. Spreader  200  includes a first member  202 , a second member  204 , and a handle  206 . 
         [0105]    The first member  202  includes a body  202  shaped like an elongated hollow rod. The body  202  includes a distal end  202   a , a proximal end  202   b , and a shaft portion  202   c . The body  202  further defines a lumen  202   d  and connects the distal end  202   a  and the proximal end  202   b . In addition, the body  202  includes a paddle portion  208  (e.g. a fixed paddle) located at the distal end  202   a . The paddle portion  208  includes a spreading member  208   a  with a spreading surface  208   b  that has a longitudinal axis  209  which is parallel to, but offset from, a central longitudinal axis  214  of the shaft portion  202   c . The offset distance between the spreading surface&#39;s longitudinal axis  209  and the central longitudinal axis  214  is greater than the radius of the shaft portion  202   c . The body  202  also includes an enlarged cylinder portion  210  at the proximal end  202   b  having a diameter greater than the diameter of the shaft portion  202   c  on which the handle  206  rests. 
         [0106]    The handle  206  is coupled to the second member  204 , which is, for example, a shaft that includes a distal end  204   a , a proximal end  204   b , and a shaft portion  204   c  that connects the distal end  204   a  and the proximal end  204   b  and is disposed within the lumen defined by the shaft portion  202   c  of the body  202 . In addition, the shaft  204  includes a paddle portion  212 , e.g. a movable paddle, located at the distal end  204   a  of the shaft  204 . The paddle portion  212  includes a spreading member  212   a  with a spreading surface  212   b  that has a longitudinal axis  213  which is parallel to but offset from a central longitudinal axis  214  of the shaft portion  202   c  of the body  202 . The offset distance between the spreading surface&#39;s longitudinal axis  209  and the central longitudinal axis  214  is also greater than the radius of the shaft portion  202   c  of the body  202 . 
         [0107]    The shaft  204  and the body  202  are configured to rotate relative to each other about the central longitudinal axis  214  between a closed position ( FIG. 2A ) and an open position ( FIG. 2B ). The handle  206  is coupled to the proximal end  202   b  of the body and the proximal end  204   b  of the shaft  204  such that rotation of the handle  206  causes the shaft  204  to rotate relative to the body  202 . When the spreader  200  is in the open position, the spreading members  208  and  212 , and their respective spreading surfaces  208   b ,  212   b , are substantially diametrically opposed relative to the central longitudinal axis  214 . Also, when in the open position, the first spreading surface  208   b  and the second spreading surface  212   b  are separated by a distance equal to the first offset distance between the axis  209  and  214  plus the second offset distance between the axis  213  and axis  214 . For example, the first offset distance may be 0.55 inches and the second offset distance may be 0.45 inches forming a total spreading distance of 1.0 inch. By contrast, when the spreader  200  is in the closed position, the second spreading member  212   a  is nested in the first spreading member  208   a  and the first spreading surface  208   b  substantially overlaps with the second spreading surface  212   b . So positioned, the spreader adopts a relatively low profile, permitting the spreader  200  to be easily inserted into an incision. 
         [0108]    In use, the paddle portions  208  and  212  are placed in the closed position and into an incision. Subsequently, the paddle portions  208  and  212  are rotated to the open position. The spreading surfaces  208   b  and  212   b  spread the tissue apart and thereby create an accessible opening in the tissue. 
         [0109]      FIGS. 3A-3C  are detailed illustrations of an example of a locking mechanism for a radial opening spreader  200 . The spreader  200  may include a locking mechanism to stabilize the first and second members in to the open and closed position, for example, to prevent the spreader  200  from inadvertently closing or opening during a surgical procedure. The locking mechanism includes first and second saddle shaped notches  302   a  and  302   b  formed on opposite sides of the body&#39;s shaft portion  202   c  at the distal end  202   a  and a post  304  located on the shaft portion  204   c  at the second distal end  204   a  of the shaft  204 . As illustrated in  FIG. 3A , when the body  202  and the shaft  204  are in the open position, the post  304  rests in the first notch  302   a . As illustrated in  FIG. 3B , when the body  202  and the shaft  204  are in the closed position ( FIG. 3B ) the post  304  rests in the second notch  302   b . In addition, the locking mechanism includes a spring  306  that biases the shaft  204  along the body&#39;s central longitudinal axis  214  towards the first proximal end  202   b . For example, the spring  306  may be compressed inside the handle  206  ( FIG. 3C ) against an inner surface  308  of the handle  206  and the enlarged cylindrical portion  210  of the body  202  to create a force along the central longitudinal axis  214 , biasing the shaft  204  towards the proximal end  202   b  of the body  202 . Moreover, the spring force holds the post  304  in either of the notches  302   a  and  302   b , thereby locking the spreader  200  in either the open or closed position. 
         [0110]    The first and second spreading members  208   a  and  212   a  include respective lumens  312   a  and  312   b  that align to form a single passage through the first and second spreading members  208   a  and  212   a  when the spreader  200  is in the closed position. These lumens may, for example, permit the use of a guide wire to direct the closed paddle portions  208  and  212  into an incision, for example. Also, in some implementations, the shaft portion  204   c  defines a second lumen  310  concentric with the lumen  202   d  defined by the first shaft portion  202   c , for example, to permit passing another surgical tool (e.g. a drill or guide wire) into the spread tissue. 
         [0111]      FIGS. 4A-4D  illustrate a half-cannulated radial opening tissue spreader  400  used, for example, to spread muscle tissue during a surgical procedure and allow a secondary tool, such as a screwdriver, to be passed through the spread tissue. The half-cannulated radial opening spreader device  400  includes a first member  402 , a second member  404 , and a removable obturator  406 . The half-cannulated spreader  400  may be similar to spreader  200  except that a side of the body  402  and shaft  404  is cutaway resulting in a “C”-shaped cross section. 
         [0112]    The first member  402  is, e.g., a body shaped like an elongated hollow rod with a “C”-shaped cross section. The body  402  includes a first distal end  402   a , a proximal end  402   b , a shaft portion  402   c , and a slot  402   e  in the shaft portion  402   c  which extends from the distal end  402   a  to the proximal end  402   b . The shaft portion  402   c  further defines a lumen  402   d  and connects the distal end  402   a  and the proximal end  402   b . In addition, the body  402  includes a paddle portion  408 , e.g. a fixed paddle, located at the distal end  402   a . The paddle portion  408  includes a spreading member  408   a  with a spreading surface  408   b  that has a longitudinal axis  409  which is parallel to but offset from a central longitudinal axis  407  of the shaft portion  402   c . The offset distance between the longitudinal axis  409  and the central longitudinal axis  407  is greater than the radius of the shaft portion  402   c.    
         [0113]    The second member  404 , which is, for example, a shaft that includes a distal end  404   a , a proximal end  404   b , and a shaft portion  404   c  that defines a lumen  404   d  and connects the distal end  404   a  and the proximal end  404   b  and is disposed within the lumen defined by the shaft portion  402   c  of the body  402 . The shaft portion  404   c  also includes a slot  404   e  which extends from the distal end  404   a  to the proximal end  404   b . Similar to the body&#39;s shaft portion  402   c , the shaft portion  404   c  forms a “C”-shaped cross section in the second shaft portion  404   c . In addition, the shaft  404  includes a paddle portion  410 , e.g. a moveable paddle, located at the second distal end  404   a . The paddle portion  410  includes a spreading member  410   a  with a spreading surface  410   b  that has a longitudinal  30  axis  411  which is parallel to but offset from the central longitudinal axis  407 . This second offset distance between the spreading surface&#39;s longitudinal axis  409  and the central longitudinal axis  407  is also greater than the radius of the shaft portion  402   c.    
