Patent Publication Number: US-2021177394-A1

Title: Syndesmosis Fixation Assembly

Description:
BACKGROUND 
     Field 
     The present device relates to constructs that are used in the fixation of syndesmosis disruptions. 
     Description of the Related Art 
     A present method for syndesmotic ankle fixation requires screws or suture button systems. Both types of these fixation devices are inserted through the fibula and into the syndesmosis. The cross section of the fibula is relatively small, particularly at the syndesmosis, which can result in the clinician having a difficult time inserting the screw or suture button system through the fibula. 
     Accordingly, there exists a need for a syndesmosis fixation system that does not extend through the fibula. 
     SUMMARY 
     This Summary is provided to introduce a selection of concepts in a simplified form that are further described below in the Detailed Description. This Summary is not intended to identify key features or essential features of the claimed subject matter, nor is it intended to be used to limit the scope of the claimed subject matter. 
     According to one embodiment, a syndesmosis fixation assembly may include a plurality of implantable devices configured to aid in anatomic reduction. 
     In one embodiment, the syndesmosis fixation assembly may include a suture retaining portion having a plurality of suture openings formed therein and a suture securing portion rotatably connected to the suture retaining portion. The suture securing portion is movable between a first position wherein a suture is moveable within the suture retaining portion and a second position wherein the suture is frictionally secured within the suture retaining portion. A bone insertion portion has a distal bone insertion end adapted for insertion into a bone, a proximal bone insertion end connected to the suture retaining portion, and a central longitudinal axis extending between the distal bone insertion end and the proximal bone insertion end. 
     In an alternative embodiment, the syndesmosis fixation assembly includes a suture retaining portion having a plurality of suture openings formed therein and a suture extending through each of the plurality of suture openings. A suture securing portion is connected to the suture retaining portion. The suture securing portion is movable between a first position wherein the suture is moveable within the suture retaining portion and a second position wherein the suture is frictionally secured within the suture retaining portion. A bone insertion portion has a distal bone insertion end adapted for insertion into a bone and a proximal bone insertion end connected to the suture retaining portion. 
     In still another alternative embodiment, the syndesmosis fixation assembly comprises a suture retaining portion and a suture securing portion adapted to move from a first position wherein a suture in the suture retaining portion is moveable with respect to the suture retaining portion and a second position wherein the suture is fixed with respect to the suture retaining portion. A bone insertion portion has a distal portion adapted for insertion into a bone and a proximal portion connected to the suture retaining portion. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       Other aspects, features, and advantages of the present device will become more fully apparent from the following detailed description, the appended claims, and the accompanying drawings in which like reference numerals identify similar or identical elements. 
         FIG. 1  is a sectional view showing an exemplary method of reducing a syndesmosis according to the exemplary embodiments; 
         FIG. 2  is an exploded view of a fixation assembly according to an exemplary embodiment; 
         FIG. 3  is a sectional view of the assembly of  FIG. 2  in a suture release position; 
         FIG. 4  is a sectional view of the assembly of  FIG. 2  in a suture restraining position; 
         FIG. 5  is a perspective view of a fixation assembly according to an alternative exemplary embodiment; 
         FIG. 6  is a sectional view of the assembly of  FIG. 5  in a suture release position; 
         FIG. 7  is a sectional view of the assembly of  FIG. 5  in a suture restraining position; 
         FIG. 8  is a side elevational view of a fixation assembly according to an alternative exemplary embodiment; 
         FIG. 9  is a sectional view of the assembly of  FIG. 8  in a suture release position; 
         FIG. 10  is a sectional view of the assembly of  FIG. 8  in a suture restraining position; 
         FIG. 11  is a side elevational view of a fixation assembly according to an alternative exemplary embodiment; 
         FIG. 12  is a side elevational view of the assembly of  FIG. 11  with anchor legs in a deployed position; 
         FIG. 13  is a sectional view of the assembly of  FIG. 11  with the anchor legs in the deployed position; 
         FIG. 14  is a perspective view of the anchor used with the assembly of  FIG. 11 ; 
