Abstract:
A system is disclosed for repairing and reconstructing an injured anterior cruciate ligament (ACL); This system may be used irrespective of the type of patient or the ACL graft selected. Means for performing single or multiple bundle reconstruction, primary ACL repair and physeal-sparing ACL reconstruction are disclosed. A guide for inside-out creation of a femoral tunnel independent of the tibial tunnel is also disclosed, as well as a series of implant options for tibial and femoral fixation of any bone-soft-tissue composite or soft-tissue-only graft.

Description:
[0001]    This is a nonprovisional application which claims the filing date of the same applicant&#39;s provisional application Ser. No. 60/764,026 filed in the United States Patent and Trademark Office on Feb. 2, 2006. 
         [0002]    This invention relates to systems for repairing and reconstructing injured anterior cruciate ligaments. More particularly it relates to a novel method and related family of methods of orthopaedic surgery for repairing and reconstructing an injured anterior cruciate ligament. It also relates to new and improved instruments and implants used in practicing the new method and family of methods. 
         [0003]    Except for the provisional application referred to above, there are no patent applications related to this one. Neither this application nor the provisional application upon which it relies is subject to any federally sponsored research or development or to any joint research agreement. 
     
    
     BACKGROUND OF THE INVENTION 
       [0004]    Orthopaedic surgeons perform reconstructive surgery of the anterior cruciate ligament (ACL) on patients who have traumatically injured this ligament. ACL reconstructive surgery restores the function of the ACL in the human knee and provides stability for the knee allowing patients to return to athletic activities. Without ACL reconstructive surgery, patients typically experience instability, “giving way,” of the knee and incur further injury to other important anatomic structures of the knee, including meniscal and articular cartilage. 
       BRIEF SUMMARY OF THE INVENTION 
       [0005]    While there are different surgical methods, instruments and implants used to reconstruct an ACL depending upon the patient and the ACL graft selected for the reconstructive procedure, the present invention describes a novel universal system of methods, instruments and implants to repair and reconstruct an ACL irrespective of the type of patient or ACL graft selected. This invention also includes a means to perform single or multiple bundle ACL reconstruction, primary ACL repair, and physeal (growth plate)-sparing ACL reconstruction, in the skeletal immature patient. 
         [0006]    This invention includes a novel guide for “inside-out” creation of a femoral tunnel independent of the tibial tunnel, and it also includes a series of implant options providing a complete set for tibial and femoral fixation of any bone-soft-tissue composite or soft-tissue-only ACL graft. 
         [0007]    Other benefits include more reliable methods for anatomic positioning of femoral tunnels, a technically facile method of creating femoral and tibial tunnels independent of each other, and a universal method for tunnel creation irrespective of patient or ACL graft selection. 
         [0008]    The present invention especially allows a surgeon to become familiar with a single universal system of methods, instruments and implants which allows him or her to treat all patients with any graft and achieve the most reliable and reproducible technical and clinical results. 
         [0009]    Accordingly, one object of this invention is to provide a universal system for a single surgeon to use in repairing and reconstructing an ACL in any patient using any graft. 
         [0010]    Another object of this invention is to provide a novel guide for simply and easily creating an anatomic femoral tunnel independently of a tibial tunnel by directing a guide pin from a separate portal directly through the anatomic footprint of the ACL. 
         [0011]    Another object of this invention is to provide a guide which allows for the passage of a guide wire from multiple directions, through the tibial tunnel and other arthroscopic portals, and also allows for the creation of multiple femoral tunnels, the creation of an epiphyseal (physeal sparing) femoral tunnel, and the repair of the torn stump of the ACL, all using a consistent simple method. 
         [0012]    Another object of this invention is to provide a novel cannulated scalpel for improved accuracy in creating a limited passageway through skin and soft-tissue over a guide wire. 
         [0013]    Another object of this invention is to provide a method of drilling bone tunnels over a guide wire from any direction. 
         [0014]    Another object of this invention is to provide a novel surgical ring fixation tool which includes a ring and a ring capture button for fixing a loop end of a soft-tissue graft in a bone tunnel. 
         [0015]    Another object of this invention is to provide a novel surgical ring fixation tool which can be used in conjunction with a tunnel in any bone according to a simple consistent method. 
         [0016]    Another object of this invention is to provide a novel suspension pin for fixing a loop end of a soft-tissue graft in a tunnel of any bone. 
         [0017]    Another object of this invention is to provide a novel hybrid suspension pin for fixing a loop end of a soft-tissue graft in a bone tunnel. 
         [0018]    Another object of this invention is to provide a surgical pin guide capable of being placed in any bone tunnel from any direction for accurately inserting a pin in the bone across the bone tunnel and facilitating both the placement of a graft and the fixation of the graft with the pin. 
         [0019]    Another object of this invention is to provide a suspension pin insertion tool having a tip with inverse geometry to the rear end of a suspension pin for inserting the pin into any bone. 
         [0020]    Another object of this invention is to provide a wire cutting tool capable of being placed through small percutaneous skin incisions and operable to cut and remove the wire ends of a surgical pin guide wire element. 
         [0021]    Another object of this invention is to provide a guide pin having a sharp leading tip, cannulations at its ends, and a body having an enlarged diameter portion with an outwardly facing cutting surface intermediate the cannulations for cutting a passageway in a bone larger that the rest of the guide pin&#39;s body. 
         [0022]    Another object of this invention is to provide a wire passing tool for performing a novel method of passing a flexible wire from one bone tunnel to another. 
         [0023]    Another object of this invention is to provide a method of loading a soft-tissue graft onto a central loop of flexible wire and thereafter straightening the wire to draw the soft-tissue graft into a desired position in a bone tunnel. 
         [0024]    Another object of this invention is to provide a modular and non-modular interference screw-ligament washer for fixing the free end of a graft in a bone tunnel at two sites, namely, at the tunnel inner wall and at the outer cortical surface of the tunnel. 
         [0025]    Another object of this invention is to provide an insertion tensioner tool and its associated components. 
         [0026]    Another object of this invention is to provide a method of performing ACL repair. 
         [0027]    Another object of this invention is to provide a method of performing ACL reconstruction on a skeletally immature patient with open physes (growth plates). 
         [0028]    Other objects and features of this invention will be apparent to orthopaedic surgeons and other persons who are skilled in the art of ACL repair and reconstruction and who design solutions thereto, particularly after reviewing the following description of the preferred embodiments of the present invention and the accompanying drawings. 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         [0029]      FIG. 1  is a perspective view of a novel femoral guide in accordance with the present invention. 
           [0030]      FIG. 2  is a top plan view of the guide in  FIG. 1 . 
           [0031]      FIG. 3  is a perspective view of an alternative embodiment of the novel femoral guide of  FIG. 1  with a semi-circular flexible guide loop. 
           [0032]      FIG. 4  is a schematic view of the disposition of a guide pin in the femur of a knee utilizing the femoral guide of claim  1  in accordance with the present invention. 
           [0033]      FIG. 5  is a schematic view of an alternative manner of disposing a guide pin in the femur of a knee utilizing the femoral guide of claim  1  in accordance with the present invention. 
           [0034]      FIG. 6  is an exploded view of the disposition of a guide pin in the femur of a knee utilizing the femoral guide of claim  1  in accordance with the present invention. 
           [0035]      FIG. 7  is a perspective view of a cannulated scalpel in accordance with the present invention. 
           [0036]      FIG. 8  is a schematic view of a manner of incising the skin and soft-tissue over a guide wire utilizing the cannulated scalpel of  FIG. 7  in accordance with the present invention. 
           [0037]      FIG. 9  is a schematic view of a manner of creating a tunnel in a bone over a guide wire utilizing a cannulated reamer or drill in accordance with the present invention. 
           [0038]      FIG. 10  is a schematic view of an alternative manner of creating a tunnel in a bone over a guide wire utilizing a cannulated reamer or drill in accordance with the present invention. 
           [0039]      FIG. 11  is a schematic view of a second alternative manner of creating a tunnel in a bone over a guide wire utilizing a cannulated reamer or drill in accordance with the present invention. 
