Abstract:
A suture anchor (e.g.  100 ) for knotlessly securing nearby tissue to bone is formed from an anchor body (e.g.  101/102 ) that includes a mechanism for being securely anchored to the bone, an elongated suture puller (e.g.  122 ) extending through the anchor body with a proximal end for being pulled in a proximal direction by a surgeon and a distal end (e.g.  125 ) with a suitable mechanism for engaging suture (e.g.  127 ), suture (e.g.  132 ) carried by the engaging mechanism (e.g.  127 ) at the distal end (e.g.  125 ) of the elongated suture puller (e.g.  122 ), and a suture locking mechanism (e.g.  110 ) that substantially prevents the suture (e.g.  122 ) from moving in at least a first direction after being pulled into and through the anchor body (e.g.  101/102 ) by the elongated suture puller (e.g.  122 ).

Description:
CROSS REFERENCE TO RELATED APPLICATIONS  
       [0001]     This application claims the benefit of Provisional Application Ser. No. 60/613877 filed on Sep. 28, 2004, entitled “SUTURE ANCHOR,” which application is fully incorporated herein by reference. 
     
    
     BACKGROUND OF THE INVENTION  
       [0002]     1. Field of the Invention  
         [0003]     This invention relates generally to surgical fixation devices and, more specifically, to medical implants known as suture anchors that are used to attach soft tissue to hard tissue via a strand of suture in order to implement a repair. The following disclosure presents several suture anchor designs that will greatly simplify the attachment step of this repair by eliminating the need to create a knot.  
         [0004]     1. Discussion of Related Art  
         [0005]     A common surgical procedure is to repair an injury by re-attaching soft tissue to bone. This surgical attachment is required to hold the soft and hard tissues together until the body&#39;s natural healing response permanently attaches the two together.  
         [0006]     There are many styles of anchors currently on the market. Most require the anchor to be implanted into bone with suture already threaded through an eyelet thereof, the strand of suture to be passed through soft tissue, and then a knot to be tied so that the soft tissue is brought adjacent to the bone for proper healing. The last step, knot tying, is very critical and for many surgeons one of the more difficult steps. This is especially true for the doctor performing the procedure arthroscopically where everything is viewed on a monitor via a camera and most of the work is performed through small diameter cannulas.  
         [0007]     Some anchors systems have been released in the past few years that attempt to address the difficult knot tying issue. Though they have created a knotless system many of the methods are cumbersome. A knotless design that is easy and intuitive is required.  
       SUMMARY OF THE INVENTION  
       [0008]     In one aspect, the invention is a suture anchor for securing nearby tissue to bone, the suture anchor comprising an anchor body having an axis and a proximal end that is substantially transverse to the axis; means for anchoring the anchor body to the bone of the patient; an elongated suture puller slidably located in the anchor body with first and second lengths extending therefrom, the second length including means for engaging suture; suture connected to the second length of the elongated suture puller via the means for engaging whereby the suture may be pulled into and through the anchor body behind the elongated suture puller when the elongated suture puller is pulled outward therefrom via the first length; and a suture locking mechanism that substantially prevents the suture from moving in at least a first direction after being pulled into and through the anchor body by the elongated suture puller.  
         [0009]     These and other features and advantages of the invention will become more apparent with a description of preferred embodiments in reference to the associated drawings.  
     
    
     DESCRIPTION OF THE DRAWINGS  
     First Embodiment  
       [0010]      FIGS. 1-7  show an embodiment implemented within a screw-in style anchor that has one end of a strand of suture already affixed to the anchor body, and an integral suture locking mechanism;  
         [0011]      FIG. 1  shows a screw-in style anchor having an integral suture locking mechanism with a suture puller passing therethrough, and having one end of a strand of suture affixed thereto (optional);  
         [0012]      FIG. 2  shows the suture being passed through a piece of tissue;  
         [0013]      FIG. 3  shows the suture being threaded though a loop at the end of the suture puller;  
         [0014]      FIG. 4  shows the suture puller being used to draw the suture toward the suture anchor&#39;s suture locking mechanism;  
         [0015]      FIG. 5  shows the suture being pulled through the suture anchor&#39;s suture locking mechanism;  
         [0016]      FIG. 6  shows the suture drawing the tissue toward the suture anchor at a desired tension;  
         [0017]      FIG. 7  shows the suture after it has been trimmed by the surgeon;  
       Second Embodiment  
       [0018]      FIGS. 8-13  show an embodiment of a suture anchor having a particular locking mechanism that is formed from a pivoting member that is biased against an inner wall of the suture anchor with a bent spring that contacts an opposite wall of the suture anchor;  
         [0019]      FIGS. 8-9  show the suture anchor without the suture yet present;  
         [0020]      FIG. 8  is a top view of a suture anchor with a locking mechanism formed from a spring, a locking paddle, and a connecting member;  
         [0021]      FIG. 9  is a cutaway side view of the suture anchor of  FIG. 8 ;  
         [0022]      FIGS. 10-11  are similar to  FIGS. 8-9  but with the suture being pulled in one direction;  
         [0023]      FIG. 10  is the same as  FIG. 8  but with the suture present;  
         [0024]      FIG. 11  is the same as  FIG. 9  with the suture being pulled through the locking mechanism in a direction represented by the arrows;  
         [0025]      FIGS. 12-13  are similar to  FIGS. 8-9  but with the suture being pulled in an opposite direction;  
         [0026]      FIG. 12  is the same as  FIG. 8  but with the suture present;  
         [0027]      FIG. 13  is the same as  FIG. 9  showing the suture being pulled in the opposite direction will result in little or minimal movement due to the locking paddle;  
       Third Embodiment  
       [0028]      FIGS. 14-16  relate to a third embodiment of a suture anchor having another particular locking mechanism that is formed from a pivoting member, but here the spring is a torsional spring;  
         [0029]      FIG. 14  shows a top plan view of suture anchor with suture present;  
         [0030]      FIG. 15  is a cutaway side view of the suture anchor of  FIG. 14 , and also shows a roughened surface that comes into contact with the suture in order to enhance the effectiveness of the suture locking mechanism;  
         [0031]      FIG. 16  shows several alternative cross-sectional profiles for a torsional spring used in suture anchor of  FIGS. 14 and 15 ;  
