Patent Publication Number: US-2022233302-A1

Title: Methods and devices for tissue graft fixation

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
     This application is a 371 U.S. National Phase Entry of PCT Application Serial No. PCT/U52020/038401 filed Jun. 18, 2020 and titled “METHODS AND DEVICES FOR TISSUE GRAFT FIXATION”, which claims the benefit of U.S. Provisional App. No. 62/862,807 filed Jun. 18, 2019 and U.S. Provisional App. No. 62/901,463 filed Sep. 17, 2019 and U.S. Provisional App. No. 62/933,695 filed Nov. 11, 2019 and U.S. Provisional App. No. 62/978401 filed Feb. 19, 2020 and U.S. Provisional App. No. 62/978,425, also filed February 19, 2020 and 63/036,570 filed Jun. 9, 2020; all of which are titled “METHODS AND DEVICES FOR TISSUE GRAFT FIXATION” and herein incorporated by reference in its entirety. 
     This application also claims priority to U.S. Provisional App. No. 62/869,593 filed Jul. 2, 2019 titled “ADJUSTABLE ACL FIXATION DEVICE”; herein incorporated by reference in its entirety. 
     This application also incorporates by reference commonly owned U.S. Pat. No. 10,383,617; herein incorporated by reference in its entirety. 
    
    
     FIELD 
     The present disclosure relates to methods and devices for tissue graft fixation in a surgical repair. 
     BACKGROUND 
     Soft tissue (such as ligaments and tendons) that has ruptured and non-repairable is generally replaced arthroscopically by a tissue graft. Currently, for a soft tissue repair where the surgeon wishes to use adjustable suspensory fixation, one of two methods have to be utilized. In instances where the tendon graft is not long enough to drape over the closed loop of the adjustable fixation device, the end of the graft must be secured to the closed loop, generally by whipstitching, which may compromise the graft and may be difficult to form on such a small piece of tissue. In the other methods, suture tape or a comparable material is used to couple the loop of the adjustable fixation device through a hole drilled in the bone block, requiring additional materials to complete the repair. Another issue encountered with adjustable fixation loops is that slip or creep of the suture within the loop is more common than in non-adjustable loops. Additionally, graft fixation devices are primarily designed to cradle or attach to a soft tissue graft that is attached to bone blocks. Instead, grafts with bone blocks are typically fixed into bone tunnels with an interference screw. 
     Adjustable fixation devices have become more popular as they minimize fixation length calculations and allow the graft to bottom in the tunnel. Additionally, over the last decade the femoral and tibia tunnels used in ACL reconstruction have become shorter. These shorter tunnels are a by-product of the preferred more horizontal orientation of the tunnels through the femur and tibia that improves the functionality of the graft post-procedure. Shorter tunnels translate to less tunnel length available for suture loops and therefore an adjustable suture loop that requires a minimal length is preferable. Adjustable suture loops require oftentimes pulling with high forces on the loops to reduce them, which can sometimes injure the surgeon or damage the surgeon&#39;s gloves. Some attempted solutions have included wrapping sutures multiple times around an instrument such as a forceps or using reinforced gloves, but this has not sufficiently addressed the needs of the industry. Therefore, there is a need for a means of achieving the required forces to reduce an adjustable suture construct in a safe and reliable manner. 
     SUMMARY 
     Described herein, are various improvements in methods and devices for tissue graft fixation using an adjustable fixation loop. Such improvements include examples of fixation devices that are attached to an adjustable fixation loop of suture without compromising the graft or requiring additional material to complete the repair. Other improvements include suture loop/fixation device constructs, which are designed to minimize slip/creep of the suture within the loop. Further improvements include a helical needle for stitching a tissue graft, which is designed to minimize suture ingrowth blockage. Still other improvements include fixation devices that can be used with grafts attached to bone blocks, for example, patella tendon or quad tendon grafts. Yet further improvements include fixation devices that could be attachable to an independent adjustable suture system. 
     For example, a first embodiment may disclose a fixation device that may be a cortical button and may include two bodies; a first body having a first recess defined in a sidewall between first and second ends and a second body having a second recess defined in a sidewall between first and second ends, wherein the first and second bodies are detachably coupleable in a same plane whereby the first end of the second body is insertable into the first recess, and the second end of the first body is insertable into the second recess. The first body and second body may be mirror images of each other. The first and second body are both configured to assemble with a portion of an adjustable suture construct. At least one of the bodies is configured to thread a portion of the adjustable suture construct through tissue before coupling to the other body. A suture cradle of the adjustable suture construct may be disposed between the first and second body. The first and second bodies each define a longitudinal axis extending between their respective first and second ends and wherein when coupled the two bodies partially axially overlap and partially axially extend away from each other and thereby do not axially overlap. The first body may assemble with a first loop of the adjustable suture construct and the second body may assemble with a second loop of the adjustable suture construct and when coupled, the first loop may be disposed within the second body recess and the second loop may be disposed within the first body recess. 
     In a further example embodiment, a fixation device may be disclosed including a first body with a first and second end. The first body may define the maximum fixation device footprint. The first body may include a slot formed through an upper surface of the body and transverse to a body longitudinal axis, closer to a first end. The slot may define a hole through a lower surface of the body. The device may also include a second body having a plurality of holes and configured to be extend through the hole in a first orientation and then nest within the slot in a second orientation. The first body may be operatively coupled to a first loop of an adjustable suture construct. The first body may include a pair of holes adjacent the slot to operatively couple to the first loop. The second body may be operatively coupled to a second loop of an adjustable suture construct. The second body may having a length that extends across a width of the first body from a first lateral side of the first body to a second lateral side. When operatively coupled the upper surface of the first body and an upper surface of the second body may be flush. The second body is configured to thread the second loop of the adjustable suture construct through tissue before coupling to the other body. A suture cradle of the adjustable suture construct may be disposed between the first and second body. 
     In a further example embodiment, a fixation device may be disclosed including a body having parallel first and second slots formed through the body and extending along the longitudinal axis of the body. The body also includes a plurality of openings defining a path between the sidewalls of the body, the openings in communication with the first and second slots. The plurality of openings, may all define a path, oriented transverse to the longitudinal axis of the body. The fixation device may also include a pin for insertion through the plurality of openings. Pin may bifurcate the first and second slots. Pin may be configured to selectively operatively couple to a loop of an adjustable suture construct. Pin may be configured to selectively operatively couple to a first loop of an adjustable suture construct within the first slot, and a second loop of the adjustable suture construct within the second slot. A method of repairing a tissue may including coupling a first loop of an adjustable suture construct to a fixation device by partially inserting a pin of the fixation device across a first slot, and inserting a second loop of the adjustable suture construct though the tissue. The second loop may then be inserted through the second slot and the pin advanced across the second slot and through the second loop to assemble the second loop with the fixation device. 
     A further example embodiment disclosed herein may include a fixation device comprising a first body having a first end defining a triangular shape cavity formed in an upper surface of the first body. The cavity also includes a hole extending from the bottom of the cavity and extending through to a bottom surface of the first body. The first body also includes a plurality of holes through the entire thickness of the first body for engaging a first end of a suture. The device also includes a second body, defining a plurality of slots and configured to nest within the triangular shaped cavity of the first body. The plurality of slots may be surrounded when disposed within the cavity. The plurality of slots may engage peripheral surfaces of the cavity when nested. The plurality of slots may couple to a second end of the suture after the suture has extended through the hole that extends from the cavity. The first and second body cooperate to engage the second end of the suture and prevent the second end from disengaging from the second body. 
     A further exemplary embodiment disclosed here includes a fixation device with a pivoting member comprising a body having a first sidewall and a second sidewall defining a longitudinal slot. The body also includes a plurality of slots perpendicular to the longitudinal slot configured to engage a first end of a suture. The body also includes a plurality of holes for engaging a second end of the suture and a closing member configured to pivot relative to the second sidewall within the longitudinal slot between an open position and a closed position to engage the suture. 
     A further exemplary embodiment disclosed here includes a fixation device having first and second slotted holes formed through the first side of the body and third and fourth slotted holes formed through the second opposing side of the body. The body is configured to receive a first side of an adjustable suture loop construct through the first and third slotted holes; and wherein the first and third slotted holes comprise tortuous paths to retain the first side of the suture loop construct. The body is configured to receive a second side of the adjustable suture loop construct through the second and fourth slotted holes. The body may include at least one pair of holes through the body, medially disposed relative to the slotted holes. The pair of holes may operatively couple with the adjustable suture construct. A method of tissue repair using this fixation device may include extending a first or second side of an adjustable suture loop through the tissue to place a suture cradle of the adjustable suture loop within the tissue. The first side may then be coupled to the first and third slotted holes. In some example methods, the first side may be coupled before extending a second side of the adjustable suture loop through the tissue. The slotted holes are configured to form a tortuous paths for the adjustable suture construct when assembled to the fixation device. 
     An embodiment of a fixation device embodiment is disclosed herein including a cannulated, cylindrical body and a hollow suture extending through an inner passage of the body. The fixation device also includes a plug configured to be inserted within the hollow suture and pushed through the hollow suture, and be secured within the inner passage of the body, such that the suture is prevented from sliding relative to the body. 
     A further exemplary embodiment disclosed here includes a fixation device operatively coupled to an adjustable suture construct having at least one constriction portion or longitudinal passage. This construction portion may be disposed adjacent a bottom surface of the fixation device. The constriction member configured to apply 360 degrees of compression to at least one loop of suture extending through the constriction member. 
     A further exemplary embodiment disclosed here includes a fixation device comprising an anchor body comprising a plurality of apertures and a suture being threaded through the plurality of apertures such that first and second loops extend from the bottom surface of the anchor body while the first and second free ends extend from the top surface of the anchor body. Each of the first and second loops extend through a cradle region and exit a same side of the cradle region, and a connection member joins a portion of the first and second loops extending from the same side of the cradle region. 
     An example method of attaching a graft to a fastener is disclosed and may comprise inserting a helical needle coupled to a suture into a graft, passing the needle and the suture through the graft along a first suture path, passing the needle and the suture through an adjustable suture loop of a fixation device, reinserting the needle into the graft, and passing the needle and the suture through the graft along a second suture path. 
     A further exemplary embodiment disclosed here includes a fixation member and an adjustable suture loop attached to the fixation member. The adjustable suture loop includes a cradle portion and an implant coupled to the cradle region configured to engage an outer surface of a bone block, the bone block being pre-attached to soft tissue. 
     An exemplary method for attaching a fixation device/suture loop construct to a graft is disclosed and may include inserting a needle into a proximal end of the graft and out through a top surface of the graft; looping the cradle over an end of the graft such that the needle and the cradle are disposed below a bottom surface of the graft; inserting the needle from the bottom surface to the top surface of the graft at a second exit point distal to the first exit point to draw the cradle above the top surface of the graft; and attaching a reinforcing material to the graft at least between the first and second exit points of the needle such that the needle passes through the reinforcing material. 
     A further example embodiment is disclosed herein and includes a fixation system for suspending a bone-tendon graft within a bone tunnel, the bone-tendon graft including a bone block. The fixation system includes a fixation device, a continuous suture loop and an adjustable suture loop. The adjustable suture loop is operatively coupled to the fixation device providing the link between the fixation device and continuous loop. The adjustable loop is operatively coupled to the continuous loop at a loop intersection. The continuous loop has a length configured to extend through a passage in the bone block and along an outer surface of the bone block such that the loop intersection is disposed at a target location that is along the outer surface and axially spaced away from a first proximal end of the bone block, the first end proximal adjacent the fixation device. In some embodiments, the continuous loop may comprise a means to maintain the loop intersection at the target location. In some embodiments, the means may include a luggage tag loop with the adjustable loop. In some embodiments, the means may include a knot at a first end of the continuous loop. In some embodiments, the means may include a button operatively coupled to a continuous loop first end. In some embodiments, the adjustable loop may comprise at least two adjustable loops and the continuous loop loops over at least one adjustable loop of the adjustable loop, to form a luggage tag loop and maintain the loop intersection at the target location. In some embodiments, the adjustable portion may include a cradle, the cradle operatively coupled to the continuous loop via a luggage tag loop 
     An example embodiment of a fixation system is disclosed for suspending a bone-tendon graft within a bone tunnel, the bone-tendon graft including a bone block. The fixation system includes a fixation device, a continuous loop and an adjustable loop; the adjustable loop operatively coupled to the fixation device and links the fixation device to the continuous loop. The adjustable loop is operatively coupled to the continuous loop at a loop intersection; wherein the continuous loop has a length configured to extend through a passage in the bone block and along an outer surface of the bone block such that the loop intersection is disposed at a target location that is axially spaced away from a first end of the bone block, the first end adjacent the fixation device. 
     An example method of securing soft tissue to bone is disclosed including preparing a tunnel along a longitudinal axis of a bone block of a graft. A fixation construct may then be coupled to the bone block, the fixation construct including a fixation button, an adjustable suture loop and a continuous suture loop. Both suture loops are formed as separate sutures. Coupling comprises first extending a first end of the continuous suture loop through the entire tunnel and then passing the fixation button through the first end to form a luggage tag loop through and around the bone block, the continuous loop and the adjustable suture loop both forming a portion of the luggage tag loop. 
     A further example fixation system is disclosed herein for use in surgical implantation, including a first flexible member having a first free end, a second free end, and a first body extending between the first free end and the second free end of the first flexible member. The first body defines a first longitudinal passage portion in the first flexible member, the first flexible member forming an adjustable loop by passing a first free end through the first longitudinal passage portion. The embodiment also includes a second flexible member, defining a continuous loop and coupled to the first flexible member; wherein the first and the second flexible member are formed as separate members. A fixation button anchor is directly coupled to the first flexible member, the apparatus formed such that the first flexible member adjustable loop defines a link between the anchor and the second flexible member. The first flexible member defines a first loop end and a second loop end at an opposite end of the first loop end, the second flexible member coupled to a first loop end. The anchor is coupled to the second loop end. The fixation system also includes a retaining button slidingly coupled to at least one of the first or second flexible members to limit migration of the continuous loop into a prepared bone block tunnel. In some example embodiments, the second flexible member has a length configured to form a portion of a loop around and through a bone block, the first flexible member completing the loop. In some example embodiments, the second flexible member has a length that is limited to form an incomplete loop around a bone block such that the first flexible member completes the loop and an intersection between the first and secondly flexible member places the longitudinal passage portion on an external surface of the bone block spaced between a distal-most and proximal-most end of the bone block. 
     An example method of securing soft tissue to bone is also disclosed herein including preparing a tunnel through a bone block of a graft, the bone block having a longitudinal axis and a transverse axis and the tunnel oriented at an angle between the longitudinal and transverse axis. The tunnel defines a first opening through a cortical external surface of the bone block and a second opening though a lower cancellous external surface between the distal-most and proximal-most end of the bone block. The method also includes extending an adjustable loop of suture operatively coupled to a bone fixation device through the angled bone tunnel and then over the tendon/bone interface opposite the first opening; and thereby attaching the suture loop to the bone block. The adjustable loop of suture may include a suture cradle and wherein after extending the loop of suture over the tendon/bone interface, the adjustable loop may shortened so as to draw the bone fixation device to the bone block. The method may also include forming bilateral grooves around the lateral surface of the bone block and extending the loop of suture over the tendon/bone interface to place the loop into the bilateral grooves. 
     A further example embodiment disclosed herein includes a graft suspension device comprising an elongated body. The elongate body may include a first end, a second end, and a longitudinal axis extending therebetween, a first sidewall extending between the first and second ends along the longitudinal axis, and a second sidewall opposite the first sidewall extending between the first and second ends along the longitudinal axis. The elongate body also includes at least a first and a second aperture defined through the body adjacent a midpoint of the body defined by the first and second ends and a first slot formed through one of the first or second sidewalls such that the first slot is adjacent the first aperture and a second slot formed through one of the first side or second sidewalls such that the second slot is adjacent the second aperture. At least the first and second apertures are preassembled to a first loop of an adjustable suture loop. The first and second slots are configured to receive a second loop of the adjustable suture loop. In some embodiments, the adjustable suture loop includes a cradle disposed between the first and second loops. The second loop may define a free end as provided. In some example embodiments, the free end is configured to draw the cradle into or through graft tissue rather than cradle it and then wrap around the first and second slots to couple to the elongate body. In some example embodiments, the cradle comprises a longitudinal passage portion through which ends of a first and second suture limb extend, and wherein the elongate body further comprises a third and fourth hole, disposed adjacent the first and second end respectively, the third and fourth holes configured to receive the first and second limbs therethrough. 
     An example method for attaching an adjustable suture loop construct to a graft may include placing a reinforcement means around a graft proximal end, including around a bottom surface, an end surface and a top surface of the graft proximal end. A needle is coupled to a cradle of the adjustable suture loop construct and is inserted through the reinforcement means and into a proximal end of the graft and out through a top surface of the graft and through the reinforcement means, defining a first exit point. The cradle is then looped over an end of the graft such that the needle and the cradle are disposed below a bottom surface of the graft. In some embodiments, the needle is inserted from the bottom surface to the top surface of the graft at a second exit point distal to the first exit point to draw the cradle above the top surface of the graft. In some example methods, the needle is coupled to the cradle via a flexible member; the flexible member having a tapered member coaxially disposed therealong. The tapered member defines a smaller opening end adjacent the needle and a larger opening end that houses a portion of the cradle therein. Inserting the needle through the reinforcement means and graft thereby draws the tapered member through the reinforcement means and graft. In some example embodiments, the reinforcement means is selected from a group consisting of a flat braided suture, a woven cap or a rigid implant. In some example embodiments, the reinforcement means comprises pre-formed apertures for receiving the needle therethrough. 