         [0114]    The shaft  404  also includes a first set of teeth  412  located at the shaft&#39;s proximal end  404   b . The removable obturator  406  engages the shaft  404  by way of a second set of corresponding teeth  414  located at an obturator proximal end  406   a  that meshes with the shaft&#39;s first set of teeth  412 . The obturator  406  is used to rotate the shaft  404  relative to the body  402  about the central longitudinal axis  407  between a closed position ( FIG. 4A ) and an open position ( FIG. 4B ) in a fashion similar to the operation of spreader  200  described above. In addition, the body  402  and the shaft  404  are configured such that when the half-cannulated spreader  400  is in the open position, the first and second slots  402   e  and  404   e  are aligned (FIG.  4 B) and when the half-cannulated spreader  400  is in the closed position, the first and second slots  402   e  and  404   e  are not aligned ( FIG. 4A ). 
         [0115]    The obturator  406  may be removed ( FIG. 4C ) thereby making room for a secondary tool  422  to be inserted through the shaft  404  and body  402  into an incision ( FIG. 4D ). The slots  402   e  and  404   e  are aligned when the spreader  400  is in the open position to prevent confining the secondary tool  422  to the center of the spreader device  400 , for example. 
         [0116]    Furthermore, friction between the inner surface of the body  402  and the outer surface of the shaft  404  may prevent the spreader device  400  from inadvertently closing. Additionally, a first guide notch  424   a  and a second guide notch  424   b  are cut into opposite sides of the shaft portion  402   c  at the distal end  402   a  and a post  426  located on one side of the shaft portion  404   c  to prevent over rotation of the shaft when opening and closing the spreader  400 . For example, the post  426  may rest in the first guide notch  424   a  when the spreader device  400  is in the closed position and the post  426  may rest in the second guide notch  424   b  when the spreader  400  is in the open position.  FIG. 5  illustrates a parallel tissue spreader  500  used, for example, to spread muscle tissue during a surgical procedure. The spreader  500  includes a body member  502 , an actuating member  504 , a plurality of arms (e.g.,  506   a - 506   d ), and a plurality of jaw members (e.g.,  508   a - 508   b ). 
         [0117]    The body member  502  includes a first lumen  503 , and four ports  510 , each of which is configured to accept a toothed end  512  of an arm  506   a - 506   d . The body member  502  also includes a distal end  513  and a proximal end  515  opposite the distal end, the distal end  513  being configured for insertion into tissue and the proximal end  515  including a handle or actuator. The actuating member is a shaft  504  that is disposed within the first lumen  503  of the body member  502  and is configured to move axially relative to the body member  502  and along the central longitudinal axis  520 . The shaft  504  includes toothed regions  514  aligned with the ports  510  and is coupled to the handle at the proximal end  515 , the handle used to provide an axial force on the shaft  504 . The teeth in the toothed regions  514  of the shaft  504  are configured to mesh with the teeth  512  on the arms  506   a - 506   d , as illustrated in  FIG. 6 . The arms  506   a - 506   d  are coupled to the body member  502  at the ports  510  on a pivot, for example, a pin-less pivot joint  516  at the toothed end  512  of the arms  506   a - 506   d . Furthermore, the arms  506   a - 506   d  are generally oriented with the toothed end  512  towards the proximal end of the body  515  and a second end of the arms  518  towards the distal end of the body  513 . 
         [0118]    In the example shown, two jaw members  508   a  and  508   b  are each coupled by pivots to a pair of arms  506   a  and  506   b  and  506   c  and  506   d , respectively. In particular, a first jaw member  508   a  is coupled by a pivot at a proximal end of the jaw member  508   a  to the second end  518  of a first arm  506   a  and at a distal end of the jaw member  508   a  to the second end  518  of a second arm  506   b . A second jaw member  508   b  is coupled by a pivot at a proximal end of the jaw member  508   b  to the second end  518  of a third arm  506   c  and at a distal end of the jaw member  508   b  to the second end  518  of a second arm  506   d . The first jaw member  508   a , the first arm  506   a , and the second arm  506   b  are located on an opposite side of the body member  502  from the second jaw member  508   b , the third arm  506   c , and the fourth arm  506   d.    
         [0119]    The arms  506   a  and  506   b  and the shaft  504  are configured such that movement of the shaft  504  relative to the body member  502  causes the arms  506   a  and  506   b  to move the jaw member  508   a  away from the body member  502  while maintaining a longitudinal axis  522  of the jaw member  508   a  parallel to the central longitudinal axis  520  of the parallel tissue spreader  500 . For example, when the shaft  504  is moved axially within the body member  502  along the central axis  520  the shaft teeth mesh with the arm teeth causing the arms  506   a  and  506   b  to pivot and the second end  518  of the arms  506   a  and  506   b  with the coupled jaw member  508   a  to move towards or away from the body member  502 . In the example shown, when the shaft  504  is driven axially towards the distal end  513  of the body member  502 , the arms  506   a  and  506   b  pivot outwards moving the jaw member  508   a  away from the body member  502 , for example, opening the parallel tissue spreader  500 . When the shaft  504  is driven axially towards the proximal end  515  of the body member  502 , the arms  506   a  and  506   b  pivot inwards moving the jaw member  508   a  towards the body member  502 , for example, closing the parallel tissue spreader  500 . The arms  506   c  and  506   d  and jaw member  508   b  operate in the same manner. Thus, when the shaft  504  is driven towards the distal end  513 , the first jaw member  508   a  moves in a first direction and the second jaw member  508   b  moves in a second direction, both directions being away from the body member  502 . Similarly, when the shaft is driven axially towards the proximal end  515  of the body  502 , the first jaw member  508   a  and the second jaw member  508   b  move towards the body member  502 . 
         [0120]    The shaft  504  includes a lumen  524  that extends through the shaft  504  from the proximal end  515  to the distal end  513  and includes an opening at the proximal end of the shaft  504  to receive another surgical instrument, for example, a drill or a guide wire, that can be passed down the lumen  524  to exit from an opening of the lumen located at distal end of the shaft  504 . 
         [0121]    In some embodiments, the parallel tissue spreader includes only one pair of arms and a single jaw member such that tissue spreading is performed between the body member and the single jaw member, instead of between two jaw members  508   a  and  508   b  located on opposite sides of the body member  502 . In further alternative embodiments, three or more arms may be coupled to each jaw member, for example, to increase the spreading force applied by each jaw member to the tissue. Additionally, some implementations may include three or more jaw members coupled to three or more sets of arms each set coupled to the body member, spaced around the body member (e.g., evenly spaced). For example, a parallel tissue spreader may include three jaw members each coupled to a pair of arms, the pairs of arms coupled to the body in locations spaced 120° apart around the body member, thereby spreading tissue in a wider pattern. 