           [0040]      FIG. 12  is a perspective view of a surgical ring fixation tool with its ring engaged in its ring capture button in accordance with the present invention. 
           [0041]      FIG. 13  is a perspective view of the ring of  FIG. 12 . 
           [0042]      FIG. 14  is a perspective view of a ring capture button in the surgical ring fixation tool of  FIG. 12 . 
           [0043]      FIG. 15  is a side elevational view of the ring capture button of  FIG. 14 . 
           [0044]      FIG. 16  is a schematic view of a manner of passing the ring of  FIG. 13  along with a looped end of soft-tissue graft in accordance with the present invention. 
           [0045]    FIG,  17  is a schematic view of a manner of assembling the ring of  FIG. 13  and the ring capture button of  FIG. 14  in accordance with the present invention. 
           [0046]      FIG. 18  is a schematic view of a manner of femoral placement of the surgical ring fixation tool of  FIG. 12  in a knee in accordance with the present invention. 
           [0047]      FIG. 19  is a schematic view of a manner of tibial placement of the surgical ring fixation tool of  FIG. 12  in a knee in accordance with the present invention. 
           [0048]      FIG. 20A  is a perspective view of a suspension pin in accordance with the present invention. 
           [0049]      FIG. 20B  is a perspective view of an alternative embodiment of a suspension pin in accordance with the present invention. 
           [0050]      FIG. 20C  is a perspective view of a suspension pin insertion tool in accordance with the present invention. 
           [0051]      FIG. 20D  is a perspective view of a guide wire cutting tool for removing the wire ends of a surgical pin guide wire element in accordance with the present invention. 
           [0052]      FIG. 21  is a perspective view of a surgical pin guide in accordance with the present invention. 
           [0053]      FIG. 22  is a perspective view of a surgical guide pin in accordance with the present invention. 
           [0054]      FIG. 23A  is a schematic view of a manner of inserting the surgical guide pin shown in  FIG. 22  across a bone tunnel in accordance with the present invention. 
           [0055]      FIG. 23B  is a schematic view of a manner of inserting the surgical guide pin shown in  FIG. 22  across a bone tunnel in accordance with the present invention. 
           [0056]      FIG. 24A  is a schematic view of an alternative manner of inserting the surgical guide pin shown in  FIG. 22  across a bone tunnel in accordance with the present invention. 
           [0057]      FIG. 24B  is a schematic view of a flexible wire attached to the surgical guide pin of  FIG. 22  traversing a bone tunnel in accordance with the present invention. 
           [0058]      FIG. 24C  is a schematic view of a manner of exchanging the surgical guide pin shown in  FIG. 22  with the flexible wire of the suspension pin of the present invention. 
           [0059]      FIG. 24D  is a schematic view of an alternative manner of attaching a flexible wire of the suspension pin to the surgical guide pin traversing a bone tunnel in accordance with the present invention. 
           [0060]      FIG. 24E  is a schematic view of an alternative manner of exchanging the surgical guide pin of this invention with the flexible wire of the suspension pin of this invention. 
           [0061]      FIG. 25A  is a perspective view of a wire passing tool in accordance with the present invention. 
           [0062]      FIG. 25B  is an exploded view of the wire passing tool shown in  FIG. 25A  opening its functional tip. 
           [0063]      FIG. 25C  is a schematic view of a manner of utilizing the wire passing tool shown in  FIG. 25A  to pass a central loop of flexible wire from a tunnel in a bone out through a tunnel in another bone in accordance with the present invention. 
           [0064]      FIG. 26  is a sectional view of  FIG. 25C  showing the wire passing tool of  FIG. 25A  passing the central loop of flexible wire in the manner illustrated in  FIG. 25C . 
           [0065]      FIG. 27  is a schematic view of a manner of loading a free soft-tissue graft into a central loop of a flexible wire in accordance with the present invention. 
           [0066]      FIG. 28  is a schematic view of a manner of straightening and advancing a flexible wire to draw the loop end of a free soft-tissue graft through a tunnel in a bone into a tunnel of another bone in accordance with the present invention. 
           [0067]      FIG. 29  is a schematic view of a manner of making an additional pass of a central loop of flexible wire from a tunnel in a bone out through an additional tunnel in another bone in accordance with the present invention. 
           [0068]      FIG. 30  is a schematic view of a manner of loading a free soft-tissue graft into a central loop in a flexible wire in accordance with the present invention. 
           [0069]      FIG. 31  is a schematic view of a manner of straightening and advancing a flexible wire to draw a loop end of a second free soft-tissue graft through a second tunnel in a bone into a tunnel of another bone in accordance with the present invention. 
           [0070]      FIG. 32A  is a schematic view of a manner of inserting the suspension pin shown in  FIGS. 20A and 20B  using the suspension pin insertion tool shown in  FIG. 20C  in accordance with the present invention. 
           [0071]      FIG. 32B  is a schematic view of a manner of cutting a flexible wire from the end of a suspension pin of this invention utilizing the wire cutting tool shown in  FIG. 20D  in accordance with the present invention. 
           [0072]      FIG. 32C  is a schematic view of a manner of inserting the suspension pin shown in  FIGS. 20A and 20B  to secure a loop end of a free soft-tissue graft in a bone tunnel in accordance with the present invention. 
           [0073]      FIG. 33  is a schematic view of an alternative manner of passing a central loop of flexible wire from a tunnel in a bone out through a tunnel in another bone in accordance with the present invention. 
           [0074]      FIG. 34  is a sectional view of  FIG. 33  showing the passage of the central loop of flexible wire illustrated in  FIG. 33 . 
           [0075]      FIG. 35  is a schematic view of a manner of loading a free soft-tissue graft into a central loop of flexible wire in accordance with the present invention. 
           [0076]      FIG. 36  is a schematic view of a manner of straightening and advancing a flexible wire to draw the loop end of a free soft-tissue graft through a tunnel in a bone into a tunnel of another bone in accordance with the present invention. 
           [0077]      FIG. 37A  is a schematic view of a manner of inserting the suspension pin shown in  FIGS. 20A and 20B  utilizing the suspension pin insertion tool shown in  FIG. 20C  to secure a loop end of a free soft-tissue graft in a bone tunnel in accordance with the present invention. 
           [0078]      FIG. 37B  is a schematic view of a manner of cutting a flexible wire from a suspension pin of this invention utilizing the wire cutting tool shown in  FIG. 20D  in accordance with the present invention. 
           [0079]      FIG. 38  is a perspective view of a modular interference screw-ligament washer in accordance with the present invention. 
           [0080]      FIG. 39  is a perspective view of a cannulated interference screw component of the modular interference screw-ligament washer shown in  FIG. 38 . 
           [0081]      FIG. 40  is a perspective view of a separate cannulated screw component and mobile ligament washer component of the interference screw-ligament washer shown in  FIG. 38 . 
           [0082]      FIG. 41  is a perspective view of a non-modular interference screw-ligament washer in accordance with the present invention. 
           [0083]      FIG. 42  is a perspective view of an insertion-tensioner tool in accordance with the present invention. 
           [0084]      FIG. 43  is a top plan view of the insertion-tensioner tool shown in  FIG. 42 . 
           [0085]      FIG. 44  is a perspective view of a trocar component of the insertion-tensioner tool shown in  FIG. 42 . 
           [0086]      FIG. 45  is a perspective view of a graft loader component of the insertion-tensioner shown in  FIG. 42 . 
           [0087]      FIG. 46  is a perspective view of a cannulated screw driver component of the insertion-tensioner tool shown in  FIG. 42 . 
           [0088]      FIG. 47  is a perspective view of a cutter component of the insertion-tensioner shown in  FIG. 42 . 
           [0089]      FIG. 48  is a schematic view of a manner of loading the free end of a soft-tissue graft into the insertion-tensioner shown in  FIG. 42  utilizing the graft loader component shown in  FIG. 45  in accordance with the present invention. 