     Some exemplary embodiments disclosed herein may include an adjustable fixation system for suspending a graft within a bone tunnel. This system may include a suspension device including a fixation device and an adjustable suture construct, the adjustable suture construct operatively coupled to the fixation device. The adjustable suture construct has a first limb, a second limb and a bifurcated portion therebetween. In some embodiments, the adjustable suture construct may include at least two adjustable loops. In some embodiments, the bifurcated portion may link or cradle the graft. In some embodiments, the bifurcated portion defines two longitudinal passages of the adjustable suture construct. In some embodiments, the bifurcated portion is continuous with the first and second limb and is formed during braiding of the suture construct. In some embodiments, the first and second limbs both include a braided core, thereby defining a length of the bifurcated portion therebetween, the length of the bifurcated portion defining two parallel longitudinal passages. In some embodiments, a first longitudinal passage of the bifurcated portion is configured to receive one of either the first or second limb there through and form a first adjustable suture loop and wherein a second longitudinal passage of the bifurcated portion is configured to receive the other of either the first or second limb therethrough and form a second adjustable suture loop. In some embodiments, the first and second limbs both comprise an outer wall comprising a first plurality of braided strands, and a core section comprising a second plurality of braided strands. Each longitudinal passage may comprises at least one strand of the first plurality of braided strands, and at least one strand of the second plurality of braided strands. In some embodiments, the first plurality of strands and the second plurality of strands are split equally between the longitudinal passages. 
     In another embodiment of an adjustable tissue fixation system disclosed herein, the system includes a tissue anchor and a flexible member coupled to the tissue anchor. The flexible member has a first free end, a second free end, and a body extending between the first free end and the second free end of the flexible member, the body defining a first and a second longitudinal passage portion in the flexible member. The first and the second longitudinal passage portions are parallel to each other. The flexible member forms a first adjustable loop by passing the first free end through the first longitudinal passage portion. The flexible member forms a second adjustable loop by passing the second free end through the second longitudinal passage portion. In some embodiments, tension on the first free end is configured to either reduce the first adjustable loop length or reduce a diameter of the first longitudinal passage portion to selectively limit further adjustment of the first adjustable loop length. In some embodiments, tension on the second free end is configured to either reduce the second adjustable loop length or reduce a diameter of the second longitudinal passage portion to selectively limit further adjustment of the second adjustable loop length. In some embodiments, the first end passes through the first longitudinal passage portion in a first direction and the second free end pass through the second longitudinal passage portion in an opposite direction to the first direction. In some embodiments, the first and second longitudinal passages are formed from a single suture construct that is continuously braided to form a length including the first and second longitudinal passages. In some embodiments, the first and second longitudinal passages are configured to cradle a tissue to be fixed within a bone tunnel. 
     An example method of securing soft tissue to bone is also disclosed including coupling the soft tissue to a cradle of an adjustable suture loop construct. The cradle has two parallel longitudinal passages of a bifurcated length of the adjustable suture loop construct. The method also includes extending the adjustable loop suture construct that is operatively coupled to a bone fixation device through a bone tunnel. A first end of the adjustable suture loop construct is drawn to slide the first end through a first of the two parallel longitudinal passages and draw the soft tissue into the bone tunnel. A first end of the adjustable suture loop construct may also be drawn to cinch the first of the two parallel longitudinal passages around the first free end. The method may also include drawing on a second end of the adjustable suture loop construct to slide the second end through a second of the two parallel cores and draw the soft tissue into the bone tunnel. Drawing on the second end of the adjustable suture loop construct may also cinch the second of the two parallel cores around the second free end. The method may also include operatively coupling a button anchor of the adjustable suture loop construct to the bone. 
     Another example embodiment is disclosed herein including a suture-tensioning device that defines a bar shaped handle with a longitudinal axis and two lateral ends. A groove extends along a portion of the handle between the lateral ends defining an elongate opening along a first outer surface of the handle. The groove has a bottom surface extending along the handle defining a medial-most surface of the groove. At least one notch extends radially from the groove, the at least one notch having a first end at the first outer surface and an opposing medial end radially offset from the bottom surface of the groove. The groove may be configured to receive a length of suture and the at least one notch may be configured to retain a linking means associated with the length suture therein, and limit the suture from sliding laterally along the groove. The at least one notch comprises a plurality of notches axially spaced along the intermediate portion of the groove. The groove may terminate with a first end and a second end, each of the groove ends continuous with a ramped slot and spaced away from the two lateral ends. The ramped slots may extend from the grooves through the handle to a second outer surface, opposite the first outer surface. The at least one notch may have a larger cross sectional dimension than a corresponding cross sectional dimension of the groove. The groove may be sized to prevent a linking means associated with the suture from engaging the groove bottom surface. The at least one notch may be sized to receive a linking means associated with the suture and retain the linking means within the at least one notch during use. The at least one notch may be sized to receive a linking means associated with the suture and the groove may be sized to receive the length of suture extending from the linking means, such that the length of suture is disposed medially from the linking means. The suture-tensioning device may be configured to receive a suture loop formed by two suture tails coupled by a linking means, the groove configured to receive the two suture tails and the at least one notch configured to engage the linking means. 
     In a further embodiment, a suture-loop reducing device is disclosed including a handle with bilateral slots extending from a first outer surface of the handle to a second outer surface of the handle. The first and second outer surfaces are on opposing sides of the handle. The device also includes a groove extending between and continuous with the bilateral slots, wherein a suture loop is receivable through the bilateral slots and into the groove. The handle also includes at least one notch for receiving a knot or splice of the suture loop, the at least one notch extending from an inner surface of the groove up to the second outer surface. In some embodiments, the groove has a bottom surface extending along the handle defining a medial-most surface of the groove. In some embodiments, the at least one notch has an axis that is disposed transverse a longitudinal axis of the handle. In some embodiments, the at least one notch medial most end is offset from the bottom surface of the groove. In some embodiments, the at least one notch is a plurality of notches axially spaced along an intermediate portion of the groove. In some embodiments, the at least one notch is larger in cross section than a groove cross section such that the groove cross section obstructs the knot or splice from entry. In some embodiments, the suture loop is a portion of an adjustable fixation construct and wherein applying tension to the suture loops is configured to reduce a suture loop of the adjustable fixation construct. 
     A method of reducing a perimeter of an adjustable suture construct is also disclosed herein, the method including placing a first and second suture tail of the adjustable suture construct within an elongate groove of a tensioning handle and placing a linking means of the first and second tail within a notch extending from the groove, and thereby limiting sliding of the suture tails along the groove. The method also includes rocking the tensioning handle back and forth to apply an alternating tension between a first tail and a second tail and thereby reduce a perimeter of the adjustable suture construct. In some example methods, the suture splice is retained within the notch, while rocking the tensioning handle. 
     Another method of reducing a perimeter of an adjustable suture construct is also disclosed herein, the method including placing a first side of the adjustable suture construct within a first slot through a tensioning handle and placing a second side of the adjustable suture construct within a second slot through a tensioning handle; the first and second openings disposed adjacent ends of the tensioning handle, The tensioning handle is then rocked back and forth so as to apply an alternating tension between the first side and the second side and thereby reduce a perimeter of the adjustable suture construct. In some example methods, there may be a linking means of the adjustable suture construct that may be placed within a notch of the tensioning handle to limiting sliding of the adjustable suture construct along the tension bar while rocking. In some example methods, the adjustable suture construct is operatively coupled to a fixation device, and is also configured to couple to a graft and wherein rocking the tensioning handle draws the graft towards the fixation device. The first and second side may define first and second loops and placing the first side within the first slot comprises wrapping the first loop around the tensioning handle and through the first slot and placing the second side within the second slot comprises wrapping the second loop around the tensioning handle and through the second slot. 
     Disclosed herein is a tissue repair system including an open looped adjustable fixation construct having a first end assembled with a cortical button and a second end defining a free end. The system also includes a needle system including a needle operatively coupled to a first and second loop, the first and second loop extending different lengths from the needle. Both the first and second loop may be directly coupled to the needle. The first loop may be longer than the second loop. The first and second loop may be separately formed and include means that readily distinguish them from each other, the means different surface markings, trace braids, shapes, sizes or colors. A first loop of the construct second end may be coupled to the first loop of the needle system. A second loop of the construct second end may be coupled to the second loop of the needle system. 
     These and other features and advantages will be apparent from a reading of the following detailed description and a review of the associated drawings. It is to be understood that both the foregoing general description and the following detailed description are explanatory only and are not restrictive of aspects as claimed. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       The disclosure will be more fully understood by reference to the detailed description, in conjunction with the following figures, wherein: 
         FIGS. 1A and 1B  illustrate a first example of a fixation device of this disclosure for use with an adjustable fixation suture construct, in accordance with this disclosure; 
         FIGS. 2A-2C  illustrate a second example of a fixation device of this disclosure; 
         FIGS. 3A and 3B  illustrate a third example of a fixation device of this disclosure; 
         FIGS. 4A and 4B  illustrate a fourth example of a fixation device with an open loop adjustable suture construct of this disclosure; 
         FIGS. 5A-5G  illustrate a fifth example and method of use of a fixation device with an open loop adjustable suture construct of this disclosure; 
         FIGS. 6A-C  illustrate a sixth example and method of use of a fixation device with an open loop adjustable suture construct of this disclosure; 
         FIGS. 7A-7D  illustrate a seventh example and method of use of a fixation device with an open loop adjustable suture construct of this disclosure 
         FIGS. 8A-8C  illustrate an eighth example of a fixation device with an open loop adjustable suture construct in accordance with this disclosure; 
         FIG. 8D  illustrates a method of forming an suture construct that may be an open loop construct for use with the fixation device of at least  FIGS. 1A, 1B, 2A-2C, 3A, 3B, 4A, 4B, 5A-5G, 6A-6C, 7A-7D, 8A-8C and 12A-12D  of this disclosure; 
         FIGS. 9A-9G  illustrate a ninth example of a fixation device of this disclosure; 
         FIGS. 10A-10I  illustrate examples of device/suture loop constructs of this disclosure for minimizing suture slip/creep; 
         FIGS. 11A and 11C  illustrate a fixation device known in the art; 
         FIGS. 11B and 11D-11G  illustrate a tenth example of a fixation device with an open loop adjustable suture construct with two joined tension suture ends in accordance with this disclosure; 
         FIGS. 11H-11V  illustrate examples of a fixation device for use in the device/suture loop constructs of  FIGS. 11A-G ; 
         FIGS. 12A-12D  illustrate an eleventh example of a fixation device with an open loop adjustable suture construct of this disclosure; 
         FIGS. 13A-13F  illustrate examples of a helical needle of this disclosure for stitching a tissue graft; 
         FIGS. 13G-J  illustrate examples of a fixture for operating the helical needle of  FIGS. 13A-13F ; 
         FIGS. 14A-K  illustrate examples of a means of coupling a fixation device to a graft including a bone block, in accordance with at least some embodiments; 
         FIGS. 15A-15N and 15P-15R  illustrate examples of systems and associated methods of attaching a device/suture loop construct directly to a graft or a bone block, in accordance with at least some embodiments; 
         FIGS. 16A, 16B and 16C  schematically show isometric views of adjustable constructs for fixing a graft with a bone block within a bone tunnel in accordance with at least some embodiments; 
         FIGS. 17A and 17B  schematically show an adjustable construct adjusted between an extended and shorted loop length respectively; 
         FIGS. 18A-18D  schematically shows a method of coupling an adjustable construct through a longitudinal bone block passage in accordance with at least some embodiments; 
         FIGS. 19A  illustrates an adjustable construct, in accordance with at least some embodiments; 
         FIGS. 19B  illustrates the adjustable construct coupled to a bone block, in accordance with at least some embodiments; 
         FIGS. 20A-20D  schematically show alternative embodiment of adjustable construct coupled to a bone block, in accordance with at least some embodiments; 
         FIG. 21  schematically shows an alternative system and method of coupling an adjustable fixation construct to a bone block including a retaining button, in accordance with at least some embodiments; 
         FIG. 22  schematically shows an alternative method of coupling an adjustable fixation construct to a bone block, in accordance with at least some embodiments; 
         FIGS. 23A-23C  schematically show alternative embodiment of adjustable constructs coupled to a bone block, in accordance with at least some embodiments; 
         FIG. 24  schematically shows an adjustable fixation construct, in accordance with at least some embodiments; 
         FIGS. 25A and 25B  schematically show the routing of a first adjustable loop and both adjustable loops respectively; 
         FIG. 26A  schematically shows routing of a first adjustable loop by disposing a first loose end  2430  along longitudinal passage  2418 ′ in accordance with at least some embodiments; 
         FIGS. 26B and 26C  schematically show example cross sections of the suture along a non-bifurcated length and a bifurcated length respectively in accordance with at least some embodiments; 
         FIGS. 27A-27C  schematically show a variety of views of an embodiment of a tension bar in accordance with at least some embodiments; 
         FIG. 27D  schematically shows a cross section along the handle longitudinal axis; 
         FIG. 27E  schematically shows an isometric of the section shown in  FIG. 27D . 
         FIGS. 28A and 28B  shown a section of a tension bar and a corresponding end view of the cross section respectively in accordance with at least some embodiments; 
         FIGS. 29A and 29B  shown a section of a tension bar and a corresponding end view of the cross section respectively in accordance with at least some embodiments; 
         FIG. 30  schematically represents an example adjustable fixation construct with a tension bar operably coupled in accordance with at least some embodiments; 
         FIGS. 31A and 31B  show a method of using the tension bar with an adjustable fixation construct in accordance with at least some embodiments; 
         FIG. 32A  shows a double loop needle system formed with a knot; 
         FIG. 32B  illustrates a needle system including two loops in accordance with at least some embodiments; 
         FIG. 32C  illustrates an open looped fixation construct operatively coupled to a needle system in accordance with at least some embodiments; 
         FIG. 32D  illustrates an alternative needle system including two loops in accordance with at least some embodiments; 
         FIG. 32E  illustrates an alternative needle system including two loops in accordance with at least some embodiments; 
         FIG. 32F  illustrates an alternative needle system including two loops in accordance with at least some embodiments; 
         FIGS. 33A-33C  illustrate an alternative open looped construct with bypass loops in accordance with at least some embodiments; 
         FIGS. 34A-34B  illustrate a method of coupling an open looped fixation construct to tissue; 
         FIGS. 35A-35C  illustrate a low profile tibial button in accordance with at least some embodiments; 
         FIGS. 36A-36C  illustrate an alternative low profile tibial button in accordance with at least some embodiments; 
         FIGS. 37A-37B  illustrate an alternative low profile tibial button in accordance with at least some embodiments; 
         FIG. 37C  illustrates an open loop fixation construct assembled to a low profile tibial button in accordance with at least some embodiments; 
         FIG. 38  illustrates an open loop construct assembly tool in accordance with at least some embodiments; 
         FIG. 39A-39D  illustrate various views of the assembly tool in accordance with at least some embodiments; 
         FIG. 40A-40F  illustrate a method of repairing tissue using an open loop fixation construct and assembly tool of  FIG. 38  and  FIG. 39A-39D , in accordance with at least some embodiments; and 
         FIG. 41  illustrates an alternative assembly tool in accordance with at least some embodiments. 
     
    
    
     DETAILED DESCRIPTION 
     In the description that follows, like components have been given the same reference numerals, regardless of whether they are shown in different examples. To illustrate example(s) in a clear and concise manner, the drawings may not necessarily be to scale and certain features may be shown in somewhat schematic form. Features that are described and/or illustrated with respect to one example may be used in the same way or in a similar way in one or more other examples and/or in combination with or instead of the features of the other examples. 
     As used in the specification and claims, for the purposes of describing and defining the invention, the terms “about” and “substantially” are used to represent the inherent degree of uncertainty that may be attributed to any quantitative comparison, value, measurement, or other representation. The terms “about” and “substantially” are also used herein to represent the degree by which a quantitative representation may vary from a stated reference without resulting in a change in the basic function of the subject matter at issue. “Comprise,” “include,” and/or plural forms of each are open ended and include the listed parts and can include additional parts that are not listed. “And/or” is open-ended and includes one or more of the listed parts and combinations of the listed parts. Use of the terms “upper,” “lower,” “upwards,” and the like is intended only to help in the clear description of the present disclosure and are not intended to limit the structure, positioning and/or operation of the disclosure in any manner. 
     Referring now to  FIG. 1A , a first example of a detachable two-part suspensory fixation device  100  for soft tissue repair is shown in a disassembled view. The device  100  comprises a first elongated, substantially flat body  102  and a second elongated, substantially flat body  104 . The first body  102  and the second body  104  may be made of a biocompatible material, such as titanium or polyether ether ketone (PEEK). The first body  102  has a first end  102   a  and a second end  102   b.  A recess  102   c  is formed in a sidewall of the body  102  between the first end  102   a  and the second end  102   b.  Similarly, the second body  104  has a first end  104   a  and a second end  104   b.  A recess  104   c  is formed in a sidewall of the body  104  between the first end  104   a  and the second end  104   b.  The first body  102  is preassembled to a first side  106   a  of an adjustable fixation loop  106  through a first plurality of holes  108  defined in the second end  102   b.  The second body  104  is preassembled to a second side  106   b  of the adjustable fixation loop  106  through a second plurality of holes  110  defined in the first end  104   a,  creating an open loop configuration. Disclosed in more detail later, a cradle portion  106   c  is disposed between the two sides  106   a  and  106   b  and spaced away from both the first and second body. 
     During the repair, the graft (not shown) may be attached to or suspended over the adjustable fixation loop  106  to be pulled into a bone tunnel. More specifically the graft may loop over the cradle  106   c.  The first body  102  and the second body  104  are detachably coupleable in a same plane whereby the first end  104   a  of the second body  104  is insertable into the recess  102   c  of the first body  102 , and the second end  102   b  of the first body  102  is insertable into the second recess  104   c  of the second body  104 , creating a closed loop configuration ( FIG. 1B ). In this way, the first body  102  can be fed through a hole created in the bone block or soft tissue to place the cradle  106   c  within the bone block or soft tissue. First body  102  may then be coupled to the second body  104  before completing the repair in a normal fashion for suspensory fixation. The adjustable fixation loop  106  can be formed in the manner shown in at least 8D. Other adjustable loops however may be formed wherein the loops include a means of adjusting the loops that may include sleeve portions therealong that define hollow lengths of the adjustable loop that may receive lengths of the adjustable loop therethrough. Example adjustable loops are also shown in  FIG. 16A-16C , for example. The open loop configuration of the adjustable fixation loop  106  advantageously allows the second side  106   b  of the fixation loop  106  to be shuttled through the tissue graft or bone block before being assembled to the device  100 . As shown each body  102  and  104  are approximately mirror images of each other and form a left and right side of the fixation body. 