         FIG. 15  is a side elevational view of a fixation assembly according to an alternative exemplary embodiment; 
         FIG. 16  is a side elevational view of the assembly of  FIG. 15  with anchor legs in a deployed position; 
         FIG. 17  is a sectional view of the assembly of  FIG. 15  with the anchor legs in the deployed position; 
         FIG. 18  is a perspective view of the assembly of  FIG. 15  with the anchors deployed; 
         FIG. 19  is a perspective view of a fixation device according to an alternative exemplary embodiment; 
         FIG. 20  is a perspective view of a fixation device according to another alternative exemplary embodiment; 
         FIG. 21  is a sectional view of the device of  FIG. 20 ; 
         FIG. 22  is a perspective view of a pair of fixation assemblies according to an alternative exemplary embodiment embedded in a tibia and used to reduce a syndesmosis; 
         FIG. 23  is a perspective view of a washer with a buckle used with the assembly of 
         FIG. 22 ; 
         FIG. 24  is a sectional view of the assembly of  FIG. 22 ; 
         FIG. 25  is a perspective view of a fixation device according to an alternative embodiment; 
         FIG. 26  is a side elevational view, in section, of a washer with a cam operated buckle in a release position according to an alternative exemplary embodiment; 
         FIG. 27  is a side elevational view, in section, of the washer with am operated buckle of  FIG. 26  in a locking position; 
         FIG. 28  is a sectional view showing an exemplary method of reducing a syndesmosis according to an alternative exemplary embodiment; 
         FIG. 29  is a sectional view of the embodiment of  FIG. 28  with a clamp connecting two sutures; 
         FIG. 30  is a perspective view of an exemplary clamping tool used to clamp the clamp of  FIG. 29 ; 
         FIG. 31  is a top plan view of a staple inserted into the clamp of  FIG. 30 ; 
         FIG. 32  is a top plan view of the clamp and staple of  FIG. 31  having clamped down on the staple; and 
         FIG. 33  is a schematic view of a fixation assembly according to an alternative exemplary embodiment. 
     
    
    
     DETAILED DESCRIPTION 
     In the drawings, like numerals indicate like elements throughout. Certain terminology is used herein for convenience only and is not to be taken as a limitation on the present device. The terminology includes the words specifically mentioned, derivatives thereof and words of similar import. As used herein, the term “proximal” is intended to mean a direction closer to a clinician implanting the inventive devices and the term “distal” is intended to mean a direction farther from the clinician. 
     The embodiments illustrated below are not intended to be exhaustive or to limit the device to the precise form disclosed. These embodiments are chosen and described to best explain the principle of the device and its application and practical use and to enable others skilled in the art to best utilize the device. 
     Reference herein to “one embodiment” or “an embodiment” means that a particular feature, structure, or characteristic described in connection with the embodiment can be included in at least one embodiment of the device. The appearances of the phrase “in one embodiment” in various places in the specification are not necessarily all referring to the same embodiment, nor are separate or alternative embodiments necessarily mutually exclusive of other embodiments. The same applies to the term “implementation.” 
     As used in this application, the word “exemplary” is used herein to mean serving as an example, instance, or illustration. Any aspect or design described herein as “exemplary” is not necessarily to be construed as preferred or advantageous over other aspects or designs. Rather, use of the word exemplary is intended to present concepts in a concrete fashion. 
     Additionally, the term “or” is intended to mean an inclusive “or” rather than an exclusive “or”. That is, unless specified otherwise, or clear from context, “X employs A or B” is intended to mean any of the natural inclusive permutations. That is, if X employs A; X employs B; or X employs both A and B, then “X employs A or B” is satisfied under any of the foregoing instances. In addition, the articles “a” and “an” as used in this application and the appended claims should generally be construed to mean “one or more” unless specified otherwise or clear from context to be directed to a singular form. 
     Unless explicitly stated otherwise, each numerical value and range should be interpreted as being approximate as if the word “about” or “approximately” preceded the value of the value or range. 
     The use of figure numbers and/or figure reference labels in the claims is intended to identify one or more possible embodiments of the claimed subject matter in order to facilitate the interpretation of the claims. Such use is not to be construed as necessarily limiting the scope of those claims to the embodiments shown in the corresponding figures. 
