Patent Publication Number: US-2022218327-A1

Title: Systems and methods for ankle syndesmosis repair

Description:
CROSS-REFERENCES TO RELATED APPLICATIONS 
     This application is based on, claims benefit of, and claims priority to U.S. Provisional Application No. 62/853,572 filed on May 28, 2019, which is hereby incorporated by reference herein in its entirety for all purposes. 
    
    
     STATEMENT REGARDING FEDERALLY SPONSORED RESEARCH 
     Not Applicable. 
     BACKGROUND OF THE INVENTION 
     1. Field of the Invention 
     The invention relates to systems and methods for the stabilization and repair of an ankle syndesmosis. More particularly, the invention relates to systems and methods for multi-level, multi-directional stabilization of the ankle syndesmosis. 
     2. Description of the Related Art 
     There is a high prevalence of ankle injuries both in athletic and non-athletic populations. The ankle joint is formed by three bones coming together in a syndesmotic relationship: the tibia, the fibula, and the talus. Post-injury, the ankle syndesmosis may be stabilized through surgery to allow for the repair of the joint. However, traditional methods have yielded various drawbacks. Specifically, some methods, such as bone-screw stabilization, have been shown to effectively stabilize the ankle syndesmosis, but do not provide a natural amount of flexibility of the ankle joint. Other methods, such as traditional suture-button stabilization have conversely allowed for too much flexibility of the joint, diminishing the stabilization effects, and reducing efficacy of the repair of the ankle syndesmosis. 
     Therefore, there is a need for improved systems and methods for ankle syndesmosis repair. 
     SUMMARY OF THE INVENTION 
     The present invention provides a dramatic improvement to current ankle syndesmosis repair techniques. This invention is designed to achieve multi-level, multi-directional stabilization of the ankle syndesmosis, while effectively reducing play in the stabilization system. Further, a specialized clamp for fixing the fibula and the tibia relative to each other during the implantation of the ankle syndesmosis repair system allows for the effective creation of multi-level, multi-directional bone tunnels, through which various lengths of suture may be used to stabilize the ankle joint. 
     In one aspect, the present disclosure provides an ankle syndesmosis repair system comprising a first length of suture, a second length of suture, a suture advancing device, a fibula engaging arrangement, and a tibia engaging arrangement. The suture advancing device comprises an elongated shaft having a distal end and a proximal end, wherein the distal end terminates in a pointed tip, and the proximal end is dimensioned to individually receive the first length of suture and the second length of suture. The fibula engaging arrangement is dimensioned to engage a lateral surface of the fibula. The fibula engaging arrangement has a first through hole dimensioned to receive the first length of suture and a second through hole dimensioned to receive the second length of suture. The tibia engaging arrangement is dimensioned to engage a medial surface of the tibia. The tibia engaging arrangement has a first passageway dimensioned to receive the first length of suture and a second passageway dimensioned to receive the second length of suture. At least one of the fibula engaging arrangement and the tibia engaging arrangement is configured such that the first length of suture and the second length of suture are at an oblique angle in an axial view of the fibula or the tibia when the first length of suture, the second length of suture, the fibula engaging arrangement, and the tibia engaging arrangement are implanted in the ankle. 
     In some embodiments, the ankle syndesmosis repair system can further include a third length of suture, wherein the proximal end of the suture advancing device can be dimensioned to individually receive the third length of suture and the fibula engaging arrangement can have a third through hole dimensioned to receive the third length of suture. The tibia engaging arrangement can have a third passageway dimensioned to receive the third length of suture and at least one of the fibula engaging arrangement and the tibia engaging arrangement can be configured such that the first length of suture and the third length of suture are at an oblique angle in the axial view of the fibula or the tibia when the first length of suture, the second length of suture, the third length of suture, the fibula engaging arrangement, and the tibia engaging arrangement are implanted in the ankle. 
     In some embodiments, the fibula engaging arrangement can include a fibula bone plate having the first through hole and the second through hole, the first through hole and the second through hole can be dimensioned such that the suture advancing device can pass through the first through hole and the second through hole. The first through hole can have a first longitudinal axis, the second through hole can have a second longitudinal axis, and the first longitudinal axis and the second longitudinal axis can be angled with respect to each other such that the suture advancing device is guided along a first path when passing through the first through hole and the suture advancing device is guided along a second path when passing through the second through hole, the first path and the second path being at an oblique angle in the axial view of the fibula or the tibia. 
     In some embodiments, the first through hole and the second through hole can be axially spaced in relation to a longitudinal axis of the fibula bone plate. The first through hole and the second through hole can be transversely spaced in relation to the longitudinal axis of the fibula bone plate. The fibula bone plate can have a third through hole located between the first through hole and the second through hole. The fibula bone plate can have a concave inner surface to conform to a surface of the fibula. The fibula engaging arrangement can include (i) a first fibula button having the first through hole and a first additional through hole, and (ii) a second fibula button having the second through hole and a second additional through hole. 
     In some embodiments, the suture advancing device can have a longitudinal length exceeding a transverse distance from the anteromedial surface of the tibia to the posterolateral surface of the fibula at a distal tibiofibular joint such that the suture advancing device can form a bone tunnel extending from the anteromedial surface of the tibia to the posterolateral surface of the fibula when the suture advancing device is moved through the tibia and the fibula at the distal tibiofibular joint. At least one of the first fibula button and the second fibula button can be dimensioned such that the at least one of the first fibula button and the second fibula button cannot pass through the bone tunnel. 
     In some embodiments, at least one of the first fibula button and the second fibula button can have a concave inner surface to conform to a surface of the fibula. The tibia engaging arrangement can include a tibia bone plate having the first passageway and the second passageway. The first passageway and the second passageway can be dimensioned such that the suture advancing device can pass through the first passageway and the second passageway. The first passageway can include a first longitudinal axis and the second passageway can include a second longitudinal axis. The first longitudinal axis and the second longitudinal axis can be angled with respect to each other such that the suture advancing device is guided along a first path when passing through the first passageway and the suture advancing device is guided along a second path when passing through the second passageway, the first path and the second path being at an oblique angle in the axial view of the fibula or the tibia. 
     In some embodiments, the first passageway and the second passageway can be axially spaced in relation to a longitudinal axis of the tibia bone plate. The first passageway and the second passageway can be transversely spaced in relation to the longitudinal axis of the tibia bone plate. The tibia bone plate can include a third passageway located between the first passageway and the second passageway. The tibia bone plate can have a concave inner surface to conform to a surface of the tibia. The tibia engaging arrangement can include (i) a first tibia button having the first passageway and a first additional passageway, and (ii) a second tibia button having the second passageway and a second additional passageway. 
     In some embodiments, the suture advancing device can have a longitudinal length exceeding a transverse distance from the anteromedial surface of the tibia to the posterolateral surface of the fibula at a distal tibiofibular joint such that the suture advancing device can form a bone tunnel extending from the anteromedial surface of the tibia to the posterolateral surface of the fibula when the suture advancing device is moved through the tibia and the fibula at the distal tibiofibular joint. At least one of the first tibia button and the second tibia button can be dimensioned such that the at least one of the first tibia button and the second tibia button cannot pass through the bone tunnel. 
     In some embodiments, at least one of the first tibia button and the second tibia button can have a concave inner surface to conform to a surface of the tibia. The elongated shaft of the suture advancing device can be cylindrical and have a diameter in a range of 0.5 to 2.5 millimeters. 
     In some embodiments, the ankle syndesmosis repair system can further include a third length of suture. The proximal end of the suture advancing device can be dimensioned to individually receive the third length of suture. The fibula engaging arrangement can include a fibula bone plate having the first through hole and the second through hole and a third through hole. The first through hole and the second through hole and the third through hole can be dimensioned such that the suture advancing device can pass through the first through hole and the second through hole and the third through hole. The first through hole can have a first longitudinal axis, the second through hole can have a second longitudinal axis, and the third through hole can have a third longitudinal axis. The first longitudinal axis and the second longitudinal axis can be angled with respect to each other such that the suture advancing device is guided along a first path when passing through the first through hole and the suture advancing device is guided along a second path when passing through the second through hole, the first path and the second path being at an oblique angle in the axial view of the fibula or the tibia. The tibia engaging arrangement can include (i) a first tibia button having the first passageway and a first additional passageway, (ii) a second tibia button having the second passageway and a second additional passageway and (iii) a third tibia button having a third passageway and a third additional passageway. 
     In another aspect, the present disclosure provides a method for performing ankle syndesmosis fixation. The method includes the steps of: (a) moving a suture advancing device comprising an elongated shaft having a distal end terminating in a pointed tip and a proximal end through a fibula and a tibia of a distal tibiofibular joint until the proximal end of the elongated shaft is adjacent an outer surface of the fibula or the tibia, wherein the proximal end receives a first length of suture; (b) securing a first section of the first length of suture to one of a fibula engaging arrangement and a tibia engaging arrangement; and (c) securing a second section of the first length of suture to the other of the fibula engaging arrangement and the tibia engaging arrangement. 