         [0122]      FIG. 6  illustrates an embodiment of a pin-less joint  516  used for the arm  506   a  (and  506   b - 506   d ) of the spreader  500 . The arm  506   a  and port  510  located in the body  502  are sized such that the side surfaces  602  of the arm  506   a  either nearly contact or loosely contact the corresponding inner surfaces  604  of the port  510 . The toothed end  512  of the arm  506   a  includes a pair of arcuate flanges  606  projecting outward from the arm&#39;s side surfaces  602 . Likewise, the port  510  includes a corresponding pair of arcuate grooves  608  cut into the port&#39;s inner surfaces  604 . The arcuate flanges  606  and grooves  604  are configured to be of appropriate radius and size such that the arcuate flanges  606  are slidable within the arcuate grooves  608 . Thus, the flanges  606  and grooves  608  form an arcuate lug and groove arrangement which allows the arm  506   a  to pivot about the axis  610 . For example, as the shaft  504  is moved relative to the body member  502 , the shaft teeth  514  engage the arm teeth  512  causing the arcuate flanges  606  to slide within the arcuate grooves  608  thereby causing the arm  506   a  to pivot. 
         [0123]    In some implementations the location of the arcuate flanges  606  and grooves  608  may be reversed. For example, the flanges  606  may be located on the inner surfaces  604  of the port  510  while the grooves  608  may be cut into the side surfaces  602  of the arm  506   a . Furthermore, some implementations may use different shaped arcuate flanges  606  and grooves  608 , for example, the flanges  606  and grooves  608  may have a dovetail cross section, a rectangular cross section, or a key-hole shaped cross section. 
         [0124]      FIGS. 7A and 7B  illustrate a bone contouring device, or rasp,  700  used, for example, to prepare the surface of a joint to receive a bone graft during a surgical procedure. The rasp  700  includes a body portion  702  and a head portion  704 , including a plurality of teeth  706  and a channel  708  above the teeth  706 .  FIG. 7B  shows a detailed view of cross section A-A of the head portion  704 . 
         [0125]    The body portion  702  is an elongated rectangular structure having an upper surface  710  and a lower surface  712 . The upper surface  710  and lower surface  712  are generally flat with the upper surface  710  tapered at the end nearest the head portion  704 . In particular, the body portion  702  has a first portion  709  with a distance between the upper surface  710  and lower surface  712  of D 1 , a second portion  711  with a distance between upper surface  710  and lower surface  712  of D 2 , and a tapering portion  713  in which the distance tapers from D 1  to D 2 . Additionally, the taper portion  713  tapers from the upper surface  710  towards the lower surface  712  with the lower surface  712  remaining substantially straight along its full length. 
         [0126]    The end of the body portion  702  opposite the head portion  704  includes a powered handpiece connection portion  714 . The handpiece connection portion  714  is configured to permit attaching the rasp  700  to a powered handpiece. In the example shown, the two sidewalls  720  of the rasp  700  are beveled inwards to narrow from the body portion  702  to the connection portion  714  and a notch is located at the end  716  of the connection portion  714  to permit attaching the rasp  700  to a powered handpiece, for example, a powered reciprocating saw handpiece. 
         [0127]    The head portion  704  is generally rectangular in shape with a rounded distal end and includes a plurality of teeth  706  protruding from the lower surface  712  and a channel  708  cut into the upper surface  710  above the teeth. The array of teeth  706  may be used, for example, to cut away uneven areas on a bone. As shown in  FIG. 7B , the channel  708  is cut completely through the head portion  704  from the upper  710  surface to the lower surface  712  such that gaps  718  are formed between the teeth  706 . In other words, the head portion includes an upper surface  712 , a lower surface  710  opposite the first surface, and sidewalls  720  connecting the first and second surfaces. The first surface includes the multiple teeth  706  and gaps  718  positioned between the teeth. The second surface defines an opening  722  of the channel and the channel  708  extends from the opening to the multiple teeth  706  and gaps  718  along an axis perpendicular to a longitudinal axis of the head portion  704 . 
         [0128]    The opening  722 , channel  708 , teeth  706 , and gaps  718  are configured such that, during use, bone fragments are able to move through the gaps  718 , through the channel  708 , and out the opening  722  of the channel. Thus, the channel  708  cut above the teeth  706  may facilitate the flow of bone chips away from the teeth  706  through the gaps  718  and thereby reduce the possibility of the chips clogging the area or obscuring a user&#39;s view of a rasped bone structure, for example. 
         [0129]    Embodiments of the rasp  700  may employ various shapes for the channel  708 , as necessary. For example, the channel may be rectangular, oblong, or any other suitable shape. In some implementations, the channel may extend slightly past the teeth. For example, as illustrated in  FIGS. 7A ,  7 B, the channel  708  extends along the longitudinal axis of the head portion  704  from the cutting surface of a first tooth  726  (at a distal end) past the cutting surface of a last tooth  728  (at a proximal end). 
         [0130]      FIGS. 8A-8C  illustrate several variations of the rasp  700 . As depicted in the embodiments of  FIGS. 8A-8C , the head portion  704  may be angled with respect to the body portion  702 , for example, to accommodate different patients or surgical procedures. For instance, in one embodiment, the head portion  704  is angled upwards relative to the body portion  702  such that a longitudinal axis of the head portion  704  forms a positive angle with respect to a longitudinal axis of the body portion  702  (device  802 ,  FIG. 8A ). In another embodiment, the head portion  704  is aligned with the body portion  702  such that a longitudinal axis of the head portion  704  forms a straight line with the longitudinal axis of the body portion  702  (device  804 ,  FIG. 8B ). In a further embodiment, the head portion  704  is angled downwards relative to the body portion  702  such that a longitudinal axis of the head portion  704  forms a negative angle with respect to a longitudinal axis of the body portion  702  (device  806 ,  FIG. 8C ). 
         [0131]      FIGS. 9A-9D  illustrate a drill guide  900  for positioning a bone tunnel. Drill guide  900  includes a handle  902  located at a first end, in the form of a pistol grip, so that the surgeon may easily grasp and manipulate drill guide  900  during surgery, and an elongate aimer arm  904  towards a second end. Handle  902  includes a cylindrical bullet channel  906  for receiving an elongate drill bullet (not shown). In the illustrated embodiment, the bullet channel  906  and drill bullet are orientated horizontally relative to a slightly backwards sloping handle  902 —thus providing a pistol style construction. In alternative embodiments, not shown, the handle is an in-line handle, formed substantially coaxially with the bullet channel. 
         [0132]    In addition, the handle  902  includes a passage  908  that receives a one-way ratchet pawl adjacent to bullet channel  906 , such that the ratchet pawl can engage with the drill bullet to prevent its movement within bullet channel  906 . Drill bullet is sized for insertion through bullet channel  906 , and has an elongated body and an angled distal tip. The elongated body of drill bullet has a cylindrical bore which provides a passageway for receipt of a guidewire. Drill bullet also includes a rack, in the form of a series of ratchet teeth or radial grooves along one side of body. The one-way ratchet pawl of handle engages with the rack and holds the drill bullet in place within bullet channel  906 . Such an arrangement is shown in WO2012/061733, incorporated herein by reference in its entirety 
         [0133]    The distal tip of the drill bullet has an angled opening surrounded by teeth. The extent of the angle will largely depend on the architecture of the particular bone surface that is to be drilled. When drill bullet is inserted through bullet channel  906 , the distal tip of the drill bullet provides a stable engagement with a bone surface because of the contact made between the teeth and bone surface. The drill bullet is configured to direct a guidewire into a bone surface to locate the bone tunnel. 
