Patent Publication Number: US-2021186580-A1

Title: Knotless suture locking bone plate

Description:
This application claims the benefit of priority of U.S. Provisional Patent Application No. 62/518,312, filed Jun. 12, 2017 of which is expressly incorporated herein by reference in its entirety. 
    
    
     BACKGROUND 
     Various injuries include separation of soft tissue from one or more bones and/or separation of bones from normally anatomical correct positioning. Maintaining the bones in the correct anatomical positions during healing is important to provide proper soft tissue reattachment and proper bone healing. For example, during syndesmosis repair, a first bone and a second bone must be maintained in a fixed position to allow the connective tissue to heal. 
     Current suture systems include one or more knots for maintaining sutures in a fixed position. Knots formed on the sutures can cause irritation during healing and may be subject to tearing due to friction or other forces applied to the knot. Current systems further require surgeons to form knots during surgery. Such systems are prone to failure and increase time of surgery. 
     SUMMARY 
     In various embodiments, a system is disclosed. The system includes an anchoring device and an anchor. The anchoring device includes a body extending between a first surface and a second surface. The body defines a strand-locking hole extending from the first surface to the second surface. A first locking element and a second locking element each extend from a first side wall of the strand-locking hole to a second side wall of the strand-locking hole. Each of the first anchor and the second anchor extend transverse to a central axis of the anchor hole. The anchor includes a body defining a first wing and a second wing. The first and second wings are coupled at a distal end and biased away from a longitudinal axis of the body. The first and second wings are configured to maintain the anchor in a fixed position when the anchor is inserted into a hole formed in a bone. 
     In various embodiments, a method of syndesmosis is disclosed. The method includes forming a bone tunnel through a first bone and a second bone and passing at least one flexible strand through the bone tunnel from a first side to a second side. The at least one flexible strand is coupled to an anchor including a body defining a first wing and a second wing coupled at a distal end and biased away from a longitudinal axis of the body. The body is sized and configured for insertion into a first side of the bone tunnel. The at least one flexible strand is passed through a locking hole formed in a bone plate. The bone plate is configured to abut a surface of the second bone defining the second side of the bone tunnel. The first bone and the second bone are positioned at a predetermined spacing by applying a tensioning force to the at least one flexible strand. The at least one flexible strand is locked at a predetermined length. The at least one flexible strand is locked by a first locking element and a second locking element positioned within the locking hole formed in the bone plate. 
     In various embodiments, a system is disclosed. The system includes a bone plate, an anchor, and a flexible strand extending between the bone plate and the anchor. The bone plate includes a body extending between a first surface and a second surface and defining a strand-locking hole extending from the first surface to the second surface. A first locking element and a second locking element each extend from a first side wall of the strand-locking hole to a second side wall of the strand-locking hole. Each of the first locking element and the second locking element extend transverse to a central axis of the anchor hole. The anchor includes a body defining a first wing and a second wing that are coupled at a distal end and biased away from a longitudinal axis of the body. The first and second wings are configured to maintain the anchor in a fixed position when the anchor is inserted into a hole formed in a bone. The anchor includes a coupling extension extending from the distal end of the first wing and the second wing and defining at least one hole extending therethrough. A first end of the flexible strand is coupled to the at least one hole formed in the coupling extension of the anchor and a second end of the flexible strand extends beneath the second locking element, between the first locking element and the second locking element, and above the first locking element of the bone plate. 
    
    
     
       BRIEF DESCRIPTION OF THE FIGURES 
       The features and advantages of the present invention will be more fully disclosed in, or rendered obvious by the following detailed description of the preferred embodiments, which are to be considered together with the accompanying drawings wherein like numbers refer to like parts and further wherein: 
         FIG. 1  illustrates a joint including a first bone and a second bone coupled by at least one flexible strand extending between a bone plate and an anchor, in accordance with some embodiments. 
         FIG. 2  illustrates a bone plate including at least one strand-locking hole, in accordance with some embodiments. 
         FIG. 3  illustrates an expanded view of the strand-locking hole of the bone plate of  FIG. 2 , in accordance with some embodiments. 
         FIG. 4  illustrates a cross-sectional view of the strand-locking hole taken along line A-A of  FIG. 3 , in accordance with some embodiments. 