     In some embodiments, the method can further include the steps of: (d) moving the suture advancing device through the fibula and the tibia of the distal tibiofibular joint until the proximal end of the elongated shaft is adjacent an outer surface of the fibula or the tibia, the proximal end receiving a second length of suture; (e) securing a first section of the second length of suture to one of the fibula engaging arrangement and the tibia engaging arrangement; and (f) securing a second section of the second length of suture to the other of the fibula engaging arrangement and the tibia engaging arrangement. The second length of suture can be at an oblique angle with respect to the first length of suture in the axial view of the fibula or the tibia. 
     In some embodiments, the method can further include the steps of: (g) moving the suture advancing device through the fibula and the tibia of the distal tibiofibular joint until the proximal end of the elongated shaft is adjacent an outer surface of the fibula or the tibia, the proximal end receiving a third length of suture; (h) securing a first section of the third length of suture to one of the fibula engaging arrangement and the tibia engaging arrangement; and (i) securing a second section of the third length of suture to the other of the fibula engaging arrangement and the tibia engaging arrangement. The third length of suture can be at an oblique angle with respect to the first length of suture or the second length of suture in the axial view of the fibula or the tibia. 
     In some embodiments, the fibula engaging arrangement can include a fibula bone plate having a first through hole and a second through hole. The first through hole and the second through hole can be dimensioned such that the suture advancing device can pass through the first through hole and the second through hole. The first through hole can have a first longitudinal axis and the second through hole can have a second longitudinal axis. The first longitudinal axis and the second longitudinal axis can be angled with respect to each other such that the suture advancing device is guided along a first path when passing through the first through hole and the suture advancing device is guided along a second path when passing through the second through hole, the first path and the second path being at the oblique angle in the axial view of the fibula or the tibia. 
     In some embodiments, the first through hole and the second through hole can be axially spaced in relation to a longitudinal axis of the fibula bone plate. The first through hole and the second through hole can be transversely spaced in relation to the longitudinal axis of the fibula bone plate. The fibula engaging arrangement can include (i) a first fibula button having a first through hole and a first additional through hole, and (ii) a second fibula button having a second through hole and a second additional through hole. 
     In some embodiments, the suture advancing device can include a longitudinal length exceeding a transverse distance from the anteromedial surface of the tibia to the posterolateral surface of the fibula at a distal tibiofibular joint such that the suture advancing device can form a bone tunnel extending from the anteromedial surface of the tibia to the posterolateral surface of the fibula when the suture advancing device is moved through the tibia and the fibula at the distal tibiofibular joint. At least one of the first fibula button and the second fibula button can be dimensioned such that the at least one of the first fibula button and the second fibula button cannot pass through the bone tunnel. 
     In some embodiments, the tibia engaging arrangement can include a tibia bone plate having a first passageway and a second passageway. The first passageway and the second passageway can be dimensioned such that the suture advancing device can pass through the first passageway and the second passageway. The first passageway can include a first longitudinal axis and the second passageway has a second longitudinal axis. The first longitudinal axis and the second longitudinal axis can be angled with respect to each other such that the suture advancing device is guided along a first path when passing through the first passageway and the suture advancing device is guided along a second path when passing through the second passageway, the first path and the second path being at the oblique angle in the axial view of the fibula or the tibia. 
     In some embodiments, the first passageway and the second passageway can be axially spaced in relation to a longitudinal axis of the tibia bone plate. The first passageway and the second passageway can be transversely spaced in relation to the longitudinal axis of the tibia bone plate. The tibia engaging arrangement can include (i) a first tibia button having a first passageway and a first additional passageway, and (ii) a second tibia button having a second passageway and a second additional passageway. 
     In some embodiments, the suture advancing device can have a longitudinal length exceeding a transverse distance from the anteromedial surface of the tibia to the posterolateral surface of the fibula at a distal tibiofibular joint such that the suture advancing device can form a bone tunnel extending from the anteromedial surface of the tibia to the posterolateral surface of the fibula when the suture advancing device is moved through the tibia and the fibula at the distal tibiofibular joint. At least one of the first tibia button and the second tibia button can be dimensioned such that the at least one of the first tibia button and the second tibia button cannot pass through the bone tunnel. 
     In some embodiments, the method can include step (a) that includes moving the suture advancing device through the fibula and then the tibia of the distal tibiofibular joint until the proximal end of the elongated shaft is adjacent an outer surface of the tibia, step (b) that includes securing the first section of the first length of suture to the tibia engaging arrangement, and step (c) that includes moving the suture advancing device through the tibia and then the fibula of the distal tibiofibular joint until the proximal end of the elongated shaft is adjacent an outer surface of the fibula and thereafter securing the second section of the first length of suture to the fibula engaging arrangement. 
     In some embodiments, the method can include step (a) that includes moving the suture advancing device through the tibia and then the fibula of the distal tibiofibular joint until the proximal end of the elongated shaft is adjacent an outer surface of the fibula, step (b) that includes securing the first section of the first length of suture to the fibula engaging arrangement, and step (c) that includes moving the suture advancing device through the fibula and then the tibia of the distal tibiofibular joint until the proximal end of the elongated shaft is adjacent an outer surface of the tibia and thereafter securing the second section of the first length of suture to the tibia engaging arrangement. The elongated shaft of the suture advancing device can be cylindrical and has a diameter in a range of 0.5 to 2.5 millimeters. 
     In another aspect, the present disclosure provides an ankle syndesmosis repair system comprising a first anchor dimensioned to engage and be secured within an interior of a tibia, a first length of suture secured to the first anchor, a suture advancing device dimensioned to receive the first length of suture, and a fibula engaging arrangement dimensioned to engage a lateral surface of the fibula, the fibula engaging arrangement having a first through hole dimensioned to receive the first length suture. At least one of the fibula engaging arrangement and the first anchor is configured such that the first length of suture is at an oblique angle in an axial view of the fibula or the tibia when the first length of suture, the fibula engaging arrangement, and the first anchor are implanted in the ankle. 
     In some embodiments, the ankle syndesmosis repair system can further include a second anchor that can be dimensioned to engage and be secured within an interior of a tibia and a second length of suture that can be secured to the second anchor. The fibula engaging arrangement can include a second through hole dimensioned to receive the second length of suture and at least one of the fibula engaging arrangement, the first anchor, and the second anchor can be configured such that the first length of suture and the second length of suture are at an oblique angle in the axial view of the fibula or the tibia when the first length of suture, the second length of suture, the fibula engaging arrangement, the first anchor, and the second anchor are implanted in the ankle. 
     In some embodiments, the first through hole and the second through hole can be axially spaced in relation to a longitudinal axis of the fibula bone plate. The first through hole and the second through hole can be transversely spaced in relation to the longitudinal axis of the fibula bone plate. The fibula bone plate can have a third through hole located between the first through hole and the second through hole. The fibula bone plate can have a concave inner surface to conform to a surface of the fibula. The fibula engaging arrangement can include (i) a first fibula button having the first through hole and a first additional hole, and (ii) a second fibula button having the second through hole and a second additional through hole. At least one of the first fibula button and the second fibula button can have a concave inner surface to conform to a surface of the fibula. The first anchor can be configured to be guided into the tibia and engage lateral walls therein to prevent distal movement of the first anchor from the tibia. 
     In some embodiments, a third anchor can be dimensioned to engage and be secured within an interior of a tibia. A third length of suture can be secured to the third anchor. The fibula engaging arrangement can have a third through hole dimensioned to receive the third length of suture. At least one of the fibula engaging arrangement, the first anchor, the second anchor, and the third anchor can be configured such that the first length of suture, the second length of suture, and the third length of suture are at an oblique angle in the axial view of the fibula or the tibia when the first length of suture, the second length of suture, the third length of suture, the fibula engaging arrangement, the first anchor, the second anchor, and the third anchor are implanted in the ankle. 
     In another aspect, the present disclosure provides a method for performing ankle syndesmosis fixation. The method includes the steps of: (a) creating a first bone tunnel that extends through a fibula and partially into a tibia of a distal tibiofibular joint; (b) moving a first anchor secured to a first length suture, the first anchor removably secured to a distal end of a suture advancing device, through the first bone tunnel until the first anchor is proximate a first tunnel end; and (c) securing the first anchor within the first bone tunnel and removing the suture advancing device from the first bone tunnel. 
     In some embodiments, the method can further include (d) securing the first length suture to a fibula engaging arrangement; (e) creating a second bone tunnel that extends through a fibula and partially into a tibia of a distal tibiofibular joint; (f) moving a second anchor secured to a second length suture, the second anchor removably secured to a distal end of a suture advancing device, through the second bone tunnel until the second anchor is proximate a second tunnel end; and (g) securing the second anchor within the second bone tunnel and removing the suture advancing device from the second bone tunnel. 
     In some embodiments, the fibula engaging arrangement can include a fibula bone plate having a first through hole and a second through hole. The first through hole and the second through hole can be dimensioned such that the suture advancing device can pass through the first through hole and the second through hole. The first through hole can include a first longitudinal axis and the second through hole can include a second longitudinal axis. The first longitudinal axis and the second longitudinal axis can be angled with respect to each other such that the suture advancing device is guided along a first path when passing through the first through hole and the suture advancing device is guided along a second path when passing through the second through hole, the first path and the second path being at the oblique angle in the axial view of the fibula or the tibia. 