           [0090]      FIG. 49  is a schematic view of a manner of positioning the insertion-tensioner shown in  FIG. 42  loaded with a soft-tissue graft over an opening of a bone tunnel utilizing the trocar component shown in  FIG. 44  and a guide wire in accordance with the present invention. 
           [0091]      FIG. 50  is a schematic view of a manner of inserting the interference screw component of the modular interference screw-ligament washer shown in  FIG. 38  utilizing the insertion-tensioner shown in  FIG. 42  and the cannulated screwdriver component shown in  FIG. 46  in accordance with the present invention. 
           [0092]      FIG. 51  is a schematic view of a manner of inserting the interference screw component of the modular interference screw-ligament washer shown in  FIG. 38  utilizing the insertion-tensioner shown in  FIG. 42  and the cannulated screwdriver component shown in  FIG. 46  in accordance with the present invention. 
           [0093]      FIG. 52  is a schematic view of a manner of inserting the separate cannulated screw and mobile ligament washer components of the modular interference screw-ligament washer shown in  FIG. 40  utilizing the insertion-tensioner tool shown in  FIG. 42  and the cannulated screw driver shown in  FIG. 46  in accordance with the present invention. 
           [0094]      FIG. 53  is a schematic view of a manner of cutting free ends of soft-tissue graft utilizing the cutter component shown in  FIG. 47  of the insertion-tensioner tool shown in  FIG. 42  after the graft has been secured by the modular or non-modular interference screw-ligament washer shown in  FIGS. 38 and 41  in accordance with the present invention. 
           [0095]      FIG. 54  is a schematic view of a manner of inserting the non-modular interference screw-ligament washer shown in  FIG. 41  utilizing the insertion-tensioner tool shown in  FIG. 42  and the cannulated screw driver shown in  FIG. 46  in accordance with the present invention. 
           [0096]      FIG. 55  is a schematic view of a manner of repairing an ACL tear utilizing the femoral guide tool shown in  FIG. 1 , the surgical guide pin shown in  FIG. 22 , and the cannulated scalpel shown in  FIG. 7  in accordance with the present invention. 
           [0097]      FIG. 56  is an enlarged schematic view of a portion of  FIG. 55  illustrating a manner of positioning the surgical guide pin shown in  FIG. 22  to pass a suture placed in the torn end of the ACL in accordance with the present invention. 
           [0098]      FIG. 57  is an enlarged schematic view of a portion of  FIG. 55  illustrating a manner of positioning the surgical guide pin shown in  FIG. 22  to pass an additional suture placed in the torn end of the ACL in accordance with the present invention. 
           [0099]      FIG. 58  is a schematic view of a manner of securing the sutures used to repair the ACL tear after using the femoral guide tool shown in  FIG. 1 , the surgical guide pin shown in  FIG. 22  and the cannulated scalpel shown in  FIG. 7  in accordance with the present invention. 
           [0100]      FIG. 59  is a schematic view of a manner of securing an ACL graft in a femoral and tibial epiphysis of a skeletally immature knee without crossing either the femoral or tibial physis utilizing the femoral interference screw-ligament washer shown in  FIGS. 38 and 41  and the suspension pin shown in  FIGS. 20A and 20B  in accordance with the present invention. 
           [0101]      FIG. 60  is a perspective view of a protective sleeve in accordance with the present invention. 
           [0102]      FIG. 61  is a top plan view of the protective sleeve shown in  FIG. 60 . 
           [0103]      FIG. 62  is a perspective view of a bullet guide in accordance with the present invention. 
           [0104]      FIG. 63  is a perspective view of a cannulated drill bit in accordance with the present invention. 
           [0105]      FIG. 64  is a schematic view of a manner of placing a guide pin into the ACL footprint of the tibial epiphysis of a skeletally immature knee without crossing the tibial physis utilizing the protective sleeve of  FIG. 60 , the bullet guide of  FIG. 62  and a guide pin in accordance with the present invention. 
           [0106]      FIG. 65  is a schematic view of a manner of drilling a bone tunnel into the ACL footprint of the tibial epiphysis of a skeletally immature knee without crossing the tibial physis utilizing the protective sleeve of  FIG. 60 , a guide pin, and the cannulated drill bit of  FIG. 63  in accordance with the present invention. 
           [0107]      FIG. 66  is a schematic view of a manner of inserting a surgical guide pin of  FIG. 22  across a bone tunnel in the tibial epiphysis of a skeletally immature knee without crossing the tibial physis utilizing the surgical pin guide of  FIG. 21  in accordance with the present invention. 
           [0108]      FIG. 67  is a schematic view of a manner of passing a central loop of flexible wire from an epiphyseal tibial bone tunnel out through a femoral tunnel in accordance with the present invention. 
           [0109]      FIG. 68  is a schematic view of a manner of loading a free soft-tissue graft into a central loop of flexible wire in accordance with the present invention. 
           [0110]      FIG. 69  is a schematic view of a manner of securing an ACL graft in the femoral and tibial epiphysis of a skeletally immature knee without crossing either the femoral or tibial physis utilizing a femoral interference screw-ligament washer of  FIG. 38 and 41  and a tibial suspension pin of  FIG. 20A and 20B  in accordance with the present invention. 
       
    
    
     DETAILED DESCRIPTION OF THE INVENTION 
       [0111]    The present invention relates to a family of methods, instruments and implants for performing ACL reparative and reconstructive surgery to the knee  1 , including femur  2  and tibia  3 . The present invention utilizes novel techniques and incorporates a novel femoral guide  12 , a cannulated scalpel  40 , novel graft fixation devices  60 ,  80 ,  81 ,  130 , 140 , a novel surgical pin guide  90  and associated instruments  82 ,  83 ,  110 ,  120 , a novel insertional-tensioner tool  151  and associated instruments  165 ,  168 ,  180 ,  175 ,  190 , a special protective sleeve  225 , a bullet guide  235 , and a cannulated drill bit  230 . 
         [0112]    Initially, conventional techniques of arthroscopic assisted ACL surgery are performed. After one or more tibial tunnels  6  are created, creation of a femoral tunnel is undertaken by either a traditional two-incision outside-in femoral guide or the novel femoral guide  12  of the present invention (see  FIGS. 1 and 2 ). 
         [0113]    The femoral guide  12  can be used to create a single or multiple femoral tunnels  55  (see  FIGS. 4 ,  5 , and  6 ). The single femoral tunnel technique is performed as follows. With the arthroscope  10  viewing from either the traditional medial infrapatellar arthroscopic portal  4  or the tibial tunnel  6 , a sharp-tipped guide pin  30  is inserted into the knee  1  from another portal, either the previously created tibial tunnel  6  or an accessory medial infrapatellar arthroscopic portal  7  (or similar separate medial percutaneous insertion). The femoral guide  12  is placed through the lateral infrapatellar arthroscopic portal  5  to grasp and direct the guide pin  30 . 
         [0114]    The femoral guide  12  is a handheld instrument with functional end  13 , shaft  14  and scissor-action handle  15 . In one version of this femoral guide  12 , the functional end  13  has an adjustable calibrated reference tip  16  and a guide ring  17  with a mobile opening and closing arm  18 . The adjustable calibrated reference tip  16  can shorten or lengthen to adjust the offset distance  19  between the tip  16  and the center of the guide ring  17 . The offset distance  19  has a range from 2 to 20 mm, preferably 4 to 8 mm. The reference tip  16  may also swivel to allow it to point in different directions relative to the handle  15  and allow proper positioning of the guide  12  for left and right knees  1  with varying anatomy. The reference tip  16  may also extend and retract to allow variable offset distances  19 . A single adjustable femoral guide  12  (as described), or several guides which are non-adjustable with respect to swivel directions or offset distances, can provide all of the necessary options. 