       Fourth Embodiment  
       [0032]      FIGS. 17-18  show an embodiment of how one end of a suture strand may be affixed to the anchor body of a suture anchor;  
         [0033]      FIG. 17  is a top view of an anchor body with a cross pin present in order to hold a suture strand therein and extending from one side thereof;  
         [0034]      FIG. 18  is a cutaway side view of the anchor body of  FIG. 17  showing the suture strand within and extending from the cross pin;  
       Fifth Embodiment  
       [0035]      FIGS. 19A, 19B , and  20  show a variation on the embodiment  FIGS. 17-18  wherein two strands of suture are affixed to the anchor body;  
         [0036]      FIG. 19A  is a top view of an anchor body with a cross pin present in order to hold a suture strand therein and extending from both sides thereof, and also showing an optional notch that provides relief for the suture to turn upward after extending outward from the cross pin;  
         [0037]      FIG. 19B  is similar to  FIG. 19A , but two separate strands have been affixed to the anchor body with the cross pin;  
         [0038]      FIG. 20  is a is a cutaway side view of the anchor body of  FIG. 19A  showing the suture strands within and extending from the cross pin, and also showing the optional notch;  
       Sixth Embodiment  
       [0039]      FIG. 21  is an embodiment of how one end of a suture strand may be affixed to the anchor body by being placed directly in the wall of the Anchor Body  
       Seventh Embodiment  
       [0040]      FIGS. 22-29  show an embodiment implemented within a screw-in style anchor that has one end of a strand of suture already affixed to the anchor body (as shown in  FIG. 1 ), but which uses a locking mechanism that is not integral with the anchor body but rather is pushed down the suture after the suture has been passed through the patient&#39;s tissue;  
         [0041]      FIG. 22  shows a screw-in style anchor having an anchor body that is capable of receiving a suture locking mechanism, and having one end of a strand of suture affixed thereto (optional);  
         [0042]      FIG. 23  shows the suture being passed through a piece of tissue;  
         [0043]      FIG. 24  shows a suture locking mechanism comprising a spring-loaded anchor clip being slid down the suture;  
         [0044]      FIG. 25  shows the anchor clip being attached to the anchor body;  
         [0045]      FIG. 26  shows the suture being pulled in a direction such that the suture weaves through the anchor clip and pulls the tissue toward the anchor body at a desired tension;  
         [0046]      FIG. 27  shows the suture after it has been trimmed by the surgeon;  
         [0047]      FIG. 28  shows three views of the anchor clip used in the embodiment illustrated by  FIGS. 22-27 , this particular anchor clip having a pinching notch on a paddle side thereof;  
         [0048]      FIG. 29  is a cutaway side view showing how the anchor clip permits the suture to move in one direction but substantially prevents it from moving in the other direction;  
       Eighth Embodiment  
       [0049]      FIGS. 30-34  illustrate an alternative anchor clip that functions as suture locking mechanism that is not integral with the anchor body but rather is pushed down the suture after the suture has been passed through the patient&#39;s tissue;  
         [0050]      FIG. 30  shows three views of the alternative anchor clip, this particular anchor clip having a pinching void on a paddle side thereof, rather than a pinching notch as shown in  FIG. 28 ;  
         [0051]      FIG. 31  shows how the pinching void become misshapen when a force is applied to a collapsible wall of the pinching void;  
         [0052]      FIG. 32  shows how the misshapen pinching void can pinch a suture contained therein;  
         [0053]      FIG. 33  is a cutaway side view showing how the anchor clip permits the suture to move in one direction but substantially prevents it from moving in the other direction;  
       Ninth Embodiment  
       [0054]      FIGS. 34-36  show a release tool that can be used to release the suture locking mechanism of  FIGS. 22-29  (or  FIGS. 8-13 ), so that suture can be temporarily slid in either direction;  
         [0055]      FIG. 34  shows the direction in which the suture is locked and cannot move;  
         [0056]      FIG. 35  shows a release tool having two distal arms that define a V-notch being brought toward the suture locking mechanism;  
         [0057]      FIG. 36  shows how the release tool&#39;s distal arms collapse the suture locking mechanism by temporarily bringing the locking paddle and spring together;  
       Tenth Embodiment  
       [0058]      FIGS. 37-42  show an embodiment implemented within a screw-in style anchor that includes an integral suture locking mechanism comparable to the embodiment of  FIGS. 1-7 , but that differs from the earlier embodiment in that it is intended for use with a loose strand of suture and does not have one end of a strand of suture already affixed to the anchor body;  
         [0059]      FIG. 37  shows a screw-in style anchor having an integral suture locking mechanism with a suture puller passing therethrough, and a loose strand of suture having a suture loop that may be used therewith illustrated nearby;  
         [0060]      FIG. 38  shows the separate suture being passed through a piece of tissue;  
         [0061]      FIG. 39  shows the end of the suture that was passed through the tissue passed through the suture loop at the end of the suture and the looping being pulled taught such that the suture begins to tighten against the tissue;  
         [0062]      FIG. 40  shows the a free end of the suture that has been tightened against the tissue being threaded though a loop at the end of the suture puller so that the suture puller can pull the suture through the suture anchor&#39;s suture locking mechanism;  
         [0063]      FIG. 41  shows the suture being pulled through the suture anchor&#39;s suture locking mechanism;  
         [0064]      FIG. 42  shows the suture drawing the tissue toward the suture anchor at a desired tension;  
       Eleventh Embodiment  
       [0065]      FIGS. 43A-43B  illustrate an alterative embodiment for use with loose suture where not one, but two strands of suture consisting of opposite ends of the same piece of loose suture will be passed through a suitable locking mechanism;  
         [0066]      FIG. 43A  shows a loose strand of suture attached to tissue adjacent to a suture anchor, the suture having been attached to the tissue with a so-called “mattress stitch” forming a loop on one side of the tissue and with two strands extending from an opposite side of the tissue;  
         [0067]      FIG. 43B  shows how the two extending strands of suture may be passed through the mattress stitch in preparation for both strand thereafter being passed through the suture locking mechanism to draw the tissue toward the suture anchor (not shown);  
       Twelfth Embodiment  