     In some embodiments, the first through hole and the second through hole can be transversely spaced in relation to the longitudinal axis of the fibula bone plate. The fibula engaging arrangement can include (i) a first fibula button having a first through hole and a first additional through hole, and (ii) a second fibula button having a second through hole and a second additional through hole. 
     In another aspect, the present disclosure provides a bone reduction clamp comprising a first arm, a second arm opposed to the first arm, and an adjustment mechanism. The second arm is connected to a guide for a bone piercing tool. The adjustment mechanism is for moving the second arm toward or away from the first arm. The adjustment mechanism includes a position adjustor that is rotatable with respect to the second arm such that rotation of the position adjustor in a first direction moves the second arm toward the first arm and rotation of the position adjustor in a second direction moves the second arm away from the first arm. 
     In some embodiments, one of the first arm and the second arm can include an internally threaded hole, the other of the first arm and the second arm can include an externally threaded post, and the internally threaded hole can engage the externally threaded post for translation of the first arm relative to the second arm. 
     In some embodiments, the guide can include a first guide hole having a first longitudinal axis and a second guide hole having a second longitudinal axis, the first longitudinal axis and the second longitudinal axis being angled with respect to each other such that the bone piercing tool is guided along a first path when passing through the first guide hole and the bone piercing tool is guided along a second path when passing through the second guide hole, the first path and the second path being at an oblique angle. 
     In some embodiments, the guide can include a third guide hole having a third longitudinal axis, the first longitudinal axis and the third longitudinal axis being angled with respect to each other such that the bone piercing tool is guided along a third path when passing through the third guide hole, the first path and the third path being at an oblique angle. 
     In another aspect, the present disclosure provides a method for performing ankle syndesmosis fixation. The method includes the steps of (a) applying pressure to one of a fibula and a tibia with the first arm of the bone reduction clamp of the present disclosure; (b) applying pressure to the other of the fibula and the tibia with the guide of the bone reduction clamp; (c) moving a suture advancing device comprising an elongated shaft having a distal end terminating in a pointed tip and a proximal end through a guide hole of the guide, and through the fibula and through the tibia of a distal tibiofibular joint until the proximal end of the elongated shaft is adjacent an outer surface of one of the fibula and the tibia, wherein the proximal end receives a first length of suture; (d) securing a first section of the first length of suture to one of a fibula engaging arrangement and a tibia engaging arrangement; and (e) securing a second section of the first length of suture to the other of the fibula engaging arrangement and the tibia engaging arrangement. 
     In another aspect, the present disclosure provides a jig mechanism for guiding a suture advancing device. The jig mechanism comprises a first tubular guide having a first tubular passageway having a first axis; a second tubular guide having a second tubular passageway having a second axis; a first support attached to the first tubular guide; a second support attached to the second tubular guide; and a support spacer configured to connect the first support and the second support, the support spacer defining a distance between the first tubular guide and the second tubular guide. The support spacer is configured such that the first axis and the second axis can be aligned to be substantially collinear. 
     In some embodiments, the jig mechanism can further include a suture advancing device including an elongated shaft having a distal end and a proximal end, the distal end terminating in a pointed tip, the proximal end being dimensioned to individually receive a first length of a suture. 
     In some embodiments, the support spacer can include a jig adjuster configured to increase and decrease the distance between the first tubular guide and the second tubular guide. The jig adjuster can include a threaded telescoping section of the support spacer. The jig adjuster can be rotated in a first direction to increase the distance between the first tubular guide and the second tubular guide. The jig adjuster can be rotated in a second direction to decrease the distance between the first tubular guide and the second tubular guide. The first tubular passageway can be dimensioned to slidably receive the suture advancing device. The second tubular passageway can be dimensioned to slidably receive the suture advancing device. 
     In some embodiments, the jig mechanism can further include a suture removal slot formed in the second tubular guide. The suture removal slot can have a width such that a suture may be removed from inside the second tubular passageway after being threaded through the second tubular passageway by the suture advancing device. 
     In some embodiments, the suture advancing device can be dimensioned to be guided by the jig mechanism through a fibula and a tibia at a tibiofibular joint. The first tubular guide can be structured to be aligned on a posterolateral surface of the fibula. The second tubular guide can be structured to be aligned on an anteromedial surface of the tibia. The suture advancing device can be structured to be passed through the first tubular passageway, a tibiofibular joint, and the second tubular passageway to create a first bone tunnel. 
     In another aspect, the present disclosure provides a method for guiding a suture advancing device during ankle syndesmosis fixation. The method can include (a) locating the jig mechanism such that the first tubular guide is aligned on a posterolateral surface of a fibula and such that the second tubular guide is aligned on an anteromedial surface of a tibia; (b) moving a suture advancing device comprising an elongated shaft through the fibula and the tibia until a proximal end of the elongated shaft is adjacent an outer surface of the fibula or the tibia, the proximal end receiving a first length of suture; (c) securing a first section of the first length of suture to a fibula engaging arrangement; and (d) securing a second section of the first length of suture to the fibula engaging arrangement. 
     In some embodiments, the method can further include (e) locating the jig mechanism such that the first tubular guide is aligned on a second posterolateral surface of the fibula and such that the second tubular guide is aligned on a second anteromedial surface of the tibia; and (f) moving the suture advancing device through the second tubular passageway, the tibiofibular joint, and the first tubular passageway to create a second bone tunnel. 
     These and other features, aspects, and advantages of the present invention will become better understood upon consideration of the following detailed description, drawings, and appended claims. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG. 1  shows a front elevational view of an ankle syndesmosis repair system in accordance with the invention. 
         FIG. 1A  shows a front elevational view of tibia engaging plate of another ankle syndesmosis repair system in accordance with the invention. 
         FIG. 1B  shows a detailed view of the tibia engaging plate of  FIG. 1A  taken along line  1 B- 1 B of  FIG. 1A . 
         FIG. 2  shows a lateral view of the ankle syndesmosis repair system of  FIG. 1 , showing a fibula engaging arrangement implanted on the fibula of a subject. 
         FIG. 2A  shows a lateral view of another ankle syndesmosis repair system, showing another embodiment of a fibula engaging plate in accordance with the invention. 
         FIG. 3  shows a medial view of the ankle syndesmosis repair system of  FIG. 1 . 
         FIG. 3A  shows a medial view of another tibia engaging plate of another ankle syndesmosis repair system in accordance with the invention. 
         FIG. 3B  shows a medial view of another tibia engaging plate of another ankle syndesmosis repair system in accordance with the invention. 
         FIG. 4A  shows a front elevational view of an exemplary button for use with the ankle syndesmosis repair system of  FIG. 1 . 
         FIG. 4B  shows a front elevational view of another exemplary button for use with the ankle syndesmosis repair system of  FIG. 1 . 
         FIG. 4C  shows a cross-sectional view of the button of  FIG. 4A  taken along line  4 C- 4 C of  FIG. 4A . 
         FIG. 5  shows a front elevational view of a suture advancing device of the ankle syndesmosis repair system of  FIG. 1  being moved medially through a fibula and tibia. 
         FIG. 5A  shows a side elevational view of the suture advancing device of  FIG. 5  taken along line  5 A- 5 A of  FIG. 5 . 
         FIG. 5B  shows a perspective view of suture retaining tabs of a proximal end of another suture advancing device in accordance with the invention. 
         FIG. 6A  is a cross-sectional view of the ankle syndesmosis repair system of  FIG. 1 , taken along line  6 A- 6 A of  FIG. 2 . 
         FIG. 6B  is a cross-sectional view of the ankle syndesmosis repair system of  FIG. 1 , taken along line  6 B- 6 B of  FIG. 2 . 
         FIG. 6C  is a cross-sectional view of the ankle syndesmosis repair system of  FIG. 1 , taken along line  6 C- 6 C of  FIG. 2 . 
         FIG. 6D  is a cross-sectional view, similar to  FIG. 6B , of another ankle syndesmosis repair system in accordance with the invention. 
         FIG. 7A  is a cross-sectional view of an ankle syndesmosis repair system extending in a first direction in accordance with the invention. 
         FIG. 7B  is a cross-sectional view of the ankle syndesmosis repair system of  FIG. 7A , extending in a second direction in accordance with the invention. 
         FIG. 7C  is a cross-sectional view of the ankle syndesmosis repair system of  FIG. 7A , extending in a third direction in accordance with the invention. 
         FIG. 7D  is a cross-sectional view, similar to  FIG. 7B , of another ankle syndesmosis repair system in accordance with the invention. 
         FIG. 8  is a plan view of a bone reduction clamp for use with the ankle syndesmosis repair system of  FIG. 1 . 
         FIG. 9  is a right elevational view of a guide of the bone reduction clamp of 
         FIG. 8 . 
         FIG. 10A  is a cross-sectional view of the guide of  FIG. 9 , taken along line  10 A- 10 A of  FIG. 9 . 
         FIG. 10B  is a cross-sectional view of the guide of  FIG. 9 , taken along line  10 B- 10 B of  FIG. 9 . 
         FIG. 10C  is a cross-sectional view of the guide of  FIG. 9 , taken along line  10 C- 10 C of  FIG. 9 . 