     Turning now to  FIG. 2A , a second example of a detachable two-part suspensory fixation device  200  for soft tissue repair is shown in a disassembled view. The device  200  comprises a first elongated, substantially flat body  202  and a second elongated, substantially flat body  204 . The first body  202  has a first end  202   a  and a second end  202   b.  A recess  202   c  is formed in a sidewall of the body  202  between the first end  202   a  and the second end  202   b.  A rib  212  extends along an interior surface of the recess  202   c  and along an exterior surface of the second end  202   b.  The second body  204  has a first end  204   a  and a second end  204   b.  A recess  204   c  is formed in a sidewall of the body  204  between the first end  204   a  and the second end  204   b.  A groove  214  extends along an interior surface of the recess  204   c  and along an exterior surface of the first end  204   a.  The first body  202  is preassembled to a first side  206   a  of an adjustable fixation loop  206  through a first plurality of holes  208  defined in the second end  202   b.  The second body  204  is preassembled to a second side  206   b  of the adjustable fixation loop  206  through a second plurality of holes  210  defined in the first end  204   a,  creating an open loop configuration. The first body  202  and the second body  204  are detachably coupleable in a same plane whereby the first end  204   a  of the second body  204  is insertable into the recess  202   c  of the first body  202 , and the second end  202   b  of the first body  202  is insertable into the second recess  204   c  of the second body  204 , creating a closed loop configuration ( FIG. 2B ). In this way, the first body  202  can be fed through a hole created in the bone block or soft tissue and coupled back to the second body  204  before completing the repair in a normal fashion for suspensory fixation. The adjustable fixation loop  206  may be formed in the manner shown in  FIG. 8D . The open loop configuration of the adjustable fixation loop  206  advantageously allows the second side  206   b  of the fixation loop  206  to be shuttled through the tissue graft or bone block before being assembled to the device  200 . 
     Two locking mechanisms of the device  200  are shown in more detail in  FIG. 2C . A first locking mechanism can include the rib  212  of the first body  202  being insertable into the groove  214  of the second body such that the first body  202  and the second body  204  can be locked together for easier passage during the repair to reduce the possibility separation. An additional locking mechanism can include a first mating shape between the first end  204   a  of the second body  204  and the recess  202   c  of the first body  202 , and a second mating shape between the second end  202   b  of the first body  202  and the second recess  204   c  of the second body  204 . The first and second mating shapes resist separation of the anchor bodies  202 ,  204 . Additionally, for final fixation, each body  202 ,  204  can span the cortical tunnel for added strength. 
     Turning now to  FIG. 3A , another example of a detachable two-part suspensory fixation device  300  for soft tissue repair is shown in a disassembled view. The device  300  comprises a first elongated, substantially flat body  302  and a second, smaller body  304 . 
     The first body  302  has a first end  302   a  and a second end  302   b.  A slot  302   c  is formed through an upper surface the body  302  transverse to a longitudinal axis L of the body  302  and closer to the first end  302   a.  The slot  302   c  includes an opening  312  in a lower surface of the body  302 . The first body  302  is preassembled to a first side  306   a  of the adjustable fixation loop  306  through a first plurality of holes  308  disposed either side of the longitudinal axis and towards the second end  302   b  of relative to slot  302   c.  The second body  304  is preassembled to a second side  306   b  of the adjustable fixation loop  306  through a second plurality of holes  310  defined in the body  304 , creating an open loop configuration. The open loop configuration of the adjustable fixation loop  306  advantageously allows the second side  306   b  and the free end  306   c  of the fixation loop  306  to be shuttled through the tissue graft or bone block before being assembled to the device  300 . The hole in the bone block or soft tissue could advantageously be smaller than the hole in the bone block or soft tissue required for the passage of the anchor bodies described above with regard to  FIG. 1A and 2A . 
     As shown in  FIG. 3B , the first body  302  and the second body  304  are detachably coupleable whereby the second body  304  is insertable upwards through the opening  312  and securable into the slot  302   c  of the first body  302  to create a closed loop configuration. The second body  304  is held in place by the adjustable fixation loop  306 , which, after implantation, will always be in tension, keeping the second body  304  in place. In this way, the second body  304  can be passed through a small hole or stitched with, and later assembled into the larger first body  302  to create the closed loop configuration. The second body  304  can be fed through a hole created in a bone block or soft tissue and coupled back to the first body  302  before completing the repair in a normal fashion for suspensory fixation. The adjustable fixation loop  306  can be formed in the manner shown in  FIG. 8D . Tension on ends  306   c  and  306   d  may reduce the adjustable fixation loop and draw the graft tissue towards body  302  and  304 . 
     Turning now to  FIG. 4A , another example of a detachable two-part suspensory fixation device  400  for soft tissue repair is shown. The device  400  comprises an elongated, substantially flat body  402  and an insertable pin  404 . The body  402  has a first end  402   a  and a second end  402   b.  Two parallel slots  402   c,    402   d  are formed through the body  402  at a center of the body  402  that extend along a longitudinal axis L of the body  402 . The sidewalls of the slots  402   c,    402   d  include openings  412  defining a path P that extends through the body  402  transverse to the longitudinal axis L. The pin  404  is inserted through the openings  412  in the slot  402   d  and preassembled to a first side  406   a  of the adjustable fixation loop  406 , creating an open loop configuration. The open loop configuration of the adjustable fixation loop  406  advantageously allows the second side  406   b  and the free end  406   c  of the fixation loop  406  to be shuttled through the tissue graft or bone block before being assembled to the device  400 . The hole in the bone block or soft tissue could advantageously be smaller than the hole in the bone block or soft tissue required for the passage of the anchor bodies described above with regard to  FIG. 1A and 2A . The second side  406   b  of the adjustable fixation loop  406  may be inserted upwards through the slot  402   c.  As shown in  FIG. 4B , the pin  404  is then insertable through the openings  412  in the slot  402   c  to couple to the second side  406   b  of the adjustable fixation loop  406 , creating a closed loop configuration. In this way, the second side  406   b  of the adjustable fixation loop  406  can be passed through a small hole or stitched with, and later assembled into the larger body  402  to create the closed loop configuration. The second side  406   b  can be fed through a hole created in a bone block or soft tissue and coupled back to the body  402  before completing the repair in a normal fashion for suspensory fixation. The adjustable fixation loop  406  can be formed in the manner shown in  FIG. 8D . 
     Turning now to  FIGS. 5A and 5B , another example of a detachable two-part suspensory fixation device  500  for soft tissue repair is shown in a disassembled view. In  FIG. 5A , the device  500  and the adjustable fixation loop  506  create an open loop configuration. As shown in  FIG. 5B , the device  500  comprises a first elongated, substantially flat body  502  and a second, triangular-shaped body  504 . The first body  502  has a first end  502   a  and a second end  502   b.  A triangular-shaped slot  502   c  is formed through an upper surface the body  502  closer to the first end  502   a.  The slot  502   c  includes an opening  512  in a lower surface of the body  502 . The second body  504  includes a plurality of slots  510  defined through the body  504 . As shown in  FIG. 5C , the first body  502  is preassembled to a first side  506   a  of the adjustable fixation loop  506  through a plurality of closed holes  508  defined in the second end  502   b.  The second end  506   b  and the free end  506   c  can be looped around a soft tissue graft or settled through a bone block of the graft tissue. The second end  506   b  and the free end  506   c  of the adjustable fixation loop  506  are then insertable upwards through the opening  512  and coupleable to the second body  504  through the plurality of slots  510  by inserting strands of the loop  506  through the slots  510  ( FIG. 5D ). 
     As shown in  FIG. 5E , the first body  502  and the second body  504  are detachably coupleable whereby the second body  504  is securable into the slot  502   c  of the first body  502  to create a closed loop configuration. An assembly jig (not shown) can facilitate the handling of the second body  504 —that is, holding the second body  504 , passing suture, and placing the second body  504  in the slot  502   c  of the first body  502 . In this way, the second body  504  can be passed through a small hole or stitched with, and later assembled into the larger first body  502  to create the closed loop configuration. The repair can then be completed in a normal fashion for suspensory fixation without adding any significant amount of time to the repair. The hole in the bone block or soft tissue could advantageously be smaller than the hole in the bone block or soft tissue required for the passage of the anchor bodies described above with regard to  FIG. 1A and 2A .  FIGS. 5F and 5G  illustrate perspective and top views, respectively, of the assembled device  500  without the adjustable fixation loop  506 . 
     Open loop adjustable construct such as construct  406 , and  506  defines a free end. Unlike the double-looped, adjustable loop construct as disclosed in U.S. Pat. No. 10,383,617; commonly owned and herein incorporated by reference in its entirety, this open loop adjustable construct forms a first loop limited to a first end of a cradle and a second loop limited to a second end. This configuration as shown in  FIG. 8D  allows for a first loop for example to be coupled to a fixation anchor and the second loop to define a free end as provided, which then is placed through a hole of graft tissue for example to subsequently draw the cradle into the graft tissue hole. Counter to this, since each loop described in U.S. Pat. No. 10,383,617 extends from both ends of the cradle, drawing one of the loops of this construct would appear to draw both ends of the cradle into a tissue hole and at best wedge the cradle ends into a tissue hole. This would not address the need to form an adjustable suture construct coupled through a tissue hole. This adjustable fixation loop  5 - 6  forms two adjustable loops, one loop remaining on a first side of the single suture cradle, and the other loop on the opposite side of the single suture cradle. Cradle  520  may be a separate sleeve element from the length of suture in some embodiments. However preferably cradle  520  defines a length of a braided suture with a hollow core that is continuously braided with the rest of the suture and thereby adjustable suture loop. Stated otherwise cradle  520  and strands of suture  522  and  524  are a single element. The first strand  522  preferably extends from and is continuously braided with the first end of the cradle  520 , the second strand  524  preferably extends from and is continuously braided from the opposite or second end of the cradle  520 . Stated otherwise, first strand of suture  522  forms the first side  506   a  of the adjustable fixation loop  506 , and a second strand of suture  524  forms the second side  506   b  of the adjustable fixation loop  506 . The open loop configuration of the adjustable fixation loop  506  advantageously allows the second side  506   b  of the fixation loop  506  to be provided free of a fixation button and therefore shuttled through the tissue graft or bone block before being assembled to the device  500 . First strand  522  extends from a first end of the cradle and may form first loop or bight and then extend through braids of the length of suture at the first end of the cradle then along the hollow core of the cradle  520  and then exit between braids of the length of suture. Second strand  524  extends from a second end of the cradle  520  and may form second loop bight on second side  506   b  and then extend through braids of the length of suture at the second end of the cradle  520  along the hollow core of the cradle  520  and then exit between braids of the length of suture at the cradle first end. Some of the example fixation devices include slots configured to selectively receive bight ends or loops from free end of the adjustable suture construct therethough 
     Turning now to  FIG. 6A , another example of a suspensory fixation device  600  for soft tissue repair is shown. The device  600  comprises an elongated, substantially flat body  602 . The body  602  has a first end  602   a  and a second end  602   b.  Two closed holes  608  are formed adjacent a first side  602   c  of the body  602  at a center of the body  602 . Two slotted holes  610  are formed adjacent a second side  602   d  of the body  602  at a center of the body  602 . The two slotted holes  610  may be directly opposite the two closed holes  608 . The two closed holes and two slotted holes may be disposed adjacent the midpoint between the first end  602   a  and  602   b.  A first of the two holes may be adjacent and directly opposite a first of the two slotted holes. A second of the two holes may be adjacent and directly opposite a second of the two slotted holes. The two closed holes  608  may be disposed on a first side of a body longitudinal axis L, while the two slotted holes disposed on the opposite side of the longitudinal axis L. Slotted holes  610  and holes  608  may both define a maximum diameter than are all equivalent to each other. Body also defines a top surface  602   e  and lower surface  602   f.  Lower surface defined in that it is configured to engage a cortical layer of bone. The body  602  is preassembled to a first side  606   a  of an adjustable fixation loop  606  through the closed holes  608 , creating an open loop configuration. The first side  606   a  includes a loop portion that during construction of the adjustable construct  606 , is threaded through both closed holes  608 , before being threaded through a cradle portion  606   d.  Construction of this adjustable loop is shown in more detail in at least  FIG. 8D . The open loop configuration of the adjustable fixation loop  606  advantageously allows the second side  606   b  and the free limb  606   c  of the fixation loop  606  to be shuttled first through the tissue graft or bone block before being assembled to the device  600 . The hole in the bone block or soft tissue could advantageously be smaller than the hole in the bone block or soft tissue required for the passage of the anchor bodies described above with regard to  FIG. 1A and 2A . As shown in  FIG. 6B , the second side  606   b  of the adjustable fixation loop  606  may be coupled to the slotted holes  610  by placing a bight of loop  606   b  first directly adjacent the body top surface  606   e  and inserting strands of the loop  606   b  through the slots disposed on second side  602   d  of the slotted holes  610  to create a closed loop configuration. Body top surface  602   e  may include a contoured recess  602   g,  recessed below surface  606   e  and connecting the two slotted holes  610 , parallel to the longitudinal axis. Recess  602   g  is configured to nest bight of loop  606   b  and reduce the suture loop standing proud of body surface  602   e.  Slotted holes  610  include narrow entrances at the second surface  606   d  slots to inhibit loop  606   b  from inadvertently sliding out of slots  610 . Bone hole is also preferably sized such that the width of body  602  (from the first side  602   c  to  602   d ) is larger than bone hole formed. Therefore once lower surface  602   f  engages the bone, slotted holes  610  are partially enclosed such that second side loop  606   b  is trapped within slotted holes  610 .  FIG. 6C  shows the body  602  disassembled from the adjustable fixation loop  606 . The adjustable fixation loop  606  can be formed in the manner shown in  FIG. 8D . 
     Body  602  also include at least two additional holes  612  that may lit on body longitudinal axis L. Holes  612  may each lie either side of holes  608  and may be equal in size. Holes  612  are configures to receive free limbs such as limb  606   c  therethrough. Holes  612  may be circular and larger in diameter or cross section than the slotted holes  610  or holes  608 . In some embodiments, holes  612  may be oval. Holes  612  are generally maximized in opening size to thread suture limbs easily therethough while maintaining structural integrity of the body  602 . In an alternative embodiment of anchor  602 , shown in  FIG. 39B  holes  612  may have larger oval shaped holes  612  as discussed previously. 
     Turning now to  FIG. 7A , another example of a suspensory fixation device  700  for soft tissue repair is shown. The device  700  comprises an elongated, substantially flat body  702 . The body  702  has a first end  702   a  and a second end  702   b.  Two closed holes  708  are formed adjacent a first side  702   c  of the body  702  at a center of the body  702 . Two slotted holes  710  are formed adjacent a second side  702   d  of the body  702  at a center of the body  702 . A groove  714  is formed in the second side  702   d  of the body  702  adjacent the slotted holes  710 . A pin  712  is hingedly attached to the first end  702   a  of the body  702 . The body  702  is preassembled to a first side  706   a  of the adjustable fixation loop  706  through the closed holes  708 , creating an open loop configuration. The open loop configuration of the adjustable fixation loop  706  advantageously allows the second side  706   b  and the free end  706   c  of the fixation loop  706  to be shuttled through the tissue graft or bone block before being assembled to the device  700 . The hole in the bone block or soft tissue could advantageously be smaller than the hole in the bone block or soft tissue required for the passage of the anchor bodies described above with regard to  FIG. 1A and 2A . 
     As shown in  FIG. 7B , the second side  706   b  of the adjustable fixation loop  706  may be coupled to the slotted holes  710  by inserting strands of the loop  706  through the slots of the slotted holes  710  to create the closed loop configuration. The pin  712  may be inserted into the groove  714  in a “safety pin” fashion ( FIG. 7C ) to ensure that the second side  706   b  of the adjustable fixation loop  706  does not migrate from the device  700  during use. The pin  712  also provides greater structural strength to the grooved side of the body  702 .  FIG. 7D  shows the body  702  disassembled from the adjustable fixation loop  706 . The adjustable fixation loop  706  can be formed in the manner shown in  FIG. 5H . 
     Turning now to  FIG. 8A , another example of a suspensory fixation device  800  for soft tissue repair is shown. The fixation device  800  can be used with an open loop adjustable suture construct, described in more detail below. The device  800  comprises an elongated, substantially flat body  802 . The body  802  has a first end  802   a  and a second end  802   b.  Two closed holes  808  are defined through the entire thickness of the flat body  802  and at a center of the body  802 . A first slotted hole  810   a  is formed through a first side  802   c  of the body  802  between the closed holes  808  and the first end  802   a.  A second slotted hole  810   b  is formed through the first side  802   c  of the body  802  between the closed holes  808  and the second end  802   b.  A third slotted hole  810   c  is formed through a second side  802   d  of the body  802  between the closed holes  808  and the first end  802   a.  A fourth slotted hole  810   d  is formed through the second side  802   d  of the body  802  between the closed holes  808  and the second end  802   b.  All the slotted holes  810   a, b, c  and  d  may define the same shape to each other. All slotted holes may have a more medial opening that defines a first maximum dimension for seating a portion of the adjustable suture construct and an entrance portion for receiving the adjustable suture construct therethrough to allow the adjustable suture construct access to the medial opening that is smaller in size than the medial opening to reduce inadvertent escape of the adjustable suture construct. As shown in  FIGS. 8B and 8C , the body  802  may be during the procedure to a first side  806   a  of the open loop adjustable suture construct  806  through the slotted holes  810   a,    810   c.  This embodiment allows the surgeon for example to assembly the entire adjustable loop construct  806  during the procedure. The slotted holes  810   a, b, c,  and  d  feature “tortuous paths” to retain the first side  806   a  and the second side  806   b  of the suture construct  806  once mated. Furthermore, the closed holes  808  may receive the finger loops  830   a,    830   b  therethrough and tension on the finger loops  803   a  and  803   b  may reduce the adjustable suture loop and draw the graft towards the body  802 . Finger loops  803   a  and  803   b  may then be joined by tying a knot stack  832  over a top surface of the body  802 . The finger loops  830   a,    830   b  allow for tensioning of the suture construct  806 . 