         FIG. 5  illustrates the cross-sectional view of  FIG. 4  having a second locking element in a second, locked position, in accordance with some embodiments. 
         FIG. 6  illustrates an anchor, in accordance with some embodiments. 
         FIG. 7  illustrates the anchor of  FIG. 6  having a first flexible strand and a second flexible strand coupled thereto, in accordance with some embodiments. 
         FIG. 8  illustrates a method of syndesmosis, in accordance with some embodiments. 
     
    
    
     DETAILED DESCRIPTION 
     This description of the exemplary embodiments is intended to be read in connection with the accompanying drawings, which are to be considered part of the entire written description. In the description, relative terms such as “lower,” “upper,” “horizontal,” “vertical,”, “above,” “below,” “up,” “down,” “top,” “bottom,” “proximal,” “distal,” “superior,” “inferior,” “medial,” and “lateral” as well as derivative thereof (e.g., “horizontally,” “downwardly,” “upwardly,” etc.) should be construed to refer to the orientation as then described or as shown in the drawing under discussion. These relative terms are for convenience of description and do not require that the apparatus be constructed or operated in a particular orientation. Terms concerning attachments, coupling and the like, such as “connected,” refer to a relationship wherein structures are secured or attached to one another either directly or indirectly through intervening structures, as well as both movable or rigid attachments or relationships, unless expressly described otherwise. 
       FIG. 1  illustrates a joint  2  including a first bone  4  and a second bone  6  coupled by at least one flexible strand  16   a,    16   b  extending between a bone plate  12  and an anchor  14 , in accordance with some embodiments. In some embodiments, the joint  2  is an ankle joint including a tibia  4 , a fibula  6 , and a talus  8 . An anchoring construct  10  includes a bone plate  12  and an anchor  14  having at least one flexible strand  16   a,    16   b  extending therebetween. The flexible strands  16   a,    16   b  can include any suitable material, such as one or more sutures, threads, ribbons, and/or any other suitable flexible material. The flexible strands  16   a,    16   b  extend through a bone tunnel  18  having a first portion  20   a  extending through the first bone  4  and a second portion  20   b  extending through the second bone  6 . The first and second portions  20   a,    20   b  can be aligned along a common longitudinal axis (as shown in  FIG. 1 ) and/or can be offset. 
     In some embodiments, the flexible strands  16   a,    16   b  of the anchoring construct  10  can be adjusted (e.g., shortened) to apply a tensioning force to the first bone  4  and the second bone  6  to position the first bone  4  and the second bone  6  in a predetermined spaced relationship. In some embodiments, the predetermined spaced relationship is selected to mimic a natural spacing of the first bone  4  and the second bone  6 . The flexible strands  16   a,    16   b  allow the first bone  4  and the second bone  6  to be maintained in the predetermined spaced relationship while allowing natural range of movement between the first bone  4  and the second bone  6 . 
     In some embodiments, the flexible strands  16   a,    16   b  can be locked after adjustment to maintain the first bone  4  and the second bone  6  in the predetermined spaced relationship. For example, in the illustrated embodiment, a first end  22   a  of each of the flexible strands  16   a,    16   b  is fixedly coupled to an anchor  14  coupled to the first bone  4 . The first end  22   a  of the flexible strands  16   a,    16   b  can be coupled to the anchor  14  using any suitable coupling mechanism. For example, in some embodiments, the flexible strands  16   a,    16   b  can be inserted through one or more holes formed in the anchor  14 , as described in greater detail below. A knot can be formed at the first end  22   a  of each of the flexible strands  16   a,    16   b  to prevent the flexible strands  16   a,    16   b  from passing back through the one or more holes formed in the anchor  14 . In other embodiments, the flexible strands  16   a,    16   b  can be coupled to the anchor  14  using a crimp and/or other compression coupling. Although specific embodiments are discussed herein, it will be appreciated that the flexible strands  16   a,    16   b  can be coupled to the anchor  14  using any suitable coupling mechanism. 
     In some embodiments, a second end  22   b  of each of the flexible strands  16   a,    16   b  is passed through a strand-locking hole  50  formed in the bone plate  12 . The strand-locking hole  50  is configured to prevent movement (e.g., lengthening/shortening) of the flexible strands  16   a,    16   b  when a predetermined tension is applied to the flexible strands  16   a,    16   b.  In some embodiments, the predetermined tension corresponds to a predetermined spacing of the first bone  4  and the second bone  6 . The strand-locking hole  50  can include one or more locking elements configured to lock the first strand  16   a  and/or the second strand  16   b  in a fixed position when the predetermined tension is applied to the flexible strands  16   a,    16   b,  as discussed in greater detail below with respect to  FIGS. 2-5 . 