         FIG. 11A  shows a cross-sectional view of a length of suture arranged within a bone tunnel in accordance with the invention. 
         FIG. 11B  shows a cross-sectional view of two lengths of suture arranged within a bone tunnel in accordance with the invention. 
         FIG. 12  shows a front elevational view of an ankle syndesmosis repair system and a jig mechanism for guiding a suture advancing device. 
     
    
    
     Like reference numerals will be used to refer to like parts from Figure to Figure in the following description of the drawings. 
     DETAILED DESCRIPTION OF THE INVENTION 
     Referring to  FIG. 1 , an ankle syndesmosis repair system  10  for stabilizing the syndesmosis of an ankle is shown. The system  10  includes a fibula engaging arrangement  12  and a tibia engaging arrangement  14  coupled together by a plurality of lengths of suture  16 . 
     As best shown in  FIG. 1  and  FIGS. 6A-6C , the fibula engaging arrangement  12  is dimensioned to engage a lateral surface of a fibula  18 . For example, the fibula engaging arrangement  12  comprises a fibula bone plate  20  having a concave inner surface  21  (shown in  FIGS. 6A-6C ) configured to conform to the lateral surface of the fibula  18 . 
     Referring now to  FIG. 2 , the fibula bone plate  20  includes an upper screw receiving portion  22  and a lower screw receiving portion  24  connected by a central suture receiving portion  26 . 
     The upper screw receiving portion  22  extends axially upward from the central suture receiving portion  26 , along a longitudinal axis  27  of the fibula bone plate  20 . The upper screw receiving portion  22  includes a plurality of bone screw apertures  28 . In the illustrated non-limiting example, the upper screw receiving portion  22  includes two bone screw apertures  28 . In other examples, the upper screw receiving portion  22  can include one, three, or any other suitable number of bone screw apertures  28 , as necessary. The plurality of bone screw apertures  28  may be sized to receive a plurality of bone screws  30 . The plurality of bone screws  30  are configured to secure the fibula bone plate  20  to the fibula  18 . 
     The lower screw receiving portion  24  extends axially downward from the central suture receiving portion  26 , along the longitudinal axis  27  of the fibula bone plate  20 . The lower screw receiving portion  24  similarly includes a plurality of bone screw apertures  32 . Similarly, in the illustrated non-limiting example, the lower screw receiving portion  24  includes two bone screw apertures  32 . In other examples, the lower screw receiving portion  24  can include one, three, or any other suitable number of bone screw apertures  32 , as necessary. The plurality of bone screw apertures  32  may be sized to receive a plurality of bone screws  34 . The plurality of bone screws  34  are configured to secure the fibula bone plate  20  to the fibula  18 . 
     The central suture receiving portion  26  is disposed between the upper screw receiving portion  22  and the lower screw receiving portion  24 . The central suture receiving portion  26  comprises a first through hole  36 , a second through hole  38 , and a third through hole  40 . The first through hole  36 , the second through hole  38 , and the third through hole  40  are of a smaller inside diameter compared to the bone screw apertures  28  and the bone screw apertures  32 . 
     The first through hole  36  is dimensioned to receive a first length of suture  42 . The first length of suture  42  may be secured within the first through hole  36  by a first fibula button  45  of the fibula engaging arrangement  12 . The second through hole  38  is dimensioned to receive a second length of suture  46 . The second length of suture  46  may be secured within the second through hole  38  by a second fibula button  48  of the fibula engaging arrangement  12 . The third through hole  40  is dimensioned to receive a third length of suture  50 . The third length of suture  50  may be secured within the third through hole  40  by a third fibula button  52  of the fibula engaging arrangement  12 . 
     In the illustrated non-limiting example, the first, second, and third fibula buttons  45 ,  48 ,  52  each have a concave inner surface configured to conform to a surface of the fibula bone plate  20 . In some non-limiting examples, the first, second, and third fibula buttons  45 ,  48 ,  52  may each have a concave inner surface configured to conform to the fibula  18  directly. 
     As illustrated, the first through hole  36  and the second through hole  38  are axially spaced in relation to the longitudinal axis  27  of the fibula bone plate  20 . The first through hole  36  and the second through hole  38  are also transversely spaced in relation to the longitudinal axis  27  of the fibula bone plate  20 . The third through hole  40  is arranged between the first through hole  36  and the second through hole  38 . The third through hole  40  is substantially aligned with the longitudinal axis  27  of the fibula bone plate  20 . 
     It should be appreciated that, while in the non-limiting illustrated example there are three through holes  36 ,  38 ,  40 , in some other non-limiting examples, the central suture receiving portion  26  may comprise more or less than three through holes. Further, while in the non-limiting illustrated example the first, second, and third through holes  36 ,  38 ,  40  are generally aligned, in other non-limiting examples the through holes can be misaligned or in other arrangements generally as necessary for a given desired treatment. 
     Referring now to  FIG. 3 , the tibia engaging arrangement  14  may be dimensioned to engage a medial surface of a tibia  54 . For example, the tibia engaging arrangement  14  may comprise a tibia bone plate  56  having a concave inner surface  58  (shown in  FIGS. 6A-6C ) configured to conform to the medial surface of the tibia  54 . The tibia bone plate  56  comprises a first passageway  60 , a second passageway  62 , and a third passageway  64 . 
     The first passageway  60  is dimensioned to receive the first length of suture  42 . The first length of suture  42  may be secured within the first passageway  60  by a first tibia button  66  of the tibia engaging arrangement  14 . The second passageway  62  is dimensioned to receive the second length of suture  46 . The second length of suture  46  may be secured within the second passageway  62  by a second tibia button  68  of the tibia engaging arrangement  14 . The third passageway  64  is dimensioned to receive the third length of suture  50 . The third length of suture  50  may be secured within the third passageway  64  by a third tibia button  70  of the tibia engaging arrangement  14 . 
     In the illustrated non-limiting example, the first, second, and third tibia buttons  66 ,  68 ,  70  each have a concave inner surface configured to conform to a surface of the tibia bone plate  56 . In some non-limiting examples, the first, second, and third tibia buttons  66 ,  68 ,  70  may each have a concave inner surface configured to conform to the tibia  54  directly. 
     Accordingly, in some instances, the tibia bone plate  56  may not be included in the tibia engaging arrangement  14 , and the first, the second, and the third lengths of suture  42 ,  46 ,  50  may be secured by the first, second, and third tibia buttons  66 ,  68 ,  70 , which may directly contact the tibia  54 . In these instances, the first, second, and third buttons  66 ,  68 ,  70  may have a larger diameter to prevent damage of the tibial metaphysis by increasing the surface area that is in contact with the tibia  54 . For example, the first, second, and third tibia buttons  66 ,  68 ,  70  may have a diameter of 4 millimeters to 15 millimeters and may be configured to conform directly to the tibia  54 . 
     As illustrated, the first passageway  60  and the second passageway  62  are axially spaced in relation to a longitudinal axis  72  of the tibia bone plate  56 . The first passageway  60  and the second passageway  62  are also transversely spaced in relation to the longitudinal axis  72  of the tibia bone plate  56 . The third passageway  64  is arranged between the first passageway  60  and the second passageway  62 . The third passageway  64  is substantially aligned with the longitudinal axis of the tibia bone plate  56 . 
     It should similarly be appreciated that, while in the non-limiting illustrated example there are three passageways  60 ,  62 ,  64 , in some other non-limiting examples, the tibia bone plate  56  may comprise more or less than three passageways. Further, while in the non-limiting illustrated example of  FIG. 3 , the first, second, and third passageways  60 ,  62 ,  64  are generally aligned, in other non-limiting examples, the passageways can be misaligned or in other arrangements generally as necessary for a given desired treatment. Additionally, the passageways  60 ,  62 ,  64  of the tibia bone plate  56  may generally correspond to the through holes  36 ,  38 ,  40  of the fibula bone plate  20 . 
     It should be appreciated that the non-limiting shape of the tibia bone plate  56  illustrated in  FIG. 3  may be of a more or less oblong or rectangular shape. For example,  FIG. 3A  illustrates another embodiment of a tibia engaging arrangement  14 A. The tibia engaging arrangement  14 A may be dimensioned to engage a medial surface of a tibia  54 . For example, the tibia engaging arrangement  14 A may comprise a tibia bone plate  56 A having a concave inner surface configured to conform to the medial surface of the tibia  54 . The tibia bone plate  56 A comprises a first passageway  60 A, a second passageway  62 A, and a third passageway  64 A. 
     The first passageway  60 A is dimensioned to receive the first length of suture  42 . The first length of suture  42  may be secured within the first passageway  60 A by a first tibia button  66 A of the tibia engaging arrangement  14 A. The second passageway  62 A is dimensioned to receive the second length of suture  46 . The second length of suture  46  may be secured within the second passageway  62 A by a second tibia button  68 A of the tibia engaging arrangement  14 A. The third passageway  64 A is dimensioned to receive the third length of suture  50 . The third length of suture  50  may be secured within the third passageway  64 A by a third tibia button  70 A of the tibia engaging arrangement  14 A. 