       FIG. 8D  illustrates the steps of forming the open loop adjustable suture construct  806  (also shown as at least construct  106 ,  206 ,  306 ,  3206 ). The suture construct  806  includes a cradle  820 , a first strand of suture  822  (that may include finger loop  830   a ) forming the first side  806   a  of the suture construct  806 , and a second strand of suture  824  (including finger loop  830   b ) forming the second side  806   b  of the suture construct  806 . Cradle  820  is shown with a larger cross section than strands  822  and  824 . As braided, cradle  802  and strands  822  and  824  may all define a similar cross section of hollow core suture. Cradle may be dilated during processing to expand the cross section. Cradle  820  may be expanded simply because of threading strands  822  and  824  therethrough while constructing the adjustable loop construct described herein. The first strand of suture  822 , cradle  820  and second strand of suture  824  may be a single continuously braided flexible material. The open loop configuration of the suture construct  806  advantageously allows the second side  806   b  of the suture construct  806  to be shuttled through the tissue graft or bone block before being assembled to the bodies such as at least body  102 ,  202 ,  302 ,  402 ,  502 ,  602  and  802 . This may place the length of cradle  820  through the graft tissue or bone block. Drawing on ends  830   a  and  830   b  may reduce sides  806   a  and  806   b  and thereby forms an adjustable loop construct. 
     Turning now to  FIG. 9A , another example of a two-bodied suspensory fixation device  900  for soft tissue repair is shown. The device  900  comprises a cannulated, cylindrical body  902  and a cannulated, cylindrical plug  904 . An outer surface of the plug  904  may include a plurality of retaining features, such as annular ribs  938 , as shown. The body  902  has a first portion  902   a  and a second portion  902   b.  An outer diameter of the first portion  902   a  is selected to the larger than an outer diameter of the second portion  902   b.  An inner diameter of the body  902  is selected to receive a hollow suture  940  therethrough, as shown in  FIG. 9B . As shown in  FIG. 9C , the plug  904  is insertable within the hollow suture  940  and capable of being pushed through the suture  940  toward the inner diameter of the body  902 . As shown in  FIG. 9D , the plug  904  can then be locked within the inner diameter of the body  902  to prevent the suture  940  from sliding relative to the body  902 . During a repair, the hollow suture  940  can be “luggage tagged” around the bone block/soft tissue and passed through the bone tunnel. The body  902  can then be placed around the hollow suture  940  and pushed down toward the cortical bone surface. The plug  904  is then inserted into the hollow suture  940 , thereby locking the suture  940 .  FIGS. 9E and 9F  illustrate cross-sectional and perspective views, respectively, of the assembled device  900  without the hollow suture  940 .  FIG. 9G  is a detailed view of the plug  904 . 
       FIGS. 10A-I  illustrate suture loop/fixation device constructs  1001  which are designed to minimize slip/creep by including a “Chinese finger trap” concept to provide suture trap compression on 360° of the single suture running within the trap. Compared to a cradle style construct that receives  2  suture therethrough, this concepts are configured to receive only a single suture and thereby reduce slip/creep by having 360° or compression around the single suture upon tendon and elongation of the trap. For example  FIG. 10A  illustrates a single loop adjustable suture loop  1006  which is dead-ended in the fixation device  1000  and wherein suture loop  1006  extends within the trap  1050  under high trap tension and high adjustable suture tension.  FIG. 10B  illustrates a single loop adjustable suture loop  1006  which is dead-ended via a loop on the fixation device  1000 .  FIG. 10C  illustrates a single loop adjustable suture loop  1006  in which the trap  1050  is formed above the device  1000  under high trap tension and high adjustable suture tension. For these examples, half the applied tension should result in similar hold on the suture through the trap  1050 . 
       FIG. 10D  illustrates a double loop adjustable suture loop  1006  including two traps  1050   a,b  formed below the device  1000  under trap partial trap tension (T/4) and partial adjustable suture tension (T/4) such that the two suture loops receive full 360° suture compression. Optionally, a stopper  1052  (i.e., a knot/bead or expanded trap section) could be included to eliminate toggle sutures, as shown in  FIG. 10E  (or in  FIG. 10D  at position “a”).  FIG. 10F  illustrates a quadruple loop adjustable suture loop  1006  including two traps  1050   a  ( 1050   b  not shown) formed below the device  1000  under partial trap tension (T/8) and partial adjustable suture tension (T/8) such that the four suture loops receive full 360° suture compression with two limbs adjusted together.  FIG. 10G  illustrates an alternative threading of two of the four suture loops (the mirror image loops omitted for clarity) through the device  1000 .  FIGS. 10H and 10I  illustrate the use of a trap  1050  under high trap tension (T/2) and low adjustable suture tension (T/3 or T/4) with full 360° suture compression.  FIG. 10H  shows a spliced suture. It is further contemplated that, by increasing suture-to-suture friction, the traps  1050  will exhibit less suture slip/creep. This could be accomplished by adding the amount of co-braid (i.e., a higher friction material) to the weave of the suture or by manipulating the suture texture. 
       FIGS. 11A  illustrates a device/suture loop construct  1101  including a fixation device  1100  and an adjustable suture loop  1106 , which includes the use of two joined tension sutures  1102  as opposed to two independent tension sutures. Device in  11 A is disclosed in commonly owned U.S. Pat. No. 10,383,617; herein incorporated by reference in its entirety.  FIG. 11B  shows a device/suture loop construct  1151  including a fixation device  1150  and an adjustable suture loop  1156 , which includes the use of two joined tension sutures  1152  as opposed to two independent tension sutures. While the construct shown in  FIG. 11A  requires splitting a tissue  1160  to couple cradle with tissue, constructs similar to construct  1151  allows for inserting a free end of suture construct through the tissue  1160 . Stated otherwise instead of using continuous circular loops with no opening to allow the adjustable suture loop  1106  to be put through tissue  1160  ( FIG. 11A ), one of the loops of the adjustable suture loop  1106  could be unfolded and passed through the tissue  1160  and then attached to the fixation device  1150  ( FIG. 11B ). In the example of  FIG. 11C  (and  11 A) , the adjustable suture loop  1106  is composed of a series of suture loops each of which pass across the  12  o′clock position (vertical dotted line) then continue around to the cradle  1120 . In order to pass the adjustable suture loop  1106  through tissue then back to the device  1150 , the sutures could not pass this 12 o&#39;clock position. Instead, the sutures would still make a 180° turn but on the same side from which they came, then continue passing through the cradle  1120  in the opposite direction from the device  1150 , as shown in  FIG. 11D . Notably, the two free ends  1156   c,    1156   d  of the adjustable suture loop  1156  could not be joined, as the free end  1156   c  would need to be passed through tissue. In order for the two free ends  1156   c,d  to be joined, both would need to exit the cradle  1120  on the same side of the device  1150 , as shown in  FIG. 11E . In examples, this would be accomplished by adding a “redirect” turn  1192  to the adjustable suture loop  1106 . Although this would eliminate the need for one of the free ends  1156   a,b  to be passed through tissue, it may still require two loops to be passed through tissue and then attached to the device  1150 . It may require more holes in the device  1150 , and thus a larger size of the device  1150 , as well as an additional suture to pass through the cradle  1120 . A preferred embodiment, shown in  FIG. 11F , would require only one loop  1156   a  to be attached to the device  1150 , thus allowing the size of the device  1150  to be smaller, yet still having the joined suture feature. In examples, this could be accomplished by moving the “redirect” turn  1192  from the device  1150  onto the suture adjacent to the cradle  1120 . In examples, the redirect turn  1192  would include a bypass loop  1193  tied in the suture, a spliced-in suture, or a rigid pulley. Alternatively, as shown in  FIG. 11G , the final redirected path could be external to the cradle  1120 . A second redirect turn  1192 ′ could aid in controlling the path. Turning now to  FIGS. 11H-V , further examples of the device  1150  for use in the device/suture loop construct  1156  described above are shown. Examples of the device  1150  are substantially similar to the devices  600  and  700 , except as described below. In the examples of the device  1150  shown in  FIGS. 11  H-J, a cross-pin  1154  could be captively held to the body  1152  of the device  1150  and sprung in a plane perpendicular to the load. A wireform  1194  could be bent over-center, thus preventing the cross-pin  1154  from falling off the device  1150 . An end of the wireform  1194  would also bottom within the body  1152 , thus providing closure via forced bending. In further examples of the device  1150  show in  FIGS. 11  K-M, the cross-pin  1155  could be captively held to the body  1152  of the device  1150  and open in a plane parallel to the load. In further examples of the device  1150  shown in  FIGS. 13N-P , a retainer pin  1198  could be held captive in the body  1152  of the device  1150  while allowed to slide longitudinally between “load” and “locked” positions. Detents would ensure the retainer pin  1198  did not reopen prematurely. In the “load” position ( FIG. 11N ), the retracted retainer pin  1198  would allow suture access from the exterior of the body  1152  to the interior “pulley” holes  1160 . When the “locked” position ( FIG. 11O ), the retainer pin  1194  would add to the rigidity of the body  1152 . The retainer pin  1198  would not encounter the relatively high suture loads but, instead, the relatively low forces needed to retain the sutures in the “pulley” holes  1160 .  FIG. 11P  is a cross-sectional view of the device  1150 . In an alternative example, shown in  FIG. 11Q , the holes  1158  for the adjustable suture loop (not shown) could be in communication with the pulley holes  1110 . 
     In further example embodiments of the device  1150 , shown in  FIGS. 11R and 11S , a wireform  1194  could be held captive in the body  1152  of the device  1300  while allowed to slide perpendicularly between “load” and “locked” positions. In the “load” position ( FIG. 11R ), the retracted wireform  1194  would allow suture access from the exterior of the body  1152  to the interior “pulley” holes  1160  before sliding into the “locked position ( FIG. 11S ). The wireform  1194  would not encounter the relatively high suture loads but, instead, the relatively low forces needed to retain the sutures in their “pulley” holes  1160 . The flipping sutures would be looped about the two cross members  1199   a,    1199   b  of the wireform  1194 . The wireform  1194  could include a spring latch  1196 , thus ensuring non-opening once closed. In examples of the device shown in  FIGS. 11T-V , the wireform  1194  could be held captive in the body  1152  of the device  1150  while allowed to bend in the plane parallel to the force between “load” and “locked” positions. In the “load” position ( FIG. 11T ) the wireform  1194  would allow suture access from the exterior of the body  1152  to the interior “pulley” holes  1160  before being snapped back into the locked position ( FIG. 11U ). The wireform  1194  would not encounter the relatively high suture loads but, instead, the relatively low forces needed to retain the sutures in their “pulley” holes  1160 . Critical to creation of the spring force is the offset  0  between pivoting axes of the wireform  1194 , as shown in  FIG. 11V . 
     Turning now to  FIG. 12A , another example of a suspensory fixation device  1200  for soft tissue repair is shown. The device  1200  comprises an elongated, substantially flat body  1202 . The body  1202  has a first end  1202   a  and a second end  1202   b  and a longitudinal axis extending therebetween. Two closed holes  1208  are formed adjacent a first side  1202   c  and a second side  1202   d  respectively of the body  1202  and closer to the first end  1202   a.  The two closed holes are formed on opposite sides of the longitudinal axis to each other and directly opposite each other. A first and second of the two slotted holes  1210  are formed adjacent the first side  1202   c  and the second side  1202   d  of the body  1202  respectively and closer to the second end  1202   b.  As shown in  FIG. 12B , the body  1202  is preassembled to a first side  1206   a  of an adjustable fixation loop  1206  through the closed holes  1208 , creating an open loop configuration. The open loop configuration of the adjustable fixation loop  1206  advantageously allows the second side  1206   b  and the free end  1206   c  of the fixation loop  1206  to be shuttled through the tissue graft or bone block before being looped over the body  1200  to place the second side  1206   b  through both slotted holes  1220 . Both sides  1206   a  and  1206   b  are oriented when assembled to cross the longitudinal axis of the body  1202 . The hole in the bone block or soft tissue could advantageously be smaller than the hole in the bone block or soft tissue required for the passage of the anchor bodies described above with regard to  FIG. 1A and 2A . As shown in  FIG. 12C , the second side  1206   b  of the adjustable fixation loop  1206  may then be coupled to the slotted holes  1210  by inserting strands of the loop  1206  through the slots of the slotted holes  1210  to create a closed loop configuration ( FIG. 12D ). A “V” shape slot opening  1211  at holes  1210  ensures that the second side  1206   b  of the adjustable fixation loop  1206  does not migrate from the device  1200  during use. Slotted holes  1210  and holes  1208  may both define a maximum diameter than are equivalent to each other. Body  1202  also defines a top surface  1202   e  and lower surface  1202   f.  Lower surface defined in that it is configured to engage a cortical layer of bone. As shown in  FIG. 12C  and  FIG. 40C , the second side  1206   b  of the adjustable fixation loop  1206  may be coupled to the slotted holes  1210  by placing a bight of loop  1206   b  first around an end of body such as end  1202   b  and directly adjacent the body top surface  1206   e  and the drawing strands of the loop  1206   b  through the slots  1210 , one slot disposed through first side  1202   c  of body  1202  and the other slot through the second side  1202   d  of the body  1202  to create a closed loop configuration. Similar to embodiment shown in  FIG. 6A-6C , body top surface  602   e  may include a contoured recess, recessed below surface  1206   e  and connecting the two slotted holes  1210 . This recess may perpendicular to the longitudinal axis. The adjustable fixation loop  606  may be formed in the manner shown in  FIG. 8D . 
       FIGS. 13A-F  illustrate a helical needle for whipstitching a tissue graft, which is designed to minimize suture ingrowth blockage.  FIG. 13A  shows the graft  1360  and a fixation device  1300  with a suture  1362  threaded into the graft  1360 . In  FIG. 13A , two helices  1364   a  and  1364   b  are shown to illustrate the suture paths. However, in practice, only one needle  1364  may be used for two passes and the needle  1364  does not remain in the graft  1360 . The two suture paths are shown interwoven, concentric and completely within the graft  1360 . Advantageously, the needle  1364  is completely below the surface of the graft  1360 , which eliminates graft-to-bone ingrowth blockage by the suture  1362 . Additionally, contact between the graft  1360  and the tunnel wall may be maintained even when tension compresses the core of the graft  1360 . As shown in  FIG. 13B , the helix  1364   a  represents one pass, and helix  1364   b  represents the other pass. The same needle  1364  is used for both passes but is offset axially by half of the pitch length of each pass. This prevents the paths from intersecting and thus minimizing the likelihood of the sharp needle  1364  piercing the previously placed suture. In  FIG. 13C , the segments  1366   a,    1366   b,    1366   c,  and  1366   d  illustrate some of the infinite number of compression lines between the two helices  1364   a  and  1364   b.  All segments  1366   a,    1366   b,    1366   c,  and  1366   d  pass directly through the centerline extending along axis A. As shown in  FIG. 13D , in an example using one needle  1364  with both ends sharpened, the needle  1364  with suture  1362  would be passed toward the end of the graft  1360 , through the fixation device  1300 , and then away from the end of the graft  1360 .  FIG. 13E  illustrates the knot  1368  in the suture  1362  at the lowest tension point. In other examples, not shown, two needles  1364  could be used.  FIG. 13F  shows an additional example of a needle  1364  in which the axes of the helices  1364   a  and  1353   b  are non-collinear. In this example, the paths of the suture  1362  could still be entirely within the graft  1360  or at least partially on an exterior of the graft  1360 . Alternatively, helixes of opposite rotational winding directions could be used. As shown in  FIGS. 13G-J , the motion of the helical needle  1364  could be accomplished via a fixture  1370  that includes a base  1372 , a graft compressor  1374  for compressing the graft  1360  within the base  1372 , and needle drivers  1376  keyed to match the helix of the needle  1364 . This may advance helix  1634  through the tissue in both directions and through a loop of an adjustable suture construct. 
       FIGS. 14A-C  illustrate a first example of a means of attaching a fixation device  1400  with grafts  1460  attached to bone blocks  1480 , for example, patella tendon or quad tendon grafts. Fixation device may be any adjustable suture fixation device, such as for example, constructs disclosed at least in construct  600 , construct  1200 , construct  1650 , and construct  1680  or the construct disclosed in commonly owned U.S. Pat. No. 10,383,617; herein incorporated by reference in its entirety. As shown in  FIG. 14A , a small hole  1482  (e.g. 2.4 mm) is initially drilled longitudinally through the bone block  1480 . The adjustable fixation loop  1406  is passed through the hole  1482  and a means of coupling the loop  1406  with the bone including a cross pin implant  1484  is passed laterally through the loop  1406 , thus acting as a pulley against the cortex of the bone block  1480 . In some example suture constructs with a cradle such as embodiments shown in  FIG. 8D  and  FIG. 11A , cradle portion may wrap around the means to couple the loop such as the cross pin implant  1484 . Implant  1484  may include a recess or channel circumferentially disposed around implant to receive and retain the loop  1406  therein. The bottom surface of the tissue graft  1460  intersects the bone block  1480  at different heights. Thus, there may be various techniques for placing the implant  1484 . For example, as shown in  FIG. 14B , the graft  1460  can be deflected upwards and the implant  1484  can be placed under the graft  1460 . Alternatively, as shown in  FIG. 14C , the implant  1484  can be introduced through a slit  1486  in the graft  1460 . Additionally, as shown in  FIG. 141 , a keeper  1485  can be utilized to minimize movement of the implant  1484  relative to the bone block  1480 . The keeper  1485  may include suture or other materials that may wrap around an external portion of bone block  1480 . Alternatively, as shown in  FIG. 14J , an intermediate tension member  1487  can be positioned within the longitudinal hole connecting the implant  1484  and the adjustable fixation loop  1406 . 