         [0115]    A modified form  12 A of the guide  12  is shown in  FIG. 3 . In the guide  12 A, there is a semi-circular guide loop  20  attached to the functional end  13  on the opposite side from which the mobile arm  18  opens and closes. The radius distance  21  from the guide loop  20  to a point spaced apart from the center of the guide ring  17  is equal in all directions and has an adjustable range from 2 to 20 mm, preferably 4 to 8 mm. This version of the femoral guide may or may not have a reference tip  16 . If there is no reference tip  16 , the distal end of the guide loop  20  attaches to the end of the tool. If there is a reference tip, the distal end of the guide loop  20  attaches  1  to  2 mm short of the reference tip  16  such that the radius distance  21  is 1 to 2 mm smaller than the offset distance  19 . 
         [0116]    For both femoral guides  12  and  12 A, the mobile arm  18  is controlled by the scissor-action handle  15 . As the loops of the handle  15  are separated, the mobile arm  18  opens the guide ring  17 . The handle  15  moves in the same plane as the mobile arm  18  and may lie on the opposite side, as shown in  FIG. 3 , or on the same side from the mobile arm  18 . The shaft  14  of the femoral guide  12 , or of the guide  12 A, may range from 1 to 50 cm, preferably 10 to 20 cm. The guide ring  17  directs the spinning guide pin  30  into the femoral bone  2 . The guide ring  17  and/or its bearing surfaces may consist of materials designed to resist surface wear, fatigue and fracture. 
         [0117]    After femoral guide  12  is inserted into the knee  1  from the lateral infrapatellar portal  5 , the handle  15  is opened manually to open the mobile arm  18 . Once open, the femoral guide  12  is maneuvered to catch the sharp tip of the guide pin  30  in the guide ring  17 . The handle  15  is then closed to close the mobile arm  18  and capture the guide pin  30  within the guide ring  17 . With the captured guide pin  30 , the femoral guide  12  is positioned with either the reference tip  16  over the back of the lateral femoral condyle  2  or the guide loop  20  overlying the anatomic position of the femoral attachment site of the ACL. The inner diameter of the guide ring  17  corresponds to the outer diameter of the guide pin  30  to allow it to direct the pin  30 , yet allow it to spin freely. With the tip of guide pin  30  anatomically placed in the femoral attachment site of the ACL, the guide pin  30  is advanced with power drill  11  through the femoral guide  12  and femur  2  to exit the skin on the lateral thigh  35  of the patient. The handle  15  is opened manually to open the mobile arm  18  of the femoral guide  12  in order to release guide pin  30  and allow removal of femoral guide  12  from the knee  1 . Alternatively, the guide pin  30  may be inserted just into the femoral bone  2  to create a blind-ended femoral tunnel  55 . 
         [0118]    A cannulated disposable scalpel  40  is passed over the guide pin  30  exposed from the skin on the lateral thigh  35  to create a passage through the skin and soft-tissue to the lateral cortex of the femur  2  (see  FIGS. 7 ,  8 ). The cannulated scalpel  40  consists of a leading sharp blade  41  and flat handle  42  with a central cannulation  43  to fit over the guide pin  30 . 
         [0119]    A flexible reamer  50  can be passed through the tibial tunnel  6  or accessory medial infrapatellar portal  7  in retrograde fashion over the guide pin  30  to create a femoral tunnel  55  through the bony lateral femoral condoyle  2 , or a rigid reamer  50  can be passed through the proximal lateral incision in antegrade fashion over the guide pin  30  to create the femoral tunnel  55 , through the bony lateral femoral condyle  2  (see  FIGS. 9 ,  10  and  11 ). 
         [0120]    For the double or multiple femoral tunnel techniques, a conventional outside-in guide or femoral guide  12  can be used as described above to create two or more separate femoral tunnels  55 . Guide pins  30  can be passed through either the accessory anteromedial arthroscopic portal  7  or the tibial bone tunnel  6  or both, and the remaining steps described above can be repeated, to create multiple separate tunnels  55 . After the creation of the first femoral tunnel  55 , the femoral guide  12  can be positioned to reference off previous tunnels to create additional femoral tunnels like tunnel  55 . 
         [0121]    For a bone-patellar tendon-bone graft or other bone-tendon composite grafts, the graft may be passed either retrograde or antegrade into the tunnels  6  and  55  using conventional techniques, and the bone end grafts may be fixed in their femoral tunnels  55  or tibial tunnels  6  with conventional cannulated interference screws, 
         [0122]    For the hamstring graft or other soft-tissue grafts that can be folded to create a looped end, the novel surgical ring fixation tool  60  may be used to fix a graft in a bone tunnel (see  FIGS. 12 ,  13 ,  14  and  15 ). The surgical ring fixation tool  60  consists of a ring  61  and a ring capture button  62 . The ring  61  and the ring capture button  62  are made of durable materials which are either non-absorbable, bio-absorbable, or capable of bio-integration. The ring has width dimensions  65  ranging from 2 to 20 mm, preferable 4 to 12 mm, and length dimensions  66  ranging from 5 to 100 mm. The ring capture button  62  has a base member  72  which has an outer diameter  64  ranging from 5 to 25 mm, preferably 5 to 15 mm and an inner diameter  67  ranging from 2 to 20 mm, preferably 4 to 12 mm. The base member  72  of the ring capture button  62  has two separate surfaces, deep  68  and superficial  69 . The ring capture button  62  also has a central capture bar  63  which allows capture of the ring  61 . The deep surface  68  may possess bone adhesive properties or geometry. The deep surface  68  may also maintain a protruding shape to interface with either the tibial or femoral tunnel  6  or  55  openings. The superficial surface  69  is smooth to prevent overlying soft-tissue adhesion. The central capture bar  63  of the ring capture button  62  moves on a hinge and allows the capture bar  63  to freely swing open and closed on the superficial surface  69  side. The capture bar  63  stops at the base member  72  of the ring capture button  62  and cannot open towards the deep surface  68 . The capture bar  63  stopping mechanism results from limitations on the hinge, mismatch between the capture bar length  70  and the member  72  inner diameter  67  or other stopping or locking mechanism. The geometry or other design features maintain the ring  61  centered in the opening of the base member  72  of the ring capture button  62 . 
         [0123]    For tibial  6  or femoral  55  tunnel graft fixation, the surgical ring fixation tool  60  can be used in accordance with the methods illustrated in  FIGS. 16 ,  17 ,  18  and  19 . The free ends of the soft-tissue grafts  75  are passed through the ring  61  so that equal lengths of soft-tissue grafts  75  protrude from each side of the ring  61 . The ring  61 , with the looped ends of the soft-tissue grafts  75 , is passed either antegrade through the femur  2  and out the tibia  3 , or retrograde through the tibia  3  and out through femur  2 . After ring  61  and the looped ends of the soft-tissue grafts  75  are passed, the ring  61  is assembled with the ring capture button  62 . Once assembled, the free ends of the soft-tissue grafts  75  are tensioned, thus drawing the surgical ring fixation tool  60  into position with its deep surface  68  up against either the tibial  3  or femoral  2  cortical bone surfaces. The outer diameter  64  of the base member  72  of the ring capture button  62  is larger than the tibial or femoral tunnels  6  and  55 , respectively, restricting further advancement of the graft  75  and the surgical ring fixation tool  60  into knee  1 . 
         [0124]    For a hamstring graft or other soft-tissue grafts which can be folded to create a looped end, the suspension pin  80  (or alternatively, the suspension pin  81 ) may be utilized to fix a graft in a bone tunnel (see  FIGS. 20A and 20B ). Such fixation is accomplished in the following manner. After creating the tibial tunnel  6  and the femoral tunnel  55 , the surgical pin guide  90  is used to prepare for insertion of the suspension pin  80  ( or, alternatively, of pin  81 ). The surgical pin guide  90  may be used on both the femur  2  and the tibia  3 . 
         [0125]    The guide  90  consists of three components, a target arm  91 , a curved guide arm  100  and a bullet  105 . The diameter of the target arm  91  may vary from 2 mm to 25 mm, preferably from 5 to 15 mm. Targeting tips  92  may be of various sizes. The tip  92  has an open target slot  94  at the target end ranging in depth from 0 to 100 mm, preferably 40 mm. Targeting tip  92  of the target arm  91  optionally has a small hook  93  protruding from its end. The small hook  93  protrudes up to 5 mm, but preferably about 2 mm. The small hook  93  may incorporate a mechanism to make the hook retractable. 