     It should be understood that the steps of the exemplary methods set forth herein are not necessarily required to be performed in the order described, and the order of the steps of such methods should be understood to be merely exemplary. Likewise, additional steps may be included in such methods, and certain steps may be omitted or combined, in methods consistent with various embodiments of the present device. 
     Although the elements in the following method claims, if any, are recited in a particular sequence with corresponding labeling, unless the claim recitations otherwise imply a particular sequence for implementing some or all of those elements, those elements are not necessarily intended to be limited to being implemented in that particular sequence. 
     Also for purposes of this description, the terms “couple,” “coupling,” “coupled,” “connect,” “connecting,” or “connected” refer to any manner known in the art or later developed of joining or connecting two or more elements directly or indirectly to one another, and the interposition of one or more additional elements is contemplated, although not required. Conversely, the terms “directly coupled,” “directly connected,” etc., imply the absence of such additional elements. 
     The present disclosure provides embodiments of fixation device assemblies that can be used in syndesmosis fixation. The devices and assemblies described herein can be attached to a tibia  40  in two locations, with a suture  50  or suture tape connected to each device and wrapped around a fibula  42  to stabilize the syndesmosis. A simplified illustration of fixation device assemblies described herein is shown in  FIG. 1 , using generic screws  30  implanted into a tibia  40  on either side of a fibula  42 , with a suture  50  or suture tape  52  connected to screws  30  and wrapped over fibula  42  to draw fibula  42  closer to tibia  40  and reduce the syndesmosis. 
     Referring to  FIGS. 2-4 , a syndesmosis fixation assembly  100  (“assembly  100 ”) according to a first exemplary embodiment is shown. Assembly  100  includes a suture retaining portion  110 , a suture securing portion  140 , and a bone insertion portion  180 . Assembly  100  is cannulated along a central longitudinal axis  102  to allow for the optional use of a guide wire through assembly  100  to assist in inserting assembly  100  into bone. 
     Suture retaining portion  110  includes a generally hollow body  112  having a proximal portion  114 , a distal portion  116 , and an intermediate portion  118 , between the proximal portion  114  and the distal portion  116 . Proximal portion  114  includes a cavity  119  having internal threads  120  that are sized to mate with external threads  142  on suture securing portion  140 . 
     Distal portion  116  includes a plurality of distally extending fingers  122  that are separated from adjacent fingers  122  by a longitudinal gap  124 . Fingers  122  form an internal space  125  in distal portion  116 . In an exemplary embodiment, four fingers  122  are provided, although those skilled in the art will recognize that more or less than four fingers  122  can be provided. A distal end of each finger  122  includes an internal lip  126  that is used to engage bone insertion portion  180 . Internal space  125  has an internally extending radial lip  128  that narrows internal space  125  in a proximal direction. 
     Intermediate portion  118  includes a plurality of suture openings  130  formed therein. In an exemplary embodiment, suture openings  130  include a first suture opening  130   a  and a second suture opening  130   b  that are diametrically opposed from each other. 
     Suture securing portion  140  comprises a set screw that is insertable into cavity  119  and is movable between a first position, shown in  FIG. 2 , wherein a suture  50  is moveable within the suture retaining portion and a second position, shown in  FIG. 3 , wherein the suture  50  is frictionally secured within suture retaining portion  110 . 
     Bone insertion portion  180  includes a distal bone insertion end  182  that is adapted for insertion into a bone. Distal bone insertion end  182  includes a threaded portion  184  for gripping the bone. 
     Bone insertion portion  180  also includes a proximal bone insertion end  186  connected to suture retaining portion  110 . Proximal bone insertion end  186  includes a radially extending lip  188  that is used to retain suture retaining portion  110 . A hex head  190  is located proximally of lip  188  and is used to insert bone insertion portion  180  into a bone. 
     To insert assembly  100 , bone insertion portion  180  is threaded sub-flush into bone, either using a guide wire (not shown) or, alternatively, without a guide wire. A suture  50  is inserted into first suture opening  130   a  through suture retaining portion  110  and out second suture opening  130   b.    