       [0068]      FIGS. 44-48  illustrate another alternative embodiment for use with two strands of loose suture consisting of ends of two different pieces of loose suture will be passed through a suitable locking mechanism;  
         [0069]      FIG. 44  shows the two sutures loaded in the suture locking mechanism of the anchor body;  
         [0070]      FIG. 45  shows the first suture passed through the tissue;  
         [0071]      FIG. 46  shows the second suture passed through the tissue at a different location;  
         [0072]      FIG. 47  shows a knot tied in the two sutures adjacent to the tissue;  
         [0073]      FIG. 48  shows the two sutures being pulled in the indicated direction such that the tissue is drawn toward the anchor body;  
       Thirteenth Embodiment  
       [0074]      FIG. 49  shows a disk that may be captured by suture in order to prevent the suture from damaging the tissue;  
       Fourteenth Embodiment  
       [0075]      FIG. 50  shows a dual anchor configuration wherein both ends of single piece of loose suture loaded into the locking mechanism of one anchor body are passed through tissue, where one end is passed back through to the other side and loaded in the locking mechanism of the other anchor body (using a suture puller as described earlier), and where the free end of the suture is passed through the tissue again, and where the two free ends are brought together to form a knot;  
       Fifteenth Embodiment  
       [0076]      FIGS. 51-52  show another embodiment where suture is locked in place with a locking clip that is pushed down the suture;  
         [0077]      FIG. 51  shows the suture having been threaded through the Anchor Body and then around a Retaining Pin, and a locking clip being pushed down toward the anchor body;  
         [0078]      FIG. 52  shows the locking clip holding the suture and preventing it from being pulled in the opposite direction via friction, or deformation, or other suitable manner;  
       Sixteenth Embodiment  
       [0079]      FIGS. 53-68  show a presently preferred embodiment of a suture anchor that includes a suture puller and an integral suture locking mechanism that permits suture to be pulled through the anchor body in one direction using the suture puller, and then after that, substantially permits the suture to be pulled in that same direction but substantially prevents the suture from moving in the other direction (the embodiment show accommodates two sutures, but a suture anchor with only one suture channel would be useful under certain circumstances);  
         [0080]      FIG. 53  shows a suture anchor  100  having a body formed from an Insert  102  assembled into a Housing  101 ;  
         [0081]      FIG. 54  is a cross sectional view of the suture anchor of  FIG. 53  showing the insert and the housing;  
         [0082]      FIG. 55  is a cross sectional view of the suture anchor of  FIG. 53  with the insert removed to show only the housing;  
         [0083]      FIG. 56  is a perspective view of the insert itself;  
         [0084]      FIG. 57  is another view of the Insert from a different angle;  
         [0085]      FIG. 58  is another perspective view of the insert, rotated relative to  FIG. 56  and  57 ;  
         [0086]      FIG. 59  shows how the Insert allows suture to slide in one direction and locks it in the other direction;  
         [0087]      FIG. 60  shows small directionally biased hooks (optional) that are intended to enhance the suture locking mechanism;  
         [0088]      FIG. 61  is an isometric view of a suture puller provided in the form of a pull tab;  
         [0089]      FIG. 62  is a close-up view of the tip of the suture puller of  FIG. 61 ;  
         [0090]      FIG. 63  shows the suture puller pre-loaded into the suture anchor;  
         [0091]      FIG. 64  shows the sutures loaded into suture slots in the suture puller;  
         [0092]      FIG. 65  shows that each suture&#39;s two tails are being lined up to be pulled into Suture Slots on either side of the suture puller as the suture puller is pulled through the suture anchor;  
         [0093]      FIG. 66  shows suture puller having been pulled all the way through the suture anchor such that the two tails of each suture have been threaded through the suture slots in the suture anchor;  
         [0094]      FIG. 67  shows one tail of the suture after is has been fully through and clear of the suture anchor, leaving the other tail attached to the suture anchor;  
         [0095]      FIG. 68  is a close-up perspective view showing the suture after it has been cut so that a stub is left on one side of the suture anchor and a long tail holding tissue, for instance, is left on the other side.  
       Seventeenth Embodiment  
       [0096]      FIGS. 69-74  show an alternative embodiment of a suture anchor that includes a suture puller and an integral suture locking mechanism that includes a ratcheting mechanism for moving the suture locking mechanism between a first open position and a second closed position;  
         [0097]      FIG. 69  is a cross sectional view of the housing of the alternative suture anchor;  
         [0098]      FIG. 70  is a cross sectional view of the housing taken in a plane that is perpendicular to the plane used in  FIG. 69 ;  
         [0099]      FIG. 71  is a perspective view of the mating insert that cooperates with the housing of  FIGS. 69-70 ;  
         [0100]      FIG. 72  is a cross sectional view of the insert of  FIG. 70  assembled in the housing of  FIGS. 69-70 ;  
         [0101]      FIG. 73  shows the insert after it has been moved inward relative to the housing by causing the locking tabs to interface with lower locking notches;  
         [0102]      FIG. 74  is a close-up cutaway view of one of many possible configurations for the locking notch and locking tabs;  
       Eighteenth Embodiment  
       [0103]      FIGS. 75-80  show an alternative embodiment that is comparable to the suture anchor embodiment of  FIGS. 69-74  except that the ratcheting mechanism has been changed to an interface between the centerline of the insert and a cross pin that has been placed through the center of the housing;  
         [0104]      FIG. 75  is a perspective view of the modified insert provided with a cross pin channel;  
         [0105]      FIG. 76  shows the cross pin;  
         [0106]      FIG. 77  shows the cross pin assembled to the housing with the insert missing;  
         [0107]      FIG. 78  is a cross sectional view of the cross pin, insert, and housing after they have been assembled;  
         [0108]      FIG. 79  is a cross sectional view showing the suture anchor in a suture unlocked position with a relatively large gap below the insert;  
         [0109]      FIG. 80  is a cross sectional view showing the suture anchor in a suture locked position with a smaller gap below the insert;  
       Nineteenth Embodiment  
       [0110]      FIGS. 81-84  show an another embodiment of a suture anchor having a particular locking mechanism that is formed from a pivoting member (here a cam member) that is biased against an inner wall of the suture anchor;  
