Abstract:
An apparatus for suturing tissue includes first and second needles. A first structure associated with the first needle is adapted and configured to pass a leading portion of the suture from a near side of a tissue to a far side of the tissue. A second structure cooperates with the second needle to capture and secure the suture. Proximal movement of the apparatus after the suture is captured moves the suture from the far side of the tissue to the near side of the tissue.

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
     This patent application is a divisional of U.S. patent application Ser. No. 11/805,223, filed May 22, 2007, now U.S. Pat. No. 7,918,868, and claims priority to U.S. Provisional Patent Application Ser. No. 60/802,378, filed May 22, 2006, and U.S. Provisional Patent Application Ser. No. 60/921,403, filed Apr. 2, 2007, the entire contents of each of these prior applications are hereby incorporated herein by reference. 
     REFERENCE TO PENDING PRIOR PATENT APPLICATIONS 
     This patent application claims benefit of: 
     (i) prior U.S. Provisional Patent Application Ser. No. 60/802,378, filed May 22, 2006 by Peter Marshall et al. for METHOD AND APPARATUS FOR MENISCAL REPAIR; and 
     (ii) prior U.S. Provisional Patent Application Ser. No. 60/921,403, filed Apr. 2, 2007 by Peter Marshall et al. for METHOD AND APPARATUS FOR MENISCAL REPAIR. 
     The two above-identified patent applications are hereby incorporated herein by reference. 
    
    
     FIELD OF THE INVENTION 
     This invention relates to surgical methods and apparatus in general, and more particularly to surgical methods and apparatus for the repair of the meniscus. 
     BACKGROUND OF THE INVENTION 
     Looking first at  FIGS. 1 and 2 , the meniscus  5  is a piece of cartilage located in the knee joint, between the top of the tibia  10  and the bottom of the femur  15 . Meniscus  5  serves to facilitate stable movement of the tibia and femur relative to one another, and to absorb shock and to spread load. 
     Meniscus  5  is frequently damaged (e.g., torn) as the result of injury and/or accident. See, for example, the tear  20  shown in  FIG. 3 . A damaged meniscus can impede proper motion of the knee joint and cause pain, among other things. 
     At one time, the standard treatment for a badly damaged meniscus was the partial or complete removal of the meniscus. However, it was subsequently recognized that patients having a partial or complete removal of their meniscus frequently suffered from long term joint problems, e.g., arthritis. 
     The current trend is toward repairing a damaged meniscus, rather than removing part or all of the meniscus. This approach typically requires that tears in the meniscus be closed. There are currently two approaches to closing a tear in the meniscus: suturing and fastening. 
     Suturing a tear in the meniscus has heretofore been technically difficult. This is because the knee joint is a relatively tight space and has limited access points, thus making it hard to maneuver suturing instruments and visualization devices. In addition, there are delicate blood vessels and nerves adjacent to the knee joint (e.g., at the back of the knee) which can be easily damaged, particularly by the sharp needles used to place the suture. 
     Due to the technical difficulties of suturing, fasteners have been developed to close a meniscal tear. Many different types of meniscal fasteners have been produced, e.g., arrows, tacks, T-bars, barbs-and-sutures, screws, etc. However, all of the fasteners developed to date tend to suffer from one or more disadvantages. Among these is the common—and quite significant—disadvantage associated with positioning a rigid component within the interior of the knee. More particularly, all of the fasteners developed to date incorporate at least one rigid component into their design. If the rigid component is not properly positioned at the time of deployment, and/or if the rigid component should subsequently migrate out of position, serious joint abrasion can result. 
     As a result, there is a significant need for a new and improved method and apparatus for meniscal repair. 
     SUMMARY OF THE INVENTION 
     The present invention provides an improved method and apparatus for meniscal repair which addresses the problems associated with the prior art. More particularly, the present invention comprises the provision and use of a novel meniscal suturing system which makes suturing of the meniscus easy, safe and reliable. 