         [0134]    The elongate aimer arm  904  is rounded, and has a proximal arm portion and a distal arm portion. The proximal arm portion is connected to, and extends distally from handle  902 . The distal arm portion of the aimer arm  904  includes a distal tip  910  with a spiked hook  912 , and is configured to contact a bone surface (e.g., the glenoid) to secure the glenoid drill guide  900  to the glenoid. The hook  912  is small enough and positioned so as to be offset from the drill bullet and resulting drill path. Consequently, the drill will not be stopped from advancing past the hook. 
         [0135]      FIGS. 10A-11D  illustrate a drill guide  1000  used, for example, to position a drill when drilling through bone, such as a coracoid process. The guide  1000  includes a body member  1002 , an actuating member or shaft  1004 , a handle  1006 , and a gripping head that includes a plurality of jaw members (e.g.,  1008   a - 1008   c ). As discussed in detail below, the plurality of jaw members are adapted to move between an open position and a closed position for grasping a bone to be drilled.  FIGS. 10A-10D  illustrate the jaw members  1008   a - 1008   c  in a closed position, while  FIGS. 11A-11D  illustrate the jaw members  1008   a - 1008   c  in an open position. 
         [0136]    The body member  1002  includes a distal end  1013  and a proximal end  1015  opposite the distal end  1013 . The body member  1002  is fully cannulated and defines a lumen  1003  that extends from the proximal end  1015  to the distal end  1013 . The lumen  1003  terminates in a first opening (not shown) at the proximal end  1015  and a second opening  1003   a  at the distal end  1013 . The lumen  1003  is substantially straight and extends along a longitudinal axis of the body member  1002 . 
         [0137]    The body member  1002  includes a plurality of ports formed in the distal end  1013  and distributed about the circumference. For example, as illustrated in  FIGS. 10A-11D , the drill guide  100  includes three ports  1010   a - 1010   c  ( 1010   b  and  1010   c  not shown) located at approximately 120 degrees around the circumference of the body member  1002 . Each of the ports  1010   a - 1010   c  is configured to accept a corresponding geared end of a jaw member (e.g.,  1012   a - 1012   c  of a jaw member  1008   a - 1008   c ). Each jaw member  1008   a - 1008   c  further includes a gripping end  1017   a - 1017   c  ( 1017   c  not shown) opposite the geared end  1012   a - 1012   c . Each gripping end  1017   a - 1017   c  includes a protrusion  1019   a - 1019   c.    
         [0138]    Each jaw member  1008   a - 1008   c  and corresponding port  1010   a - 1010   c  are sized such that the side surfaces  1005  of each jaw member  1008   a - 1008   c  either nearly contact or loosely contact the corresponding inner surfaces  1007  of the port  1010   a - 1010   c . The geared end  1012   a - 1012   c  of each jaw member  1008   a - 1008   c  includes a pair of arcuate grooves  1009  formed in the jaw member&#39;s side surfaces  1005  (one grove on each side of the jaw member). Likewise, each port  1010   a - 1010   c  includes a corresponding pair of arcuate flanges  1011  formed on opposing inner surfaces  1007  (e.g., one flange on each opposing sidewall). The arcuate flanges  1011  and grooves  1009  are configured to be of appropriate radius and size such that the arcuate flanges  1011  are slidable within the arcuate grooves  1009 . Thus, the flanges  1011  and grooves  1009  form an arcuate lug and groove arrangement that allows the jaw members  1008   a - 1008   c  to pivot relative to the longitudinal axis of the body member  1002 . In particular, the lug and groove arrangement allows the gripping ends  1017   a - 1017   c  to pivot towards and away from the body member  1002 . 
         [0139]    The actuating member  1004  is an elongate shaft that is disposed within the lumen  1003  of the body member  1002 . The shaft  1004  is fully cannulated and defines a lumen  1024  that extends through the shaft  1004  from a proximal end of the shaft  1004  (which coincides with the proximal end  1015  of the body  1002 ) to the distal end of the shaft  1004  (which coincides with the distal end  1013  of the body  1002 ). The lumen  1024  further includes an opening (not shown) at the proximal end of the shaft  1004  to receive another surgical instrument, for example, a drill or a guide wire. So configured, a drill or guide wire inserted within the lumen  1024  can be passed from the proximal opening of the lumen  1024  to an opening  1024   a  of the lumen  1024  located at the distal end of the shaft  1004 . 
         [0140]    The shaft  1004  is configured to move relative to the body member  1002  along the longitudinal axis of the body member  1002 , which coincides with the longitudinal axis of the shaft  1004 . The shaft  1004  includes geared regions  1014   a - 1014   c  ( 1014   c  not shown) formed in a distal end and aligned with the ports  1010   a - 1010   c . The teeth in the geared regions  1014   a - 1014   c  of the shaft  1004  are configured to mesh with the teeth in the geared regions  1012   a - 1012   c  on the jaw members  1008   a - 1008   c . As the shaft  1004  is moved along the longitudinal axis of the shaft  1004  and body  1002 , the meshed teeth cause the jaw members  1008   a - 1008   c  to move, and the arcuate lug and groove arrangement (the flanges  1011  and grooves  1009 ) translates this movement into a pivoting motion of the jaw members  1008   a - 1008   c  relative to the longitudinal axis of the body member  1002 . In particular, as the shaft  1004  is moved relative to the body member  1002 , the meshed teeth cause the arcuate flanges  1011  to slide within the arcuate grooves  1009  thereby causing the jaw members  1008   a - 1008   c  to pivot. Movement of the shaft  1004  towards the distal end  1013  results in the gripping ends  1017   a - 1017   c  pivoting away from the body member  1002  to an open position ( FIGS. 11A-11D ), while movement of the shaft  1004  towards the proximal end  1015  results in the gripping ends  1017   a - 1017   c  pivoting towards the body member  1002  to a closed position ( FIGS. 10A-10D ). 
         [0141]    The handle  1006  is coupled to the body member  1002  and the shaft  1004  at the distal ends of the body member  1002  and the shaft  1004 . The handle  1006  includes a first handle member  1006   b  that is coupled to the body member  1002  and a second handle member  10061006   a  that is coupled to the shaft  1004  at an end  1006   f  and to the body member  1002  at a pivot point  1006   e . As the handle  1006  is squeezed, the second handle member  1006   a  pivots in a first rotational direction about the pivot point  1006   e  (e.g., clockwise). In turn, the shaft  1004  is urged in a first axial direction along the longitudinal axis of the shaft  1004  (e.g., towards the distal end  1013 ). Conversely, pivoting second handle member  1006   a  pivots in a second rotational direction about the pivot point  1006   e  (e.g., counter-clockwise) urges the shaft  1004  in a second axial direction along the longitudinal axis of the shaft  1004  (e.g., towards the proximal end  1015 ). 
         [0142]    In certain embodiments, the handle  1006  is biased. For example, the handle includes a biasing mechanism (e.g., a scissor spring  1006   c ) that applies a force that tends to cause the second handle member  1006   a  to pivot in a desired rotational direction (e.g., counter-clockwise). 