       FIG. 2  illustrates a bone plate  12   a  including at least one locking hole  50   a,  in accordance with some embodiments. The bone plate  12   a  is similar to the bone plate  12  discussed above, and similar description is not repeated herein. The bone plate  12   a  includes a body  30  extending between a bone-contacting surface  32   a  and an opposed, outer surface  32   b.  A perimeter of the bone plate is defined by a first side edge  34  and a second side edge  34   b  extending generally along a longitudinal axis  38  of the bone plate  12   a  and a top edge  36   a  and a bottom edge  36   b  generally extending perpendicular to the longitudinal axis  38 . The body  30  has a predetermined thickness between the bone-contacting surface  32   a  and the outer surface  32   b.    
     In some embodiments, the body  30  includes a shaft portion  40  and a head portion  42 . The shaft portion  40  extends generally along a longitudinal axis  38  of the bone plate  12   a  and is sized and configured to conform to a portion of the second bone  6 , such as, for example, a diaphysis of the second bone  6 . The shaft portion  40  has a first width. The shaft portion  40  can include one or more locking fastener holes  44   a - 44   b,  non-locking fastener holes  46   a - 46   b,  slots  48 , and/or strand-locking holes  50   a.  Although embodiments are discussed herein having locking fastener holes  44   a - 44   b,  non-locking fastener holes  46   a - 46   b,  and compression slots  48 , it will be appreciated that the bone plate can include any combination of locking fastener holes  44   a - 44   b , non-locking fastener holes  46   a - 46   b,  and slots  48  and is within the scope of this disclosure. 
     In some embodiments, each of the locking fastener holes  44   a - 44   b  includes a circumferential opening extending from the bone-contacting surface  32   a  to the outer surface  32   b . An interrupted thread  52  extends at least partially therethrough. The interrupted thread  52  is formed by tapping a continuous thread into the locking fastener holes  44   a - 44   b  and forming one or more interruptions (or cutouts)  54  through the thread. The interrupted thread  52  is configured to allow a locking fastener to be inserted into the locking fastener holes  44   a - 44   b  at a variable, user-selected angle, to lock the bone plate  12   a  to a bone, such as the second bone  6 . 
     In some embodiments, each of the non-locking fastener holes  46   a - 46   b  include a circumferential opening having a smooth side surface extending from the bone-contacting surface  32   a  to the outer surface  32   b.  The non-locking fastener holes  46   a - 46   b  are configured to receive a non-locking fastener therein. The non-locking fastener is coupled to a bone, such as the second bone  6 , to pull the bone-contacting surface  32   a  of the bone plate  12   a  into contact with an outer surface of the bone  6 . In some embodiments, the non-locking fastener holes  46   a - 46   b  are omitted. 
     In some embodiments, a slot  48  includes an oblong opening having a smooth side surface extending from the bone-contacting surface  32   a  to the outer surface  32   b.  The slot  48  is sized and configured to receive a non-locking fastener therein. The non-locking fastener can be variably positioned within the slot  48  and coupled to a bone. 
     In some embodiments, the shaft portion  40  is coupled to a head portion  42  at a lower end of the shaft portion  40 . The head portion  42  has a second width. In some embodiments, the second width of the head portion  42  is greater than the first width of the shaft portion  40 . The head portion  42  can be configured to conform to a portion of the second bone  6 , such as a metaphysis of the second bone  6 . In some embodiments, the head portion  42  can include a plurality of locking fastener holes, non-locking fastener holes, and/or slots extending from the bone-contacting surface  32   a  to the outer surface  32   b.  For example, in the illustrated embodiment, the bone plate  12   a  defines five locking fastener holes  54   a - 54   e  extending therethrough, although it will be appreciated that a greater and/or lesser number of locking fastener holes and/or one or more non-locking fastener holes or slots can be formed through the head portion  42 . The locking fastener holes  54   a - 54   e  are similar to the locking fastener holes  44   a - 44   b  formed through the shaft portion  40 , and similar description is not repeated herein. 