     In one form of the present invention, there is provided apparatus for suturing tissue, wherein the apparatus comprises: 
     a housing; 
     a first needle mounted to the housing; 
     a second needle mounted to the housing; 
     a suture having a leading portion and a trailing portion; 
     a first structure associated with the first needle for passing the leading portion of the suture from a near side of the tissue to a far side of the tissue; and 
     a second structure associated with the second needle for retracting the leading portion of the suture from the far side of the tissue back to the near side of the tissue. 
     In another form of the present invention, there is provided apparatus for suturing tissue, wherein the apparatus comprises: 
     a housing; 
     a first needle mounted to the housing; 
     a second needle mounted to the housing; 
     a suture having a leading portion and a trailing portion; 
     a first structure associated with the first needle for passing the leading portion of the suture from a near side of the tissue to a far side of the tissue; 
     a second structure associated with the second needle for retracting the leading portion of the suture from the far side of the tissue back to the near side of the tissue; 
     a pre-formed, uncinched knot formed in the trailing portion of the suture; and 
     a support for releasably supporting the pre-formed, uncinched knot relative to the housing. 
     In another form of the present invention, there is provided a method for suturing tissue, the method comprising the steps of: 
     providing a suture having a leading portion and a trailing portion, wherein a pre-formed, uncinched knot is formed in the trailing portion of the suture; 
     passing the leading portion of suture from a near side of the tissue to a far side of the tissue; 
     retracting the leading portion of the suture from the far side of the tissue back to the near side of the tissue; 
     passing the retracted leading portion of the suture through the pre-formed, uncinched knot formed in the trailing portion of the suture; and 
     cinching the knot so as to secure the suture in the tissue. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       These and other objects, features and advantages of the present invention will be more fully disclosed in, or rendered obvious by, the following detailed description of the preferred embodiments of the invention, which is to be considered together with the accompanying drawings wherein like numbers refer to like parts and further wherein: 
         FIG. 1  is a schematic front view of a knee joint; 
         FIG. 2  is a schematic top view, in cross-section, of the meniscus of the knee joint; 
         FIG. 3  is a schematic perspective view, in partial section, of the meniscus of the knee joint; 
         FIGS. 4-16  are a series of views showing a first method and apparatus for repairing a meniscal tear; 
         FIGS. 17-30  are a series of views showing a second method and apparatus for repairing a meniscal tear; 
         FIGS. 31-65  are a series of views showing a third method and apparatus for repairing a meniscal tear, with the meniscus being omitted from selected views in order to simplify the drawing and enhance comprehension; 
         FIGS. 66-91  are a series of views showing a fourth method and apparatus for repairing a meniscal tear, with the meniscus being omitted from selected views in order to simplify the drawing and enhance comprehension; and 
         FIGS. 92-103  are a series of views showing a fifth method and apparatus for repairing a meniscal tear. 
     
    
    
     DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS 
     First Preferred Method And Apparatus 
     Looking first at  FIGS. 4 and 5 , there is shown an apparatus  100  for use in closing tear  20  in meniscus  5 . 
     More particularly, in one preferred form of the present invention, and still looking now at  FIGS. 4 and 5 , a first needle  105  is first advanced so that its distal tip  110  is positioned within, but not completely through, meniscus  5 . 
     Next, as seen in  FIG. 6 , a second needle  115  is advanced completely through the meniscus, so that the distal tip  120  of second needle  115  is positioned on the far side of the meniscus. 
     Then, and looking now at  FIGS. 7-9 , a snare  125  is advanced out the distal end  120  of second needle  115 . Snare  125  is formed and arranged so that when the snare is in its fully-extended position ( FIG. 9 ), the loop  130  of snare  125  is axially aligned with the longitudinal axis  135  of first needle  105 . To this end, snare  125  may comprise an elongated body  140  having the loop  130  set at its distal end, with loop  130  being set at an angle to the longitudinal axis of elongated body  140 . At least one of loop  130  and elongated body  140  comprises a resilient material, in order that loop  130  and elongated body  140  may be (i) received within second needle  115 , and (ii) loop  130  may project across the longitudinal axis  135  of first needle  105  when snare  125  is in its fully-extended position ( FIG. 9 ). 