     Suture retaining portion  110  is secured onto proximal bone insertion end  186  such that lip  126  on suture retaining portion  110  is forced over lip  188  on bone insertion portion  180  to rotatably secure suture retaining portion  110  onto bone insertion portion  180 . Suture  50  can be tensioned by pulling on a free end  58 . 
     Suture securing portion  140  can be screwed down into cavity  119  to frictionally secure suture  50  within suture retaining portion  110 . 
     Referring to  FIGS. 5-7 , a syndesmosis fixation assembly  200  (“assembly  200 ”) according to an alternative exemplary embodiment is shown. Assembly  200  includes a suture retaining portion  210 , a suture securing portion  240 , and a bone insertion portion  280 . 
     Suture retaining portion  210  includes a generally hollow body  212  having a proximal portion  214  and a distal portion  216 . Proximal portion  214  includes a cavity  219  having internal threads  220  that are sized to mate with external threads  242  on suture securing portion  240 . Proximal portion  214  also includes a plurality of suture openings  218  extending therethrough. Proximal portion  214  also includes a cap  215 . 
     Distal portion  216  includes a head  222  having a circular outer perimeter  223  and a threaded body  224  having a narrower cross section than head  222 . Head  222  has a cavity  225  adapted to receive an insertion tool  206  to rotate head  222 . In an exemplary embodiment, cavity  225  accepts a hex head driver. Head  222  is sized to fit within cap  215  so that head  222  rotatably engages cap  215 . Threaded body  224  is sized to internally thread into a proximal threaded cavity  285  in a proximal bone insertion end  283  of bone insertion portion  280 . 
     Suture securing portion  240  comprises a set screw  242  that is insertable into cavity  219  and is movable between a first position, shown in  FIG. 6 , wherein a suture is moveable within suture retaining portion  210  and a second position, shown in  FIG. 7 , wherein the suture can be frictionally secured within suture retaining portion  110 . Set screw  242  is generally hollow with an internal hex face  244  and a distal end  248 . 
     Bone insertion portion  280  includes a distal bone insertion end  282  that is adapted for insertion into a bone. Distal bone insertion end  282  includes a threaded portion  284  for gripping the bone. A central longitudinal axis  292  extends between distal bone insertion end  282  and proximal bone insertion end  283 . 
     Suture securing portion  240  is threadingly disposed in cavity  219  and movable between a first position wherein the suture is moveable within suture retaining portion  210  and a second position wherein the suture is frictionally secured within suture retaining portion  210 . The first position is a distal position relative to bone insertion portion  280  and the second position is a proximal position relative to the bone insertion portion  280 . 
     To insert assembly  200 , head  222  is inserted through cap  215  such that threaded body  224  extends distally from cap  215 . A suture (not shown) in inserted into one suture opening  218  and out another suture opening  218 . A retaining tool  202  is inserted over suture retaining portion so that nubs  204  on distal ends of retaining tool  202  are inserted into diametrically opposing suture openings  218  and help to prevent rotation of cap  215  and the suture as assembly  200  is driven into the bone. 
     Next, threaded body  215  is inserted into threaded cavity  285  in proximal bone insertion end  283  of bone insertion portion  280  and bone insertion portion  280  is driven into a bone using a driver  206  inserted into head  222 . Then, an outer driver  208  is used to rotate set screw  242  distally from the position shown in  FIG. 6  to the position shown in  FIG. 7  until distal end  248  of set screw  242  engages the top of head  222 , thereby securing the suture between set screw  242  and head  222 . 
     Referring to  FIGS. 8-10 , a syndesmosis fixation assembly  300  (“assembly  300 ”) according to an alternative exemplary embodiment is shown. Assembly  300  includes a suture retaining portion  310 , a suture securing portion  340 , and a bone insertion portion  380 . 
     Suture retaining portion  310  includes a generally hollow body  312  having a proximal portion  314  and a distal portion  316 . Proximal portion  314  includes internal threads  317  that accepts an insertion tool  302 . Proximal portion  314  also includes a plurality of suture openings  318  extending therethrough. The plurality of suture openings  318  comprises a first opening  318   a  and a second opening  318   b , proximal of first opening  318   a.    