     In some embodiments, the head  42  of the bone plate  12   a  is offset from the shaft  40  by an offset portion  56 . The shaft  40  is substantially disposed in a first plane and the head  42  is substantially disposed in a second plane. The offset portion  56  extends from the shaft  40  (e.g., the first plane) to the head  42  (e.g., the second plane) at a predetermined angle. The offset portion  56  positions an outer surface  32   b  of the head  42  above an outer surface  32   b  of the shaft  40  and the bone contacting surface  32   a  of the head  42  above the bone contacting surface  32   a  of the shaft  40 . In some embodiments, the offset portion  56  positions the bone contacting surface  32   a  of the head  42  above the outer surface  32   b  of the shaft  40 . In some embodiments, the offset portion  56  is configured to position the shaft  40  and the head  42  such that the bone plate  12   a  conforms to an outer surface of a bone, such as, a lateral side of a fibula, a medial side of a tibia, and/or any other suitable bone. The bone plate  10   a  can be coupled to the second bone  6  using any combination of locking and/or non-locking fasteners inserted through any combination of locking holes  44   a - 44   b,    54   a - 54   b,  non-locking holes  46   a - 46   b,  and/or slots  48 . 
     In some embodiments, the bone plate  12   a  includes at least one strand-locking hole  50   a.  A strand-locking hole  50   a  can extend through any portion of the plate  12   a,  such as the shaft  40 , the head  42 , and/or the offset portion  56 . The strand-locking hole  50   a  is sized and configured to receive a flexible strand, such as flexible strands  16   a,    16   b,  therethrough. The strand-locking hole  50   a  includes a locking element  60  including one or more locking elements  62 ,  64  configured to lock a flexible strand  16   a,    16   b  in a fixed position when a predetermined tension is applied to the flexible strand  16   a,    16   b.    
       FIG. 3  illustrates an expanded view of the strand-locking hole  50   a  of the bone plate  12   a,  in accordance with some embodiments. The strand-locking hole  50   a  extends hole  50   a  from the bone contacting surface  32   a  to the outer surface  32   b.  The strand hole  50   a  can include any suitable shape, such as a circular, oblong, square, and/or any other suitable shape. In some embodiments, a locking element  60  is disposed within the strand-locking hole  50   a.  The locking element  60  includes a first locking element  62  and a second locking element  64  extending from a first side  60   a  of the strand hole  50   a  to a second side  60   b  of the strand hole  50   a.  For example, in some embodiments, the first locking element  62  and the second locking element  64  include beams or pins extending from the first side  60   a  to a second side  60   b  of the strand hole  50   a  and that are transverse to a central axis  61  of the strand hole  50   a.  The first locking element  62  and the second locking element  64  are configured to lock a flexible strand  16   a,    16   b  in a fixed position when a predetermined tension is applied. 
     In some embodiments, the first locking element  62  is a fixed locking element having a fixed position within the strand hole  50   a  and the second locking element  64  is a moveable locking element having a variable position within the strand hole  50   a.  The second locking element  64  is configured to be transitioned from a first, unlocked position to a second, locked position. For example, in the illustrated embodiment, the second locking element  64  is disposed within a first channel  66   a  and a second channel  66   b  extending through the first side  60   a  and the second side  60   b  of the strand hole  50   a,  respectively. The second locking element  64  is configured to transition from a first end of each of the channels  66   a,    66   b  to a second end of each of the channels  66   a,    66   b  when a predetermined force is applied to the second locking element  64 . The predetermined force can be applied to the second locking element  64  by the at least one flexible strand  16   a,    16   b.  When the second locking element  64  is transitioned to a second end of the channels  66   a,    66   b,  a retention element (not shown) is configured to lock and/or fix the second locking element  64  at the second end of the channels  66   a,    66   b.  The retention element can include any suitable element, such as a notch, a hook, an adhesive, a mechanical retention element, and/or any other suitable retention element. 