         [0143]    In further embodiments, the handle  1006  includes a locking mechanism (e.g., a ratchet  1006   d ) adapted to move between an engaged position and a disengaged position. In the engaged position, the ratchet mechanism  1006   d  permits pivoting of the second handle member  1006   a  in the first rotational direction (e.g., clockwise) and inhibits pivoting of the second handle member  1006   a  in the second direction (e.g., counter-clockwise). In the disengaged position, the ratchet mechanism  1006   d  allows pivoting of the second handle member  1006   a  in the second direction (e.g., counter-clockwise). 
         [0144]    During use, when the handle  1006  is squeezed, the shaft  1004  is driven axially towards the distal end  1013  of the body member  1002 , which results in the jaw members  1008   a - 1008   c  pivoting outwards to an open position. The ratchet mechanism  1006   d  holds the jaw members  1008   a - 1008   c  in the open position until released. Once the ratchet mechanism  1006   d  is released, the scissor spring  1006   c  forces the handle  1006  to open, which moves the shaft axially towards the proximal end  1015  of the body member  1002 . When the shaft  1004  is driven axially towards the proximal end  1015  of the body member  1002 , the jaw members  1008   a - 1008   c  pivot towards the body member  1002  to the closed position. 
         [0145]    When used in a surgical procedure, a bone, such as the coracoid process, can be gripped with the jaw members  1008   a - 1008   c  to align the lumen  1024  in the proper position with respect to the bone. A guide wire or drill can then be passed through the lumen  1024  and drilled through the bone. In the event a guide wire is used, the guidewire can be left in the bone. A cannulated drill can then be placed over the guide wire and used to drill a hole through the bone. 
         [0146]    In some implementations, the handle  1006  is coupled to the body member  1002  and the shaft  1004  such that squeezing the handle  1006  moves the shaft  1004  axially towards the proximal end  1015 , thereby resulting in the jaw members  1008   a - 1008   c  pivoting towards the body member  1002  to a closed position with the ratchet mechanism  1006   d  holding the jaw members  1008   a - 1008   c  in the closed position. When the ratchet mechanism  1006   d  is released, the scissor spring  1006   c  opens the handle  1006 , result in the jaw members  1008   a - 1008   c  pivoting away from the body member  1002  towards the open position. 
         [0147]    It may be understood that, in alternative embodiments, mechanisms other than those illustrated herein may be provided for biasing and/or locking the handle. Furthermore, the number of jaw members may be varied. In some embodiments, the drill guide includes only a pair of jaw members arranged around the circumference of the body member (e.g., 180° apart). In other implementations, the guide includes more than three jaw members, which may be spaced equally or unequally around the circumference of the body member. In some implementations the location of the arcuate flanges and grooves are reversed. For example, the flanges may be located on the surfaces of the jaw members, while the grooves are formed on the inner surfaces of the ports. Furthermore, some implementations may use different shaped arcuate flanges and grooves, for example, the flanges and grooves may have a dovetail cross section, a rectangular cross section, or a key-hole shaped cross-section. 
         [0148]      FIG. 12  illustrates an example perspective view of a screw button and self-retaining driver system  1200 . This system includes screw button  1300  and screwdriver  1400 . The screw button  1300  and screwdriver  1400  include an active self-retaining mechanism that securely and rigidly connects the screw button  1300  to a tip of screwdriver  1400 . This secure attachment is such that the screw button  1300  can be driven into bone or other media without requiring manually holding the screw button  1300  on the tip of the screwdriver  1400 . The active self-retaining mechanism can be released after fully or partially advancing the screw button  1300  into bone media. 
         [0149]    Referring to  FIGS. 12 ,  13 A,  13 B, and  13 C, the screw button includes an elongated member having a distal end  1305 , a proximal end  1310 , and a longitudinal axis  1315 . The elongated member is generally cylindrical, though other cross-sectional shaft shapes can be used. At least a portion of the distal end  1305  has external threading  1320  adapted to advance the screw button into bone media. In some embodiments external threading  1320  can extend or cover essentially the entire screw button  1300 , while in other embodiments the external threading  1320  covers just a portion of the elongated member or shaft in general. External threading geometry can be based on a particular media of use, or a particular application. 
         [0150]    The proximal end  1310  or head of screw button  1300  has a force-receiving structure  1330 , configured to receive applied torque. Typically the applied torque will be transferred to the screw button  1300  from screwdriver  1400 . The force-receiving structure  1330  can have various shapes, sizes and configurations.  FIG. 13B  shows force-receiving structure  1330  defining slots  1332 . In this example there are thr 16  of slots  1332 , defined essentially by protrusions/structures in the proximal portion  1310  of the screw button  1300 . In other embodiments there may be a single slot or at least two slots. 
         [0151]    Note that, in alternative embodiments, instead of defining slots, the force-receiving structure can instead define a number of lobes as recessed features for accepting the screwdriver, such as three or more lobes sized and shaped to connect with corresponding lobe structures of the external shaft of the screwdriver. Moreover, the force-receiving structure can be embodied as any pentagon, lobe, or slot arrangement, including conventional drive geometry. In some embodiments, the force-receiving structure is a recessed design having a shape that corresponds to the force-transfer structure of the screw button driver. 
         [0152]    The screw button  1300  is cannulated in that the screw button  1300  defines a passage  1334  or lumen that follows the longitudinal axis  1315 . The defined passage  1334  is sized to enable the screw button  1300  to travel along a guide wire as well as have suture pass through the screw button. 
         [0153]    The proximal end  1310  of screw button  1300  defines a socket  1336  having internal threading  1337 . The defined socket  1336  is aligned with the defined passage. For example, the defined socket  1336  can be concentric with the defined passage, sharing a longitudinal axis. The defined socket can also be centered with the force-receiving structure. The defined socket can have a larger diameter than the passage  1334 . In alternative embodiments, this feature is not required.  FIG. 13C  illustrates concave surface  1339 , which is essentially a bottom side of the screw head. With such curvature, an outside edge of the screw button head first contacts bone media before a surface adjacent to the shaft. 
         [0154]    Referring now to  FIGS. 12 ,  14 A,  14 B,  14 C, and  14 D, the screw button driver  1400  includes a shaft portion  1405  connected to a handle portion  1410 . The shaft portion  1405  includes an external shaft  1420  and an internal shaft  1430 . The internal shaft  1430  is positioned within the external shaft  1420 . The internal shaft  1430  is configured to rotate independent of the external shaft  1420 . The external shaft  1420  can be fixedly connected to handle portion  1410 . Thus, the external shaft defines a longitudinal space or cavity within which the internal shaft can rotate and slide. 
         [0155]    A distal end  1411  (driver tip) of the external shaft  1420  has a force-transfer structure  1425  configured to transfer applied torque to the force receiving structure  1330  of the screw button  1300  when in contact with the force-receiving structure  1330 . A distal end  1411  of the internal shaft  1430  has external threading  1426  adapted to advance into the defined socket  1336  of the screw button  1300  such that when advanced into internal threading  1337  of the defined socket  1336 , the screw button  1300  is securely attached to the screw button driver  1400  via the internal shaft  1430  such that the force-transfer structure  1425  is in contact with the force-receiving structure  1330 . 
         [0156]    The handle portion  1410  further includes a rotation mechanism  1412  that controls rotation of the internal shaft  1430  independent of the external shaft  1420 . The rotation mechanism  1412  can be a rotatable wheel, a lever, or other manually controlled mechanism that controls the internal shaft  1430 . The rotation mechanism can be framed within an opening defined by or within handle portion  1410 . The rotation mechanism  1412  can also slide longitudinally with the handle portion  1410  or defined window. Sliding the rotation mechanism  1412  within the framed opening causes the internal shaft  1430  to travel longitudinally within the external shaft  1420 . The amount of travel can be sufficient for the internal shaft  1430  to retract within the external shaft  1420 , and to extend to couple with the defined socket  1336 . 