         [0126]    The targeting tip  92  of target arm  91  may also include a groove  95  which allows for attachment of an elastic ring or open horseshoe-shaped ring  96  which can be attached at the site of the groove  95  to close the open end of target slot  94 . 
         [0127]    Target arm  91  may possess a mechanism to open or close the open end of the target slot  94 , and it may also be calibrated to reference either direction along the target arm  91  from target point  97  in the target slot  94 . Target point  97  is a consistent point in space along the target slot  94  to which a surgical guide pin  110  will be directed by the completely assembled surgical pin guide  90 . Target point  97  is located a short distance from the end of the target tip  92  of the target arm  91  in the target slot  94 . That distance may range from 0 to 100 mm, preferably 10 to 25 mm. 
         [0128]    There is a target marker  98  on the surface of target tip  92 , marking the level of the target point  97 . The marker  98  may be radiographic, such as linear radio-opaque mark or a radiolucent hole, notch, or defect, which can be identified with conventional intraoperative radiographic techniques. 
         [0129]    The surgical pin guide  90  also includes a curved guide arm  100  and aiming bullet  105 . The curved guide arm  100  incorporates an aiming end  104  which allows for the attachment of an aiming bullet  105  and a separate mobile target arm attachment site  101 . The mobile arm attachment site  101  moves freely along the curved arm guide  100  and its position can be secured by a locking mechanism  102 . The curved arm guide  100  is calibrated with degrees to measure the angle between the aiming end  104  and the mobile target arm attachment site  101 . With the target arm  91  attached to the mobile target arm attachment site  101  of the curved guide arm  100  and the aiming bullet  105  attached to the aiming end  104  of the curved guide arm  100 , the surgical pin guide  90  is assembled. Thereafter, a surgical guide pin  110  may be passed through cannulation  106  in the aiming bullet  105 , and the tip of the surgical guide pin  110  directed to the target point  97  located in the target slot  94  of the target guide  91 . 
         [0130]    After creating the tibial and femoral tunnels  6  and  55 , the target arm  91  of the assembled surgical pin guide  90  is placed into a bone tunnel, preferably either the tibial tunnel  6  or the femoral tunnel  55 . The target arm  91  can be placed in the bone tunnel in either an antegrade fashion (inside-out on the tibia  3 , outside-in on the femur  2 ) or a retrograde fashion (outside-in on the tibia  3 , inside-out on the femur  2 ). If the tunnels are co-linear, the target arm may traverse either the tibial tunnel  6  or the femoral tunnel  55  to be placed in the opposite tunnel, either  6  or  55 . Conventional intraoperative radiographic techniques can assist with proper placement of the target arm  91  in the tunnels  6  and  55  by identifying the radiographic marker  98  overlying the target point  97 . The mobile target arm attachment site  101  allows movement and proper positioning of the aiming end  104  of the curved guide arm  100  relative to either femur  2  or tibia  3  to provide a safe trajectory for the surgical guide pin  110 . Once in proper position, a small incision is made in the skin and soft tissue in-line with the cannulation  106  of the aiming bullet  105 . The aiming bullet  105  within its connection  104  to the curved guide arm  100  is advanced down the bony surface of either femur  2  or tibia  3 . 
         [0131]    Using power drill  11 , the surgical guide pin  110  is advanced through the cannulation  106  in the aiming bullet  105  through the skin  35 , soft tissue, and bone of the femur  2  or tibia  3  until both ends of the surgical guide pin  110  extend outside the knee  1  and its bone, soft-tissue, and skin (see  FIGS. 23A ,  23 B,  24 A, and  66 ). The surgical guide pin  110  possesses cannulations or slots  111 , preferably two or more, and a sharp leading tip (see  FIG. 22 ). The slots  111  preferably are positioned near the opposite ends of the surgical guide pin  110 . 
         [0132]    The surgical guide pin  110  may possess a region of slightly increased diameter with a cutting surface  113 , preferably near its leading tip  112  but situated between the cannulations or slots,  111 . As this region  113  is passed completely through the bone, it cuts a slightly larger diameter than the diameter of the other portions of the surgical guide pin  110  to assist with the passage of flexible wire  120  to be described later. Cannulated drills, reamers and/or taps may be passed over either end of the surgical guide pin  110  and used to prepare either the femoral  2  or tibial  3  bone for later passage of the novel suspension pin  80  or  81 . These drills, reamers, and/or taps may be calibrated to assist in determining the size of the suspension pin  80  or  81  to be used. The surgical guide pin  110  may also be calibrated to assist in determining the size of the suspension pin, referencing from the aiming bullet  105  against the femoral or tibial bones  2  and  3 . Surgical pin guide  90  can be removed from knee  1 . 
         [0133]    Flexible guide wire  120  is exchanged, using surgical guide pin  110 , by connecting an end of the wire to one of the exposed ends of the guide pin  110  and withdrawing guide pin  110  by its other exposed end to pull flexible wire  120  into position (see  FIGS. 24B ,  24 C,  24 D and  24 E). The guide pin  110  has cannulations or slots  111  running perpendicular to the long axis of the pin near either of both of its ends. One method of making the flexible wire exchange using the guide pin  110  is to pass the guide pin  110  as previously described and advance a few centimeters of the flexible wire  120  through either of the exposed slots  111 . The guide pin  110  is then withdrawn by its opposite end, pulling flexible wire  120  into its previous position. 
         [0134]    Using wire passing tool  125 , a central loop of the flexible guide wire  120  can be drawn outside of knee  1  through either of the femoral or tibial tunnels  55  or  6  which is opposite to the tunnel which wire  120  initially traversed as shown in  FIGS. 25A ,  25 B,  25 C,  26 ,  29 ,  33 ,  34  and  67 . The wire passing tool  125  consists of a long thin shaft  128  and a handle with a scissor-like mechanism  127  which controls the opening and closing of the claw-like wire-grasping tip  126 . Alternatively, an elastic ring or open horseshoe-shaped ring  96  can be attached to close the open end of the target slot  94  of surgical pin guide  90 . Using the closed end, the exchanged flexible wire  120  is drawn out of the tunnel with the target arm  91  of the surgical pin guide  90  to help facilitate the passage of the flexible wire  120 . Free ends of soft-tissue grafts  75  are passed through the exposed central loop of flexible wire  120  so that equal lengths of soft tissue grafts  75  protrude from each side of the loop, as illustrated in  FIGS. 27 ,  30 ,  35  and  68 . Then, the free ends of flexible wire  120  outside of knee  1  are pulled to straighten flexible wire  120  and reduce the central loop of the soft-tissue grafts  75  through one of the tunnels  6  or  55  and into the opposite tunnel  6  or  55 , as illustrated in  FIGS. 28 ,  31  and  36 . 
         [0135]    If there are two or more tunnels on the opposite side of the knee from the tunnel traversed by the flexible wire  120 , the steps described above can be repeated by individually passing the same central loop of wire  120  out of the remaining empty tunnel, loading another graft  75 A, and re-straightening wire  120  to reduce the additional loop of soft-tissue graft through the additional tunnel into the initial tunnel traversed by the flexible wire  120 , as illustrated in  FIGS. 29 ,  30  and  31 . 
         [0136]    With flexible wire  120  straight and the soft-tissue graft  75  in position within both the femoral tunnel  55  and the tibial tunnel  6 , novel suspension pin  80 , or alternatively, novel suspension pin  81 , is inserted, using the suspension pin insertion tool  83 , into either femur  2  or tibia  3 , replacing the position of the flexible wire  120 , traversing either the femoral tunnel  55  or the tibial tunnel  6 , and securing the loop end of soft-tissue graft  75 , as illustrated in  FIGS. 20A ,  20 B,  31 ,  32 A,  36 ,  37 A,  69 . 