     The flexible strand  16   a  can extend through the bone tunnel  18  from an anchor  14  coupled to the first bone  4 , as discussed above. The flexible strand  16   a,    16   b  can further be passed through the strand-locking hole  50   a  in a locking arrangement with the first locking element  62  and/or the second locking element  64 . In some embodiments, at least one flexible strand, such as flexible strand  16   a,  extends through the strand hole  50   a  from the bone contacting surface  32   a  to the outer surface  32   b  below the second locking element  64 . The flexible strand  16   a  is returned through the strand hole  50   a  from the outer surface  32   b  to the bone contacting surface  32   a  in a gap  68  between the first locking element  62  and the second locking element  64  such that the flexible strand  16   a  loops around the second locking element  64 . The flexible strand  16   a  extends a second time through the strand hole  50   a  from the bone contacting surface  32   a  to the outer surface  32   b  above the first locking element  62 . Although specific embodiments are discussed herein, it will be appreciated that the flexible strands  16   a,    16   b  can be coupled to the locking elements  62 ,  64  in any suitable locking arrangement. 
     In use, a tensioning force is applied to a proximal end  22   b  of the flexible strand  16   a.  The tensioning force initially causes the flexible strand  16   a  to advance through the locking hole  50  and reduce the spacing between the first bone  4  and the second bone  6 . For example, in some embodiments, the first end  22   a  of the flexible strand  16   a,    16   b  is coupled to the first bone  4  by the anchor  14 . As the flexible strand  16   a,    16   b  is advanced through the strand-locking hole  50   a  (for example, by the tensioning force) the spacing between the first bone  4  and the second bone  6  is reduced. As the first bone  4  and the second bone  6  are adjusted, a force applied by the flexible strand  16   a  to the second locking element  64  increases. When the force exceeds a predetermined threshold, the second locking element  64  moves from the first, unlocked position to the second, locked position. In the unlocked position, the flexible strand  16   a  is capable of advancing through the locking hole. The second locking element  64  is retained in the locked position by a retention element (not shown). 
     When the second locking element  64  transitions to the second, locked position, the flexible strand  16   a  is prevented from moving through the strand-locking hole  50   a.  For example, as shown in  FIG. 4 , a flexible strand  16   a  extends through a gap  68  between the first locking element  62  and the second locking element  64 . In the first position, the gap  68  has a first spacing and is configured to allow free movement of the flexible strand  16   a.  When the force applied by the flexible strands  16   a,    16   b  exceeds the predetermined threshold, the second locking element  64  transitions to the second position, as shown in  FIG. 5 . In the second position, the gap  68  is reduced to a spacing less than the thickness of the flexible strand  16   a  such that the flexible strand  16   a  is compressed and locked between the first locking element  62  and the second locking element  64 . In some embodiments, the predetermined threshold corresponds to a predetermined spacing of the first bone  4  and the second bone  6 . 
     Although embodiments are discussed herein including a bone plate  12 ,  12   a , it will be appreciated that the locking element  60  can be positioned within any suitable anchoring body configured to be coupled to the first bone  4  and/or the second bone  6 . For example, in various embodiments, a locking element  60  can be disposed within a capsule anchor configured to be at least partially inserted into the first bone  4  and/or the second bone  6 . In other embodiments, the locking element  60  can be positioned within an opening defined by a flat button and/or other fastener configured to be positioned against an outer surface of the first bone  4  and/or the second bone  6 . It will be appreciated that the locking element  60  can be positioned within any suitable structure and/or body, and is within the scope of this disclosure. 
       FIGS. 6-7  illustrates an anchor  14   a , in accordance with some embodiments. The anchor  14   a  is similar to the anchor  14 , and similar description is not repeated herein. The anchor  14   a  includes a body  80  defining a first wing  82   a  and a second wing  82   b  defining a slot  84  therebetween. The first wing  82   a  and the second wing  82   b  each define a longitudinal section  86  extending generally along a longitudinal axis  88  and a lateral section  90  extending at an angle with respect to the longitudinal axis  88 . In some embodiments, the lateral sections  90  extend at a substantially 90° angle, although it will be appreciated that the lateral sections  90  can have a greater and/or lesser angle. 
     In some embodiments, the first wing  82   a  and the second wing  82   b  are biased in opposite directions. For example, in some embodiments, the first wing  82   a  and the second wing  82   b  are coupled at a distal end  92   a  and are separated by a slot  84  at a proximal end  92   b  such that the first wing  82   a  and the second wing  82   b  can be compressed towards each other. In use, the first wing  82   a  and the second wing  82   b  are compressed towards a center line  88  for insertion into a bone tunnel  18   a . After insertion, the first wing  82   a  and the second wing  82   b  expand apart and apply a force to an inner surface of the bone tunnel  18   a  to maintain the anchor  14   a  in a fixed position within the bone tunnel  18   a.    