         [0111]      FIG. 81  is a perspective view of the cam member;  
         [0112]      FIG. 82  is an end view of the cam member;  
         [0113]      FIG. 83  is a cross sectional view of the cam member assembled into the housing and having a cam actuation wire attached thereto;  
         [0114]      FIG. 84  is a cross sectional view of the suture anchor wherein the cam member has been rotated such that its cam surface is pinching the suture (not shown) against the inner housing wall and such that a locking knob on the cam member has clicked into a into a mating notch on the housing;  
       Twentieth Embodiment  
       [0115]      FIGS. 85-88  show an another embodiment of a suture anchor having a particular locking mechanism that is formed from a one-part housing, an insert, and a locking pin (that latter two might be regarded as a two-part insert) that provide a circuitous path for enhanced locking;  
         [0116]      FIG. 85  is an exploded view of the three parts;  
         [0117]      FIG. 86  shows the general path  187  of the pull-tab and the suture;  
         [0118]      FIG. 87  shows the insert in the up position such that the locking pin is in a spacious condition and the suture may slide freely through the gap illustrated by the arrows;  
         [0119]      FIG. 88  shows the insert after it has been pushed in to the housing and is pushing the locking pin into a position that creates a very small gap thus holding the suture in place;  
       Twenty-First Embodiment  
       [0120]      FIGS. 89A-89D  show an alternative suture puller formed as a trap pull tab where at least the distal end is made of a woven material such that the device acts like a finger trap when grabbing the suture and pulling it through the anchor;  
         [0121]      FIG. 89A  shows the end of the trap pull tab;  
         [0122]      FIG. 89B  shows the suture is about to be placed in the opening of the trap pull tab;  
         [0123]      FIG. 89C  shows the motion of sliding the suture into the trap pull tab;  
         [0124]      FIG. 89D  shows that when the motion is reversed, the trap pull tab collapses around the suture for pulling it through the suture locking mechanism of a suture anchor according to an embodiment of the present invention;  
       Twenty-Second Embodiment  
       [0125]      FIG. 90  shows a cross sectional view of a housing and insert that have been modified slightly such that their distal ends are substantially V-shaped rather than U-shaped.  
     
    
     DESCRIPTION OF PREFERRED EMBODIMENTS  
       [0126]     In accordance with at least one embodiment of the present invention, an anchor is presented with an elongated suture puller (aka a shuttle) to thread suture through the locking mechanism located in the anchor&#39;s center. The anchor in this embodiment as with all the presented designs can be embodied in an anchor having an anchor body with any suitable means for anchoring the anchor body to the bone of a patient. The anchoring means includes, for example, a push-in, screw-in, eared, or other styles of implant.  FIG. 1  shows a screw-in style anchor as an example.  
         [0127]     A strand of Suture  1  is affixed to the Anchor Body  2  at an Affixation Point  5 . The Affixation Point  5  is shown as a method of how the suture can be attached to the anchor. A Locking Mechanism  4  is shown schematically in the Anchor Body  2  that has a bias to allow the Suture  1  or elongated suture puller  3  having first and second lengths extending from the anchor body to slide in one direction but not the other. For this example the Anchor Body  2  can be considered as in bone. The elongated suture puller  3  is shown threaded in the Anchor Body  2  around the Locking Mechanism  4 .  
         [0128]     In  FIG. 2  the Suture  1  has been passed through a piece of Tissue  6 . The Suture  1  is then threaded through a suitable means for engaging the suture such as, but not limited to, the Shuttle Loop  7  shown in  FIG. 3 . The elongated suture puller  3  is then pulled in a direction allowed by the Locking Mechanism  4  so that the Suture  1  is pulled (see  FIG. 4 ) until the Suture  1  is threaded in the Anchor Body  2  around the Locking Mechanism  4  as shown in  FIG. 5 .  
         [0129]     The Suture  1  can then be pulled to the proper tension so that the Tissue  6  is pulled toward the Anchor Body  2  and against the bone for proper healing. The Locking Mechanism  4  restricts movement of the Suture  1  in the opposite direction so the tension on the Tissue  6  does not decrease (see  FIG. 6 ). To complete the process the Suture  1  is trimmed as in  FIG. 7  to the desired length.  
         [0130]     This same example could be slightly modified such that the Suture  1  is passed through Tissue  6  before the Anchor Body  2  is placed in bone. This allows the Suture  1  to be threaded into the Anchor Body  2  outside of the body. The Anchor Body  2  can then be easily placed in the bone and the Suture  1  tightened to the desired position.  
         [0131]     The following section describes some possible locking mechanisms.  FIGS. 8 and 9  are a top and side cut-away view respectively of Locking Mechanism  4  in an Anchor Body  2 . The Locking Mechanism  4  is made of the Spring  8 , the Locking Paddle  9 , and the Connecting Member  10 . In this configuration the Connecting Member  10  holds the Locking Mechanism  4  in place relative to the Anchor Body  2 . The Spring  8  is pushed against the Inner Wall  11  of the Anchor Body  2  so that a resulting force translates to the Locking Paddle  9  pushing it against the opposite Inner Wall  12  of the Anchor Body  2 .  
         [0132]     The same Locking Mechanism  4  is shown in  FIGS. 10 and 11  except Suture  13  has been added. The Suture  13  is threaded into the Anchor Body  2  between the Inner Wall  12  and the Locking Paddle  9 , through the Spring  8  and out the other side of the Anchor Body  2 . When the Suture  13  on the side of the Spring  8  is pulled as shown  14  it tends to rotate the Locking Paddle  9  away from adjacent Wall  12 , shown here as counterclockwise so that a gap is created between the Locking Paddle  9  and the Inner Wall  12  allowing the Suture  13  to slide freely  15 .  
         [0133]     In  FIGS. 12 and 13  everything is the same except the direction of the Suture  13  has changed. The action of the Suture  13  being pulled in the opposite direction  16  will cause the Locking Paddle  9  to rotate toward the adjacent Wall  12 , shown here as clockwise. With the addition of the transmitted force from the Spring  8 /Inner Wall  11  interaction the Locking Paddle  9  will tend to push against the Inner Wall  12  and pinch the Suture  13 ) so as to minimize movement  17 . The harder the Suture  13  is pulled  16  the greater the pinching force between the Locking Paddle  9  and the Inner Wall  12  further hindering any suture movement  17 . With the Suture  13  at rest the Locking Paddle  9  will be biased to pinch the Suture  13  against the Inner Wall  12  from the force generated by the Spring  8 /Inner Wall  11  interaction.  