         [0137]    There are two versions,  80  and  81 , of the novel suspension pin which are shown in  FIGS. 20A and 20B , respectively. The pin  80  is a cannulated pin not yet assembled on the flexible guide wire  120 , and the pin  81  is already assembled as a unit on wire  120 . The cannulated suspension pin  80  has a central longitudinal cannulation  79  which allows the pin to be engaged on the wire, and, thus mounted, inserted within either the femur  2  or the tibia  3  and across either the femoral tunnel  55  or the tibial tunnel  6  to secure the looped end of the soft-tissue graft  75  in position. Pin  81  is already assembled with the flexible wire  120  component, either freely moving over it by a cannulation  79  or fixed in place upon the wire  120  at a site or assembled with two separate flexible wire  120  components, one attached each end of the pin&#39;s body component. 
         [0138]    Pin  80  and pin  81 &#39;s body component are longitudinal pins of mostly uniform diameter corresponding to that of the widest diameter of the surgical guide pin  110 . Alternatively, the diameter of the pins may vary and the outer surfaces may possess different geometry and bone adhesive properties (such as threads of a screw) to assist with fixation in the bone. The length of pin  80 , and of the body component of pin  81 , may vary, ranging up to 200 mm, but preferably from 40 mm to 100 mm. The pins are made of durable materials which are either non-absorbable, bio-absorbable, or capable of bio-integration. Pin  80  and pin  81 &#39;s body component each possess a pointed end  89  and a rear end  87 . The rear end  87  has specialized geometry which interfaces with inverse geometry on tip  86  of the suspension pin insertion tool  83 . 
         [0139]    Insertion tool  83  includes a handle  85 , a shaft  84 ; and an insertion tip  86  which incorporate a cannulation  77 , as shown in  FIG. 20C . The cannulation  77  allows the tool  83  to be placed on the flexible wire  120  to guide the insertion of a suspension pin such as pin  80  or its alternate, pin  81 . The handle  85  allows a surgeon to provide manual insertion forces with his hands or with an instrument such as a mallet. The tip  86  includes specialized geometry which interfaces with an inversely geometrical surface on the rear end  87  of suspension pin  80  or its alternate, pin  81  to prevent tip  86  from disengaging from rear end  87  during the pin insertion process. 
         [0140]    Flexible wire  120  and the flexible wire  120  components of pin  81  preferably are made of durable materials which are non-absorbable, bio-absorbable, or capable of bio-integration, but they may also be made of materials which are similar to other commercially available surgical wires or sutures. 
         [0141]    After the suspension pin  80  (or its alternate, pin  81 ) is secured in either femur  2  or tibia  3 , the flexible wire  120  is removed from the cannulation  79 . When a wire  120  component is fixed to a suspension pin  81 , a wire cutter  82  with cannulation  78  is placed on the flexible wire  120  and inserted through skin  35  and soft-tissue to the bone surface of either femur  2  or tibia  3 , as illustrated in  FIGS. 20D ,  32 B,  32 C and  37 B. Handle  15  of the cutter  82  is closed, causing the sharp jaw  88  of the cutter to close completely and sever the wire  120  flush with the bone surface. 
         [0142]    The free ends of soft-tissue grafts  75  and  75 A are fixed in a bone tunnel using a novel interference screw-ligament washer which may be a modular form  130  or a non-modular form  140 . The modular form is shown in  FIGS. 38 ,  39  and  40 , while the non-modular form is shown in  FIG. 41 . The interference screw-ligament washer is made of durable materials which are non-absorbable, bio-absorbable, or capable of bio-integration. 
         [0143]    The modular interference screw-ligament washer  130  includes a cannulated interference screw component  131 , a separate cannulated screw component  135 , and a mobile ligament washer component  138 , shown in  FIGS. 38 ,  39  and  40 . The sizes of the cannulated interference screw component  131  may vary, with length ranging up to 100 mm, but preferably 20 mm to 30 mm, and having an outer diameter up to 25 mm, preferably 4 mm to 15 mm. The component  131  also incorporates a central longitudinal cannulation  144  to allow it to be inserted over a guide wire  190 . The outer surface  132  of the cannulated interference screw component  131  is threaded for purchase in both the walls of the bone tunnel and in the adjacent soft-tissue graft. The rear end  134  of the cannulated interference screw component  131  may be flat, tapered or oblique. In addition to its cannulation  144  for guide wire  190 , the cannulated interference screw component  131  additionally includes a longitudinal female socket  133  having a hexagonal, star, diamond or other complementary cross sectional geometry to accept a male connector on the tip  181  of a cannulated screw driver  180  ( FIG. 46 ). 
         [0144]    The separate cannulated screw component  135  includes a partially threaded end  136  and a head  137 , as shown in  FIGS. 38 and 40 . The screw component  135  has a central longitudinal cannulation  141  to allow it to be inserted over guide wire  190 . The partially threaded end  136  has a diameter and length which corresponds to that of the female socket  133  of the interference screw component  131  in order to allow the separate cannulated screw component  135  to seat all the way to the depth of its head  137  and gain purchase. The head  137  is low-profile with the female socket  129 , and the size and geometry of head  137  is sufficiently different from cannulation  145  in mobile ligament washer component  138  to allow head  137  to capture washer component  138 . 
         [0145]    The mobile ligament washer component  138  can be of variable geometry but is relatively flat in one dimension in order to allow it to be low profile when seated, as shown in  FIGS. 38 ,  40  and  41 . This washer&#39;s width, or diameter, ranges up to 25 mm, and is preferably between 5 mm and 15 mm. Other cannulations  146  may be formed in mobile ligament washer  138  which provide additional means for fixing an ACL graft with sutures passed through these cannulations and secured or tied. 
         [0146]    The central cannulation  145  in the mobile ligament washer component  138  possesses sufficient size and geometry to allow it to tilt up to 90 degrees relative to the long axis of the cannulated screw component  136 , preferably between zero and 60 degrees. The undersurface  139  of the ligament washer component  138  is an irregular surface, formed with spikes or other soft-tissue adhesive features, and it may possess other protruding surface geometry to assist in centering the washer  138  over the entrance to either of the femoral tunnels  55  or the tibial tunnels  6 . The central cannulation  75  in the washer component  138  may be surrounded by a recessed portion in the washer  138  which accepts the head  137  of the separate cannulated screw component  135 . 
         [0147]    After a soft-tissue graft  75  is positioned in a bone tunnel, preferably with its free ends extending beyond the outside end of the tunnel, the modular form  130  of the interference screw-ligament washer is inserted. First, the cannulated interference screw component  131  is advanced over a guide wire  190  to a position adjacent to the soft-tissue graft  75  in the bone tunnel using a proper screw driver  180 , as in  FIGS. 50 and 51 . Once the rear end  134  of the interference screw component  131  is advanced to the level of the opening of the bone tunnel or just below it, another cannulated screw driver is used to advance the separate cannulated screw component  135  with the mobile ligament washer component  138  into female socket  133  of the interference screw component  131  until the irregular undersurface  139  of the ligament washer component  138  firmly compresses the protruding ends of the soft-tissue graft  75  up against the cortical surface of the bone surrounding the tunnel opening (see  FIGS. 52 ,  53 ,  59  and  69 ). Sutures  200  are placed in the protruding ends of the soft-tissue grafts  75  to provide manual tension while the interference screw-ligament washer device  130  is inserted. 
         [0148]    The non-modular form of the interference screw-ligament washer is a single unit made of a single or composite material (see  FIG. 41 ). The features of the non-modular form are identical to the modular form  130 , including a threaded outer surface on the interference screw portion  132 , a flat, tapered or oblique rear-end  134 , a mobile ligament washer component  138 , and a head  142  with sufficient size and geometry to capture the ligament washer component  138 . The non-modular form of the interference screw-ligament washer  140  is a single preassembled or manufactured unit which can be inserted into a bone tunnel in a single step until the irregular undersurface  139  of the ligament washer component  138  firmly compresses the protruding ends of the soft-tissue graft  75  up against the cortical surface of the bone surrounding the tunnel opening, as illustrated in  FIGS. 54 ,  59  and  69 . Non-modular form  140  also maintains a longitudinal female socket  143  of specified cross-sectional geometry (hexagonal, star, diamond, or the like) to accept a male connection on the tip  181  of cannulated screw driver  180 . The female socket  143  extends just into head  142 , although it may extend all of the way through the head into the interference screw portion  132  of the non-modular form  140  of interference screw-ligament washer. Also, there is a longitudinal cannulation  144  in the non-modular form  140  which allows the non-modular form to be inserted over guide wire  190 . 