     In the illustrated non-limiting example, the first, second, and third tibia buttons  66 A,  68 A,  70 A each have a concave inner surface configured to conform to a surface of the tibia bone plate  56 A. In some non-limiting examples, the first, second, and third tibia buttons  66 A,  68 A,  70 A may each have a concave inner surface configured to conform to the tibia  54  directly. 
     Accordingly, in some instances, the tibia bone plate  56 A may not be included in the tibia engaging arrangement  14 A, and the first, the second, and the third lengths of suture  42 ,  46 ,  50  may be secured by the first, second, and third tibia buttons  66 A,  68 A,  70 A, which may directly contact the tibia  54 . In these instances, the first, second, and third buttons  66 A,  68 A,  70 A may have a larger diameter to prevent damage of the tibial metaphysis by increasing the surface area that is in contact with the tibia  54 . For example, the first, second, and third tibia buttons  66 A,  68 A,  70 A may have a diameter of 4 millimeters to 15 millimeters and may be configured to conform directly to the tibia  54 . 
     As illustrated, the first passageway  60 A and the second passageway  62 A are axially spaced in relation to a longitudinal axis of the tibia bone plate  56 A. The first passageway  60 A and the second passageway  62 A are also transversely spaced in relation to the longitudinal axis of the tibia bone plate  56 A. The third passageway  64 A is arranged between the first passageway  60 A and the second passageway  62 A. The third passageway  64 A is substantially aligned with the longitudinal axis of the tibia bone plate  56 A. 
     Referring now to  FIG. 3B , another embodiment of a tibia engaging arrangement  14 B may be dimensioned to engage the medial surface of the tibia  54 . For example, the tibia engaging arrangement  14 B may comprise a tibia bone plate  56 B configured to conform to the medial surface of the tibia  54 . The tibia bone plate  56 B comprises an upper screw receiving portion  222  and a lower screw receiving portion  224  connected by a central suture receiving portion  226 . 
     The upper screw receiving portion  222  extends axially upward from the central suture receiving portion  226 , along a longitudinal axis  72 B of the tibia bone plate  56 B. The upper screw receiving portion  222  includes a plurality of bone screw apertures  228 . In the illustrated non-limiting example, the upper screw receiving portion  222  includes two bone screw apertures  228 . In other examples, the upper screw receiving portion  222  can include one, three, or any other suitable number of bone screw apertures  228 , as necessary. The plurality of bone screw apertures  228  may be sized to receive a plurality of bone screws  230 . The plurality of bone screws  230  are configured to secure the tibia bone plate  56 B to the tibia  54 . 
     The lower screw receiving portion  224  extends axially downward from the central suture receiving portion  226 , along the longitudinal axis  72 B of the tibia bone plate  56 B. The lower screw receiving portion  224  similarly includes a plurality of bone screw apertures  232 . Similarly, in the illustrated non-limiting example, the lower screw receiving portion  224  includes two bone screw apertures  232 . In other examples, the lower screw receiving portion  224  can include one, three, or any other suitable number of bone screw apertures  232 , as necessary. The plurality of bone screw apertures  232  may be sized to receive a plurality of bone screws  234 . The plurality of bone screws  234  are configured to secure the tibia bone plate  56 B to the tibia  54 . 
     The central suture receiving portion  226  is disposed between the upper screw receiving portion  222  and the lower screw receiving portion  224 . The central suture receiving portion  226  comprises a first passageway  60 B, a second passageway  62 B, and a third passageway  64 B. 
     The first passageway  60 B is dimensioned to receive the first length of suture  42 . The first length of suture  42  may be secured within the first passageway  60 B by a first tibia button  66 B of the tibia engaging arrangement  14 B. The second passageway  62 B is dimensioned to receive the second length of suture  46 . The second length of suture  46  may be secured within the second passageway  62 B by a second tibia button  68 B of the tibia engaging arrangement  14 B. The third passageway  64 B is dimensioned to receive the third length of suture  50 . The third length of suture  50  may be secured within the third passageway  64 B by a third tibia button  70 B of the tibia engaging arrangement  14 B. 
     In the illustrated non-limiting example, the first, second, and third tibia buttons  66 B,  68 B,  70 B each have a concave inner surface configured to conform to a surface of the tibia bone plate  56 B. In some non-limiting examples, the first, second, and third tibia buttons  66 B,  68 B,  70 B may each have a concave inner surface configured to conform to the tibia  54  directly. 
     As illustrated, the first passageway  60 B and the second passageway  62 B are axially spaced in relation to the longitudinal axis  72 B of the tibia bone plate  56 B. The first passageway  60 B and the second passageway  62 B are also transversely spaced in relation to the longitudinal axis  72 B of the tibia bone plate  56 B. The third passageway  64 B is arranged between the first passageway  60 B and the second passageway  62 B. The third passageway  64  is substantially aligned with the longitudinal axis  72 B of the tibia bone plate  56 B. 
     It should similarly be appreciated that, while in the non-limiting illustrated example there are three passageways  60 B,  62 B,  64 B, in some other non-limiting examples, the tibia bone plate  56  may comprise more or less than three passageways. 
     Referring now to  FIGS. 4A and 4C , an exemplary button  74  is shown. The exemplary button  74  may be substantially similar to any of the fibula buttons  45 ,  48 ,  52  and/or any of the tibia buttons  66 ,  68 ,  70 , such that the following description of the exemplary button  74  may also apply to any of the fibula buttons  45 ,  48 ,  52  and/or any of the tibia buttons  66 ,  68 ,  70 . 
     As illustrated in  FIGS. 4A and 4C , the button  74  can include a single through hole  76  having an inner wall  76   w  defining a conical shape for the hole  76 . The wider end of the conical shape of the hole  76  allows one to more easily guide the suture into the hole  76 . Each of the through holes  76  may be dimensioned to receive any of the first, second, and third lengths of suture  42 ,  46 ,  50 . The narrower end of the conical shape of the through holes  76  may further be dimensioned only slightly larger than a thickness of the corresponding length of suture  42 ,  46 ,  50  received therein. As such, the corresponding length of suture  42 ,  46 ,  50  can be passed through the through hole  76 , and can subsequently have a knot tied thereon, preventing the corresponding length of suture  42 ,  46 ,  50  from backing out of the through hole  76 . 
     As illustrated in  FIG. 4B , another embodiment of a button  174  includes a pair of through holes  176 . Each of the through holes  176  may be dimensioned to receive any of the first, second, and third lengths of suture  42 ,  46 ,  50 . The through holes  176  may further be dimensioned only slightly larger than a thickness of the corresponding length of suture  42 ,  46 ,  50  received therein. Because the button  174  includes a pair of through holes  176 , the corresponding length of suture  42 ,  46 ,  50  may be passed through each of the through holes  176 , and can subsequently have the knot tied thereon to prevent the corresponding length of suture  42 ,  46 ,  50  from backing out of the through holes  176 . 
     Looking now at  FIGS. 1A and 1B , another embodiment of the tibia engaging arrangement  14 A may be dimensioned to engage a medial surface of a tibia  54  having a fracture F. The tibia engaging arrangement  14 A comprises a tibia bone plate  156  having an inner surface  258  (shown in  FIG. 1A ) configured to conform to the medial surface of the tibia  54 . The tibia bone plate  156  includes a longitudinal section  157  and a pair of flanges  158 ,  159  that extend outwardly from a distal end of the tibia bone plate  156 . The tibia bone plate  156  also includes a first passageway  161 , a second passageway  162 , a third passageway  163 , a fourth passageway  164 , a fifth passageway  165  and a sixth passageway  166 . The first passageway  160  is dimensioned to receive the first length of suture  42 . The first length of suture  42  may be secured within the first passageway  60  by a first tibia button  66  of the tibia engaging arrangement  14 A. The second passageway  162  is dimensioned to receive the second length of suture  46 . The second length of suture  46  may be secured within the second passageway  162  by a second tibia button  68  of the tibia engaging arrangement  14 A. The third passageway  163  is dimensioned to receive the third length of suture  50 . The third length of suture  50  may be secured within the third passageway  163  by a third tibia button  70  of the tibia engaging arrangement  14 A. The fourth passageway  164 , the fifth passageway  165 , and the sixth passageway  166  may each receive a bone screw when the tibia bone plate  156  engages a medial surface of a tibia  54 . 
     Referring now to  FIG. 2A , another embodiment of a fibula bone plate  320  includes an upper screw receiving portion  322  and a lower screw receiving portion  324  connected by a central suture receiving portion  326 . The upper screw receiving portion  322  extends axially upward from the central suture receiving portion  326 , along a longitudinal axis of the fibula bone plate  20 A. The upper screw receiving portion  322  includes a plurality of bone screw apertures  328 . In the illustrated non-limiting example, the upper screw receiving portion  322  includes six bone screw apertures  328 . In other examples, the upper screw receiving portion  322  can include one, three, or any other suitable number of bone screw apertures  328 , as necessary. The plurality of bone screw apertures  328  may be sized to receive a plurality of bone screws  330 . The plurality of bone screws  330  are configured to secure the fibula bone plate  20 A to the fibula  18 . 