     Next, and looking now at  FIG. 10 , first needle  105  is advanced completely through meniscus  5 , so that the distal end  110  of first needle  105  extends through loop  130  of snare  125 . 
     Then first needle  105  is used to advance a suture  145  through loop  130  of snare  125 . This may be effected in a variety of ways. 
     By way of example but not limitation, and looking now at  FIGS. 10-12 , suture  145  may be pre-disposed within first needle  105  so that suture  145  is carried through the meniscus and through loop  130  of snare  125  with the advancement of first needle  105 . Then a driver  150  may be used to eject the leading portion  145 L ( FIG. 11 ) of suture  145  from the interior of first needle  105 . To this end, a slot  155  may be provided in first needle  105  to assist in ejecting leading portion  145 L of suture  145  from first needle  105 . Finally first needle  105  is withdrawn, leaving leading portion  145 L of suture  145  extending through (i) meniscus  5 , and (ii) loop  130  of snare  125 . The approach shown in  FIGS. 10-12  can be advantageous in many circumstances, since it works well with both braided suture and monofilament suture. In this respect it will be appreciated that braided suture is generally preferable for meniscal repairs, since it tends to form a smaller knot which is less susceptible to slipping. 
     In an alternative approach, where suture  145  has sufficient column strength (e.g., where suture  145  comprises relatively thick monofilament suture), after first needle  105  is advanced through meniscus  5  ( FIG. 10 ) and through loop  130  of snare  125 , the suture can be pushed through first needle  105  so that leading portion  145 L of suture  145  extends through both meniscus  5  and loop  130  of snare  125 . Then, while suture  145  is maintained in place, first needle  105  can be withdrawn, with the column strength of the suture ensuring that leading portion  145 L of suture  145  does not retreat from its position extending through meniscus  5  and loop  130  of snare  125 . Of course, this latter approach does suffer from the disadvantage that it requires the use of suture with sufficient column strength (e.g., monofilament suture) and hence this approach can be difficult to practice with conventional braided suture. 
     Regardless of the particular approach used to achieve the position shown in  FIG. 12 , once this position has been achieved, the next step is to carry leading portion  145 L of suture  145  back to the near side of the meniscus. More particularly, and looking now at  FIGS. 13-15 , snare  125  is retracted back into second needle  115 , and then second needle  115  is withdrawn back through the meniscus, carrying leading portion  145 L of suture  145  with it. 
     Thus, at this point in the procedure, suture  145  will have been passed from the near side of the meniscus, across the meniscus and then back again. Significantly, by appropriately positioning the first needle  105  and second needle  115  during the suture passing operation, the suture will extend across the tear  20  formed in meniscus  5 . 
     Next, the suture is tied down so as to close the tear in the meniscus. This may be done in a variety of ways which will be apparent to those skilled in the art in view of the present disclosure. However, in one preferred form of the invention, a trailing portion  145 T of suture  145  may be arranged in the form of a pre-formed, uncinched knot  160  disposed about the exterior of second needle  115  (see, for example, FIGS.  13  and  14 ), with an intermediate portion  145 I of suture  145  being disposed within apparatus  100 . As a result of this construction, when snare  125  and second needle  115  carry leading portion  145 L of suture  145  back through the meniscus, they will also carry leading portion  145 L of suture  145  back through pre-formed, uncinched knot  160  ( FIG. 15 ), which is itself formed from trailing portion  145 T of that same suture  145 . It will be appreciated that, as second needle  115  is withdrawn, pre-formed, uncinched knot  160  will slip off the end of second needle  115 , into direct contact with leading portion  145 L of suture  145 , as the suture passes back through itself. 