         [0157]    The screw button driver  1400  is configured as cannulated through its entire longitudinal axis by defining a passage  1444  that follows a longitudinal axis  1415  of the screw button driver  1400  such that the screw button driver  1400  can travel along a guide wire. Moreover, the self-retaining mechanism is configured such that when the screw button  1300  is being securely retained by the screw button driver  1400 , the coupled  30  system (screw retained by driver) still provides a passage or lumen for sliding along a guide wire, essentially following a same longitudinal axis through the handle  1410 , internal shaft  1430 , and screw button  1300 . 
         [0158]      FIGS. 15A-15C  shows progression of steps for engaging the active self-retaining mechanism.  FIG. 15A  shows a side sectional view of a tip of screwdriver  1400  aligned with screw button  1300 . In  FIG. 15B , the screwdriver  1400  and/or screw button  1300  have been moved so that the force receiving structure is in contact with the force transfer structure, but without the internal shaft extended. In  FIG. 15C , the internal shaft has been manipulated or advanced so that external threading of the internal shaft engages with internal threading of the screw button, thereby actively retaining the screw button  1300  against the screwdriver. 
         [0159]      FIG. 16  shows an embodiment of an alternative screw button  1600  in which the threads only extend over a portion of the screw button. The screw button  1600  includes a proximal portion  1610  with a head configured like the head of the distal portion  1310  of the screw button  1300 . The screw button  1600  has a distal portion  1605  that includes a shaft that has a threaded portion  1602  at a proximal portion of the shaft, near the head of the proximal portion  1610 . The shaft has a non-threaded portion  1606  at a distal portion of the shaft. 
         [0160]    When the screw button  1600  is used in the procedure described above, the non-threaded extension may cross the fracture line (between the resected coracoid process and the glenoid) to provide stability in the shear direction. 
         [0161]      FIG. 17  illustrates a surgical saw  1700  used, for example, to resect a piece of bone for use in a bone graft procedure. The surgical saw  1700  includes a tang  1702 , a blade portion  1704  having an array of teeth  1706 , and a connection portion  1708  for attaching the surgical saw  1700  to a reciprocating saw handpiece (e.g., a powered handpiece). 
         [0162]    The tang  1702  is a substantially flat rectangular structure having a thickness, T 1 , with the blade portion  1704  attached at one end (a distal end), and the connection portion  1708  at the end opposite the blade portion  1704  (a proximal end). The connection portion  1708  is configured to connect the surgical saw  1700  to a powered handpiece. In the example shown, the connection portion  1708  is thinner than the tang  1702  and includes a notch  1716  to permit attachment to a powered handpiece, for example, a powered reciprocating saw handpiece. 
         [0163]    The blade portion  1704  includes an array of teeth  1706  and has two surfaces, a first surface  1710  and second surface  1712 . The second surface  1712  is slightly recessed from the first surface  1710  and is formed, for example, by etching. In the example shown, the blade  1704  has a first surface  1710  and etched second surface  1712  on both sides. As a result, the blade portion  1704  includes a recessed portion formed from the second surface  1712  on both sides and a non-recessed (or raised) portion formed from the first surface  1710  on both sides. The recessed portion has a thickness, T 2 , which is thinner than the non-recessed (or raised) portion, which has a thickness, T 3 . This thinner (recessed) portion of the blade may prevent the blade  1704  from becoming jammed in a cutting notch of a bone while sawing. Some of the teeth  1714  are cut into the second surface while others are cut into the first surface  1710 . In other words, some teeth may have a thickness T 2  while others have a thickness T 3 , where T 2  is less than T 3 . 
         [0164]    As shown in FIG. A, the teeth  1706  may alternate thickness between T 2  and T 3 , thus creating a divergent set of teeth. A divergent set of teeth may improve the surgical saw device&#39;s  1700  cutting performance by transporting bone chips away from the cutting area and creating a flat sawn surface on the bone, for example. In alternative embodiments, other may be used. For example, pattern including one tooth having a thickness of T 3  followed by two teeth having a thickness of T 2 . 
         [0165]    In some implementations the first surface  1710  may be in the same plane as the surface  1711  of the tang  1702 . For example, the first surface  1710  may be an original, unetched surface of the surgical saw device  1700  and have a thickness, T 3 , equal to the thickness of the tang, T 1 . In other implementations, the tang&#39;s surface  1711  may reside in a different plane than the blade&#39;s first surface  1710 . For example, the thickness of the non-etched portion of the blade  1710 , T 3 , may be different than the thickness of the tang  1702 , T 1 . In addition, some implementations may have an etched surface on only one side of the blade, thus leaving the opposing side of the blade substantially flat, for example. Furthermore, in other embodiments, some implementations the teeth are made by laser cutting instead of grinding to reduce costs, for example. 
         [0166]      FIG. 18  is a photograph  1800  of an example surgical saw device  1700 . In the photograph  1800 , the surgical saw  1700  is attached to a powered reciprocating saw handpiece  1802  and is being used to cut the coracoid process. For example, the handpiece connection  1708  portion of the tang  1702  may be inserted into an attachment receiving slot  1806  on the powered handpiece  1804  to attach the surgical saw  1700  to the powered handpiece  1804 . 
         [0167]      FIGS. 19A-19C  illustrate an example of a surgical fastener  1900  used, for example, to secure a piece of bone in place during a bone graft procedure. The surgical fastener  1900  includes a body  1902 , a post  1904 , and a plurality of holes (e.g.,  1906   a - 1906   c ). The device  1900  can be made from metal, a suture based, absorbable material, or collagen based material that may hold or carry healing elements (for example, blood, prp, or stem cells). 
         [0168]    The body  1902  is generally circular and includes opposing first and second surfaces  1902   a ,  1902   b . The first surface  1902   a  of the fastener  1900  is convex and the second surface  1902   b  is concave such that the fastener  1900  has a bowl-shaped profile. A diameter of the first surface  1902   a , D 1 , may be varied according to certain embodiments. For example, the diameter may be varied to accommodate a patient or procedure. In one embodiment, the diameter D 1  is 14 mm. 
         [0169]    The body  1902  further includes a plurality of first holes formed therein, extending through the body  1902  from the convex first surface  1902   a  to the concave second surface  1902   b . For example, as illustrated in  FIGS. 19A-19C , the body  1902  includes two holes  1906   a  and  1906   b.    
         [0170]    A post  1904  is coupled to the body  1902  at a first end and extends outwards along a longitudinal axis  1908  from the concave second surface  1902   b . The longitudinal axis  1908  of the post is substantially perpendicular to the concave second surface  1902   b . The post  1904  possesses a diameter, D 2 , that extends perpendicular to the axis  1908  and is less than the diameter D 1  of the body  1902 . In an embodiment, the post  1904  further possesses a generally cylindrical shape and defines an outer curved side surface  1904   a . The post  1904  further includes a second hole  1906   c  formed therein, extending transverse to the longitudinal axis  1908  (e.g., through opposite sides of the outer curved surface  1904   a ). 