     Distal portion  316  includes a cap  322  that is sized to receive suture securing portion  340  to frictionally engage a suture  50  that extends from suture openings  318   a ,  318   b . A lip  324  extends radially inwardly from cap  322 . 
     Suture securing portion  340  comprises a head  342  adapted to receive an insertion tool  304  to rotate head  342 . In an exemplary embodiment, head  342  accepts a hex head driver. Head  342  ends in an annular shoulder  344  that engages insertion tool  304 . Head  342  includes a bulbous body  348  extending distal of shoulder  344 , with a circumferential groove  350  formed therein. A passage  351  is provided between body  348  and suture retaining portion  310  from first suture slot  318   a  to second suture slot  318   b  so that suture  50  can be slid along passage  351 . 
     A distal end  352  of suture securing portion  340  includes a threaded body  360  that is sized to internally thread into a proximal threaded cavity  385  in a proximal bone insertion end  383  of bone insertion portion  380 . A lip  388  extends around distal end  352  between threaded body  360  and head  342 . 
     Bone insertion portion  380  includes a distal bone insertion end  382  that is adapted for insertion into a bone. Distal bone insertion end  382  includes a threaded portion  384  for gripping the bone. A central longitudinal axis  392  extends between distal bone insertion end  382  and proximal bone insertion end  383 . 
     Suture securing portion  340  is disposed in suture retaining portion  310  such that and movable between a first position wherein suture  50  is moveable within suture retaining portion  310  and a second position wherein suture  50  is frictionally secured suture retaining portion  310  and suture securing portion  340 . The first position is a distal position relative to bone insertion portion  380  and the second position is a proximal position relative to the bone insertion portion  380 . 
     Referring to  FIGS. 9 and 10 , to insert assembly  300 , threaded body  360  of suture securing portion  340  is inserted through cap  322  such that threaded body  360  extends distally from cap  322  so that lip  324  is distal of lip  388 . A suture  50  in inserted into one suture opening  218   a  and out another suture opening  218   b.    
     A first retaining tool  302  is threaded onto internal threads  317  of proximal portion  314  to prevent rotation of suture retaining portion  310 . A second retaining tool  304  is inserted into first retaining tool  302  and over head  342  until second training tool engages shoulder  344 . 
     Next, threaded body  360  is inserted into threaded cavity  385  in proximal bone insertion end  383  of bone insertion portion  380  and bone insertion portion  380  is driven into a bone using a driver  304  inserted over head  342  until bone insertion portion is sub-flush with bone. Both drivers  302 ,  304  can then be removed. 
     To frictionally secure suture  50 , cap  322  is pulled proximally in the direction of arrow “A” in  FIG. 9  so that lip  324  snaps over lip  388  and remains proximally over lip  388 . Suture retaining portion  310  engages head  342  so that passage  351  is reduced, thereby frictionally securing suture  50  between body  348  of head  342  and suture retaining portion  310 . 
     Referring to  FIGS. 11-14 , a syndesmosis fixation assembly  400  (“assembly  400 ”) according to an alternative exemplary embodiment is shown. Assembly  400  includes a suture retaining portion  410 , a suture securing portion  420 , and a bone insertion portion  440 . 
     Suture retaining portion  410  includes a plurality of distally extending fingers  412  that are separated from adjacent fingers  412  by a longitudinal gap  414 . Fingers  412  form an internal space  415  in suture retaining portion  410 . In an exemplary embodiment, four fingers  412  are provided, although those skilled in the art will recognize that more or less than four fingers  412  can be provided. 
     Internal space  415  has an internal thread  416  to threadingly accept and engage suture securing portion  420 . Internal space  415  bottoms out on a landing  417 . Suture retaining portion  410  also includes external ribbing  418  that allows assembly  400  to be inserted into a pre-drilled hole (not shown) but resists being pulled out. 
     Suture securing portion  420  includes a deformable spring anchor  422  that serves as both suture securing portion  420  as well as an anchor to secure assembly  400  in bone. Spring anchor  422  includes a body portion  424  with a plurality of anchor legs  426  extending outwardly therefrom. The number of anchor legs  426  is the same number as the number of longitudinal gaps  414  such that each anchor leg  424  extends into a respective gap  414 , while body portion  424  can slide within internal space  415 . 