     Another example of a means of attaching a fixation device  1400  with grafts  1460  attached to bone blocks  1480  is shown in  FIGS. 14D and 14E , the means including an implant  1484  configured to engage a top outer surface of bone block  1480 . Again, device  1400  may include any adjustable loop fixation device such as at least construct  600 , construct  1200 , construct  1650 , and construct  1680  or the construct disclosed in commonly owned U.S. Pat. No. 10,383,617. Two small holes (e.g. 2.0 mm) may be drilled through the bone block  1480 , which may be perpendicular to a longitudinal axis of the bone block  1480 . The two small holes may be axially spaced from each other and lie on an axis that is parallel to the longitudinal axis. A small area of soft tissue may be removed around these holes down to bone  1480 . Implant  1484  may include two posts  1492  or split pins configured to be inserted into the two small holes, and fixedly engage the implant  1484  with the bone block  1480 . The adjustable fixation loop  1406  may be passed around a portion of the implant  1484 , thus acting as a pulley against the cortex of the bone block  1480 . A cradle portion of the loop  1406  may extend around an end of implant  1484 , farthest from the anchor portion of device  1400 . Implant  1484  may include a shelf or top surface that is configured to retain the loop  1406  on the implant and stop the loop  1406  from slipping off. The size of the implant  1484  is selected to fit within the bone tunnel  1488  ( FIG. 14E ). 
     As shown in  FIG. 14F , a cross section of implant  1484  includes the two posts  1492  and may include a lift-off feature  1490  (e.g., screw, clip etc.) to prevent liftoff of the implant  1484  before the graft  1460  is placed within a constraining bone tunnel. Lift off clip  1490  may engage a bottom or opposing surface of bone block. In examples, the implant  1484  could be used for traditional trapezoidal cross-section bone blocks  1480 . As shown in  FIG. 14G , the implant  1484  could further be made symmetrical to minimize misplacement. The adjustable fixation loop  1406  could be held against the implant  1484  via a clip (not shown) to prevent premature slip off prior to tensioning. The implant could be in the form of a bridge with two posts, to minimize soft tissue removal to just two spots around the posts shown in  FIG. 14G . In other examples, shown in  FIG. 14H , the adjustable fixation loop  1406  could be placed around the opposite post, thus reducing tissue removal and preventing premature slip off the loop  1406 . It is preferably to have two points of fixation with the bone block to reduce likelihood of lift off or bending of the implant  1484 . Alternatively, as shown in  FIG. 14K , holes within bone block  1480  may be non-orthogonal to the bone block longitudinal axis to account for the tensions on posts of implant. To reduce the overall profiled of implant the bridging portion  1484   c  may be at an angle relative to bone block upper surface; such that a first end  1484   a  of the implant  1484  may be recessed within the bone block and a second end,  1484   b  may include space to receive the loop  1406 . Legs or posts of  1492  may define rectangular cross-sections of the implant  1484  to improve the fixation between the implant  1484  and round (drilled) holes in the graft  1460 . 
       FIGS. 15A-15R  illustrates an example of a method for attaching a fixation device/suture loop construct  1501  of this disclosure directly to a graft  1560  (or a bone block, as further described below) without the need for splitting the graft  1560 . Splitting the graft is described in at least  FIG. 11A .  FIGS. 15A-15R  also illustrate systems that improve fixation between a fixation construct  1501  and graft, which may include improving the method of fixation illustrated throughout  FIGS. 15A-15R . Fixation construct  1501  may be any adjustable suture fixation device, such as for example, constructs disclosed at least in construct  600 , construct  1200 , construct  1650 , and construct  1680  or the construct disclosed in commonly owned U.S. Pat. No. 10,383,617; herein incorporated by reference in its entirety. As shown in  FIG. 15A , a passing suture  1561  coupled to a needle  1564  is loosely attached to the cradle  1520  of a device/suture loop construct  1501  that may be an adjustable suture loop construct. The needle  1564  may be inserted into a first end  1560   a  of the graft  1560  and out through a top surface  1560   c  of the graft  1560  to draw the cradle  1520  through the graft  1560  such that the cradle  1520  exits the top surface  1560   c  of the graft  1560  ( FIG. 15B, 15C ). As shown in  FIG. 15D , the cradle  1520  is then looped over the first end  1560   a  or the second end  1560   b  of the graft  1560  such that the cradle  1520  is disposed below a bottom surface  1560   d  of the graft  1560 . As shown in  FIG. 15E , the needle  1564  is then passed from the bottom surface  1560   d  to the top surface  1560   c  of the graft  1560  to draw the cradle  1520  above the top surface  1560   c  of the graft  1560  ( FIG. 15F ). This step forms a “herringbone” stitch  1565  in the graft  1560 . As shown in  FIG. 15G , additional “herringbone” stitches  1565  can be formed in the graft  1560  by again looping the cradle  1520  over the first or second ends  1560   a  or  1560   b  of the graft  1560  and repeating the steps as outlined above. Notably, in order not to unravel, the position of the cradle  1520  after the final stitch must be selected to be on the opposite side of the graft  1560  from the position in which the needle  1564  last exited the graft  1560  (for example, as shown in  FIG. 15G ). In an alternative example, shown in  FIG. 15H , a continuous loop of suture  1562  could be incorporated into the device/suture loop construct  1501  and passed through the graft  1560  or bone block (not shown) in the same manner as described above with regard to  FIGS. 15A-15G . In a further alternative example shown in  FIG. 15L , a second adjustable loop  1590  could be incorporated into the suture loop construct  1501 , the second adjustable loop luggage tagged to the graft  1560  (or bone block) or coupled as described above with regard to  FIGS. 15A-G . In a further alternative example shown in  FIG. 15M , continuous loop  1562  may be coupled to suture loop construct  1501  by luggage tag  1502 . A suture cradle of the suture loop construct  1501  may form part of the link with the continuous loop  1562 . In yet further examples, shown in  FIG. 151 , to minimize the resistance of pulling the cradle  1520  through the graft  1560 , a tapered member  1563  that may be attached to the needle  1564  could be used to gradually increase the graft hole diameter and minimize the chances of the cradle  1520  snagging on the graft  1560 . Cradle  1520  may be looped through holes in the tapered member  1563 . Preferably, the tapered member  1563  is made of a flexible material. In alternative embodiments shown in FIG. 15 N, a tapered member  1563  with a smaller opening end adjacent the needle  1564  may extend from the needle  1564  to a larger opening end. The larger opening may be sized to temporarily enclose a portion of the cradle  1520  and ease the cradle&#39;s passage through the graft. The cradle  1520  may be temporarily folded over to form a bight to fit within larger opening. Larger opening may be sized to form an interference fit with the cradle  1520  to help keep the cradle within the larger opening during stitching through the graft. Tapered member  1663  may slide along passing suture  1561  and be free of the needle  1564 . 
     In other examples, shown in  FIG. 15J , the attachment method described above could also be applied to attaching a fixation device  1501  to a bone block  1580  through an angled hole  1584  in the bone block  1580 . Angled hole in  FIG. 15J  begins at a first end  1580   a  of bone block, which may include a surface of cancellous bone. Alternatively, as shown in  FIG. 15K , the angled hole  1584  can begin at a cortical lateral surface  1580   b  to pass through the cortex of the bone block  1580 . 
     The system may also include reinforcement means to reduce the flexible members of an adjustable suture construct  1501  as described herein from stripping out of the graft, shown in  FIGS. 15P, 15Q and 15R . Reinforcement preferentially reinforces at least two opposing sides of the graft. Shown in  FIG. 15P  a single length of suture tape or flat braid  1550  may extend along a top side of graft  1560   c,  around an end surface  1560   a  and along a bottom surface  1560   d  of the graft. In  FIG. 15Q  an alternative reinforcement means may include a woven cap  1551  which may include a shaped braided element with apertures  1551   a  and  1551   b  preformed therethough. Apertures  1551   a  and  1551   b  are configured to receive an adjustable suture construct such as construct  1501  therethrough. Apertures  1551   a  and  1551   b  may be disposed relative to the woven cap to guide insertion locations of the needle  1564  through the graft  1560 . In  FIG. 15R  an alternative reinforcement means may include implant  1591 , formed from a more rigid material for example. This embodiment may include a plurality of apertures, including at least apertures  1591   a,    1591   b,    1591   c  and  1591   d,  preformed therethough. Apertures  1591   a,    1591   b,    1591   c  and  1591   d  are configured to receive an adjustable suture construct such as construct  1501  therethrough. More specifically apertures may be configured to receive a needle and cradle  1520  of a suture construct  1501  therethrough. Apertures  1591   a,    1591   b,    1591   c  and  1591   d  may be disposed relative to the implant  1591  to guide insertion locations of the needle  1564  through the graft  1560 . Implant  1591  may also include an aperture  1592 , orthogonally oriented relative to apertures  1591   a,    1591   b,    1591   c  and  1591   d,  to receive a needle  1564  therethrough. The method of coupling the adjustable suture construct  1501  to a graft may therefore include placing a reinforcement means such as tape  1550 , cap  1551  or implant  1591  around an end portion of a graft  1560  to dispose the reinforcement means along both a top and bottom surface of the graft, and may also place a portion of the reinforcement means along an end surface. The method may then continue by inserting a needle  1564  into a top or end surface ( 1560   c  or  1560   a ) of the graft including through a reinforcement means and then through a thickness of the graft, followed by out through a bottom surface  1560   c  of the graft  1560  and also the reinforcement means again. This draws the cradle  1520  through the graft  1560  and through at least two portions of the reinforcement means. Alternatively, the needle  1564  could enter the graft from the bottom surface  1560   d  and exit the graft from the top surface  1560   c.  The cradle  1520  may then be passed around the graft and the needle  1564  is then passed through the graft again, which may include passing the needle  1564  through the reinforcement means again, while both entering and exiting the graft  1560 . The reinforcement means may include pre-formed apertures such that passing the needle  1564  through the reinforcement means may include passing the needle through pre-formed apertures of the reinforcement means. 
     Additional embodiments are directed to an adjustable suspensory fixation construct configured to couple to a bone block and shown in  FIGS. 16-23 . Some of these embodiments include coupling the adjustable suspensory fixation with a girth hitch or ring hitch alternatively known as a luggage-tag loop. The girth hitch is formed by extending a first end of a continuous loop (sling) both through a passage in the bone block and around an external surface of the bone block, and then extending a fixation device and a portion of the adjustable loop through the first end of the continuous loop, the adjustable loop operatively coupled to the continuous loop. A hitch is now formed around and through the bone block. In this preferred embodiment, the hitch or luggage-tag loop includes both the continuous loop and adjustable loop. This girth hitch means of connecting may provide a strong and adjustable cortical fixation with increased maximum bone-to-bone ingrowth and minimal change in workflow of the procedure. The need to accurately measure the length of graft and bone tunnels is now reduced as the construct is adjustable and the bone block may be drawn right up to the fixation button. Furthermore, as explained in more detail later, by placing the adjustable loop at least partially along the length of the bone block, the adjustable loop may be more readily shortened so that the bone block may be directly adjacent or even abut the button fixation device. 
     Advantageously this coupling may now place the lengths of suture associated with the continuous and adjustable loops of suture along an external bone-block surface where bone-to-bone ingrowth is not expected. In general, the cortical surface of the bone block is typically shaped so as to be spaced away from the femoral tunnel walls, this space reducing likelihood of bone-to-bone ingrowth. As shown in various figures throughout this application, bone blocks, such as portions of the patella for example, usually include a first external surface of the patella that includes cortical bone and possibly also a thin covering of soft tissue such as tendon tissue. Other external surfaces of the bone block however may include the cancellous patella bone tissue. Bone-to bone growth is more likely from the exposed cancellous bone. Therefore, by keeping the suture loops along the cortical bone surfaces of the bone block, and thereby leaving the cancellous bone surfaces absent any suture loops, it is envisioned that the arrangement of these suture loops may minimally affect bone-to-bone ingrowth. 
     Alternative adjustable constructs and associated attachment methods are also disclosed herein, including alternative adjustable loops operatively coupled to a button-style fixation device; a continuous loop operatively coupled to the adjustable loop; the continuous loop being sufficiently short such that it places an intersection of the adjustable loop with the continuous loop along the length of the bone block. 
     A first embodiment of a fixation construct  1600  is shown in  FIG. 16A . Construct  1600  includes a fixation button  1625 , an adjustable loop  1620  including a cradle  1630  and a continuous loop  1640 . Fixation button  1625  and adjustable loop  1620  may be similar to the Ultrabutton, manufactured by Smith and Nephew and disclosed in at least in commonly assigned U.S. Pat. No. 10,383,617 the complete disclosure of which is incorporated herein by reference. Continuous loop  1640  may be looped through the adjustable loop  1620 , and may preferably engage the cradle  1630  defining a first continuous loop end  1646 . Continuous loop  1640  is preferably not directly coupled to fixation button  1625 . In alternative embodiments such as construct shown in  FIG. 16B  the construct  1650  may include an alternative adjustable loop construct, having a linked end  1666  and with sleeve portions  1665 . In further alternative embodiments such as construct shown in  FIG. 16C  the construct  1680  may include an alternative adjustable loop construct, forming two loops  1670   a  and  1670   b  linked at sleeve portions  1675   a  and  1675   b.  In all embodiments, a second fixed and continuous loop  1640  is operatively coupled to the adjustable loop  1620 ,  1660  and  1670 . Continuous Loop  1640  may be looped though the adjustable construct, may extend through a lumen of the adjustable construct or may be luggage tagged to adjustable loop ( 1620 ,  1660  or  1670 ). Adjustable constructs  1620 ,  1660  and  1670  and continuous loop  1640  may all be formed separately and thereby be separate flexible members, such as sutures, and may be provided operatively coupled or may be coupled during the surgical procedure. Each of the separate sutures ( 1620 ,  1640 ,  1660  and  1670 ) may be similar in size and material or unique. For example, the adjustable suture loops may be formed of more lubricious suture material to better slide and adjust in loop length. 
     Adjustable loop constructs such as those described in  FIGS. 16A, 16B and 16C  include suture loop constructs that tend to be limited in how short the final loop may become. For example, as shown in  FIG. 17A and 17B , an adjustable loop with a cradle portion  1630  may be shortened to a length of about 10 mm, at which point the diameter of the cradle  1630  and stiffness of three suture lengths may restrict any further significant shortening. As a further example, the embodiments shown in  FIG. 16B and 16C  also show sleeves or eye splices similar to a cradle with a single suture threaded therethrough ( 1665 ,  1675 ) that may limit the final minimal loop length. As bone tunnel lengths during ACL reconstruction have become shorter, there is less tunnel length available for long suture loops. This disclosure describes methods for attaching adjustable suture loop constructs that reduce the effective length between the fixation button and graft. 
     One example method of attaching a construct such as construct  1600 ,  1650  or  1680  to a bone-block is shown in  FIGS. 18A-18D . First a suture passer  1810  may be passed through a longitudinal passage  1865  of a bone block  1860 , and then through the tendon  1870 . Longitudinal passage  1865  may be drilled and may be between 2-3 mm in diameter. The first end  1645  of the continuous loop  1640  may then be threaded through the suture passer end  1815 , possibly using a third suture  1825 . Suture passer  1810  may then draw first end  1645  through the tendon  1870  and then along and out of the passage  1865 . Fixation button  1625  may then be passed through the first end  1645  to form the girth hitch or luggage-tag loop around the bone block  1860 , as shown in various views in  FIG. 18B, 18C and 18D . Luggage tag loop around the bone block includes both the continuous loop  1640  and adjustable loop  1620 . 
       FIG. 19A and 19B  schematically show construct  1620  or  1660  before and after coupling to the bone block  1860  respectively. Best seen in  FIG. 19B , bone block  1860  includes an outer cortical layer  1861  on the top side only, as this bone block is usually a top portion of a bone such as the patella. Top side/cortical layer may also be covered with a thin layer of soft tissue such as connective tissue and tendon  1862 . The underside and other external sides of the bone block  1860  define exposed cancellous bone  1863 . The method of coupling includes extending the suture along an external surface of bone block that preferably includes the top surface and thereby engages the cortical bone and tendon and avoids the cancellous bone surfaces. Avoiding coverage or blockage of the cancellous bone external surfaces is preferable. As explained earlier, this top surface is least expected to integrate with the femoral bone tunnel and therefore the suture loops ( 1620 ,  1660 ,  1640 ) are not anticipated to inhibit bone-to-bone ingrowth. The intersection or transition from the loop  1640  to the adjustable loop ( 1620 ,  1660  or  1670 ) is preferably disposed long the length (L) of the bone block  1860  and preferably closer to the tendon attachment end  1865  of the bone block  1860 . Typical bone blocks are 2-3 cm long and about 6-11 mm thick. The continuous loop  1640  may therefore be approximately 3-5 cm long and preferably less than or equal to double the length L of the bone block  1860  so that the continuous loop  1640  can wrap around the bone block, form the luggage tag and position the intersection with the adjustable loop on a cortical outer surface along the bone block length L. This allows the adjustable loop to reduce in length, such that the fixation button  1625  may be less than a few millimeters from the bone block end  1866 , while the intersection between the two loops is spaced further away from the fixation button  1625 . 
       FIG. 20A-20C  represents a similar method of coupling an adjustable construct to a bone block, with alternate adjustable loop constructs. For example  FIG. 20A  shows construct  1650  coupled to bone block  1860 , wherein sleeve portions  1665  limits the minimum loop length available during adjusting. The intersection  2010  remains along the length L of the bone block  1860  and includes both the link  1666  of the adjustable construct  1660  and continuous loop end.  FIG. 20B  shows an alternate adjustable loop construct  2050 , including a luggage tag portion  2060  and a sleeve  2005  that may provide the adjustability. As a further example,  FIG. 20C  shows construct  1680  coupled to bone block  1860 , wherein sleeve portions  1675   a  and  1675   b  limit the minimum loop length available during adjusting. The intersection  2010  included two loops of suture and remains along the length L of the bone block  1860 . An alternate method of operatively coupling an adjustable loops construct to a second loop is shown in  FIG. 20D . Example adjustable loop construct  1620  may be luggage tagged  2015  to continuous loop  1640  at intersection. Any of the herein disclosed adjustable loop constructs may be similar coupled. 