     The lower screw receiving portion  324  extends axially downward from the central suture receiving portion  326 , along the longitudinal axis of the fibula bone plate  20 A. The lower screw receiving portion  324  similarly includes a plurality of bone screw apertures  332 . Similarly, in the illustrated non-limiting example, the lower screw receiving portion  324  includes seven bone screw apertures  332 . In other examples, the lower screw receiving portion  324  can include one, three, or any other suitable number of bone screw apertures  332 , as necessary. The plurality of bone screw apertures  332  may be sized to receive a plurality of bone screws  334 . The plurality of bone screws  334  are configured to secure the fibula bone plate  20 A to the fibula  18 . 
     The central suture receiving portion  326  is disposed between the upper screw receiving portion  322  and the lower screw receiving portion  324 . The central suture receiving portion  326  comprises a first through hole  336 , a second through hole  338 , and a third through hole  340 . 
     The first through hole  336  is dimensioned to receive a first length of suture  42 . The first length of suture  42  may be secured within the first through hole  336  by a first fibula button  45  of the fibula engaging arrangement  12 . The second through hole  338  is dimensioned to receive a second length of suture  46 . The second length of suture  46  may be secured within the second through hole  338  by a second fibula button  48  of the fibula engaging arrangement  12 . The third through hole  340  is dimensioned to receive a third length of suture  50 . The third length of suture  50  may be secured within the third through hole  340  by a third fibula button  52  of the fibula engaging arrangement  12 . 
     It should be appreciated that, while in the non-limiting illustrated example there are three through holes  336 ,  338 ,  340 , in some other non-limiting examples, the central suture receiving portion  326  may comprise more or less than three through holes. Further, while in the non-limiting illustrated example the first, second, and third through holes  336 ,  338 ,  340  are generally aligned, in other non-limiting examples the through holes can be misaligned or in other arrangements generally as necessary for a given desired treatment. 
     Referring now to  FIGS. 5 and 5A , a suture advancing device  80  comprises an elongated shaft  82  extending along a longitudinal axis  84 . The suture advancing device  80  may comprise, for example, a K-wire or any other suitable suture advancing device. The suture advancing device  80  may comprise Nitinol or stainless steel. The suture advancing device  80  has a distal end  86  and a proximal end  88 . The distal end  86  terminates in a pointed tip  90  having four generally triangular sides  91 . The proximal end  88  includes an aperture  89  dimensioned to individually receive any of the first length of suture  42 , the second length of suture  46 , and the third length of suture  50 . 
     As illustrated, the suture advancing device  80  has a longitudinal length exceeding a transverse distance from an anteromedial surface of the tibia  54  to the posterolateral surface of the fibula  18  at the distal tibiofibular joint. As such, the suture advancing device  80  can form a bone tunnel extending from the anteromedial surface of the tibia  54  to the posterolateral surface of the fibula  18  when the suture advancing device  80  is moved through the tibia  54  and the fibula  18  at the distal tibiofibular joint. 
     In some non-limiting examples, the suture advancing device  80  may have a diameter in a range of 0.5 millimeters to 2.5 millimeters. For example, the suture advancing device  80  may have a diameter of approximately 1 millimeter. In some other non-limiting examples, the suture advancing device  80  may have a diameter in a range of 0.1 millimeters to 2.5 millimeters. 
     In some non-limiting examples, each of the first, second, and third fibula buttons  45 ,  48 ,  52  and each of the first, second, and third tibia buttons  66 ,  68 ,  70  have a minimum outside diameter that is larger than the outside diameter of the suture advancing device  80 . As such, each of the first, second, and third fibula buttons  45 ,  48 ,  52  and each of the first, second, and third tibia buttons  66 ,  68 ,  70  are dimensioned such that none of the first, second, and third fibula buttons  45 ,  48 ,  52  or the first, second, and third tibia buttons  66 ,  68 ,  70  can pass through a bone tunnel created by the suture advancing device  80 , as will be described below. 
     Referring now to  FIG. 5B , another embodiment of a suture advancing device  80 A comprises an elongated shaft  82 A extending along a longitudinal axis  84 A. The suture advancing device  80 A may comprise, for example, a K-wire or any other suitable suture advancing device. The suture advancing device  80 A has a distal end that terminates in a pointed tip having four generally triangular sides identical to the suture advancing device  80  of  FIGS. 5 and 5A . The suture advancing device  80 A has a proximal end  88 A including a pair of suture retaining tabs  89 A. A length of suture may be inserted between the suture retaining tabs  89 A and the suture retaining tabs  89 A may be moved together in directions D 1  and D 2  in order to capture the length of suture between the suture retaining tabs  89 A. A tooth  92 A of the suture retaining tabs  89 A can also engage the length of suture. One advantage of the suture advancing device  80 A is that no doubling over of suture is required in order to pass the length of suture through the bone tunnel extending from the anteromedial surface of the tibia  54  to the posterolateral surface of the fibula  18  when the suture advancing device  80 A is moved through the tibia  54  and the fibula  18  at the distal tibiofibular joint. 
     Referring now to  FIGS. 6A-6C , when the ankle syndesmosis repair system  10  is implanted on the syndesmosis of the ankle, the first through hole  36  of the fibula bone plate  20  and the first passageway  60  of the tibia bone plate  56  are coaxially arranged about a first longitudinal axis  92  (shown in  FIG. 6A ). The second through hole  38  of the fibula bone plate  20  and the second passageway  62  of the tibia bone plate  56  are coaxially arranged about a second longitudinal axis  94  (shown in  FIG. 6C ). The third through hole  40  of the fibula bone plate  20  and the third passageway  64  of the tibia bone plate  56  are coaxially arranged about a third longitudinal axis  96  (shown in  FIG. 6B ). 
     As illustrated, the first through hole  36  is arranged on an anterolateral side of the fibula  18  and the first passageway  60  is arranged on a posteromedial side of the tibia  54 . Further, the first through hole  36  and the first passageway  60  are dimensioned such that the suture advancing device  80  or the suture advancing device  80 A can pass through each of the first through hole  36  and the first passageway  60 . As such, the suture advancing device  80  or the suture advancing device  80 A can be used to create a first bone tunnel  98  extending, along the first longitudinal axis  92 , from the anterolateral side of the fibula  18  to the posteromedial side of the tibia  54 . 
     The second through hole  38  is arranged on the lateral side of the fibula  18  and the second passageway  62  is arranged on the medial side of the tibia  54 . Further, the second through hole  38  and the second passageway  62  are dimensioned such that the suture advancing device  80  or the suture advancing device  80 A can pass through each of the second through hole  38  and the second passageway  62 . As such, the suture advancing device  80  or the suture advancing device  80 A can be used to create a second bone tunnel  100  extending, along the second longitudinal axis  94 , from the lateral side of the fibula  18  to the medial side of the tibia  54 . 
     The third through hole  40  is arranged on the posterolateral side of the fibula  18  and the third passageway  64  is arranged on the anteromedial side of the tibia  54 . Further, the third through hole  40  and the third passageway  64  are dimensioned such that the suture advancing device  80  or the suture advancing device  80 A can pass through each of the third through hole  40  and the third passageway  64 . As such, the suture advancing device  80  or the suture advancing device  80 A can be used to create a third bone tunnel  102  extending, along the third longitudinal axis  96 , from the posterolateral side of the fibula  18  to the anteromedial side of the tibia  54 . 
     As illustrated, the first longitudinal axis  92  and the second longitudinal axis  94  are angled with respect to each other in the axial view of the fibula  18  or the tibia  54 . Further, the third longitudinal axis  96  is arranged between the first longitudinal axis  92  and the second longitudinal axis  94 , such that the third longitudinal axis  96  is at an angle with respect to each of the first longitudinal axis  92  and the second longitudinal axis  94  in the axial view of the fibula  18  or the tibia  54 . 
     Looking now at  FIG. 6D , another embodiment of an ankle syndesmosis repair system  10 A for stabilizing the syndesmosis of an ankle is shown. The surgeon may first fix the fibula bone plate  20  onto the lateral side of the fibula  18 . The surgeon may then use the suture advancing device  80 A, having the first length of suture  450  received between the suture retaining tabs  89 A, to create a first bone tunnel  490  through the fibula  18 . Once the first bone tunnel  490  is created, the suture advancing device  80 A can be advanced medially to create a second bone tunnel  492  through the tibia  54  until the suture advancing device  80 A is completely through the second bone tunnel  492 . The suture advancing device  80 A can then be advanced laterally to create a third bone tunnel  494  through the tibia  54  and then the suture advancing device  80 A can be directed laterally back through the first bone tunnel  490  in the fibula  18 . The surgeon may then remove the length of suture  450  from the suture advancing device  80 A, move the fibula  18  in direction Y to contact the tibia  54 , and secure the length of suture  450  at opposite ends using the fibula button  52 . Optionally, the length of suture  450  can be passed through adjacent holes in a tibia button located adjacent the medial openings of the second bone tunnel  492  and the third bone tunnel  494 . While  FIG. 6D  shows bone tunnels  490 ,  492  and  494  at an axial plane along line  6 B- 6 B of  FIG. 2 , additional similar bone tunnels can be provided at an axial plane along line  6 A- 6 A of  FIG. 2  and at an axial plane along line  6 C- 6 C of  FIG. 2  allowing for the use of additional suture and an additional fibula button with each of these additional bone tunnels in the same manner of attachment shown in  FIG. 6D . 