         [0134]      FIGS. 14 and 15  represent a variation of a Locking Mechanism  4 . The Locking Paddle  19  is attached to the Anchor Body  2  via a Torsional Spring  18 . The Torsional Spring  18  is attached firmly to the Anchor Body  2  so that Locking Paddle  19  is in close proximity to the Inner Wall  12 . As in the previous example if the Suture  13  is pulled in one direction the Locking Paddle moves away from adjacent Wall  12 , shown here as counterclockwise creating a larger gap between the Locking Paddle  19  and the Inner Wall  12  so that the Suture can move freely  21 . If the Suture  13  is pulled in the opposite direction the Locking Paddle is rotated toward the adjacent Wall  12 , shown here as clockwise. This is in addition to the Torsional Spring  18  biasing the Locking Paddle  19  toward the Inner wall  12 . With these two actions the Suture  13  tends to be pinched between the Locking Paddle  19  and the Inner Wall  12  hindering any suture movement  22 .  
         [0135]     Note that optional surface finishes can be applied to the Locking Paddle  19  to better interact with the Suture  13 . Shown are Teeth  20  but general material roughness or other surface finishes can be used.  
         [0136]     Though the cross section of Torsional Spring  18  shown in  FIG. 15  is round it can be shaped in a variety of other ways. Some examples are given in  FIG. 16 . The cross section also does not need to be consistent along its length.  
         [0137]     In accordance with an embodiment one end of the suture may need to be attached to the anchor in some fashion.  FIGS. 17 and 18  are a top and cut-away side view of an Anchor Body  2  with a Cross Pin  23  captured or attached. A void has been made in the Cross Pin  23  that receives the Suture  13 . The Suture  13  can be attached to the Cross Pin  23  in a variety of ways including but not limited to mechanical (e.g., crimping, friction) or chemical (e.g., adhesive, melting) methods.  
         [0138]     A variation of this design is shown in  FIGS. 19A, 19B , and  20 . The Suture  13  comes out both ends of the Cross Pin  23  so that two strands are ready for passing through tissue. An optional Notch  24  has been made in the Anchor Body  2  to act as a relief for the Suture  13  to make the transition from the axis of the Cross Pin  23  to roughly the axis of the Anchor Body  2 ). The Suture  13  can be fashioned in the Cross Pin  23  to slide or be permanently attached.  FIG. 19B  shows a variation of two pieces of suture ( 25  and  26 ) in the Cross Pin  23 .  
         [0139]      FIG. 21  shows the Suture  13  placed directly in the wall of the Anchor Body  2  This can be done in many ways and is not limited to mechanical coupling, chemical coupling, and over molding. More than one suture can be attached this way.  
         [0140]      FIGS. 22 through 27  present a different design for clamping suture in an anchor. A Suture  27  is attached to an Anchor Body  28  at a Fixation Point  29  as shown in  FIG. 22 . The Anchor Clip  30  is separate from the Anchor Body  28  initially. The Suture  27  is passed through the Tissue  31  in  FIG. 23 . The Anchor Clip  30  is slid down the Suture  27  and attached to the Anchor Body  28  as shown in  FIGS. 24 and 25 .  
         [0141]      FIG. 26  shows the Suture  27  being pulled in a direction  32  such that the Suture  27  weaves through the Anchor Clip  30  pulling the Tissue  31  toward the Anchor Body  28 . Once the desired tightness is reached of the Suture  27  and the Tissue  31  the Suture  27  can be trimmed to the appropriate length as in  FIG. 27 .  
         [0142]     It should be noted that many of the details described in  FIGS. 8 through 21  also apply to the previous concept. One difference is the Anchor Clip  40 . The following figures provide details for this clip.  FIG. 28  shows  3  views of the same anchor clip concept. The Connecting Member  35 , which attaches to the anchor, is the vertex for the Locking Paddle  33  and the Spring  34 . The Locking Paddle  33  has an included Notch  36  to act as a guide for suture. The height of the Notch  36  is less than the diameter of the suture to be used to that it can act to pinch the suture between the Locking Paddle  33  and the Inner Wall  39  of the anchor. The Spring  34  includes a Void  37  that acts to capture and direct the suture inside the anchor. The void  37  is shown as a circle but can be many different shapes and/or open to a side.  
         [0143]     In  FIG. 29  the Suture  40  has been threaded against the Notch  36  and through the Void  37 . The Anchor Clip  43  has been slid down the Suture  40  and placed inside the anchor so the Connecting Member  35  is attached to the anchor, the Spring  34  is pressed against one Inner Wall  38  pushing the Locking Paddle against the other Inner Wall  39 . This action tends to pinch the Suture  40  between the Notch  36  of the Locking Paddle  33  and the Inner Wall  39 . As with the earlier described idea if the Suture is pulled in one direction  42  the pinch becomes greater and the Suture  40  cannot move. But if the Suture  40  is moved in the other direction  41  the Locking Paddle  33  rotates slightly loosening the pinch and allowing the Suture  40  to slide.  
         [0144]     A variation of this concept is described in FIGS.  30  to  32 . In place of the Notch  36  on the Locking Paddle  33  a Pinching Void  46  is used. When a Force  48  is applied to the Collapsible Wall  47  the Pinching Void  46  becomes misshapen and pinches the Suture  40  to hold it in place.  FIG. 33  describes how the Suture  40  can slide when pulled in one direction  48  and locks in place when pulled in the other direction  49 .  
         [0145]     FIGS.  34  to  36  describe a tool that can be used to release the lock so suture can be slid in either direction.  FIG. 34  shows the direction  50  in which the Suture  40  is locked and cannot move. Only the distal end of the Release Tool  51  is shown. A handle is attached that allows the doctor to use it in the constraints dictated by surgery. The Release Tool  51  includes two distal Arms ( 52  and  53 ) that define a V-Notch  55  A radius on the inner distal portion of the arm or Lead-in  54  is included on each Arm ( 52  and  53 ). In use, the Release Tool  51  is placed over the clip so that the Arms ( 52  and  53 ) collapse the Locking Paddle  57  and Spring  56  together. This action releases the pinch force between the Locking Paddle  57  and the Inner Wall  58  so the Suture  40  can slide in a direction  58  that it previously could not.  