         [0171]    The diameter D 2  of the post  1904  is larger than a separation distance between the first pair of holes  1906   a  and  1906   b . As a result, the post  1904  is axially coincident with a portion of each of the first pair of holes  1906   a  and  1906   b . In this instance, the holes  1906   a  and  1906   b  extend partially through opposing sides of the curved surface  1904   a  of the post  1904  parallel to the longitudinal axis  1908  forming an arcuate surface  1904   b  on the post  1904 . In other words, the sides of the post  1904  under the holes  1906   a  and  1906   b  include a concave surface that forms semi-circular passages on both sides of the post  1904 . The arcuate surfaces of the passages generally follow the circumference of the holes  1906   a  and  1906   b . The semi-circular passages can accommodate suture passed through the holes  1906   a  and  1906   b . The post  1904  includes one or more a chamfered surfaces  1910  formed in a second end to aid in inserting the post into a passage that may be made in a bone, for example. 
         [0172]    Embodiments illustrated in  FIGS. 20A-20C  present examples of how a suture  2002  may be passed through a surgical fastener  1900 . In certain embodiments, the suture  2002  is a continuous loop of suture, formed from a length of suture material that is spliced  2008  at two free ends (not shown). 
         [0173]    The form of the suture may be varied, in certain embodiments. For example, the suture may be formed in a suture loop or bundle. In further embodiments, the suture may be formed from a high-strength polyethylene (for example, Ultrabraid® Sutures, Smith &amp; Nephew, Inc., Andover, Mass., USA) or may be formed from metallic wire. 
         [0174]    The fastener  1900  is configured such that the suture loop  2002  can be routed through either the first pair of holes  1906   a  and  1906   b  or the second hole  1906   c , with two suture loop ends  2012  ( FIG. 20C ) extending from the fastener  1900 . For example, as illustrated in  FIG. 20A , the suture loop  2002  is passed in one of holes  1906   a  and  1906   b , along the first surface  1902   a , and back through the other of holes  1906   a  and  1906   b  ( FIG. 20A ). The suture loop  2002  may then be passed through a passage made in a bone during a surgical procedure with the fastener  1900  creating an anchor point on the bone against which the suture loop  2002  may be tensioned. For example, the body  1902  is configured such that the second surface  1902   b  provides sufficient contact area with a bone to prevent the fastener  1900  from being pulled by tension on a suture loop  2002  through the passage in the bone. Passage of the suture  2002  through holes  1906   a  and  1906   b  may be used if the fastener  1900  is placed on a knot side of the suture loop  2002 , for example. 
         [0175]    In an alternative embodiment, the suture loop  2002  can be routed through the hole  1906   c  in the post  1904  ( FIGS. 20B and 20C ), for example, when the fastener  1900  is on a non-knot side of the suture and the bone. The suture loop  2002  may then be passed through a passage in a bone. As the suture loop  2002  is tensioned, the suture may align the post  1904  with the passage. 
         [0176]    As illustrated, the suture loop  2002  can be part of a suture construct B 06  formed from the suture loop  2002  and a length of pull suture  2010  threaded through two loop ends  2012  created when the suture loop  2002  is folded over. The two ends of the pull suture  2010  are tied forming a second loop which may be easily pulled through a cannula implant or other surgical instrument with the aid of a single hook, for example. As the pull suture  2010  is pulled through a cannula the loop ends  2012  are pulled through the cannula with the pull suture  2010  thereby allowing a surgeon to easily thread four strands of suture material through a narrow passage, for example. The suture loop  2002  may be formed from SZ3 or 4 suture and the pull sutures may be formed from SZ0 suture. 
         [0177]    Variations of the fastening  1900  may be used during surgical procedures, for example, the shape of the body  1902  may be changed to accommodate the cortical tip of the patient&#39;s coracoid process. 
         [0178]      FIGS. 21A-21C  illustrate an example of a suture tensioner  2100  used, for example, to tension a suture during a surgical procedure. Tensioner  2100  includes a shaft  2102 , a body  2104 , and a suture tensioning member  2106 . 
         [0179]    The shaft  2102  is generally shaped like an elongated hollow rod. The shaft  2102  includes a distal end  2102   a  a proximal end  2102   b  and defines a suture lumen  2102   c  that extends from the distal end  2102   a  to the proximal end  2102   b . The body  2104  is coupled to the proximal end  2102   b  of the shaft  2102  and is configured to receive a suture tensioning member  2106 . The suture tensioning member  2106  is, e.g., a screw having a broad wing nut shape at the screw head. In more detail, the tensioning member  2106  includes a retractable screw member  2108  having a distal end  2108   a  and a proximal end  2108   b . The retractable screw member  2108  is coupled to the body  2102  such that rotating the retractable screw member  2108  counterclockwise moves suture tensioning member  2106  axially away from the distal end  2102   a  of the shaft  2102  and along a central longitudinal axis of the shaft  2110 , while rotating the retractable screw member  2108  clockwise moves suture tensioning member  2106  axially towards the distal end  2102   a  of the shaft  2102  and along a central longitudinal axis of the shaft  2110 . 
         [0180]    The tensioning member  2106  includes a first post  2116   a  and a second post  2116   b  coupled to the proximal end  2108   b  of the retractable screw member  2108  forming, e.g., a wing nut. The first post  2116   a  extends outwards along an axis  2118  that is perpendicular to the central longitudinal axis  2110  and the second post  2116   b  extends outwards along the axis  2118  opposite the first post  2116   a . The first and second posts  2116   a  and  2116   b  may aid in rotating the tensioning member  2106 , for example. The retractable screw member  2108  defines a suture lumen  2120  that extends between the distal and proximal ends  2108   a  and  2108   b  of the retractable screw member  30   2108  and is configured to be coaxial to the shaft&#39;s suture lumen  2102   c . The suture lumen  2120  includes an opening (not shown) at the distal end  2108   a  of the retractable screw member  2108  and an opening  2122  at the proximal end  2108   b  of the retractable screw member  2108 . 
         [0181]    The retractable screw member  2108  also includes outer feature  2124  to which the suture can be coupled. In the example shown, the retractable screw member  2108  includes a smooth cylindrical portion  2124  under the wing nut. A free end of the suture can be wrapped around this cylindrical portion  2124 . 
         [0182]    The suture tensioner  2100  may be used to apply tension to the suture prior to tying the final securing knots (e.g. surgeon&#39;s knots) in the free end of the suture, for example. In operation, the free end of a suture is first passed into an opening  2112  at the distal end  2102   a  of the shaft  2102 , through the shaft lumen  2102   c  and out of an opening  2114  at the proximal end  2102   b  of the shaft  2102 . The free end of a suture is passed from the opening  2114  at the proximal end  2102   b  of the shaft  2102  through the suture lumen  2120  in the retractable screw member  2108  and out the opening  2122  at the proximal end  2108   b  of the retractable screw member  2108 . Next, the free end of the suture is coupled to the tensioning member  2106 , for example, by looping or tying it to the smooth cylindrical portion  2124  under the wing nut. The suture tensioning member  2106  is then actuated to exert a force on the suture in a direction away from the distal end  2102   a  of the shaft  2102 , for example, by rotating the retractable screw member  2108  counterclockwise. For example, the suture may be attached to tissue or a bone at one end thus as the suture tensioning member  2106  applies force away from the distal end  2102   a  of the shaft  2102  the suture is pulled tight. The suture may be passed through the shaft lumen  2102   c  and the suture lumen  2120  using a suture passer. 