     In some embodiments, a strand anchoring extension  94  extends from the distal end  92   a  of the body  80 . The strand anchoring extension  94  includes a substantially flat body  96  extending from body  80   a  substantially along the longitudinal axis  88 . The strand anchoring extension  94  is configured to couple one or more flexible strands  16   a ,  16   b  to the body  80 . For example, in the illustrated embodiment, the strand anchoring extension  94  defines a plurality of anchoring holes  98   a ,  98   b  extending through the flat body  96 . A distal end  22   b  of the flexible strands  16   a ,  16   b  extend through the anchoring holes  98   a ,  98   b . A knot can be formed at the distal end  22   b  of the flexible strands  16   a ,  16   b  to prevent the flexible strands  16   a ,  16   b  from passing back through the anchoring holes  98   a ,  98   b . In other embodiments, the strand anchoring extension can include a peg, screw, knotless coupling element and/or any other suitable anchor for coupling the flexible strands  16   a ,  16   b  to the strand anchoring extension  94 . 
       FIG. 8  illustrates a method  200  of syndesmosis, in accordance with some embodiments. At step  202 , a bone tunnel  18  is formed through a first bone  4  and a second bone  6 . The bone tunnel  18  can include a first portion  20   a  extending through the first bone and a second portion  20   b  extending through the second bone  6 . The first and second portions  20   a ,  20   b  can be aligned along a common longitudinal axis and/or can be offset. The bone tunnel  18  can be formed using any suitable device, such as a drill, needle, k-wire, and/or any other suitable device. 
     At step  204 , at least one flexible strand  16   a ,  16   b  is passed through the bone tunnel  18  from a first end corresponding to a surface  4   a  of the first bone to a second end corresponding to a surface  6   a  of the second bone  6 . In some embodiments, a first end  22   a  of the at least one flexible strand  16   a ,  16   b  is coupled to an anchor  14  and a second end  22   b  of the flexible strand  16   a ,  16   b  is passed through the bone tunnel  18 . The anchor  14  includes a body  80  defining a first wing  82   a  and a second wing  82   b  coupled at a distal end and each biased away from a longitudinal axis of the body  80 . In some embodiments, the anchor  14  includes a coupling extension  94  extending distally from the distal end  92   a  of the body  80 . The coupling extension  94  defines one or more holes  98   a ,  98   b  extending therethrough. In some embodiments, each flexible strand  16   a ,  16   b  is passed through a selected on of the holes  98   a ,  98   b . A knot or other anchor can be formed at an end of the flexible strand  16   a ,  16   b  to couple the flexible strand  16   a ,  16   b  to the coupling extension  94 . 
     At step  206 , the wings  82   a ,  82   b  of the anchor  14  are compressed and the anchor  14  is inserted into the first portion  20   a  of the bone tunnel  18 . In some embodiments, the longitudinal portion  86  of each of the wings  82   a ,  82   b  is disposed within the bone tunnel  18  and the transverse portions  90  of each of the wings is disposed against an outer surface  4   a  of the first bone  4 . In some embodiments, the anchor  14  is partially inserted into the first portion  20   a  of the bone tunnel  18  such the longitudinal portion  86  extends at least partially from the bone tunnel  18 . 
     At step  208 , the second end  22   b  of the flexible strand  16   a ,  16   b  is coupled to a strand-locking hole  50  of a bone plate  12 . The strand-locking hole  50  includes one or more locking element  62 ,  64  configured to couple to the flexible strands  16   a ,  16   b . In some embodiments, the flexible strand  16   a ,  16   b  can be coupled to the strand-locking hole  50  by passing the flexible strand  16   a ,  16   b  from a bone contact surface  32   a  to an outer surface  32   b  of the bone plate  12   a  through the strand-locking hole  50  and beneath the second locking element  64 . The flexible strand  16   a ,  16   b  is passed back through the strand-locking hole  50  from the outer surface  32   b  to the bone contacting surface  32   a  and between the first locking element  62  and the second locking element  64 . The flexible strand  16   a ,  16   b  is subsequently returned through the strand-locking hole  50  from the bone contacting surface  32   a  to the outer surface  32   b  and above the first locking element  62 . Although specific embodiments and arrangements of the flexible strands  16   a ,  16   b  and the locking elements  62 ,  64  are discussed herein, it will be appreciated that the flexible strands  16   a ,  16   b  can pass through the strand-locking hole  50  and/or interact with the locking elements  62 ,  64  in any suitable manner and is within the scope of this disclosure. 