         [0149]    If the free ends of soft-tissue graft  75  are not long enough to exit the bone tunnel, sutures  200  placed in the ends of graft  75  may be passed through small cannulations  146  in the ligament washer component  138  before insertion and then tied after either the modular form  130  or the non-modular form  140  of the interference screw-ligament washer is inserted into the tunnel adjacent to graft  75 . 
         [0150]    The modular and non-modular forms  130  and  140  of the interference screw-ligament washer may also be used on a bony free end of a graft  75 . The sutures  200  attached to the bone plug may be passed through small cannulations  146  in the ligament washer component  138  before insertion and tied after either the modular form  130  or the non-modular form  140  of the interference screw-ligament washer is inserted in the bone tunnel adjacent to the bone end of the graft. 
         [0151]    The interference screw component  131  of modular interference screw-ligament washer  130  may also be used alone to fix either a bony or a soft-tissue end of graft  75 . 
         [0152]    Either of the modular or non-modular forms of the interference screw-ligament washer,  130  or  140 , may be inserted using an insertion-tensioner tool  151  and the components  165 ,  168 ,  175 ,  180  shown in  FIGS. 48 ,  49 ,  50 ,  51 ,  52 ,  53  and  54 . The insertion-tensioner  151  assists with graft tensioning and with the insertion of fixation devices to secure free ends of graft  75  in a bone tunnel (see  FIGS. 42 and 43 ). These devices include a trocar component  168 , a graft loader component  165 , a cutter component  175  and a cannulated screw driver  180  (see  FIGS. 44 ,  45 ,  46  and  47 ). 
         [0153]    The insertion-tensioner  151  includes two hollow tubes  157  and  159  which have coordinating inner and outer diameters to allow tube  159  to telescope into tube  157 , as shown in  FIGS. 42 and 43 . The inner diameter of tube  159  may be up to 50 mm, but preferably 15 mm to 25 mm. There is a unidirectional stopping mechanism which prevents tube  159  from exiting tube  157  whenever tube  159  is moved through tube  157  toward tube  159 &#39;s end  152 . There is a separate locking mechanism  156  which may be engaged or released by a lever  160  attached to tube  157 , including teeth or other surface-engaging geometry  161  on the lever which interface with opposing surface  162  on tube  159 . The tubes  157  and  159  move freely when lever  160  is not engaged, but when it is engaged, the tubes may be moved freely in one direction and prevented from moving in the opposite direction. Preferably, that restriction prevents tube  157  from moving along tube  159  towards the end  152  of tube  159 . A spring (not shown) may be used to keep lever  160  in place when it is not manipulated by a surgeon. 
         [0154]    Handles  154  and  155  may be used by a surgeon to grasp and manipulate tubes  157  and  159  relative to each other. Tube  159  may include indicia to help calibrate movement between the tubes. Tube end  152  may be beveled or flat. There are multiple cannulations  153  in tube  159 , preferably four, through which the ends of soft-tissue graft  75  may pass. At the end of tube  157 , an arrangement of cleats  158 , or similar graft engaging elements, allow the temporary fixation of sutures  200  attached to grafts  75 . Handle  155  may be attached firmly to tube  157 , or it may be spring-biased by attaching it in series to tube  157  and the cleat arrangement  158  by means of a calibrated spring mechanism  163  in order to measure the tension of the tube engagement. 
         [0155]    The trocar  168  (see  FIG. 44 ) preferably is a long rod with an outer diameter sufficiently corresponding to the inner diameter of tube  159  to allow trocar  168  to just fit within the tube. However, the trocar may be formed as a tube, or have a central longitudinal cannulation  171 . The length of trocar  168 , excluding its stop end  170  and its leading tapered end  169  is equal to the combined length of tubes  157  and  159  when they are telescoped at their shortest starting position. The stop end  170  of the trocar  168  has a diameter greater than the diameter of tube  157 , thus limiting the depth to which trocar  168  may be inserted into the insertion-tensioner.  151 . When trocar  168  is inserted to its full depth, its tapered end  169  protrudes from end  152  of tube  159  to facilitate penetration of the insertion-tensioner down through the skin and soft-tissue of knee  1  to femur  2  or tibia  3 . Slots  173  are formed in the tapered end  169  of trocar  168  which extend beyond the inclination of the taper, allowing free ends of the soft-tissue graft  75  to run freely along the slots  173  and into the end  152  of tube  159  and on out through cannulations  153  in tube  159 . 
         [0156]    The cutter  175  (see  FIG. 47 ) is a hollow tube with a stop end  177  and a sharp cutting end  176 . Cutter  175  has an outer diameter corresponding to the inner diameter of tube  159 . The length of cutter  175 , excluding its stop end  177 , is such that when the cutter  175  is inserted into the insertion-tensioner  151  to the full depth with the telescoping tubes  157  and  159  extended to their longest finishing tensioned position, the sharp cutting end  176  extends just beyond cannulations  153  in the end  152  of tube  159 . Sharp cutting end  176  is inwardly beveled. The outer edge of the cutting end  176  is straight in order to maintain a constant outer diameter. The inner edge is beveled inwardly from the outer edge to the inner surface of the tube to create a sharp-ended cutting tube. 
         [0157]    The graft loader  165 , a long stiff but flexible wire  168  with a loop end  166  and an optional handle  167 , is shown in  FIG. 45 . The loop end is flexible and has a loop with sufficient diameter to carry a suture or the free ends of graft  75 . 
         [0158]    The cannulated screw driver  180  includes a tip  181 , a calibrated shaft  182 , and a handle  183  which has an optional stop  184  (see  FIG. 46 ). The tip  181  is formed with a specific geometrical cross section, such as a hexagon, star, diamond or the like, to fit with like connections in the interference screw-ligament washers  130  or  140  or other fixation devices. Calibrated shaft  182 , excluding its handle  183 , the stop  184  and the tip  181 , is at least as long as the combined length of telescopically connected tubes  157  and  159  extended to their longest finishing tensioned position. 
         [0159]    The above-described components are used with the insertion-tensioner  151  in the following manner. 
         [0160]    With the free ends of a soft-tissue graft  75  fixed at their opposite ends and protruding from a bony tunnel, each free end is individually placed through the loop end  166  of the graft loader  165  where it was previously positioned, i.e., extending through one of the cannulations  153  and exiting out of end  152  of tube  159  of the insertion-tensioner  151  (see  FIG. 48 ). It is preferable that the graft ends have been prepared with sutures  200  prior to loading to help facilitate graft passing and tensioning later. 
         [0161]    With all of the free ends of the soft-tissue graft  75  or their sutures  200  passed into the end  152  and out of their own cannulation  153  of tube  159 , trocar  168  is inserted into the insertion-tensioner  151  while its tubes  157  and  159  are telescoped to their shortest length, as shown in  FIG. 49 . While holding the free ends of the graft  75  or their attached sutures  200  under tension in one hand, the surgeon inserts the insertion-tensioner  151  with trocar  168  through the skin and soft-tissues down to the bone at the opening of a bone tunnel, preferably that of femur  2  or tibia  3 . The insertion-tensioner  151  with the cannulated trocar  168  may also be inserted over a guide wire  190  previously placed in bone tunnels  6  or  55 . The longitudinal cannulation  171  in trocar  168  accepts the guide wire  190  to properly direct the insertion-tensioner  151  through the skin and soft-tissue down to the opening of a bone tunnel. Once down to bone, trocar  168  is removed. The free graft ends of graft  75  or their attached sutures  200  are tensioned and secured to the cleats  158  on the insertion-tensioner  151 . With one hand on handle  154  to stabilize tube  159  and hold the tube end  152  on the bone tunnel opening, the surgeon distracts on handle  155  of tube  157  with the other hand to the desired tension and activates lever  160  to engage the locking mechanism  156 , thus holding the graft ends of graft  75  at a desired tension. 