     Suture securing portion  420  further includes a set screw  428  that is insertable into internal space  415 . Set screw  428  has a blunt distal tip  430  and a proximal head  432  that is configured to accept a driver (not shown) for rotating set screw  428  distally into internal space  415 . Set screw  428  has an external thread  434  that mates with internal thread  416  to advance set screw  428  distally. 
     Bone insertion portion  440  extends distally from suture retaining portion  410  and includes a blunt distal tip  442  and external ribbing  444  that is an extension of the external ribbing  418  on suture retaining portion  410 . 
     In an insertion condition, anchor legs  426  are stored within the perimeter of fingers  412 , as shown in  FIG. 11 . A suture (not shown) can be inserted into suture retaining portion  410  such that each end of the suture extends outwardly of one of gaps  414 . Bone securing portion  440  is inserted into the bone and set screw  428  is advanced distally into internal space  415 , driving anchor  422  distally until anchor  422  frictionally engages the suture between anchor body portion  424  and landing  417  of internal space  415 . 
     As set screw  428  is further advanced distally, anchor legs  426  are deformed to splay outwardly from the stored position, as shown in  FIG. 11 , to a deployed position, as shown in  FIGS. 12 and 13 . 
     Referring to  FIGS. 15-18 , a syndesmosis fixation assembly  450  (“assembly  450 ”) according to an alternative exemplary embodiment is shown. Assembly  450  includes a suture retaining portion  460 , a suture securing portion  470 , and a bone insertion portion  490 . 
     Suture retaining portion  460  includes a plurality of distally extending generally semi-circular leg portions  462  that are separated from each other by a pair of diametrically opposed longitudinal gaps  464 . Leg portions  462  form an internal space  465  in suture retaining portion  460 . In an exemplary embodiment, two diametrically opposed leg portions  462  are provided, although those skilled in the art will recognize that more or less than two leg portions  462  can be provided. 
     Internal space  465  has an internal thread  466  to threadingly accept and engage suture securing portion  470 . Internal space  465  bottoms out on a landing  467 . A pair of diametrically opposed suture slots  468  extend from internal space  465  through each leg portion  462 . Suture slots  468  are generally rectangular in cross section and are sized to allow a suture (not shown) to extend therethrough. Suture retaining portion  460  also includes external ribbing  469  that allows assembly  450  to be inserted into a pre-drilled hole (not shown) but resists being pulled out. 
     Suture securing portion  470  includes a pair of diametrically opposed cam-operated blades  476  that form an anchor to secure assembly  450  in bone. Blades  476  are movable between a stored position in which blades  476  are stored wholly within gaps  464 , as shown in  FIG. 15 , and a deployed position in which blades  476  extend outwardly of leg portions  462 , as shown in  FIGS. 16-18 . 
     Each blade  476  includes a sloped cam face  478  that, in a stored position, extends obliquely relative to a longitudinal axis  480  of suture retaining portion  460 . A distal end  482  of each blade  476  is pivotally attached to bone insertion portion  490  at a pivot  484 , located distal of landing  467 . 
     Suture securing portion  470  includes a set screw  479  that is insertable into internal space  465 . Set screw  479  has a blunt distal tip  480  and a proximal head  482  that is configured to accept a driver (not shown) for rotating set screw  479  distally into internal space  465 . Set screw  479  has an external thread  484  that mate with internal thread  466  to advance set screw  479  distally. 
     Bone insertion portion  490  extends distally from suture retaining portion  460  and includes a blunt distal tip  492  and external ribbing  494  that is an extension of the external ribbing  468  on suture retaining portion  460 . 
     In an insertion condition, blades  476  are stored within the perimeter of leg portions  462 . A suture (not shown) can be inserted into suture retaining portion  460  such that each end of the suture extends outwardly of one of suture slots  468 . Bone insertion portion  490  is inserted into the bone and set screw  479  is advanced distally into internal space  465 , engaging cam face  478  of each blade  476  and pushing blades  476  outwardly through their respective gap  464  to secure assembly  450  into bone. As set screw  479  is further advanced distally, set screw  479  engages the suture and frictionally secures the suture between distal tip  480  and landing  467 . 