     Then, and looking now at  FIG. 16 , suture  145  is pulled taut so as to simultaneously (i) pull tear  20  closed, and (ii) tighten pre-formed knot  160  onto the suture, whereby to fix the suture in position and thereby close tear  20  in meniscus  5 . The trailing end  145 T of suture  145  can then be trimmed away in ways well known in the art, thereby leaving a low-profile suture fixation within the meniscus. 
     Second Preferred Method And Apparatus 
     Looking now at  FIGS. 17 and 18 , there is shown an apparatus  200  for use in closing tear  20  in meniscus  5 . 
     More particularly, in one preferred form of the invention, and still looking now at  FIGS. 17 and 18 , a first needle  205  is first advanced so that its distal tip  210  is positioned within, but not completely through, meniscus  5 . 
     Next, as seen as  FIG. 19 , a second needle  215  is advanced completely through the meniscus, so that the distal tip  220  of second needle  215  lies on the far side of the meniscus. 
     Then, and looking now at  FIG. 20 , first needle  205  is advanced all the way across meniscus  5 . 
     Then, and looking now at  FIGS. 21 and 22 , a snare  225  is advanced out the distal end  220  of second needle  215 . Snare  225  is formed and arranged so that when the snare is in its fully-extended position ( FIG. 22 ), the loop  230  of snare  225  is axially aligned with the longitudinal axis  235  of second needle  215 . To this end, snare  225  may comprise an elongated body  240  having loop  230  set at its distal end, with loop  230  being aligned with the longitudinal axis of elongated body  240 . 
     Next, and looking now at  FIG. 23 , a suture holder  250  carrying a suture  245  is advanced out the distal end  210  of first needle  205 . Suture holder  250  is configured so that the suture holder will carry the leading portion  245 L of suture  245  through loop  230  of snare  225  when the suture holder is extended out of first needle  205 . 
     Then suture holder  250  is withdrawn, leaving the leading portion  245 L of suture  245  extending though loop  230  of snare  225  ( FIG. 24 ). 
     Next, leading portion  245 L of suture  245  is carried back to the near side of the meniscus. More particularly, and looking now at  FIGS. 25-29 , snare  225  is retracted back into second needle  215 , second needle  215  is withdrawn back through the meniscus, and then first needle  205  is withdrawn back through the meniscus. 
     Thus, at this point in the procedure, suture  245  will have been passed from the near side of the meniscus, through the meniscus and then back again. Significantly, by appropriately positioning first needle  205  and second needle  215  during the suture passing operation, suture  245  will extend across tear  20  formed in meniscus  5 . 
     Next, the suture is tied down so as to close the tear in the meniscus. This may be done in a variety of ways which will be apparent to those skilled in the art in view of the present disclosure. However, in one preferred form of the invention, the trailing portion  245 T of suture  245  may be arranged in the form of a pre-formed, uncinched knot  260  disposed about the exterior of second needle  215  (see, for example,  FIG. 28 ) so that when snare  225  and second needle  215  carry leading portion  245 L of suture  245  back through the meniscus, they will also carry leading portion  245 L of suture  245  back through pre-formed, uncinched knot  260  ( FIG. 29 ), which is formed by trailing portion  245 T of suture  245 . It will be appreciated that, as second needle  215  is withdrawn, pre-formed, uncinched knot  260  will slip off the end of second needle  215 , into direct contact with leading portion  245 L of suture  245 , as the suture passes back through itself. 
     Then, and looking now at  FIG. 30 , trailing portion  245 T of suture  245  is pulled taut so as to simultaneously (i) pull tear  20  closed, and (ii) tighten pre-formed knot  260  onto the suture, whereby to fix the suture in position and thereby close tear  20  in meniscus  5 . The trailing end  245 T of suture  245  can then be trimmed away in ways well known in the art, thereby leaving a low-profile suture fixation within the meniscus. 