         [0146]      FIGS. 37 through 42  describe an alternative embodiment where the suture is initially not connected to the anchor. An Anchor Body  59  is loaded with an alternative embodiment of an elongated suture puller  60 , which is wrapped around a Locking Mechanism  61 . The elongated suture puller  60  includes a means for engaging suture formed from a Threading Loop  64 . Suture  62  with a Suture Loop  65  and Tissue  63  are also presented.  
         [0147]     First the Suture  62  is passed through the Tissue  63  as shown in  FIG. 38 . The passed end of the Suture  62  is threaded through the Suture Loop  65  and the passed end is pulled taut so the Suture  62  is tight against the Tissue  63 . The free end of the Suture  62  is now passed through the Threading Loop  64  as described in  FIG. 40 . A first length of the elongated suture puller  60  is pulled in a direction  67  so that it slides around the Locking Mechanism  61  pulling the Suture  62  captured by the Threading Loop  64  with it.  
         [0148]     In  FIG. 41  the elongated suture puller  60  has been pulled all of the way through the Anchor Body  59  and has threaded the Suture  62  around the Locking Mechanism  61 . The Suture  62  can be pulled in a direction  66  so that the Tissue  63  is drawn towards the Anchor Body  2 . As previously described the Suture  62  can be trimmed once the tissue is adequately approximated. This method can also be done with two or more sutures connected to a single anchor after completion.  
         [0149]     An alternative method is shown in  FIGS. 43A and 43B  where a loose piece of Suture  67  has been attached to Tissue  63  with a Mattress Stitch  68 . A variety of stitches could be used in this situation but the Mattress Stitch  68  is used as an example. The two passed arms of the Suture  67  can now be threaded through the Anchor Body  59  as depicted in  FIG. 40 .  
         [0150]     Another alternative method is shown in FIGS.  44  to  48 . Two Sutures ( 69  and  70 ) are loaded in the Anchor Body  59 . The Sutures  69  and  70 ) are passed through the Tissue  63  one at a time in different areas. A Knot  71  is tied in the passed Sutures ( 69  and  70 ) and is then pulled in a direction  73  that tightens the Tissue  63  toward the Anchor Body  59 .  
         [0151]      FIG. 49  shows a variation with a Disk  72  looped in the Suture  79  such that when the Suture  79  is tightened against the Tissue  63  the Disk  72  acts as a barrier to keep the Suture  79  from damaging the Tissue  63 . The two strands of suture can also exit from the same hole so that the Disk  72  keeps the Suture  79  from going back through the hole when pulled in the direction  73 .  
         [0152]      FIG. 50  shows the final configuration of a method where both ends of the Suture  76  loaded in Anchor Body # 1   74  were passed through the Tissue  77 . One end was passed back through to the other side and loaded in Anchor Body # 2   75  as described earlier. This free end of suture is passed again through the Tissue  77 . The two ends of the Suture  76  are brought together to form a Knot  78 .  
         [0153]     It should be noted that these sutures could be colored differently to aid in suture management. Also the means for anchoring associated with the anchor bodies of the anchors can be the push-type, the screw-type, or the arm-type or any other style of tissue fixation device that holds adequately and can contain the above-described mechanisms. The anchors are shown with anchor bodies in cylindrical form but they can have an oval, rectangular, triangular or any other appropriately shaped cross section.  
         [0154]      FIGS. 51 and 52  describe an additional embodiment for locking the Suture  82  in the Anchor Body  83 . The Suture  82  is threaded through the Anchor Body  83 , around the Retaining Pin  86 . The Suture  82  is also threaded through or joined with the Locking Clip  84 . When the Suture  82  has been pulled  80  to the desired tautness the Locking Clip  84  is slid down the Suture  82  until it clips into place in or on the Anchor Body  83 . The Locking Clip  84  can hold the suture in a frictional manner or be deformed around the Suture  82  or utilize some other mechanism so that the Suture  82  cannot be pulled in the opposite direction  85 .  
         [0155]     The remainder of this disclosure presents other embodiments of the present invention that are comparable to the embodiments of  FIGS. 1-7  or  37 - 42  in that an anchor is presented with an elongated suture puller that is preloaded in the suture anchor in order to pull or thread suture through the locking mechanism located in the anchor&#39;s center. The suture anchor used in these embodiments, as with all the above designs, can be a push-in, screw-in, eared, or other suitable style of bone fixation implant.  
         [0156]      FIGS. 53-68  show an embodiment where the elongated suture puller is comprised of a Pull Tab  122  (best shown in  FIGS. 61 and 63 ). Starting with just the anchor body,  FIG. 53  shows a suture anchor  100  having a body formed from an Insert  102  assembled into a Housing  101 . The insert  102  can be secured to the housing  101  via any suitable means such as a mechanical interconnect, a press-in fit, a weld, adhesive, etc. There are four sets of Outer Suture Channels  104  and Inner Suture Channels  105  and two Pull Tab Channels  103 .  FIG. 54  is a cross sectional view of the previous figure. It shows how the Pull Tab Channel  103  is actually continuous between the two openings at the top.  
         [0157]     In  FIG. 55  the insert  102  has been removed leaving a cross sectional view of the Housing  101 . The Outer Suture Channel  104  is exposed showing that it is continuous between the two end points at the top of the component. The Outer Pull Tab Channel Wall  106  is also shown.  
         [0158]     The Insert  102  is shown by itself in  FIG. 56 . In this view the Inner Suture Channels  105  go along the length of the Insert  102 . One of two Locking Tabs  107  is shown.  FIG. 57  is another view of the Insert from a different angle. Again, the Inner Suture Channels  105  and the Locking Tabs  107  can be seen. The Middle Post  109  is the stationary piece between the two Locking Tabs  107 . The Suture Gap  108  separates the Locking Tab  107  from the Middle Post  109 .  FIG. 58  is another rotated view of the Insert  102 , which is meant to showcase the Locking Point  110  at the end of the Locking Tab  107 . The Locking Point  110  is shown as the intersection of three curves but could be geometrically altered to be a rough surface or be combined with a modified Inside Tab Surface  111  to perform suture-locking duties.  