     In other embodiments, the method may not include forming a luggage tag over the adjustable loop as shown as FIGs. 18 A- 18 D,  19 A,  19 B and  20 A- 20 C. In these alternative embodiments continuous loop end  1645  may include a stop element operatively coupled to the end  1645  to prevent the continuous loop  1645  from being pulled through the tunnel passage  1865 . Optionally a stop element could be a knot (not shown) in the end  1645  that is larger in width or diameter than bone hole opening  1866 . Knot (not shown) may be formed by the surgeon after threading the end  1645  through the bone passage. This option allows the intersection between the two loops to be more freely associated to the bone block, which may not be preferable as it may require additional suture management while inserting the construct  1600  into and along the tibial and femoral tunnel. Alternatively, a stop button  2180  may engage both the adjustable loop such as loop  1620  and selectively couple to end  1645  after the end  1645  has been threaded through the bone block passage. This stop button  2180  is configured to prevent the continuous loop end  1645  from migrating into the bone block passage when tension in applied to the construct and retain the adjustable loop closer to the bone block external surfaces. In this embodiment, continuous loop may be shorter than the continuous loop described in FIGs. 18 A- 18 D,  19 A,  19 B and  20 A- 20 C, as the continuous loop does not loop over the adjustable loop. For example, typical bone blocks are 6-11 mm long. The continuous loop  1640  using a stop button may therefore be close to 2-4 cm long and preferably less than double the length of the bone block  1860  to place the intersection to the adjustable loop along the outer cortical surface of the bone block and along length L. 
     A further embodiment and coupling method to a bone block  1860  is shown in  FIGS. 22A and 23A-23C . This embodiment may include adjustable fixation construct  1620 ,  1660  or  1670  for example. This embodiment, and may not utilize a second loop such as loop  1640 . In this embodiment, cradle portion  1630  may be passed through an angled passage  2222  similar to that described in FIGS. 15 J or  15 K. Cradle portion may initiate through the top side cortical surface  1861  to add structure to the entry point  2220  into the passage  2222 . An entry through a cancellous bone surface may not provide sufficient structural rigidity and may allow the suture to comb out of the bone block  1860 . A bilateral pair of circumferential grooves  2224  may extend at an angle from the first passage  2222  to receive a portion of the cradle  1630 . Grooves  2224  allow the cradle  1630  or adjustable loop  1620  to sink below the block external surface thus allowing a closer apposition of the bone block  1860  to a bone tunnel through the tibia or femur. Grooves  2224  may be axially continuous and may intersect the passage opening on the lower surface  1863  and extend at an angle across the width of the bone block  1860 . Grooves  2224  may pass through the bone block cortex on the tendon side of the bone block creating a construct more resistant to suture comb out. 
     A passing suture that may include a needle (shown in at least  FIG. 15A ) may be loosely attached to the cradle  1630  of a device/suture loop construct  1620 . The passing suture may be inserted into a first end  2220  of bone block passage  2222  preformed within the bone block  1860 , the passage extending at an angle relative to the longitudinal axis of the bone block  60 , ranging from 20-60 degrees. Passage  2222  may extend from top cortical external surface and out through a lower cancellous bone surface  1863  of the bone block  1860 . Cradle  1630  may be drawn or threaded through the passage  2222  of bone block  1860  such that the cradle  1630  exits the surface  1863  of the bone block  1860 . As shown in  FIG. 22 , the cradle  1630  is then looped over the tendon/bone interface and placed within grooves  2224 . Tension on the construct  1600  now puts compression on the tendon/bone interface  1862 . This is preferable to a cradle for example wrapped around surface  1864  for example, which may act to shear off the tendon/bone interface  1862 . Having a large radius of curvature around the bone blocks at the cradle  1630  minimizes kinking of the cradle and thereby internal suture friction within the system and allows for easier length reduction of the adjustable loop  1640 . As explained earlier, this embodiment also places the adjustable loop along the bone block, with an end long the bone block thereby upon reducing the length of the adjustable loop, the fixation button  1625  may be directly adjacent the bone block. 
       FIGS. 23A-23C  show a variety of alternate embodiments of adjustable constructs directly attached to a bone block in a similar fashion to that described in  FIG. 22 . For example shown in  FIG. 23A , an adjustable loop construct such as construct  1650  may extend through an angled passage  2222  and around to top surface of the bone/tendon interface  1862 , the link  1666  may compress the tendon onto the bone. Alternatively, bilateral grooves (not shown) may be formed in the bone block  1860  and the link  1866  may sit within the grooves. As a further example shown in  FIG. 23B , an adjustable loop construct such as construct  2050  may extend through an angled passage  2222  and around to top surface of the bone/tendon interface  1862  and into grooves  2224  be formed in the bone block  1860 . As a further example shown in  FIG. 23C , an adjustable loop construct such as construct  1670  may extend through an angled passage  2222  and around to top surface of the bone/tendon interface  1862  and may lie within performed grooves  2224 . 
       FIGS. 24  shows an alternative embodiment of an adjustable fixation device including a bifurcated or split cradle  2420 . Referring to  FIGS. 24 , an example of the graft suspension device  2410  of this disclosure is shown. The graft suspension device  2410  comprises a strand of suture  2422  having a first loop  2412  and a second loop  2414  (together, the suspension loop  2424 ) suspended from an anchor  2416 . The suture  2422  is formed from a braided material having plaited threads, which together may form a non-hollow tubular material. In some embodiments, some of the suture  2422  may be hollow or coreless. The suture  2422  may be made from a suitable bio-compatible material which may be a bio-absorbable material or a non-absorbable permanent material. A length of the strand of suture  2422  may be about 46 inches. The anchor  2416  may be of conventional construction for securement to the outside of a bone, such as a cortical button. A length of the anchor (or cortical button)  2416  may be about 10 mm to about 15 mm and a width may be about 2 mm to about 5 mm. The graft suspension device  2410  may include a bifurcated cradle  2420  located substantially midway along the length of the suture  2422 , as further described below. In other embodiments the graft suspension device  2410  may be configured to separate from a single suture into a plurality of longitudinal passages, including two, three, four or five longitudinal passages, located substantially midway along the length of the suture  2422 . The bifurcated cradle  2420  defines two parallel braided coreless longitudinal passages  2418 ′ and  2418 ″ at the opposite end of the suspension loop  2424  to the anchor  2416 , as further described below. 
     Also shown in  FIG. 24 , the anchor  2416  may include a plurality of apertures, which may be eight apertures, extending therethrough and configured for the passage of the suture  2422 . Outer and intermediate apertures  2401 ,  2402 ,  2407  and  2408  are aligned with each other along the longitudinal axis of the anchor  2416 . Central apertures  2403 ,  2404 ,  2405  and  2406  are formed in two pairs symmetrically offset from the longitudinal axis but aligned with each other transverse to the longitudinal axis. The two pairs of central apertures  2403 ,  2404 ,  2405  and  2406  are designed to accommodate the suture loops  2412 ,  2414  therethrough. The intermediate pair of apertures  2402 ,  2407  are designed to accommodate the two ends  2430 ,  2432  of the suture respectively. The outer pair of apertures  2401 ,  2408  are designed to assist in the placement of the anchor  2416  on the outside of a bone utilizing leading and trailing sutures passed through apertures  2401 ,  2408  (not shown). First and second loops  2412 ,  2414  are shown threaded through the central apertures  2403 ,  2404 ,  2405  and  2406  as further described below. The loose ends  2430 ,  2432  of the suture  2422  are shown threaded through the two separated longitudinal passages or bifurcated sleeve portions  2418 ′ and  2418 ″ to complete the suspension loop  2424 . The threading of the loose ends  2430 ,  2432  in this manner, in addition to the bifurcation may have the effect of widening the bifurcating sleeve portion  2418 ′ and  2418 ″ with respect to the remainder of the suspension loop  2424 . The loose ends  2430 ,  2432  are then shown as passing through the intermediate pair of apertures  2402 ,  2407 . In some embodiments, loose ends  2430  and  2432  may then join together to form a single tail  2434 . Advantageously, routing the suture  2422  through the plurality of apertures keeps the various strands of suture  2422  separated, making them less likely to bunch or tangle. The single tail  2434  may be further adapted to form a finger loop  2436  to provide a means whereby the surgeon can adjust the distance of the bifurcated cradle  2418 ′ and  2418 ″ from the anchor  2416 , and/or shortening the length of the suspension loop  2424 , either before or during the surgical operation. Advantageously, the finger loop  2436  may be used with just one hand. 
     The bifurcated portion  2418  forms an integral part of the first and second loop  2412 ,  2414 . First and second eyes  2438 ,  2440  may be formed in a first longitudinal passage  2418 ′ of the bifurcated portion  2418  at spaced intervals through which the loose ends  2430  may be threaded, as further described below. It is contemplated by this disclosure that first and second eyes  2438 ,  2440  need not be pre-formed in the bifurcated portion  2418  if the loose ends  2430 ,  2432  may be threaded therethrough by passing through gaps between adjacent threads of the braided suture  2422 . In an alternative embodiment, first and second eyelets  2438  and  2440  may be pre-formed or disposed in first and/or second limb, adjacent to and not necessarily within the bifurcated portion itself. The example loose end may therefore extends into and along a limb portion that is at least partially continuous with the bifurcated portion  2418 , such that the example loose end extends along both the limb portion and one of the bifurcated longitudinal passages  2418 ′ or  2418 ″. This example loose end may also remain within the suture and extend into the other limb portion adjacent the other side of the bifurcated portion  2418  before exiting between the braids or through a pre-formed eyelet. 
     A length of the bifurcated portion  2418  can vary, but may be sufficiently long enough to accommodate a ligament fixation graft suspended thereover, and short enough to facilitate efficient adjustment of the suspension loop  2424 . A distance between preformed eyelets or exit and entrance positions of the loose ends between braids can vary, but is selected to be sufficiently long enough to accommodate a ligament fixation graft suspended thereover, but short enough to facilitate efficient adjustment of the suspension loop  2424 . 
       FIG. 25A  represents in schematic form the embodiment showing the routing of the first loop only, for clarity purposes. Second loop is omitted for clarity purposes and added in  FIG. 25B  to show the preferred embodiment. Referring now to  FIG. 25A , forming the first loop  2412  involves threading the loose ends  2430  that extends from a first end of the bifurcated cradle portion  2420  through a pair of central apertures  2403  and  2405  of the anchor  2416  from the underside to the top side thereof. More particularly, loose end portion  2430   a  is threaded through central aperture  2403  and then looped back through the aperture  2405  adjacent to the aperture  2403  through which it has already been passed. Specifically, loose end portion  2430   b  passes through aperture  2405  from the top side to the underside of the anchor  2416 . Thereafter, loose end portion  2430   b  is threaded between braids and through a first longitudinal passage  2418 ′ of cradle portion  2420 ′ entering aperture  2440  and exiting aperture  2438 . At this stage, loose end portion  2430   c  is passed through the intermediate aperture  2402  from the underside of the anchor to the top side thereof, i.e., loose end portion  2430   c  is passed through aperture  2402 . Bifurcated cradle portion  2420  defines two longitudinal passages or sleeves  2418 ′ and  2418 ″ that are parallel with each other and are braided to braid into a single suture at either end. In  FIG. 25A  suture end  2432   a  is shown extending from bifurcated portion  2420 . 
     Referring now to  FIG. 25B , forming the second loop  2414  (in addition to the first loop  2412 ) involves threading the loose ends  2432  that extends from a second end of the bifurcated cradle portion  2420  through a pair of central apertures  2404  and  2406  of the anchor  2416  from the underside to the top side thereof. More particularly, loose end portion  2432   a  is first threaded through central aperture  2406  and then looped back through the aperture  2404  adjacent to the aperture  2406  through which it has already been passed. Specifically, loose end portion  2432   b  passes through aperture  2404  from the top side to the underside of the anchor  2416 . Thereafter, loose end portion  2432   b  is threaded through a second longitudinal passage  2418 ″ of cradle portion  2420  entering aperture  2442  and exiting aperture  2444 . At this stage, loose end portion  2432   c  is passed through the intermediate aperture  2407  from the underside of the anchor to the top side thereof, i.e., loose end portion  2432   c  is passed through aperture  2407 . Loose ends  2430  and  2432  each extend through individual sleeves formed by the bifurcated portion  2420 , in opposing directions to cross over each other. 
       FIG. 26A  is an alternative view representing the bifurcated portion  2420  and an example threading of free end  2430  into opening  2438  along the core or longitudinal passage of a first coreless longitudinal passage  2418 ′ and then out of opening  2440 . Free end  2432  threads through  2418 ″ in a similar manner (not shown). In some embodiments, the two free ends are threaded through in opposing directions. In some embodiments, the two free ends are threaded along the respective core for differing lengths to each other. In some embodiments, the two free ends are threaded along their respective longitudinal passages at offset locations along the cradle portion  2420 . In some embodiments, the two longitudinal passages  2418 ′ and  2418 ″ are equal in diameter to each other. 
     Using today&#39;s technology, suture can be continuously braided to bifurcate for a length and then join back to together. In addition, suture can be continuously braided to separate into a plurality of longitudinal passages, including more than two passages. In some embodiments, each longitudinal passage could have a different diameter. For example, a first longitudinal passage may have a larger diameter allowing for easier sliding of the loose end therethrough and therefore easier reduction of the suture loops. A second leg may have a smaller diameter that may more securely lock with a free end threaded therethrough and provide for a tighter lock of the suture construct. 
     In use, each of the longitudinal passages  2418 ′and  2418 ″ may be configured so that tension may create a Chinese finger lock and selectively reduce the core inner diameter. This Chinese finger lock, once activated may prevent sliding of the free end threaded therethough once the soft tissue is in the targeted location. In some examples, the tissue being in the targeted location places a counter tension on the adjustable loop and therefore contributes towards this activation tension, creating an auto-lock. Stated otherwise once the soft tissue has reaches the targeted location, the soft tissue may automatically resist further relocation, providing a counter force that acts to reduce the longitudinal passage inner diameter, prevent further suture sliding through the bifurcated cradle and thereby loop reduction, and consequentially lock the soft tissue in the targeted location. Relative to a single suture that receives a plurality of free ends therethrough, as described in the US application 2017/0231752, herein incorporated by reference in its entirely, by having a plurality of free ends each having their own dedicated longitudinal passage, circumferentially enclosed, the friction on each free end may be higher. This increased friction may reduce the likelihood of the suture loop loosening and thereby mitigate tissue displacement. The friction is now circumferential on each free end. 
     The cross section of each loose end or limb is schematically shown in  FIG. 26B , showing a cross section of a first plurality and second plurality of braids ( 2650  and  2660  respectively). The first plurality of braids  2650  define an outer wall or sheath of braided suture. The second plurality  2660 , shown shaded for clarity, may make up a core portion of braided suture. Tension on the suture  2422  as a whole tends to be unevenly distributed; much of it is taken up by the braids in the core section  2660 . The inventors therefore envision that the suture may be preferably bifurcated by continuous braiding so as to separate the suture into at least two longitudinal passages that splits the braids from both the first and second plurality  2650  and  2660  approximately evenly between both passages, represented in  FIG. 26C . This may more evenly distributes the tension along the suture as a whole and between the separated passages; leading to a more evenly distributed operation of the construct such that all of the longitudinal passages may evenly lock around a suture therethrough.  FIG. 26C  shows two longitudinal passages without a suture threaded therethrough. Stated alternatively both loops  2412  and  2414  may more evenly reduce in loop size and more equally tighten and lock around the suture therethrough when each passage of the bifurcated or separated portion includes an approximate evenly distributed mixture of braids between the first and second plurality of braids  2650  and  2660 . 
     In alterative embodiments, each longitudinal passage  2418 ′ and  2418 ″ could include an uneven distribution of the first and second plurality of braids. For example should the inventors wish to provide two longitudinal passages with differing roles, the first longitudinal passage  2418 ′ may be formed entirely or substantially with the braids from the first plurality, while the second longitudinal passage may be formed entirely or substantially with braids from the second plurality. Each longitudinal passage may be characterized therefore in that tension may be unevenly distributed. This may tend to cause one longitudinal passage to preferentially lock around a suture disposed there along than the other, while a second longitudinal passage may more preferable allow a suture to slide. 
     An example suture  2422  may include between 8-64 total braids that may be evenly split between each of the separated longitudinal passages, such as for example 32 braids separated into two passages with 16 braids each. In some alternative embodiments, each longitudinal passages  2418 ′,  2418 ″ may have a differing braid count, to offer alternative roles for each of the passages. One passage may have 22 braids, while the other has 10 for example. One passage may more tightly or preferably lock for example than the other while the other passage may preferably allow the suture to slide therethough. 
       FIGS. 27A-27C  illustrate an example of a tension bar  2700 , for use in, for example, an anterior cruciate ligament (ACL) surgery. The tension bar  2700  may be employed to couples to at least two suture tails  2750  that may be coupled together to form a suture reduction loop by a linking means  2755 . The tension bar  2700  may be employed to apply tension to at least one of the suture tails  2750 . Linking means may include any means for coupling a plurality of suture tails together, and may include for example an eye splice, a collar, a button or a knot for example. Alternatively linking means may include linking means on each suture tail such that each suture tail terminates with it owns dedicated knot, loop, and collar or button for example. For example, each suture tail  2750  may terminate with a knot (not shown) that separately engages the suture bar  2700 , and therefore each suture tail may not be coupled to form a reduction loop. For example in the suture construct shown in  FIG. 8D or 32C , the tension bar may be configured to receive the suture looped ends through example cleats  2780  (shown in  FIG. 27B and 27C ). In one embodiment, the tension bar  2700  is configured to engage the suture tails  2750  and the linking means ( 2755 ), to limit sliding of the suture  2750  relative to the suture bar  2700  and aid in tensioning the adjustable suture construct associated with the suture tails  2750 . Alternatively, lateral cleats  2780  may receive finger loops  830   a,    830   b  therethough, to wrap loop  830   a  around a first cleat  2780  and loop  830   b  around the other cleat  2780 . The suture construct and more specifically suture tails or loops may be operably coupled to an adjustable tissue fixation system such as those disclosed herein, wherein tensioning the suture tails or loops reduces an adjustable loop of the adjustable suture loop construct and thereby adjusts the tissue fixation construct. 
     The tension bar  2700  may define a generally tubular or bar shaped body member with a plurality of slots, grooves, cleats and notches arranged to selectively receive suture tails  2750  or loops  830  that may be operatively coupled to an adjustable suture fixation construct such as those described previously herein. The tension bar  2700  may define a unibody or one-piece single shot molded plastic component. The bar  2700  is configured to receive the suture tails  2750  or loops  830   a,    830   b,  and distribute the load on the fingers of a surgeon when tightening/pulling on the suture(s). The bar  2700  may include at least one notch or means to receive and engage a linking means such as a button, collar, knot or eye splice. This notch may be centrally located along the bar  2700 . The bar  2700  may include at least two notches to receive and engage a first and second linking means associated with two ends of a first and second suture tail respectively. 