     Third Preferred Method And Apparatus 
     Looking now at  FIGS. 31-35 , there is shown an apparatus  300  for use in closing tear  20  in meniscus  5 . Apparatus  300  generally comprises a suture passer  301  ( FIGS. 31-33 ), a suture cartridge  302  ( FIG. 34 ) and a knot pusher/cutter  303  ( FIG. 35 ). Specific details of the construction and function of suture passer  301 , suture cartridge  302  and knot pusher/cutter  303  will be disclosed in the course of the following discussion of using apparatus  300  to close tear  20  in meniscus  5 . 
     Looking now at  FIGS. 31-33 ,  36  and  37 , suture passer  301 , with suture cartridge  302  mounted thereon, is first manipulated so that its first needle  305  and its second needle  315  are advanced so that their distal tips  310 ,  320  are passed completely through meniscus  5 . 
     Next, as seen as  FIGS. 38-39 , a suture holder  350  carrying a suture  345  is advanced out distal end  310  of first needle  305 . Suture holder  350  is configured so that the suture holder will carry the leading portion  345 L of suture  345  through a slot  330  of second needle  315  when the suture holder is extended out of first needle  305 . 
     Then, as shown in  FIGS. 40 and 41 , an ejector wire  351  is used to eject leading portion  345 L of suture  345  from suture holder  350 . 
     At this point, suture holder  350  is withdrawn, leaving leading portion  345 L of suture  345  extending though slot  330  of second needle  315 . See  FIGS. 42 and 43 . Then an obturator  352  is advanced within second needle  315  so as to pin leading portion  345 L of suture  345  to second needle  315 . 
     Next, suture passer  301  is retracted so that its first needle  305  and second needle  315  are withdrawn from the meniscus. See  FIGS. 44 and 45 . Thus, at this point in the procedure, suture  345  will have been passed from the near side of the meniscus, through the meniscus and then back again. Significantly, by appropriately positioning first needle  305  and second needle  315  during the suture passing operation, suture  345  will extend across tear  20  formed in meniscus  5 . 
     Next, the suture is tied down so as to close the tear in the meniscus. This may be done in a variety of ways which will be apparent to those skilled in the art in view of the present disclosure. In one preferred form of the invention, this is accomplished in the following way. First, as shown in  FIG. 46 , suture cartridge  302  is dismounted from suture passer  301 . Then suture cartridge  302  is mounted to knot pusher/cutter  303  ( FIG. 47 ) and locked in place ( FIG. 48 ). At this point, and looking now at  FIGS. 49 and 50 , suture cartridge  302  is ready to receive leading portion  345 L of suture  345 . Next, leading portion  345 L of suture  345  is inserted into a loop  353  of a snare basket  354 , as shown in  FIGS. 51-53 . Snare basket  354  essentially comprises a conventional suture threader component, or needle threader component, in the sense that a collapsible loop is formed at the end of a pullable tab. Then snare basket  354  is retracted, carrying leading portion  345 L of suture  345  through a pre-formed, uncinched knot  360  formed in the trailing portion  345 T of suture  345  and disposed at the tip of knot pusher/cutter  303 . See  FIGS. 54-56 . It will be appreciated that as snare basket  354  carries leading portion  345 L of suture  345  through pre-formed, uncinched knot  360 , the suture passes back through itself. 
     Then, and looking now at  FIGS. 57-59 , knot pusher/cutter  303  is advanced distally so as to bring pre-formed, un-cinched knot  360  to the near side surface of the meniscus. Next, as shown in  FIGS. 60 and 61 , pre-formed, un-cinched knot  360  is tightened. Then leading portion  345 L of suture  345  is trimmed away by knot pusher/cutter  303  ( FIGS. 62 and 63 ). Finally, knot pusher/cutter  303  is removed, leaving suture  345  closing the tear in the meniscus ( FIGS. 64 and 65 ) with a low-profile suture fixation. 