         [0159]     The action of the Insert  102  to allow suture to slide in one direction and to lock it in the other is represented in  FIG. 59 . When the Suture  112  is pulled up  116  (directionally as shown on the figure) it slides through the Suture Gap  108  and past the Locking Point  110 . This is because the Locking Tab  107  can flex to the right  114  to allow relatively free movement of the Suture  112 . When the Suture  113  is pulled in the opposite direction, down  117 , the Suture  113  is restrained from moving by the spring force of the Locking Tab with a directional component  115  that biases the Locking Point  110  towards the Middle Post  109 . This acts to frictionally hold the suture in place. The geometries of the Locking Point  110  and the Inner Tab Surface  111  can be modified to enhance this frictional interaction or to make it so the closing force between the Locking Tab  107  and the Middle Post  109  is increased with additional pull force in the downward direction  117 . This could be done in many ways such as creating small directionally biased hooks on the Inner Tab Surface  111 .  FIG. 60  shows a possible method for this by modifying the Locking Tab  119  to include small Hooks  120 . When the Suture  118  is pulled in the downward direction  121 , the Locking Tab  119  pushes against the Suture  118  so that it presses the latter against the Middle Post  109  so that the Hooks  120  tend to ‘grab’ on to the Suture  118  holding it in place. As drawn the Hooks  120  face slightly upwards so that they will grab the Suture  118  in the downward direction  121 , but allow the Suture  118  to slide more freely when pulled in the opposite direction.  
         [0160]      FIG. 61  is an isometric view of the elongated suture puller provided here as a Pull Tab  122 . This component is used to thread sutures through the implant. It tends to be a long, thin ribbon with a cross section that allows it to bend in one axis relatively easy compared a perpendicular axis. A close-up of the tip at the end of one length thereof is shown in  FIG. 62 . A first proximal length thereof (lower right) is pulled by the surgeon in use. A second opposite distal length thereof (upper left) contains suitable means for engaging suture such as a slot.  
         [0161]     Two Suture Slots  127  and  128  can either be in line (same distance from the distal end  125 ) or offset as shown to increase the web thickness  126  in order to improve strength. A Suture Slot Opening  123  and  124  allows suture to be easily loaded in to the Suture Slot  127  and  128 . As the Pull Tab  122  is pulled away from the distal end  125  the suture will tend to slide into the tapered slot  129  and  130  and lock into place.  
         [0162]     FIGS.  63  to  67  describe how suture is loaded and locked in place.  FIG. 63  shows the Pull Tab  122  pre-loaded into the implant represented by the assembly of the Insert  102  in the Housing  101 . In  FIG. 64 , Sutures  131  and  132  have been loaded into Suture Slots  127  and  128  of the Pull Tab  122 . The Sutures  131  and  132  could also be two ends of the same suture. For the rest of the description the action of only one Suture  132  will be described but a similar action will exist for Suture  131 .  
         [0163]     As the Pull Tab  122  is pulled in the direction shown  133 , the distal end of the Pull Tab  125  moves towards the Implant  136 , pulling the Suture  132 . The suture&#39;s two tails  134  and  135  are being lined up to be pulled into Suture Slots  104  and  105 . This is shown in  FIG. 65 .  
         [0164]     In  FIG. 66 , the Pull Tab  122  has been pulled all the way through the Implant  136  so that the two Tails  134  and  135  have been threaded through Suture Slots  104  and  105  respectively. In  FIG. 67 , the Tail  134  has been pulled fully through the Implant  136  leaving Tail  135  attached to the Implant  136 . In  FIG. 68 , the Suture  132  has been cut so that a Stub  137  is left on one side of the Implant  136  and a long Tail  135  holding tissue, for instance, is left on the other side. Based on the mechanisms within the Implant  136  described in  FIGS. 54-60 , the Sutures  131  and  132  cannot move in the retro direction  138 .  
         [0165]     In the subsequent drawings related to other embodiments, the suture and the elongated suture puller have been omitted for clarity. However, it should be assumed that they are included and serve the same general purpose as in the previously presented embodiments.  
         [0166]      FIGS. 69 through 74  illustrate an alternative structure for holding suture. The basic idea is the same as previously discussed, but instead of a clamping mechanism included in the insert the suture is held between the insert and the housing by changing the position of the two components relative to each other. Thus, this is a two-state device having an open state where the suture can move in either direction and a closed state where the suture is compressed and locked in place and prevented from moving in either direction.  
         [0167]     In  FIG. 69 a  cross sectional view of the housing  139  is presented. This view exposes the outer suture channel  141  which differs from those previously discussed in that the depth tapers lower near the bottom  142  of the housing  139 . This will act to enhance interference force on the suture in the suture-hold position. One-half of each locking notch  140  can also be seen. A cross sectional view from a perpendicular plane is shown in  FIG. 70 . A full view of one set of the locking notches  140  is shown along with a different view of the tapering outer suture channel  142 .  
         [0168]     The mating insert  143  is represented in  FIG. 71 . The inner suture channels  144  are similar to those previously discussed except the channel follows the contour around the shape and the spring locking mechanism is removed. Locking tabs  145  have been added that will be mating with the locking notches in the assembly and a relief channel  164  aids the flexibility of the two insert posts  165 .  
         [0169]      FIG. 72  is a cross sectional view of the insert  143  assembled in the housing  146 . The relative position of the two parts allows for a gap  146  such that the suture can slide freely between them. The interaction of the locking notches  140  and the locking tabs  145  can also be seen. The optional relief channel  164  is not shown. In  FIG. 73 , the insert  143  has been moved relative to the housing  139  by moving the locking tabs  145  to interface with lower locking notches  140 . This leaves a smaller gap  147  which will tend to compress the suture threaded between the insert  143  and housing  139  and hold it in place. One of many possible locking notch  140 /locking tab  145  configurations is shown in the close-up view of  FIG. 74 .  
         [0170]     Another suture locking variation is presented in FIGS.  75  to  80 . Here, the positional locking mechanism has been changed to the centerline of the insert and a cross pin has been placed through the center of the housing.  