       FIG. 27A  shows a view of the bar  2700  with suture tails  2750  operatively coupled thereto, the suture tails  2750  formed into a loop using a linking means  2755  that is an eye splice. An example end to form a single tail may be similar to single tail  2434  shown in  FIG. 24 . Adjustable suture fixation systems may be any adjustable suture constructs described heretofore such as those disclosed in  FIGS. 5H, 8D, 24 and 16A-16C . 
     Bar  2700  includes a lower side surface  2720 , an upper side surface  2730  and two lateral end surfaces  2740 . Lower side surface  2720  may define a curved surface for nesting within a user&#39;s hand and better distribute the load on the fingers of the user. Lower surface  2720  faces the adjustable suture construct. Lower side surface  2720  may include two slots  2725 , each slot to receive a length suture tail  2750  therethrough to guide the suture tails into the groove. Tension bar  2700  may have an overall length L that approximates a surgeon&#39;s hand width. Tension bar  2700  may define a median working portion L m  that is spaced away from both lateral ends  2740 , which receives and engages the suture tails  2750 . This may create a mechanical advantage where some of the surgeon&#39;s fingers are lateral to the suture slots  2727  which occurs when the bar  2700  is rocked as is described later. Slots  2725  may define the outer periphery of the median working portion L m . Slots  2725  may extend from a top surface  2702  of bar  2700  towards a central axis X-X and may be continuous with groove  2760 . Slots  2725  may have a constant width “W” on the lower side surface  2720  and may extend along an angle such that the closed end  2726  of each slot  2725  is further from the most-adjacent lateral end  2740  than the open end  2727 . Part way along each slot  2725  may include a ramp  2726  that locally reduces the width “W” to better retain suture tail  2750  therein and mitigate the likelihood of the tension bar  2700  falling on the floor. Ramp  2726  may be closer to the closed end  2728  than open end  2727 . Ramp  2826  may be approximately a suture tail diameter or width from the closed end  2728 . Ramp  2826  may define a closed portion of slot  2725  that is continuous with groove  2760 . Each slot  2725  may extend from the lower side surface  2720  to the upper side surface  2730  and may be continuous with groove  2760  along the upper side surface  2730 . In alternative embodiments, the median working portion L m  may approximate the same as the overall length L, of the bar  2700 . In such a case, the slots  2725  would not exist and the sutures  2750  would exit the lateral ends  2740 . In an alternative embodiment, bar  2700  may include additional cleats  2780  laterally disposed relative to median portion L m  for optionally receiving loops  830   a  and  830   b  therethrough. 
       FIG. 27C  illustrates a bar  2700  with modified lateral ends  2740  to allow for a single action mold manufacturing process, by exposing cavities  2701  at each end. This may make the device more cost effective, and require less material. This device may be single use, formed of a plastic and provided sterile. This device may alternatively be intended as a durable or reusable device and may be formed of a material that re-sterilizes well using existing sterilization methods. Reusable tension bars may be formed from stainless steel, for example. 
     Illustrated in  FIGS. 27A and 27C , each slot  2725  extends up to and including the upper side surface  2730  and may include a curved surface  2728  that curves towards the middle  1705  of bar. The middle being approximately equidistant between the two lateral ends  2740 . Each slot  2725  and curved surface  2728  is configured to lead a suture tail  2750  into groove  2760 . Seen also in  FIGS. 27A and 27C , is at least one notch  2770  radially extending from groove  2760  for receiving a linking means such as knot, button, collar or eye slice associated with the suture tail  2750 . The at least one notch is larger is cross section to receive and engage the linking means  2755  which may generally have a larger cross section than the suture tail  2750 . 
       FIG. 27D  is a longitudinal cross section of bar  2700  showing the lower side surface  2720  with the slots  2725  therethrough. At least a portion of groove bottom surface  2765  is shown continuous with slots  2725  and spaced laterally or radially away from notches  2770 . Groove bottom surface  2765  may extends at an angle (non-zero) relative to the longitudinal axis of the bar  2700 , defining an apex at the middle of bar, approximately equidistant from both ends  2740 . Cleats  2780  are omitted from  FIG. 27D  for simplification.  FIG. 27E  illustrates an isometric view of a slot  2725  and groove bottom surface  2765  continuous. 
       FIGS. 28A and 28B  show a first cross section of bar  2700 , the cross section extending through a center of a notch  2770 . Groove  2760  extends parallel to longitudinal axis of bar and defines a bottom surface  2765  that is medially spaced relative to notch surfaces  2771 . Groove  2760  is sized to receive a suture tail, but obstruct the linking means  2755  from entry. Groove  2760  is sized to block the linking means  2755  from entering the medial most portion of groove  2760  and place the linking means within one of the notches  2770 . A plurality of axially spaced notches  2770  are shown in the medial portion L m  between the two slots  2725 . In some embodiments, there may be a single notch located at the middle  2705 , equally spaced from both lateral ends  2740 . Notch  2770  has a width configured to receive and engage the linking means to limit motion of the suture tails  2750  along the tensioning bar  2700 . The at least one notch  2770  defines two angled channels  2771   a  and  2771   b  that extend bilaterally from the groove. Channels  2771   a  and  2771   b  may be mirror images of each other. In some embodiments a single channel only, such as channel  2771   a  may be sufficient. 
       FIGS. 29A and 29B  show a second cross section of bar  2700 , the cross section offset from the first, and extending through a rib  2778  that may separate two serially disposed notches  2770 . Rib  2778  may include a chamfer  2779 . Ribs  2778  are axially spaced, defining notches  2770  to allow the linking means  2755  to lie within notch  2770 , while the suture tail  2750  is disposed more medially along groove  2760 . Since each suture tail may not be equal in length depending on the construction of the suture construct and location of the linking means  2755  a plurality of notches  2770  may be preferable to accommodate some asymmetry between the suture tails. In alternative embodiments where each suture tail terminates with its own linking means, a first linking means on a first suture tail may engage a first notch and a second linking means on a second suture tail may engage a second notch. 
       FIG. 30  illustrates an adjustable fixation construct  2800  operably coupled to a tension bar  2700 . An eye splice is shown as a linking means  2755  to the two suture tails  2750  together, the eye splice seated within a notch  2770 . 
       FIGS. 31A and 31B  represents a portion of a method of implanting a tissue graft  3124  within a knee  3150  during an anterior cruciate ligament (ACL) repair and reconstruction procedure. Drilling procedures are performed to form one or more bone tunnels, such as the appropriately sized tibial tunnel  3118  extending through tibia  3116  and femoral tunnel  3122  through the femur  3120 . Surgical construct includes a tissue graft  3124 , a suture construct  3127  (such as loops  2412  and  2414  for example in  FIG. 24 , or loop construct shown in  FIG. 8D ) and a graft attachment device  3114 . 
     In a first example using fixation device shown in  FIG. 30 , the suture tails  2750  may be coupled to a tensioning bar  2700  after the attachment device  3114  has been placed on the outer surface of femur, or before the attachment device  3114  has been threaded through the tunnels  3118 ,  3122 . Each suture tail  2750  may be provided coupled to form a loop, the loop formed using a linking means  2755  means. Each suture tail  2750  may extend through an individual slot  2725  through the tensioning bar  2700 , placing a length of each suture tail  2750  along a groove and the linking means within a notch  2770  along the groove  2760 . The surgeon may then apply tension to the suture tails  2750  via pulling on the tensioning bar  2700  to draw the suture, graft attachment device, and tissue graft through the bone tunnel. For instance, the surgeon may pull on the tension bar  2700  to draw suture tails  2750  and loops  3127  through tibial tunnel  3118  and femoral tunnel  3122 , so that the tissue graft  3124  is positioned within the femoral tunnel  3122  and tibial tunnel  3118 . While pulling on the tension bar  2700  suture tails  2750  may by prevented from sliding along the tensioning bar  2700  as the linking means  2755  may be seated within notch  2770 . The tension bar  2700  may be rocked, pulling on a first tail of the suture tails  2750  and then on the other, in an alternating rocking motion, as shown in  FIG. 31B . This allows increased tension to be isolated and focused on the first tail followed by on the other. This places more tension on a single length of suture, more readily overcoming friction of the suture construct (cradle  2420  for example) and therefore providing a means of more easily reducing the suture loop. 
     In a second example using fixation device including a suture construct as shown in  FIG. 8D , the suture loops  830   a,    830   b  may be coupled to a tensioning bar  2700  after the attachment device  3114  has been placed on the outer surface of femur, or before the attachment device  3114  has been threaded through the tunnels  3118 ,  3122 . In this example, at least one of the suture loops  830   b  for example may first have been passed through a graft tissue or bone block before being coupled to or passed through an aperture of a fixation device  3114 , as disclosed herein. Each suture loop  830   a,    830   b  may be looped around the bar  2700  and into its own cleat  2780 . The tension bar  2700  may be rocked, pulling on a first loop  830   a  and then on the other, in an alternating rocking motion, in a similar manner as disclosed in  FIG. 31B . This allows increased tension to be isolated and focused on the first tail followed by on the other. This places more tension on a single loop, more readily overcoming friction of the suture construct (cradle  820  for example) and therefore providing a means of more easily reducing the suture loop. 
     A number of implementations have been described. Nevertheless, it will be understood that various modifications may be made. For example, while the tensioning bar  2700  is shown in use with a knee joint, the tensioning bar can be used in other areas of the body, for example a hip or shoulder joint, and would be sized appropriately. The tensioning bar may be made out of many different materials such as stainless steel, aluminum, PEEK, a polycarbonate, acetal, etc, and may be intended for one time use or multiple uses. Although the tension bar  2700  has been described for use by hand, it is contemplated that the tension bar  2700  may be used with another instrument or may be connected to a pulling or winding device. Tension bar may be operatively coupled to a working head of a robot arm. Accordingly, other implementations are within the scope of the following claims. 
     Disclosed in  FIGS. 32B-32F  are a means of passing multiple sutures or suture loops through a target tissue with minimal friction/resistance and damage to this target tissue. For example, this may be required while coupling multiple suture loops and/or lengths of suture of an adjustable suture loop construct such as loops of construct  806  illustrated in at least  FIG. 8D , through a graft. Grafts may include bone blocks or a Quadriceps Tendon (QT) for example. Disclosed in  FIGS. 32B-32F  is a means of passing multiple sutures with a single pass of a needle and thus reducing the number of suture passing actions, and consequently reducing the graft preparation time of a surgical procedure. 
     Passing multiple loops of suture around a suture passer such as a needle and threading each suture simultaneously causes extra friction/resistance while being passed through tissue. Passing multiple loops of suture through tissue one at a time multiplies the number of passing sutures. Another option is to knot a looped suture to form two serial loops ( FIG. 32A ). A first suture may be coupled to the first of the two serial loops, and a second suture may be passed through a second of the two serial loops. While passing the needle through tissue the two sutures may pull though the tissue in stages. Adding knots however causes extra resistance while passing through tissue and demands higher forces. Graft tissue is typically about 10 mm wide and 5 mm thick and may be quite slippery. Therefore handling this small and slippery tissue may be difficult, and passing multiple sutures that include changes is cross section, in the form of knots or large instantaneous changes in the number of suture lengths for example is awkward, time consuming and may damage the graft tissue. Therefore, there is a need to provide a means to pass multiple sutures through tissue with minimal friction/resistance and/or needless tissue damage. 
     Reference is now made to earlier figures disclosing an open loop suspensory fixation construct such as at least construct  106 ,  206  and  806 . These constructs provide a free end that may be passed through graft tissue before assembling directly to a cortical button, such as button  1202  for example.  FIG. 32C  shows an open loop construct  3206  similar to at least construct  1205 , the method of forming disclosed in at least  FIG. 8D . Construct  3206  may include an anchor or cortical button  3220 , a preassembled end  3230  and a free end  3240 . Free end  3240  may be passed through and coupled to graft tissue as describe in at least 11B and 34A. Free end  3240  includes a loop end  3244  of an adjustable loop  3242  and a finger loop end  3246 . Finger loop end  3246  and loop end  3244  may be offset from each other as loop end  3244  is configured to link around button  3220  while finger loop end  3246  is configured to pass through an aperture of button  3220  and extend away from button  3220  providing a means of adjusting the construct  3206 . The proposed approach discloses a needle passing system with a means to stage passing these two loops ( 3244  and  3246 ) with a reduced force for a single pass of the needle through the graft tissue. This proposed approach includes a needle passing system avoiding a knot. A knot, as shown in  FIG. 32A  may increase passing force through the tissue. The disclosed needle passing system may include a double loop needle system. 
       FIG. 32B  shows a first embodiment of a double loop needle system  3250  that allows multiple lengths of a flexible material to pass through a target tissue such as graft tissue while minimally adding to the volume of flexible material being passed each time. System  3250  includes two loops of flexible material with offset or different lengths, a first shorter loop  3252  and second longer loop  3254 , both coupled directly to needle  3255 . The loop material can be any flexible material suitable for coupling in a surgical procedure such as suture strands, monofilaments, or thin wires. Loops  3252  and  3254  may have different colors or marking for suture management. The loop length difference is determined based on the configuration of the loops  3252  and  3254 . 
     An example method of use is represented in  FIG. 32C , wherein first loop  3252  may be provided coupled to the finger loop end  3246  and the second loop  3254  may be provided linked to loop end  3244 . The construct  3206  is initially, as shown, in an open loop configuration. Needle  3255  may be passed through graft tissue to draw both ends  3244  and  3246  through the graft tissue, the end  3246  being drawn first, end  3244  thereafter to stage the passing and reduce the passing resistance through tissue. Sleeve or cradle  3205  may now extend through graft tissue and loop end  3244  may be coupled to anchor  3220  to change construct  3206  to a closed configuration. Needle system  3250  may be disconnected from the loop end  3244  before coupling the loop end  3244  while the needle system  3250  remains coupled to end  3246 . The needle  3255  may then extend through the cortical button  3220  to draw the finger loop end  3246  through an aperture of the cortical button  3220  before disconnecting the needle system  3250  from the finger loop end  3246 . Tension on the finger loop end  3246  may reduce the adjustable suture construct  3206 , in a manner similar to that described in at least U.S. Pat. No. 10,383,617 and disclosed herein in earlier figures. Needle system  3250  may be disconnected by cutting the loops  3254  and  3252 . By offsetting the loops and not adding any knots, the passing force would be less (easier), saving OR time and potential graft damage. 
       FIG. 32D  presents a second embodiment of a double loop needle system  3260 . This system  3260  may include a flexible member  3262  that is cinched to the needle  3255  and two axially spaced loops  3264  and  3266  extending therefrom along the single flexible member. Flexible member  3262  may be formed of a braided yarn and loops  3264  and  3266  may be formed by altering a weaving pattern during manufacture to form a bifurcation (i.e., the yarns of suture can be woven in different patterns to go from a single stand to bifurcated, then single then bifurcated.) First loop  3264  may therefore be operatively coupled to loop  3244  for example and second loop  3266  may be operatively coupled to the finger loop end  3246 . 
     An example method of use may therefore include providing an adjustable loop fixation construct  3206  that has an opening loop configuration, and may be assembled with a double loop needle system  3260 . The first loop  3264  may be provided coupled to the loop end  3244  and the second loop  3266  may be provided linked to loop  3246 . Needle  3255  may be passed through graft tissue to draw both ends  3244  and  3246  through the graft tissue, one after the other. This may place sleeve or cradle  3205  through graft tissue before coupling the loop end  3244  to anchor  3220 . Needle system  3260  may be disconnected from the two ends  3244  and  3246  by cutting the two loops  3264  and  3266 . Needle system may first be disconnected from loop end  3244  and the loop end  3244  may be assembled to cortical button  3220 , while the finger loop end  3246  remains coupled to the double loop needle system  3260 . The needle  3255  may be used to extend the finger loop  3246  through an aperture of the cortical button  3220 . Tension on the finger loop end  3246  may reduce the adjustable suture construct  3206 , in a manner similar to that described in at least U.S. Pat. No. 10,383,617, as disclosed herein. 
       FIG. 32E  presents another embodiment of a double loop needle system  3270 . One end of a suture is cinched in a needle  3255 , the other end may include two eye splices or finger-traps  3271  and  3273  with two loops  3272  and  3274  alternating between them. 
     This construct may be formed using a single flexible member that extends from the needle  3255 , forms the first loop  3272  and then extends through itself for a length defining the first finger trap  3271 . The suture then exits the finger trap  3271  for a short length before returning to extend along the core of the flexible member for a length, defining the second finger trap  3274 . There may be a low profile knot  3275  formed using a reciprocity of splicing adjacent the second loop  3274  to stop the suture from sliding along itself. Reciprocity of slicing may be similar to that disclosed in at least U.S. Pat. No. 10,383,617, commonly owned and herein incorporated by reference. 
     An example method of use may therefore include providing an adjustable loop fixation construct, such as example construct  3206  that may be assembled with a double loop needle system  3270 . The second loop  3274  may be provided coupled to the finger loop end  3246  and the first loop  3272  may be provided linked to loop end  3244 . Needle  3255  may be passed through graft tissue to draw both ends  3244  and  3246  through the graft tissue. This may place sleeve  3205  through graft tissue before coupling the loop end  3244  directly to anchor  3220 . Needle system  3270  may be disconnected from the two ends  3244  and  3246  by cutting the two loops  3272  and  3274 . The first loop  3272  may be detached first with the second loop still attached until the end  3244  is coupled to the anchor  3220 . Tension on the finger loop end  3246  may reduce the adjustable suture construct  3206  as disclosed herein. Needle system  3250  may have a straight needle  3255  or curved. 