     In one preferred form of the invention, and looking now at  FIG. 60 , knot pusher/cutter  303  comprises a shaft S having a central bore B, a counterbore CB and a side opening SO. A hollow ram R, having a ram side opening RSO, is slidably disposed within bore B of shaft S. Prior to knot deployment, the pre-formed, uncinched knot  360  is seated within counterbore CB; and after leading portion  345 L of suture  345  is passed through pre-formed, uncinched knot  360 , leading portion  345 L is drawn through ram side opening RSO and shaft side opening SO; and when the knot is to be separated from shaft S, ram R is moved distally, first pushing the knot out of the shaft and, after cinching, thereafter cutting leading portion  345 L of suture  345  by virtue of moving side opening SO out of alignment with ram side opening RSO. 
     In one preferred form of the invention, the cinched knot is separated from shaft S in a first discrete step, and then the suture is cut in a second discrete step. 
     Fourth Preferred Method And Apparatus 
     Looking now at  FIG. 66 , there is shown an apparatus  400  for use in closing tear  20  in meniscus  5 . Apparatus  400  generally comprises a handle  401 , a needle cartridge  402  and a pusher/cutter  403 . Pusher/cutter  403  is similar to suture cartridge  302  discussed above, in the sense that it carries a pre-formed, uncinched knot, etc., as will hereinafter be discussed. Specific details of the construction and function of handle  401 , needle cartridge  402  and pusher/cutter  403  will be disclosed in the course of the following discussion of using apparatus  400  to close tear  20  in meniscus  5 . 
     Looking now at  FIGS. 67 and 68 , apparatus  400  is manipulated so that its first needle  405  and its second needle  415  are advanced so that their distal tips  410 ,  420  are passed completely through meniscus  5 . 
     Next, as seen as  FIGS. 69 and 70 , a suture holder  450  carrying a suture  445  is advanced out distal end  410  of first needle  405 . Suture holder  450  is configured so that the suture holder will carry the leading portion  445 L of suture  445  through a slot  430  of second needle  415  when the suture holder is extended out of first needle  405 . 
     Then, as shown in  FIGS. 71 and 72 , an ejector wire  451  is used to eject leading portion  445 L of suture  445  from suture holder  450 . 
     At this point, suture holder  450  is withdrawn, leaving leading portion  445 L of suture  445  extending though slot  430  of second needle  415 . See  FIGS. 73 and 74 . Then an obturator  452  is advanced within second needle  415  so as to pin leading portion  445 L of suture  445  to second needle  415 . 
     Next, handle  401  is retracted so that its first needle  405  and second needle  415  are withdrawn from the meniscus. See  FIG. 75 . Thus, at this point in the procedure, suture  445  will have been passed from the near side of the meniscus, through the meniscus and then back again. Significantly, by appropriately positioning first needle  405  and second needle  415  during the suture passing operation, suture  445  will extend across tear  20  formed in meniscus  5 . 
     Next, the suture is tied down so as to close the tear in the meniscus. This may be done in a variety of ways which will be apparent to those skilled in the art in view of the present disclosure. In one preferred form of the invention, this is accomplished in the following way. Looking now at  FIGS. 76 and 77 , pusher/cutter  403  is ready to receive leading portion  445 L of suture  445 . Then, as shown in  FIGS. 78-81 , leading portion  445 L of suture  445  is inserted into a loop  453  of pusher/cutter  403 . Again, loop  453  of pusher/cutter  403  essentially comprises a conventional suture threader component, or needle threader component, in the sense that a collapsible loop is formed at the end of a pullable shaft. Then pusher/cutter  403  is detached from handle  401 , carrying leading portion  445 L of suture  445 . Next, leading portion  445 L of suture  445  is passed through a pre-formed, uncinched knot  460  disposed at the tip of pusher/cutter  403  ( FIGS. 82-84 ). It will be appreciated that as leading portion  445 L of suture  445  is passed through pre-formed, uncinched knot  460 , the suture passes back through itself. 