     At optional step  210 , the bone plate  12   a  is coupled to the second bone  6  by one or more fasteners. In some embodiments, one or more locking fasteners are inserted through one or more locking fastener holes  44   a - 44   b ,  54   a - 54   b  formed in the shaft  40  and/or the head  42  of the bone plate  12   a . The one or more locking fasteners are inserted through the locking fastener holes  44   a - 44   b ,  54   a - 54   b  at a variable angle. The locking fasteners can include any suitable locking fastener, such as a locking fastener having a threaded shaft configured to interface with the second bone  6  and a threaded head configured to lock the locking fastener at a selected angle within the locking fastener hole  44   a - 44   b ,  54   a - 54   b . In some embodiments, one or more non-locking fasteners are inserted through one or more non-locking fastener holes  46   a - 46   b  formed in the shaft  40  and/or the head  42 . The one or more non-locking fasteners compress the bone plate  12  against the outer surface  6   a  of the second bone. In some embodiments, the non-locking fasteners include a threaded shaft and an unthreaded head, although it will be appreciated that any suitable non-locking fastener can be used. In some embodiments, one or more fasteners are inserted through one or more slots  48  formed through the shaft  40  and/or the head  42 . The one or more fasteners can be positioned within a variable location within the slot  48  and coupled to the second bone to compress the bone plate  12   a  against the second bone  6 . 
     At step  212 , a tensioning force is applied to the second end  22   b  of the at least one flexible strand  16   a ,  16   b  to position the first bone  4  and the second bone  6  at a predetermined spacing. The tensioning force advances the second end  22   b  of the flexible strand  16   a ,  16   b  through the strand-locking hole  50  of the bone plate  12 . The first end  22   a  is coupled to the anchor  14  positioned within the bone tunnel  18 . The anchor  14  maintains the first end  22   a  in a fixed position, causing the first bone  4  and the second bone  6  to move towards each other to a predetermined spacing. In some embodiments, the tensioning force causes the anchor  14  to advance into the bone tunnel  18  to a fixed position. In some embodiments, the tensioning force maintains the bone plate  12   a  in a fixed position with respect to the second bone  6 . 
     At step  214 , the at least one flexible strand  16   a ,  16   b  is locked at a predetermined length corresponding to a predetermined spacing of the first bone  4  and the second bone  6 . In some embodiments, the at least one flexible strand  16   a ,  16   b  is locked at the predetermined length by the first locking element  62  and the second locking element  64  disposed within the strand-locking hole  50 . For example, in some embodiments, the at least one flexible strand  16   a ,  16   b  applies a force to the second locking element  64  during tensioning of the first bone  4  and the second bone  6 . When the force applied to the second locking element  64  exceeds a predetermined threshold, the second locking element  64  transitions from a first position (in which the at least one flexible strand  16   a ,  16   b  is freely moveable through the strand-locking hole  50 ) to a second position (in which the at least one flexible strand  16   a ,  16   b  is compressed between the first locking element  62  and the second locking element  64 ). In some embodiments, the compressive force is configured to prevent movement of the at least one flexible strand  16   a ,  16   b  through the strand-locking hole  50  and lock the first and second bones  4 ,  6  at the predetermined spacing. 
     At optional step  216 , the at least one flexible strand  16   a ,  16   b  can be cut or otherwise shortened to remove a portion of the at least one flexible strand  16   a ,  16   b  extending substantially beyond the outer surface  32   b  of the bone plate  12 . Although specific embodiments are discussed herein, it will be appreciated that the steps of the method  200  can be performed in any suitable order, can be omitted, and/or can be repeated and are within the scope of this disclosure. 
     Although the devices, kits, systems, and methods have been described in terms of exemplary embodiments, they are not limited thereto. Rather, the appended claims should be construed broadly, to include other variants and embodiments of the devices, kits, systems, and methods, which may be made by those skilled in the art without departing from the scope and range of equivalents of the devices, kits, systems, and methods.