     Referring now to  FIGS. 7A-7C , an ankle syndesmosis repair system  10 B for stabilizing the syndesmosis of an ankle according to another embodiment is illustrated. The ankle syndesmosis repair system is generally similar to the ankle syndesmosis repair system  10  illustrated in  FIGS. 6A-6C , therefore like-reference numbers will be used where applicable. Like the ankle syndesmosis repair system  10 , the ankle syndesmosis repair system  10 B includes a fibula bone plate  20 B having a concave inner surface  21 B configured to conform to the lateral surface of the fibula  18 . 
     The fibula bone plate  20 B includes a first through hole  36 B that is dimensioned to receive a first length of suture  42 B which may be secured within the first through hole  36 B by a first fibula button  45 B. A second through hole  38 B within the fibula bone plate  20 B is dimensioned to receive a second length suture  46 B that can be secured within the second through hole  38 B by a second fibula button  48 B. A third through hole  40 B within the fibula bone plate  20 B is dimensioned to receive a third length suture  50 B that can be secured within the third through hole  40 B by a third fibula button  52 B 
     As illustrated in  FIG. 7A , the ankle syndesmosis repair system  10 B further includes a first anchor  80 B that can be secured within a first bone tunnel  98 B that extends through the fibula  18  and partially into the tibia  54 . In the illustrated embodiment, the first anchor  80 B is secured within the tibia  54 . When the ankle syndesmosis repair system  10 B is implanted on the syndesmosis of the ankle, the first through hole  36 B of the first bone tunnel  98 B are coaxially arranged about a first longitudinal axis  92 B. As illustrated, the first through hole  36 B is arranged on an anterolateral side of the fibula  18 . 
     In some embodiments, the fibula bone plate  20 B may first engage and be fixed to the fibula  18 . The first bone tunnel  98 B may then be formed by a variety of tunnel forming devices. The first through hole  36 B and the first bone tunnel  98 B are dimensioned such that a suture advancing device (not shown) can pass through each of the first through hole  36 B and the first bone tunnel  98 B. In use, the suture advancing device may be equipped with the first anchor  80 B removably attached at a distal end and the first length of suture  42 B secured to the first anchor  80 B. The suture advancing device may then be moved through the first bone tunnel  98 B in the fibula  18  and through the lateral cortex of the tibia of the distal tibiofibular joint until the first anchor  80 B is located proximate to a tunnel end  99 B within the first bone tunnel  98 B and does not penetrate through the medial cortex of the distal tibia  54 . 
     The first anchor  80 B may then be released from the suture advancing device and deployed to engage side walls of the first bone tunnel  98 B. In other embodiments, the first anchor  80 B may include one or more of barbs, threads, arms, etc. that provide a securing feature to secure the first anchor  80 B within the first bone tunnel  98 B. Following the securement of the first anchor  80 B and the first length of suture  42 B within the tibia  54 , the first length suture  42 B may then be secured at a second end within the first through hole  36 B by the first fibula button  45 B. 
     As illustrated in  FIG. 7B , the ankle syndesmosis repair system  10 B further includes a third anchor  84 B that can be secured within a third bone tunnel  102 B that extends through the fibula  18  and partially into the tibia  54 . In the illustrated embodiment, the third anchor  84 B is secured within the tibia  54 . When the ankle syndesmosis repair system  10 B is implanted on the syndesmosis of the ankle, the third through hole  40 B of the third bone tunnel  102 B are coaxially arranged about a third longitudinal axis  96 B. As illustrated, the third through hole  40 B is arranged on an anterolateral side of the fibula  18 . 
     The third bone tunnel  102 B may be formed by a variety of tunnel forming devices. The third through hole  40 B and the third bone tunnel  102 B are dimensioned such that the suture advancing device can pass through each of the third hole  40 B and the third bone tunnel  102 B. In use, the suture advancing device may be equipped with the third anchor  84 B removably attached at a distal end and the third length of suture  50 B secured to the third anchor  84 B. The suture advancing device may then be moved through the third bone tunnel  102 B until the third anchor  84 B is located proximate to a tunnel end  103 B within the third bone tunnel  102 B. 
     The third anchor  84 B may then be released from the suture advancing device and deployed to engage side walls of the third bone tunnel  102 B. In other embodiments, the third anchor  84 B may include one or more of barbs, threads, arms, etc. that provide a securing feature to secure the third anchor  84 B within the third bone tunnel  102 B. Following the securement of the third anchor  84 B and the third length of suture  50 B within the tibia  54 , the third length suture  50 B may then be secured at a second end within the third through hole  40 B by the third fibula button  52 B. 
     As illustrated in  FIG. 7C , the ankle syndesmosis repair system  10 B further includes a second anchor  82 B that can be secured within a second bone tunnel  100 B that extends through the fibula  18  and partially into the tibia  54 . In the illustrated embodiment, the second anchor  82 B is secured within the tibia  54 . When the ankle syndesmosis repair system  10 B is implanted on the syndesmosis of the ankle, the second through hole  38 B of the second bone tunnel  100 B are coaxially arranged about a second longitudinal axis  94 B. As illustrated, the second through hole  38 B is arranged on an anterolateral side of the fibula  18 . 
     The second bone tunnel  100 B may be formed by a variety of tunnel forming devices. The second through hole  38 B the second bone tunnel  100 B are dimensioned such that the suture advancing device can pass through each of the second hole  38 B and the second bone tunnel  100 B. In use, the suture advancing device may be equipped with the second anchor  82 B removably attached at a distal end and the second length of suture  46 B secured to the second anchor  82 B. The suture advancing device may then be moved through the second bone tunnel  100 B until the second anchor  82 B is located proximate to a tunnel end  101 B within the second bone tunnel  100 B. 
     The second anchor  82 B may then be released from the suture advancing device and deployed to engage side walls of the second bone tunnel  100 B. In other embodiments, the second anchor  82 B may include one or more of barbs, threads, arms, etc. that provide a securing feature to secure the second anchor  82 B within the second bone tunnel  100 B. Following the securement of the second anchor  82 B and the second length of suture  46 B within the tibia  54 , the second length suture  46 B may then be secured at a second end within the second through hole  38 B by the second fibula button  48 B. 
     In the illustrated examples of  FIGS. 7A-7C , each of the first, second, and third fibula buttons  45 B,  48 B,  52 B have a concave inner surface configured to conform to the surface of the fibula bone plate  20 B. However, in other embodiments, the first, second, and third fibula buttons  45 B,  48 B,  52 B may each have a concave inner surface configured to conform to the fibula  18  directly. Further, as illustrated, the first through hole  36 B and the second through hole  38 B are axially spaced in relation to the fibula bone plate  20 B. The third through hole  40 B is arranged between the first through hole  36 B and the second through hole  38 B. Additionally, each of the anchors described above can have a longitudinal length exceeding a transverse distance from the posterolateral (or lateral, or anterolateral) surface of the fibula at the distal tibiofibular joint to the intraosseous anteromedial (or medial, or posteromedial) aspect of the tibia without exiting the medial surface of the tibia. 
     In some embodiments, suture anchors can form a bone tunnel extending from the lateral surface of the fibula at the distal tibiofibular joint to the intraosseous aspect of the tibia. When the suture anchor is moved through the distal fibula and the lateral cortex of the distal tibia, the bone tunnels can have substantially the same diameter as the statures. For example, the diameters of the bone tunnels may being approximately within the range of 0.5 millimeters to 2.5 millimeters, 
     It should be appreciated that, while in the non-limiting illustrated example shown in  FIGS. 7A-7C , there are three through holes  36 B,  38 B,  40 B, in some other non-limiting examples, the fibula bone plate  20 B may include more or less than three through holes. Further, with reference to the ankle syndesmosis repair system  10 B illustrated in  FIGS. 7A-7C , it should be understood that any of the forming of the first, second, and third bone tunnels  98 B,  100 B,  102 B and the securement of the first, second, and third lengths of sutures  42 B,  46 B,  50 B can occur in any order, and that the order described above is by way of example. 
     In general, the ankle syndesmosis repair system  10 B provides a suture anchor device that has the ability to be placed parallel to the anterior inferior tibiofibular ligament or posterior inferior tibiofibular ligament. Use of such a suture anchor device prevents exposure devices on the medial cortex of the distal tibia. This can reduce the chance of skin irritation, device loosening, or risk of device dispositioning. Additionally, in general, the bone tunnel diameters required for the ankle syndesmosis repair system  10 B can be substantially the same size as the suture or suture anchor, thereby increases the stability of the fixation construction. 
     Some embodiments of the invention include a pair of suture anchors, such as suture anchors  80 B and  82 B, and a pair of first and second length sutures, such as sutures  42 B and  46 B, extending through a single fibula button, such as the fibula button  48 B. This configuration allows the pair of first and second suture anchors to be fired through a single plate hole, such as through hole  36 B. As illustrated in  FIGS. 7A-7C , the suture lengths are anchored at a middle section of the suture and two ends extend from each of the first, second, and third fibula buttons  45 B,  48 B,  52 B. However, in other embodiments, the pair of suture anchors may be secured to a single end of the pair of first and second suture lengths, similar to the arrangement described below with reference to  FIG. 7D . 