     Then, and looking now at  FIGS. 85 and 86 , pusher/cutter  403  is advanced distally so as to bring pre-formed, un-cinched knot  460  to the near side surface of the meniscus. Next, as shown in  FIGS. 87-89 , the pre-formed knot is tightened. Then leading portion  445 L of suture  445  is trimmed away by pusher/cutter  403  ( FIGS. 90 and 91 ). Finally, pusher/cutter  403  is removed, leaving suture  445  closing the tear in the meniscus with a low-profile suture fixation. 
     In one preferred form of the invention, and looking now at  FIG. 88 , pusher/cutter  403  comprises a shaft S having a central bore B, a counterbore CB and a side opening SO. A hollow ram R, having a ram side opening RSO, is slidably disposed within bore B of shaft S. Prior to knot deployment, the pre-formed, uncinched knot  460  is seated within counterbore CB; and after leading portion  445 L of suture  445  is passed through pre-formed, uncinched knot  460 , leading portion  445 L is drawn through ram side opening RSO and shaft side opening SO; and when the knot is to be separated from shaft S, ram R is moved distally, first pushing the knot out of the shaft and, after cinching, thereafter cutting leading portion  445 L of suture  445  by virtue of moving side opening SO out of alignment with ram side opening RSO. 
     In one preferred form of the invention, the cinched knot is separated from shaft S in a first discrete step, and then the suture is cut in a second discrete step. 
     Fifth Preferred Method And Apparatus 
     In yet another preferred form of the present invention, the pre-formed, uncinched knot can be stored in a disposable tip that is releasably mounted to the needles, with the needles themselves being releasably mounted to the handle, and with the disposable tip being connectable to a pusher after the suture has been passed through the tissue. This construction has the advantage that (i) a single handle can be used for both the needles and pusher, and (ii) a single handle and a single pusher can be provided even where a patient may require multiple stitches (i.e., multiple disposable tips with multiple pre-formed, uncinched knots). 
     More particularly, and looking now at  FIGS. 92-97 , there is shown an apparatus  500  for use in closing tear  20  in meniscus  5 . Apparatus  500  generally comprises a handle  501 , a needle cartridge  502 , and a pusher  503 . Needle cartridge  502  includes a disposable tip  504  which contains the pre-formed, uncinched knot  560 . Specific details of the construction and function of handle  501 , needle cartridge  502 , pusher  503  and disposable tip  504  will be disclosed in the course of the following discussion of using apparatus  500  to close tear  20  in meniscus  5 . 
     The apparatus  500  is prepared for use by mounting needle cartridge  502  mounted to handle  501 , and mounting pusher  503  to handle  501  ( FIG. 98 ). 
     Apparatus  500  utilizes the same suture passing approach as apparatus  400  in order to pass and retract the leading portion of the suture from the near side of the meniscus to the far side of the meniscus and then back. Once the leading portion  545 L of suture  545  is retracted to the near side of the meniscus, leading portion  545 L of suture  545  is threaded into loop  553  of a snare  554 . Snare  554  in turn extends through the body of disposable tip  504 , including through pre-formed, uncinched knot  560 , and exits disposable tip  504  before being attached to needle cartridge  502  at  555 . Then, pusher  503  is detached from handle  501  ( FIG. 99 ) and is brought down into engagement with disposable tip  504  ( FIGS. 100-102 ). Pusher  503  is then withdrawn, carrying disposable tip  504  with it. As disposable tip  504  is withdrawn from needle cartridge  502 , snare  554  is pulled back through the retreating disposable tip  504  thereby threading suture  545 L through pre-formed, uncinched knot  560 . Thereafter, suture  545  is secured in the manner previously discussed. 
     Additional Aspects of the Invention 
     It will be appreciated that needles  105 ,  115 ,  205 ,  215 ,  305 ,  315 ,  405 ,  415 , etc. may be straight (as shown) or curved as desired. 
     Furthermore, the apparatus  100 ,  200 ,  300 ,  400 ,  500  may be used with either a medial or lateral approach. 
     MODIFICATIONS 
     It is to be understood that the present invention is by no means limited to the particular constructions herein disclosed and/or shown in the drawings, but also comprises any modifications or equivalents within the scope of the invention.