         [0162]    Maintaining the position of the insertion-tensioner  151  with a hand on handle  154  and tube  159 , the surgeon inserts either the modular form  130  or the non-modular form  140  interference screw-ligament washer, as described above, over the guide wire  190 , fixing the graft ends of graft  75  in a bone tunnel, preferably that of femur  2  or of tibia  3  (see  FIGS. 50 ,  51 ,  52 ,  53 ,  54 ,  59  and  69 ). 
         [0163]    The surgeon may also elect to insert another ACL fixation device by another method utilizing the insertion-tensioner  151 . 
         [0164]    After the ACL fixation device is placed and the free graft ends of graft  75  are secured, cutter  175  is inserted into the exposed end of the insertion-tensioner  151  and advanced until the free ends of graft  75  or their attached sutures are cut, as in  FIG. 53 . 
         [0165]    Different combinations of fixation devices may be utilized when multiple bone tunnels are formed in either or both of femur  2  and tibia  3  as long as a cross pin device such as a suspension pin  80  or  81  or a surgical ring fixation tool  60  is used on the looped ends of the graft  75  and either the modular form  130  or non-modular form  140  of the interference screw-ligament washer are used on the free soft-tissue or bony ends of graft  75 . 
         [0166]    Primary repair of an ACL stump  215  torn off the femur  2  may also be performed using femoral guide  12 , as seen in  FIGS. 55 ,  56 ,  57  and  58 . After sutures  200  are passed through stump  215 , arthroscope  10  is positioned in a conventional medial infrapatellar arthroscopic portal  4 , and a conventional arthroscopic cannula  210  is positioned in an accessory medial infrapatellar arthroscopic portal  7 . The sutures  200  attached to ACL stump  215  are retrieved out of knee  1  through cannula  210 . Then a surgical guide pin  220  is introduced into knee  1  through the same arthroscopic cannula  210 , and femoral guide  12  is placed through the lateral infrapatellar arthroscopic portal  5  to grasp and direct the leading end of surgical guide pin  220  as it is drilled through femur, skin and soft-tissue with a power drill such as drill  11 . With both ends of the surgical guide pin  220  exposed from knee  1 , one limb of sutures  200  attached to ACL stump  215  is loaded through slot  221  at the back end of a surgical guide pin  220 . A cannulated scalpel, such as scalpel  40 , is then passed over the exposed leading end of guide pin  220  to create a passage through the skin and soft-tissue to the lateral bony cortex of a femur  2 . The guide pin  220  is then advanced out of knee  1  to shuttle a suture limb through the femur and out through the passageway created by the cannulated scalpel  40 . The steps just described are repeated until all of the limbs of suture  200  attached to the ACL stump are passed. The passed sutures  200  are tensioned and secured over either a conventional cannulated button or the natural cortical bony bridges remaining between each of the sutures  200  on the lateral aspect of the femur  2 , as shown in  FIG. 58 . 
         [0167]    For skeletally immature patients with open femoral and tibial growth plates such as plate  222 , nominally referred to as physes, the epiphyseal tunnel and graft fixation procedure holds substantial benefit by avoiding injury to the growth plate  222 . Using intraoperative radiographic assistance, all-epiphyseal femoral tunnels, like tunnel  55 , can be created using a conventional outside-in femoral guide or the novel femoral guide  12 , as described above, and transphyseal tibial tunnels, like tibial tunnel  6 , can be created with conventional tibial guides (see  FIG. 59 ). For epiphyseal femoral  2  graft fixation, modular form  130  and non-modular form  140  interference screw-ligament washers may be inserted into the femoral epiphysis  2 E using the methods and instruments described above (see  FIG. 59 ). For tibial epiphyseal graft fixation in a transphyseal tunnel, the suspension pin  80  or its alternative  81  may be inserted into the tibial epiphysis  3 E using the methods and instruments described above (see  FIG. 59 ). 
         [0168]    However, an alternative and novel method of antegrade epiphyseal tunnel creation and graft fixation will now be described. To perform this procedure, the surgeon needs a specially designed protective sleeve  225 , a cannulated bullet guide  235 , and a specially designed cannulated drill bit  230 , as shown in  FIGS. 60 ,  61 ,  62  and  63 . 
         [0169]    The protective sleeve  225  is a hollow tube with a beveled tip  227  and a handle  226 . Preferably, the handle points 90 degrees counterclockwise from the longest side of the beveled tip  227  as viewed looking down the longitudinal axis of the sleeve from the handle side. The inner diameter of the sleeve ranges up to 20 mm, preferably between 4 mm and 12 mm. 
         [0170]    Cannulated bullet guide  235  and cannulated drill bit  230  have outer diameters that correspond to the inner diameter of protective sleeve  225  which permits bullet guide  235  and cannulated drill bit  230  to just fit but move freely within sleeve  225 . Bullet guide  235  has a central longitudinal cannulation  238 , a tapered end  236  and an end with a stop  237  which abuts the handle end of the protective sleeve  225  when inserted. The length of the bullet guide, excluding the tapered end  236  and stop  237  equals the length of the protective sleeve  225 . Cannulated drill bit  230  is partially threaded at its cutting end  232  and smooth, with depth marks  231  which reference off the handle end of sleeve  225 . The cannulated drill bit possesses a longitudinal cannulation  233  which allows the drill bit  230  to be run over a guide pin. 
         [0171]    With the arthroscope in the conventional lateral infrapatellar arthroscopic portal  5 , the alternative method of tunnel creation and graft fixation referred to above is performed by inserting the protective sleeve  225  with the cannulated bullet guide  235  into a high medial infrapatellar portal  240  down onto the ACL footprint on tibial bone  3  (see  FIG. 64 ). Using intraoperative fluoroscopic techniques, a guide pin  30  is inserted through the cannulation  238  in the bullet guide  235  and advanced into the tibia  3  to a depth just short of the level of the tibial physis  222 . The depth of the guide pin  30  is measured from the calibrations on pin  30  referenced from the stop end of bullet guide  235 . The bullet guide  235  is removed from the protective sleeve  225  and cannulated drill bit  230  is advanced over the guide pin  30  to a depth just short of the depth of guide pin  30  as shown in  FIG. 65 . Cannulated drill bit  230  is calibrated and references off the handle end of protective sleeve  225 . Target arm  91  of surgical pin guide  90  is inserted through the high medial infrapatellar portal  240  to the depth of the blind-ended tibial tunnel  6  (see  FIG. 66 ). The radiographic marker  98  on the surface of target tip  92  marking the level of the target point  97  can be identified using intraoperative radiographic assistance in order to confirm proper positioning of the guide  90 . The remaining steps are performed as described above to place a suspension pin, such as pin  80  or pin  81 , in the tibial epiphysis  3 E of tibia  3  and an interference screw-ligament washer, such as washer  130  or washer  140 , in femoral epiphysis  2 E of femur  2  (see  FIGS. 67 ,  68  and  69 ). 
         [0172]    However, passage of the flexible wire  120  with wire passing tool  125  is done with a slight variation because of the blind-ended tibial tunnel  6  (see  FIG. 67 ). First, the wire passing tool  125  is inserted through the high medial infrapatellar portal  240  to grasp the central loop of the flexible wire  120  in the tibial tunnel  6  and pass it to a second wire passing tool  125 A which was inserted through femoral tunnel  55 . The second wire passing tool  125 A withdraws the central loop of flexible wire  120  outside the knee through femoral tunnel  55 . 
         [0173]    From all of the foregoing it will be evident that, although particular forms have been illustrated and described, nevertheless various modifications can be made without departing from the true spirit and scope of the invention. Accordingly, no limitations are intended by the foregoing description and the accompanying drawings, and the true spirit and scope of the invention are intended to be covered by the following claims.