     Alternatively, as shown in  FIG. 19 , an anchor  830  includes a distal tip  832  with a transverse passage  834  passing through. Anchor  830  also has a proximal end  836  configured to accept a driver (not shown). A body  838  having uni-directional ribbing  840  extends from proximal end  836  to distal tip  832 . 
     To insert anchor  830 , suture  50  or suture tape  52  (not shown) is passed through transverse passage  834  and anchor is tapped into a pre-drilled hole on tibia  40  (not shown). Suture  50  or suture tape  52  is wedged between anchor  830  and the wall of hole. 
     In an alternative embodiment shown in  FIGS. 20 and 21 , an anchor  880  includes a cannulated body  882  having an external thread  884 . A distal tip  886  includes a transverse, first passage  888  and an oblique, second passage  890  proximal of first passage  888 . Second passage  890  includes a first portion  891  that extends obliquely upwardly into an internal cannula  892  and a second portion  894 , diametrically opposite from first portion  891 , that also extends obliquely upwardly into internal cannula  892 . Internal cannula  892  extends from first passage  888  to a proximal end  896  that can include a hex head  898  to accommodate a driver (not shown). The driver can be cannulated to allow a suture to extend therethrough. 
     Suture  50  or suture tape  52  is looped through either first passage  888  or second passage  890  and passes through cannula  892  to proximal end  896 . 
     An alternative embodiment of an assembly  900  is shown in  FIGS. 22-24 . Assembly  900  includes a washer  910  and a buckle  920  extending outwardly from washer  910 . A suture tape  52  is secured to buckle  920 . 
     Washer  910  includes a generally annular body  912  having a flat top surface  914  and a tapered inner diameter  916 . A circular opening  918  is formed within inner diameter  916  and is sized to allow a fixation screw to be inserted therethrough. 
     Buckle  920  extends at an upward oblique angle from top surface  914  and includes parallel side walls  922 ,  924 , a top connecting member  926 , and a central connecting member  928  that each span and connect sides  922 ,  924  to each other. A first, lower gap  930  is formed between central connecting member  928  and body  912 , while a second, upper gap  934  is formed between central connecting member  928  and top member  926 . 
     Referring to  FIGS. 22 and 24 , to use assembly  900 , two screws  70  with washers  910  are inserted into tibia  40  so that suture tape  52  can be wrapped around fibula  42 . A first end  54  of suture tape  52  is secured to a first buckle  920 . A second end  56  of suture tape  52  stretched over fibula  42  and is inserted through lower gap  930  distal from washer  910  toward washer  910 . Second end  56  is then extended upwardly and over top connecting member  926  and then inserted through upper gap  934  distal from washer  910  toward washer  910 . Second end  56  is then inserted through lower gap  932 , proximate to washer  910  away from washer  910 . Second end  56  is then pulled upwardly, tightening suture tape  52  against fibula  42 . 
     Alternatively, second end  56  can be inserted through gaps  932 ,  934  prior to securing washer  910  to tibia  40 , then securing washer  910  to tibia  40 , and then tightening suture tape  52  around fibula. 
     An alternative embodiment includes a screw  1000  shown in  FIG. 25 . Screw  1000  has a distal tip  1002  and a proximal end  1004 . A threaded body  1010  can extend between tip  1002  and proximal end  1004 . Body  1010  can have varying outer diameters along the length of body, such as a narrow body portion  1012  toward distal tip  1002  and a wider body portion  1014  toward proximal end  1004 . 
     Proximal end  1004  includes a buckle  1030  similar to buckle  920  described above with respect to assembly  900 . This washerless embodiment allows buckle  1030  to be driven sub-flush of the bone cortex. The tensioning method for suture tape  52  is the same as for assembly  900  described above. 
     An alternative embodiment of an assembly  1100  is shown in  FIGS. 26 and 27 . Assembly  1100  includes a washer  1110  with a buckle  1120  that incorporates a cam  1130 . 