         [0171]     The modified insert  148  is shown in  FIG. 75  with similar inner suture channels  149 . The locking channel  165  consists of several locking levels  166 , the cross pin channel  153 , and the relief channel  154 . The locking levels consist of a taper  152  that rides along the cross pin during the motion to lock suture, a insert flat  151  which locks against the flat surface of the cross pin to keep the insert from backing out of the housing, and a radius  150  that attaches the two features and may be a resultant of the manufacturing process. The cross pin channel  153  is an optional feature that can help the assembly by allowing a place for cross pin insertion with the insert already in the housing. The relief channel  154 , which is also optional, can be varied in length to change the ability for spreading movement for a given force.  
         [0172]     The cross pin  155  is shown in  FIG. 76 . This component consists of two rounded ends  156  and a triangular cross-sectioned center with three faces  157 ,  167  and  168 . In  FIG. 77  the cross pin  155  is assembled to the housing  158  with the insert missing. The rounded ends  156  have been placed in the housing holes  159 .  
         [0173]     In the cross sectional view of  FIG. 78  the cross pin  155 , insert  148  and housing  158  have been assembled. The functions of the cross pin faces  160  are to act as a wedge to push the taper  152  apart so the cross pin can advance to the next locking level  166 . The cross pin flat  161  acts to push against the insert flat  151  so that the insert  148  will not back out of the housing  158 .  
         [0174]      FIGS. 79 and 80  show this described assembly in the suture unlocked position ( FIG. 79 ) with a relatively large gap  162  and the suture locked position ( FIG. 80 ) with a smaller gap  163 . In the two figures it can be seen that the cross pin  155  has changed from one locking level  166  to another.  
         [0175]     As with all the ideas presented there are numerous possible configurations for the presented geometries such as a non-triangular cross pin or locking tab/locking notch fits, etc.  
         [0176]     Another variation of these suture anchor ideas is presented in FIGS.  81  to  84 . In this system the insert is modified to have a cam device at its bottom, or is replaced altogether with a cam device, which may or may not be attached to the housing. The following example shows the cam pinned to the housing.  
         [0177]     Detailed views of the cam  167  are shown in  FIGS. 81 and 82 . This component has a rotation hole  169 , which connects it to the housing via a pin. This hole is off the center axis of face  172 . If the cam  167  is not attached to the housing the rotation hole  169  is optional. The cam hole  168  is off axis of the rotation hole so that if a wire or suture is attached at the cam hole  168  the wire can be pulled to rotate the cam  168  about the rotation hole  169  or some other point if not attached to the housing. The cam surface  170  acts as a curved plate to compress the suture against the inside surface of the housing thus holding the suture (not shown) in place. The locking knob  171  locks the cam  167  at the correct rotation or placement so that the suture cannot slide.  
         [0178]      FIG. 83  is a cross sectional view of the cam  167  assembled into the housing  173  and pinned at the rotation hole  169 . The housing  173  is similar to the designs discussed earlier. At this point the suture (not shown) can be pulled around the cam  167  in a counterclockwise direction. A cam actuation wire  175  is shown but not yet in use. In  FIG. 84  it is assumed that the suture (not shown) is fully threaded and in its proper place. The cam actuation wire  175  is pulled  176  for rotating the cam  167  about the rotation hole  169 . This continues until the cam surface  170  is pinching the suture (not shown) against the inner housing wall  177  and the locking knob  171  locks into a mating notch (not shown). This will hold the cam  167  in place and keep the suture from sliding.  
         [0179]     Another variation is presented in FIGS.  85  to  88 . In this embodiment, the suture is placed through a more circuitous path thus increasing the frictional surface area for holding the suture. Numerous possible approaches exist, but the one presented here differs from the previous methods in that the insert is split into two parts so that the pull tab and suture must go thru a major portion of a circumference that will act as the frictional surface.  
         [0180]      FIG. 85  shows an exploded view of the three parts. The housing  178  is similar with locking notches  183 . The insert  179  now contains the inner suture channels  185 , the outer suture channels  184 , and the pull-tab channels  186 . The locking tabs  182  exist as before. The bottom of the insert  179  has been removed creating the insert suture surface  189 . This will act as a face to hold the suture in place when forced against the locking pin suture surface  181 . As mentioned the locking pin  180  has a suture surface  181  that will act as one half of the ‘sandwich’ holding the suture in place when locked in place.  
         [0181]      FIG. 86  shows the general path  187  of the pull-tab and the suture. The pull-tab (not shown) will travel along the pull-tab channel  186  and the suture (also not shown) will follow the inner suture channel  185  and the outer suture channel  184 .  
         [0182]     In  FIG. 87  the locking pin  180  is not locked since the insert  179  is still in the up position allowing the suture to slide freely through the gap  188 . In  FIG. 88  the insert  179  has been pushed in to the housing  178  pushing the locking pin  180  into a position that creates a very small gap  188  thus holding the suture in place.  
         [0183]      FIGS. 89A  to  89 D describe a variation of the suture pull tab (see e.g.  FIG. 61 ) formed as a trap pull tab where at least the distal end is made of a woven material such that the device acts like a finger trap when grabbing the suture and pulling it through the anchor.  
         [0184]     In  FIG. 89A  the end of the trap pull tab  189  is shown. An opening  190  will be used as an insertion point for suture. The woven mesh  191  can be made of metal wire, plastic or any other material that will act to collapse the diameter when the tension is placed along its long axis.  
         [0185]     In  FIG. 89B  the suture  192  is about to be placed in the opening  190  of the trap pull tab  189 . The suture  192  is slipped into the trap pull tab  189  with the motion  194  and  193  shown in  FIG. 89C . When the motion is then reversed  195  and  196 , the trap pull tab  189  collapses  197  around the suture  192  holding the two components together as shown in  FIG. 89D . This allows the user to now thread the suture  192  through the anchor by pulling on the already loaded trap pull tab  189 .  
         [0186]     The two components can be separated by compressing the trap pull tab  189  which will increase the diameter (not shown) allowing the suture  192  to slide out of the opening  190 .  
         [0187]      FIG. 90  shows a cross sectional view of a housing  200  and insert  201  that have been modified slightly near their distal ends. Instead of a “U” shaped bottom the insert distal end  203  and the housing cavity distal end  202  are closer to a “V” shape with curved edges.  
         [0188]     Although the invention has been discussed with reference to specific embodiments, it will be apparent that the concept can be otherwise embodied to achieve the advantages discussed.