         [0183]    The shaft  2102  includes an opening  2128  located between openings  2112  and  2114  and near the distal end  2102   a . Opening  2128  may be used to pass the free end of the suture a shorter distance through the lumen  2102   c . The distal end of the shaft  2102  includes a construct engaging feature  2126  configured to engage a surgical construct. The construct engaging feature is a set of one or more posts  2126   a , for example, similar to the head of a screwdriver. The set of posts  2126   a  may be used to engage the head of a surgical screw attached to a piece of bone in a grafting procedure and thus permit a surgeon to manipulate the piece of bone while tensioning a suture that is passed through a lumen in the screw, for example. For example, when the screw button (e.g. as shown in  FIGS. 12-16 ) is inserted into a resected coracoid the set of posts  2126   a  may engage the head of the screw button thus allowing the surgeon properly position the resected coracoid. 
         [0184]    In some implementations, the tensioner  2100  includes a tension measuring mechanism coupled to the suture tensioning member  2106 , for example, to indicate the tensile force applied to the suture. The implementation illustrated in  FIGS. 21A-21C  uses a rigid shaft  2102 , but in some implementations, the shaft  2102  may be a flexible shaft. For example, the shaft  2102  may be puzzle cut, composed of interlocking sections, or made of a longitudinally stiff and radially flexible material. A flexible shaft  2102  may facilitate tensioning sutures in difficult to reach locations during a surgical procedure, for example. 
         [0185]      FIG. 22  illustrates an example of a suture tensioner  2200  having a transverse suture tensioning member  2202 . The suture tensioner  2200  is similar to the suture tensioner  2100  described above, however, the suture tensioning member  2106  is replaced with a transverse suture tensioning member  2202 . In an embodiment, the transverse suture tensioning member  2202  is, a shaft having a broad wing nut shape on one end. In more detail, the tensioning member  2202  includes a shaft member  2204  having a first end  2204   a  and a second end  2204   b . The shaft member  2204  is coupled to the body  2102  along a tensioner longitudinal axis  2206  that is perpendicular to the central longitudinal axis  2110  and is configured such that rotating the transverse tensioning member  2202  winds a suture around the first end  2204   a  of the shaft member  2204 , thereby exerting a force on the suture in a direction away from the distal end of the shaft  2102  and tensioning the suture. In some implementations the free end of the suture is attached to the tensioning bar  2202  by friction between a surface  2208  of the tensioning bar  2202  and the suture while the suture is wound around the tensioning bar  2202 . An outer feature  2210  (e.g. a loop) is coupled to the first end  2202   a  of the tensioning bar  2202  and may be used to help with winding the suture. For example, the free end of the suture may be tied to (or simply passed through) the outer feature  2210  on the transverse tensioning member  2202  and then the tensioning bar  2202  is rotated to wind the suture. 
         [0186]    The transverse tensioning member  2202  includes a first post  2212   a  and a second post  2212   b  coupled to the second end  2204   b  of the shaft member  2204  forming, e.g., a wing nut. The first post  2204   a  extends outwards along an axis  2214  that is perpendicular to the tensioner longitudinal axis  2206  and the second post  2212   b  extends outwards along the axis  2214  opposite the first post  2212   a . The first and second posts  2212   a  and  2212   b  may aid in rotating the transverse tensioning member  2202 , for example. 
         [0187]      FIGS. 23A-23C  illustrate an example of a ratcheting tensioner  2300  used, for example, to tension a suture during a surgical procedure. Tensioner  2300  includes a shaft  2302 , a body  2304 , and a suture tensioning member  2306 . The shaft  2302  is generally shaped like an elongated hollow rod. The shaft  2302  includes a distal end  2302   a  a proximal end  2302   b  and defines a suture lumen  2302   c  that extends from the distal end  2302   a  to the proximal end  2302   b  with an opening  2312  at the distal end  2302   a  and an opening  2314  at the proximal end  2302   b . The body  2304  is coupled to the proximal end  2302   b  of the shaft  2302  and is configured to receive a suture tensioning member  2306 . The suture tensioning member  2306  includes a barrel  2308  coupled to a ratcheting mechanism  2309 . The barrel  2308  is configured to be coupled to the free end of a suture  2307  that is passed in the opening  2312 , through the lumen  2302   c  and out the opening  2314 . When a handle  2316  is actuated the ratchet mechanism  2309  is configured to move the barrel  2308  away from the shaft&#39;s distal end  2302   a  and along an axis parallel to a central longitudinal axis  2310  of the tensioner  2300  thereby exerting a force on the suture in a direction away from the shaft&#39;s distal end  2302   a . The ratcheting mechanism  2309  may then be released by turning a wing nut  2318 , for example. 
         [0188]    The ratcheting mechanism  2309  includes a handle  2316 , a toothed or radially grooved ratcheting member  2320  (to which the barrel  2308  is connected), a pawl  2322 , a spring  2324 , and a wing nut  2318 . The handle  2316  is pivotally coupled to the body  2304  and configured to actuate the ratcheting mechanism  2309  when depressed in a direction towards the body  2304 . A pawl  2322  coupled to the handle  2316  engages the teeth on the ratcheting member  2320 , disposed within the body  2304 , through an opening  2325  in the body  2304 . The pawl  2322  and ratcheting member  2320  are configured such that the pawl  2322  exerts a force on the ratcheting member  2320  to incrementally move the ratcheting member  2320  (and hence the barrel  2308 ) in a direction away from the shaft  2302  and  30  along the central longitudinal axis  2310  against spring pressure. The spring pressure is created as the spring  2324  is compressed inside the body  2304  between an internal surface at the distal end of the body  2326  and a substantially flat surface at a distal end of the ratcheting member  2328 . The wing nut  2318 , coupled to the body  2304  is configured to prevent the ratcheting member  2320  from moving back towards the shaft  2302  when the handle  2316  is released. In addition, the wing nut  2318  is configured to release the ratcheting member  2320  allowing the spring pressure to push the ratcheting member  2320  back towards the shaft  2302  when the wing nut  2318  is rotated. 
         [0189]    In some embodiments, the tensioner may include one or more of the following components. In one aspect, the tensioner may include a damper to prevent the ratcheting mechanism from slamming against the body when released, for example. In another aspect, the tensioner may include a tension measuring mechanism coupled to the suture tensioning member, for example, to indicate the tensile force applied to the suture. In a further aspect, the shaft may be a flexible shaft, for example, the shaft may be puzzle cut, composed of interlocking sections, or made of a longitudinally stiff and radially flexible material. A flexible shaft may facilitate tensioning sutures in difficult to reach locations during a surgical procedure, for example. 
         [0190]    The terms comprise, include, and/or plural forms of each are open ended and include the listed parts and can include additional parts that are not listed. And/or is open ended and includes one or more of the listed parts and combinations of the listed parts. 
         [0191]    One skilled in the art will realize the invention may be embodied in other specific forms without departing from the spirit or essential characteristics thereof. The foregoing embodiments are therefore to be considered in all respects illustrative rather than limiting of the invention described herein. Scope of the invention is thus indicated by the appended claims, rather than by the foregoing description, and all changes that come within the meaning and range of equivalency of the claims are therefore intended to be embraced therein.