       FIG. 33A-33C  illustrate alternative embodiments of open loop adjustable suture constructs that allow a staging of passing flexible members through a graft tissue using a bypass loop  3310  Similar to the  FIG. 32B-F , adjustable fixation construct  3300  may be an open loop adjustable construct with a free end  3340  including the finger loop end  3346  and loop end  3344 . Free end also includes a bypass loop  3310 . Bypass loop  3310  may be formed during weaving or manufacture of the flexible member  3305  and may be a bifurcated portion where some of the yarns are woven for a short distance to form two separate lengths of flexible material before weaving back together. Alternatively, bypass loop  3310  may be formed using eye-splices or finger cinches, or reciprocating splices as described herein. An example method of forming finger loop end  3346  and loop  3310  will now be described with reference to  FIG. 33B . End of flexible member  3305  may form a loop to form finger loop end  3346  and then extend along a hollow core of flexible member  3305  to form eye splice  3311 . End of flexible member may then exit the hollow core and thread through loop end  3344 , and enter the hollow core again at point P forming bypass loop  3310 . End of flexible member may then form a reciprocating splice adjacent point P to keep it in place, or be fixed in place using an adhesive for example. Bypass loop  3310  is preferable marked to be readily discovered by the surgeon, and may be a different color or shape for example than the rest of the flexible member  3305 . System  3300  may be operatively coupled as provided to a needle system  3350  with a single loop  3252  of flexible material. The single loop  3252  may be formed as suture strands, monofilaments, or thin wires. Loop  3252  may have a different color to the flexible member  3305  and bypass loop  3310  for suture management. 
     An example method of use may include passing a free end  3340  of an open loop adjustable fixation construct  3300  through graft tissue, the free end including a finger loop end  3346  directly coupled to a needle system  3350 . The free end  3340  also includes a loop end  3344  operatively coupled to a bypass loop  3310  of the construct. The construct  3300  may initially in an open loop configuration defining the finger loop end  3346  and loop end  3344  with a second end  3330  operatively coupled to a cortical button  3335 . Needle  3255  may be passed through graft tissue to draw both ends  3344  and  3346  through the graft tissue, until the cradle  3355  extends through graft tissue. Bypass loop  3310  may then be cut to release loop end  3344 . Bypass loop  3310  is easily discovered and distinguished from other portions of flexible material to cut only the bypass loop. 
     This may be achieved with markings, shape or colored dies for example. Loop end  3344  may then be coupled to anchor  3220  to change construct  3300  to a closed configuration. Needle system  3350  may remain coupled to the finger loop end  3346  while coupling the loop end  3344 . The needle  3255  may then extend through an aperture in the cortical button  3220  to draw the finger loop end  3346  through the aperture before disconnecting the needle system  3350  from the finger loop end  3346 . Tension on the finger loop end  3346  may reduce the adjustable suture construct  3300 , in manner similar to that described in at least U.S. Pat. No. 10,383,617. Needle system  3350  may be disconnected by cutting the loop  3254 . 
       FIG. 33C  shows a similar embodiment to that shown in  FIG. 33A and 33B , with the exception that it discloses an adjustable fixation construct  3350  with two free ends  3360   a  and  3360   b.  This may be termed a symmetrical open loop configuration. At least one of the free ends ( 3360   b  shown) may be coupled to needle system  3350 . Both free ends  3360   a  and  3350   b  may include a bypass loop  3310   a  and  3310   b.  This system allows for the cortical button such as button  800  to be coupled at the surgeon&#39;s choice and prevents the loop ends being inadvertently pulled out the cradle  3355 , as this would destroy the construct 
     The number of loops can be more than  2  loops, with different offset lengths per design requirements. The needle can be straight or curved ( FIG. 32F ). The material of the loop could be suture (size depends on design requirement, but generally the thinner the better, without compromising strength), monofilament or even a metal wires. 
     Connecting adjustable suture constructs to grafts is sometimes achieved by forming a herringbone stitch through the graft, as shown in  FIG. 15C-15G . This may require the use of connecting tape or suture and may be difficult to pull multiple loops of suture through the graft. Alternatively, the graft may be split into two “legs” for about ⅔ along it longitudinal axis and passed through a closed adjustable loop construct such as that disclosed in at least U.S. Pat. No. 10,383,617. In this option, the legs are stitched back together to secure the loop within the graft. This approach is time consuming in operating room, and may compromises the integrity of the graft. In addition, sutures that stitch back the legs together, add to graft volume. Therefore, there is a need to couple an adjustable suture construct directly to graft tissue, without the need for tape or suture, pulling multiple suture loops simultaneously through the graft or splitting the graft. 
     Disclosed herein therefore is a method of forming a stitch through tissue with a single free end of an open loop adjustable fixation construct such as constructs disclosed herein in at least  FIG. 1A - FIG. 8D  and  FIG. 32C . This may attach the loop of a fixation construct to graft tissue directly without the need for a connecting tape or suture; may improve the integrity of the graft; may decrease the graft preparation time in OR; and is very versatile, i.e., can be used for soft tissue and hard tissue (patellar graft, or QT with bone block) and different type of grafts, for ACL reconstruction or ACL repair or other ligament reconstruction procedures. 
     The open looped construct may be similar to constructs disclosed herein, including at least construct  3206  and includes a free end  3240  that may be drawn through the graft tissue using a double needle system as disclosed in  FIG. 32B-32F  for example. The free end (which may include finger loop end  3246  and loop end  3244 ) of the open loop construct can be passed through soft tissue graft along the path shown in  FIGS. 34A and 34B  using a suture passer such as passer  3250 . The final cradle location  3205  is shown in  FIG. 34A .  FIG. 34B  shows the steps method of passing of the free end  3240  through the graft tissue  10  to form a stitch through the graft  10 . Graft defines a front face  11 , a top surface  12 , bottom surface  13 , first side surface  14  and second side surface  15 . In order to pass the free end of the loop through the soft tissue, either a looped needle or a suture passer can be used. Shown in Step  1  the free end  3240  may be passed from a front surface  11  to top surface  12 , then wrapped around first side surface  14  (step  2 ) before passing from the lower surface  13  through to the top surface  12  (step  3 ). Step  2  and step  3  may be repeated. End  3240  may the wrap around the lower surface of graft to the second side surface  15  into the top surface  12  and out of the bottom surface  13  of the graft (step  6 ). From the bottom surface  13 , end  3240  may wrap around the second side external surface then into the top surface  12  and out of front surface  11  (step  7  and  8 ). End  3240  is drawn through graft  10  and preferable places cradle  3205  around the two side surfaces  14  and  15  and lower surface  13 , along the graft  10  and spaced away from front face  11 . 
     The entry and exit point of suture is designed to be on front face  11  of the graft  10  to avoid bunching up during passing graft through tunnel. Since the entry and exit points are apart, a more even stress distribution through graft  10  would be provided (it could be ⅓, ⅓, ⅓ evenly, or any other way, for instance ¼, ½, ¼, etc.) While two passes are shown in  FIG. 34A and 34B , the number of rows of stiches is flexible and can be selected by the surgeon. Passing a free end  3240  through the graft  10  may form any number of stitching patterns/techniques including but not limited to Krackow, whip stitches, baseball stitches, etc. Exit and entry points may be on different faces to form different stitches through the graft. 
     Turning now to  FIGS. 35A-35C , a button style anchor is disclosed that may be operatively coupled to a suspensory fixation construct such as those disclosed herein to fix the tibial side of the reconstruction. This is closer to the patient&#39;s skin with less inherent muscle, fatty layers and connective tissue in the area and may be noticeable to the patient. Some attempted solutions have tried fixing the tibial side with a screw style anchor placed within the prepared tibia tunnel, but this has not sufficiently addressed the needs to adjust the tension on the graft tissue. Some attempted solutions have tried fixing the tibial side with a thin and squared or rectangular cross-section profile button-style anchor, but this has not sufficiently addressed the needs to provide a less palpable button. A minimal profile means of fixing the graft to the tibial cortex is therefore needed for improved tactile feel. 
       FIG. 35A and 35B  illustrate a variety of views of a low profile button style anchor  3500  that may couple flexible members of a fixation construct to the tibial cortex. A head portion  3520  is configured to sit proud of the cortical surface while the body portion  3530  may extend into the tibial tunnel. Head portion is configured to be low profile, including a dome or rounded top surface  3510  to reduce palpation by the patient. Anchor  3500  may define a circular cross section for increased contact surface with cortical tibial bone and thereby improve stress distribution around the anchor. This allows for a reduced thickness (T) of the head  3520  (see  FIG. 36 c   ) and therefore lower profile head  3520  with reduced tactile feedback to the patient for the same mechanical strength. In addition, a dome-shape profile on the top (or any gradual change of profile) helps providing a smoother tactile feeling. Other shapes may include an oval or rounded rectangular shape. 
     A cavity  3540  in the center of the anchor  3500  button is configured to house any knots formed with flexible member constructs therein. This maintains the knots preferably below the top surface  3510  to reduce tactile feedback to patient. Body portion  3530  may be tapered such that the anchor  3500  may be press fit into the tibial tunnel and may improve fixation. 
     Anchor  3500  includes a plurality of radially oriented slots  3505   a,    3505   b,    3505   c  and  3505   d  that extend through both the head  3520  and body  3530 . Slots  3505   a,    3505   b,    3505   c  and  3505   d  are configured to receive flexible members of a fixation construct therethough. Slots  3505   a,    3505   b,    3505   c  and  3505   d  are tapered having a maximum opening at the outermost peripheral edge of the head  3520  and narrows as each slot extends medially. A narrowing profile  3507  along each slot  3505  may also help retain flexible member within medial end of slots. Slots  3505   a,    3505   b,    3505   c  and  3505   d  are generally configured to direct flexible members into the slot medial end and helps maintain the flexible members therein. These flexible members may be used for suture loop reduction. Slots  3505   a,    3505   b,    3505   c  and  3505   d  all terminate and intersect a recess  3506   a  or  3506   b  best seen in  FIG. 35C . Two slots  3505   a  and  3505   d  each terminate at ends of recess  3506   a.  Recess  3506   a  extends between ends of slots  3505   a  and  3505   d.  Recess  3506   a  is continuous with and lies below bottom of cavity  3540 . Recess  3506   a  is configured to receive a flexible member therein. For example, a loop of a flexible member may extend through both slot  3505   a  and  3505   d  and nest within recess  3506   d.    
       FIGS. 36A-36C  illustrate an alternative embodiment  3600  with the addition of at least two holes  3610 , extending through both the head  3620  and body  3630 . Ends of a flexible member may extend along a tibial tunnel and then through these at least one of these two holes  3610 . Tension applied to these flexible member ends may reduce an adjustable construct, or apply tension to a graft. The at least two holes  3610  are disposed either side of recesses  3606   a  and  3606   b,  and may lie on a line through the center of anchor  3600 .  FIGS. 37A-37C  illustrate an alternative embodiment  3700  with asymmetric slots and holes. Button  1600  includes two slots  3505   b  and  3505   c.  Anchor  3700  includes at least four holes  3710   a,    3710   b,    3710   c  and  3710   d.  All holes and slots extend through both the head  3720  and body  3730 . Shown in  FIG. 37C , ends and loops of a flexible member may be threaded through at some of these holes  3710   a,    3710   b,    3710   c  and  3710   d.  In this embodiment, flexible members of an adjustable fixation construct may be provided pre-assembled to button  3700  and may include a loop pre-assembled through holes  3710   c  and  3710   d.  Similar to open loop configuration adjustable constructs described herein a free end  3750  may be passed through graft tissue before extending along slots  3505   b  and  3505   c.  Loop end  3750  may lie within recess  3506   b  once assembled with button  3700 . Button is configured to engage a tibial cortex end of prepared ACL tunnel. 
     When using an Open Loop Adjustable Fixation construct such as construct  106  or  3206  for example, suture and anchor management in a procedure requires a different and more complex operation that for a closed loop adjustable fixation construct. For example, the anchor is small, and may be difficult to see and even more difficult to work with, especially with wet/greasy gloved hands and a lack of dedicated supporting instrumentation. In addition, the multiple lengths and loops of suture may be difficult to keep track of and inadvertent cutting of the wrong suture may destroy the entire construct. A means of managing this construct is therefore disclosed herein to improve procedure efficiency and avoid costly errors. Additionally, the tool or jig is designed to provide tactile feedback when mating the suture loop and implant hole slots, reducing the need to visualize small mating features. 
     Disclosed is  FIGS. 38  is a management and assembly tool for an open looped adjustable fixation construct with the button implant (anchor) and flexible member pre-loaded. The assembly tool provides a means of suture management and may facilitate simpler assembly of anchor and suture by allowing the user a means to securely handle the tiny implant while manipulating suture into the respective features on the implant. Disclosed herein is an adjustable suture construct management and assembly tool with means of securely holding the anchor to allow for rigorous manipulation of suture on the anchor without concern of dropping/dislodging the anchor. This tool may be provided packaged and preassembled with the button/suture on it and would allow for use out-of-the-box without the need to assemble the anchor into a fixture before subsequently assembling suture onto it. 
       FIG. 38  illustrates an overall view of the assembly tool  3800 . Assembled thereto is an example anchor (button implant)  3220  and adjustable loop construct that may include a cradle portion  3205 , an example open loop adjustable suture construct  3206  and an example double needle system similar to system  3250 . Assembly tool  3800  may be cube-shaped with contours for easy handling, although other shapes that nest easily within a surgeon&#39;s hand are contemplated. Assembly tool may include means to clip to or couple to a position arm or drape of a patient (now shown). Assembly tool  3800  may include channel  3803  for nesting a length of flexible member of example adjustable suture construct  3206 . Best seen in at least  FIG. 39A , channel  3803  extends medially where it transitions to a slot  3805  that conforms to a shape of the anchor  3220 , to nest and hold cortical button or anchor  3220 . Tension on the suture construct along the channel  3803  does not release the anchor  3220 . Anchor  3220  may be nested and oriented orthogonally to slot longitudinal axis. Slot  3805  may be configured to nest anchor  3220  within the slot to sit upright within the slot  3805  and protrude a little beyond a top surface  3807 . Shown in at least  FIG. 39B , the depth of slot  3805  preferably places the anchor slots  3855   a  and  3855   b  above surface  3807 . Slots  3855  are configured to receive the free end (such as free end  3240 ) of suture construct, as disclosed herein. Slots  3855   a  and  3855   b  may be similar to slots  1210  shown in at least  FIG. 12B . A portion of slots  3855   a  and  3855   b  may be flush with surface  3807 . In providing this feature, the user is able to align the loop, such as loop  3244  with the surface  3807  of the assembly tool  3800  and simply pull on the construct  3206  to engage the loop  3244  within the hold slots  3855   a  and  3855   b,  rather than having to visualize the slots  3855   a  and  3855   b  and attempting to align the suture loop while applying tension.  FIG. 39B  also shows an aperture  3856  for receiving a finger loop end therethrough. 
       FIG. 39C  illustrates channel  3803  and example adjustable suture construct  3206  extending therealong. For example construct  3206  may include a first pre-assembled side similar to side  1206   a  shown in  FIG. 12B . The portion of the open loop adjustable suture construct  3206  that is not attached to the anchor  3220  is free to manipulate outside of the tool  3800  to allow assembly to BTB graft or QT tissue.  FIG. 39D  illustrates the underside of tool  3800 , including a suture management bobbin  3825 . From the bottom of the slot  3805  is a through-hole (not shown) which runs the depth of the assembly block  3800  (not shown). This through-hole allows a first suture, coupled to the anchor  3850  to be passed through the assembly jig  3800  and wound tightly around the bobbin feature  3825  on the bottom of the assembly tool  3800 . By winding the suture and subsequently cleating it within the bobbin feature  3825 , the button  3850  is secured into the slot  3805  to allow for manipulation of the construct  3806  around the button  3850  without fear of the button  3850  becoming dislodged from the tool  3800 . 
       FIGS. 40A-40F  show an example method of using the assembly tool  3800  to couple an open looped adjustable construct such as construct  3206  with graft tissue such as tissue  25 . Other constructs described throughout this disclosure may assemble to tool  3800  in a similar manner.  FIG. 40 a    shows Step  1 , passing a free end  3240  of the open looped adjustable construct  3860  though graft tissue  25 . This tissue may include a tunnel of a bone block. Passing may be achieved using a double loop suture system  3250  for example. Cradle  3205  may be place within tissue  25 .  FIG. 40B  illustrates the next step including detaching the suture loop  3244  of the free end  3240  from passing system  3250 . This may include cutting through the second suture segment of the system  3250 .  FIG. 40C  illustrates placing the freed suture loop flush onto the face  3807  of the assembly tool and around the anchor  3850  and pulling forcefully in the direction of the suture channel  3803  engages with the button  3220 . Suture loop  3244  may extend through and into slots  3855   a  and  3855   b  of anchor  3850 .  FIG. 40D  illustrates the step of passing a needle of the needle system  3250  for example through the aperture  3856  of the anchor  3220  and pulling the finger loop through.  FIG. 40E  illustrates detaching the finger loop from system  3250  by cutting through the first suture segment of the system  3250 .  FIG. 40F  illustrates uncleating the sutures and subsequently unwinding them one at a time, beginning with the first length of suture  3845  and then the second length of suture  3847 . Once both sutures  3845  and  3847  have been unwound, the assembly tool may be flipped over and tension on the second suture  3847  may remove construct  3206  from tool with the free end  3240  now assembled with anchor  3220  and the cradle  3205  extending through the graft tissue  25 . 
       FIG. 41  illustrates an alternative embodiment of a tool assembly  4100  including an additional suture management channel  4110 , poke-yoked to ensure proper order of operations. Once suture is wrapped around the ellipse-shaped base, the suture is brought up and secured within the cleat  4120 . After securing the suture, a suture passing device is woven through an aperture of the button implant and snapped onto the rounded outer of the cleat feature, ensuring the finger loop is passed using the suture passer through the button implant prior to disengaging the additional suture from the cleat and unwinding from the base. Additionally, numbers are imprinted on this concept, which correspond to technique steps to aid in user assembly of suture to the button implant. 
     One skilled in the art will realize the disclosure may be embodied in other specific forms without departing from the spirit or essential characteristics thereof. The foregoing examples are therefore to be considered in all respects illustrative rather than limiting of the disclosure described herein. Scope of the disclosure is thus indicated by the appended claims, rather than by the foregoing description, and all changes that come within the meaning and range of equivalency of the claims are therefore intended to be embraced therein.