     Washer  1110  includes a generally annular body  1112  having a flat top surface  1114  and a tapered inner diameter  1116 . A circular opening  1118  is formed within inner diameter  1116  and is sized to allow a fixation screw to be inserted therethrough. 
     Buckle  1120  extends at an upward oblique angle from top surface  1114  and includes parallel side walls  1122 ,  1124  and a top connecting member  1126  that spans and connects sides  1122 ,  1124  to each other. Side walls  1122 ,  1124  each include a transverse slot  1128 . Connecting member  1126  includes a concave inner face  1129 . 
     Each side of cam  1130  includes a pivot portion  1132  that is inserted into transverse slot  1128  to that cam  1130  can pivot about transverse slot  1128 . Cam  1130  also includes a lobe  1134  positioned over that is used to bias suture tape  52  against top surface  1112  of washer  1110  and a slot  1136  through which suture tape  52  is inserted. 
     First end  54  of suture tape  52  can be fixed to another securing device, not shown. Second end  56  of suture tape  52  can be inserted into gap  1127  distal from washer  110  toward washer  1110  and under lobe  1134 . Second end  56  is then inserted through slot  1136  in cam  1130 . To secure suture tape  52 , cam  1130  is pivoted along concave inner face  1129  from the position shown in  FIG. 26  to the position shown in  FIG. 27 . Lobe  1134  is rotated to pinch suture tape  52  down on top surface  114 , securing suture tape  52  to assembly  1110 . 
     While assembly  1100  is shown using washer  1110 , those skilled in the art will recognize that buckle  1120  with cam  1130  can be used on other securing devices, such as, for example, on screw  1000 . 
     An alternative embodiment of an assembly  1200  is shown in  FIGS. 28-32 . Assembly  1200  includes screws  70  that are implanted into tibia  40  on either side of fibula  42 . A suture  50  is attached to each screw  70  so that each suture  50  has a free end  58 . Free ends  58  are drawn over fibula  42  and clamped together, such as by staple  1202 . Staple  1202  can be clamped around free ends  58  by a clamping instrument  1210 . 
     Clamping instrument  1210  includes a pair of arms  1212 ,  1214  that are pivotally attached to each other at a pivot  1216 . Instrument  1210  includes a staple receiver  1215  on an opposing side of pivot  1216 . Clamping teeth  1218 ,  1220  are attached to distal ends of arms  1212 ,  1214 , respectively on the opposing side of pivot  1216  and on either side of receiver  1215 . 
     As shown in  FIG. 31 , staple  1202  is inserted into receiver  1215 . Free ends  58  of sutures  50  are inserted into staple  1202  and arms  1214 ,  1216  are compressed toward each other as shown in  FIG. 32  so that clamping teeth  1218 ,  1220  close down on staple arms  1204  to clamp free ends  58  of suture  50  within staple. 
     An alternative embodiment of an assembly  1300  is shown in  FIG. 33 . Assembly  1300  includes a band  1302  that connects two separate sutures  50  to each other. Sutures  50  can be secured to a bone (not shown) via any of the anchors disclosed herein, such that free ends  58  of sutures extend away from the anchors. Band  1302  includes clamps  1304  are either end thereof to secure free ends  58  of sutures  50 . 
     Each clamp  1304  includes a body  1306  having a closure  1308  pivotally attached thereto. Free end  58  of suture  50  can be inserted through clamp  1304  between body  1306  and closure  1308 . Closure  1308  can be pivoted to body  1306  to secure suture  50  between body  1306  and closure  1308 . 
     An advantage to using band  1302  is that band  1302  can be slid along either suture  50  to a select location prior to securing suture  50  to band  1302  in order to avoid engaging any anatomically challenging areas. 
     The anchors and assemblies disclosed herein can be constructed from biocompatible materials, such as stainless steel, titanium, or other suitable materials or combinations thereof. 
     It will be further understood that various changes in the details, materials, and arrangements of the parts which have been described and illustrated in order to explain the nature of this device may be made by those skilled in the art without departing from the scope of the device as expressed in the following claims.