     Referring now to  FIG. 7D , an ankle syndesmosis repair system  10 D is illustrated. The ankle syndesmosis repair system  10 D is substantially similar to the ankle syndesmosis repair system  10 B described above; however, a first length suture  42 D extends from a first end at the lateral side of the fibula  18  to an anteromedial portion of the tibia  54 . Additional details of the ankle syndesmosis repair system  10 D will be avoided to avoid repetition. It should be appreciated, however, that additional bone tunnel configurations as illustrated in  FIGS. 7A-7C  can be applied to the ankle syndesmosis repair system  10 D, though not shown. 
     Referring now to  FIG. 8 , a bone reduction clamp  700  configured for use with the ankle syndesmosis repair system  10  is shown. The bone reduction clamp  700  includes a first arm  702 , a second arm  704 , and an adjustment mechanism  706 . 
     The first arm  702  includes a concave inner surface  708  configured to conform to one of the lateral surface of the fibula  18  or the medial surface of the tibia  54 . The second arm  704  is arranged opposite the first arm  702  and similarly includes a concave inner surface  708  configured to conform to one of the lateral surface of the fibula  18  or the medial surface of the tibia  54 . 
     The adjustment mechanism  706  is configured to move the second arm  704  toward or away from the first arm  702 . The adjustment mechanism  706  includes a position adjustor  709  that may be rotatable with respect to the first arm  702 . The position adjustor  709  may have an externally threaded post  712  that engages an internally threaded hole of the second arm  704  to translate the second arm  704  relative to the first arm  702 . For example, rotation of the position adjustor  709  in a first direction may move the second arm  704  toward the first arm  702 . Additionally, rotation of the position adjustor  709  in a second direction may move the second arm  704  away from the first arm  702 . 
     In some instances, the position adjustor  709  may alternatively be rotatable with respect to the second arm  704 . In these instances, the externally threaded post  712  may alternatively engage an internally threaded hole of the first arm  702  to translate the first arm  702  relative to the second arm  704 . For example, rotation of the position adjustor  709  in a first direction may move the first arm  702  toward the second arm  704 . Additionally, rotation of the position adjustor  709  in a second direction may move the first arm  702  away from the second arm  704 . 
     In the illustrated non-limiting example, the second arm  704  further includes a guide  710  configured to guide a bone piercing tool, such as the suture advancing device  80 . In some other examples, the first arm  702  can alternatively include the guide  710 . The guide  710  has a first guide hole  714 , a second guide hole  715 , and a third guide hole  716 . 
     Referring now to  FIGS. 10A-10C , the first guide hole  714  has a first longitudinal axis  718  (shown in  FIG. 10A ), the second guide hole  715  has a second longitudinal axis  720  (shown in  FIG. 10C ), and the third guide hole  716  has a third longitudinal axis  722  (shown in  FIG. 10B ). 
     The first longitudinal axis  718  and the second longitudinal axis  720  are angled with respect with each other. Accordingly, the suture advancing device  80 , or any other suitable bone piercing tool, is guided along a first path when being passed through the first guide hole  714  and along a second path when being passed through the second guide hole  715 . The first path and the second path are at an oblique angle. 
     Further, the third longitudinal axis  722  is arranged between the first longitudinal axis  718  and the second longitudinal axis  720 , such that the third longitudinal axis  722  is angled with respect to each of the first longitudinal axis  718  and the second longitudinal axis  720 . Accordingly, the suture advancing device  80 , or any other suitable bone piercing tool, is guided along a third path when being passed through the third guide hole  716 , and the third path is at an oblique angle with respect to each of the first path and the second path. 
     As such, in some instances, the bone reduction clamp  700  may be configured to clamp the fibula  18  and the tibia  54  in a desired orientation, and to subsequently guide the suture advancing device  80  to create various bone tunnels, while avoiding various neurovascular elements in the ankle syndesmosis. 
     Now that the general structure of the ankle syndesmosis repair system  10  and the bone reduction clamp  700  have been described above, an exemplary method of use will be described below. It should be appreciated that the following method of use is provided as an example, and is in no way meant to be limiting. 
     During use, a surgeon may implant the ankle syndesmosis repair system  10  to fix the syndesmosis of the ankle. The surgeon may first fix the fibula engaging arrangement  12  onto the lateral side of the fibula  18  by screwing the bone screws  30 ,  34 , through the bone screw apertures  28 ,  32  of the upper and lower screw receiving portions  22 ,  24  of the fibula bone plate  20 . The surgeon may then use the suture advancing device  80 , having the first length of suture  42  received therein and extending through the aperture at the proximal end  88 , to create the first bone tunnel  98  through the fibula  18  and the tibia  54 . A powered driver may be used to advance the suture advancing device  80 . Once the first bone tunnel  98  is created, the suture advancing device  80  can be advanced until the aperture at the proximal end  88  is adjacent the outer surface of the fibula  18 . The surgeon may then pull the suture advancing device  80  completely through the first bone tunnel  98 . 
     The surgeon may then secure the first length of suture  42  within the first bone tunnel  98  using the first fibula button  45  and the first tibia button  66 . Specifically, the surgeon may thread a first section of the first length of suture  42  through the first fibula button  45  and tie a knot in the first section of the first length of suture  42  to prevent the first length of suture  42  from backing out of or being pulled through the first fibula button  45 . The surgeon may then thread a second section of the first length of suture  42  through the first passageway  60  of the tibia bone plate  56  and first tibia button  66  and tie a knot in the second section of the first length of suture  42  to prevent the second section of the first length of suture  42  from backing out of or being pulled through the first tibia button  66 . 
     The surgeon may then similarly secure the second and third lengths of suture  46 ,  50  within the second and third bone tunnels  100 ,  102  using the second and third fibula buttons  48 ,  52  and the second and third tibia buttons  68 ,  70 , as described above with reference to securing the first length of suture  42  within the first bone tunnel  98 . As described above, in some instances, the tibia buttons  66 ,  68 ,  70  can be used to secure the lengths of suture  42 ,  46 ,  50  within the bone tunnels  98 ,  100 ,  102  without the tibia bone plate  56 , with the tibia buttons  66 ,  68 ,  70  directly contacting the tibia  54 . 
     As described above, the first bone tunnel  98  and the second bone tunnel  100  are angled with respect to each other in the axial view of the fibula  18  or the tibia  54 . Accordingly, the suture advancing device  80  is guided along a first path when creating the first bone tunnel  98  and a second path when creating the second bone tunnel  100 , the first path and the second path being at an oblique angle in the axial view of the fibula  18  or the tibia  54 . 
     Further, the third bone tunnel  102  is arranged between the first bone tunnel  98  and the second bone tunnel  100 , such that the third bone tunnel  102  is at an angle with respect to each of the first bone tunnel  98  and the second bone tunnel  100  in the axial view of the fibula  18  or the tibia  54 . As such, the suture advancing device  80  is guided along a third path when creating the third bone tunnel  102 , and the third path is at an oblique angle with respect to each of the first path and the second path in the axial view of the fibula  18  or the tibia  54 . 
     Accordingly, when the fibula engaging arrangement  12  and the tibia engaging arrangement  14  are implanted on the ankle, and the first, second, and third lengths of suture  42 ,  46 ,  50  are secured within their corresponding bone tunnels  98 ,  100 ,  102 , the lengths of suture  42 ,  46 ,  50  are arranged at similar angles with respect to each other. For example, first length of suture  42  and the second length of suture  46  are at an oblique angle in the axial view of the fibula  18  or the tibia  54 . Similarly, the third length of suture  50  is at an oblique angle with respect to each of the first length of suture  42  and the second length of suture  46  in the axial view of the fibula  18  or the tibia  54 . Additionally, the lengths of suture  42 ,  46 ,  50  are spaced longitudinally along the length of the ankle joint. As such, the ankle syndesmosis repair system  10  provides multi-level, multi-directional stabilization of the ankle syndesmosis. Alternatively, the bone tunnel  98  and the bone tunnel  100  can be arranged at an angle to cross with respect to each other in a frontal view of the tibiofibular joint such that the fibula button  45  is connected with the first length of suture  42  to the tibia button  68  and the fibula button  48  is connected with the second length of suture  46  to the tibia button  66 . In another alternative embodiment, the bone tunnels  98 ,  100 ,  102  can converge to a location adjacent the central passageway  264  of tibia bone plate  56 A shown in  FIG. 3A . The passageway  264  may have an inner wall defining a conical shape similar to inner wall  76   w  in  FIG. 4C . 
     In some instances, the first, second, and/or third lengths of suture  42 ,  46 ,  50  may be a unitary piece of suture that is passed through each of the first, second, and third through holes  36 ,  38 ,  40  of the fibula bone plate  20 , each of the bone tunnels  98 ,  100 ,  102 , and each of the corresponding passageways  60 ,  62 ,  64  or buttons  66 ,  68 ,  70 . The unitary piece of suture may then be tied off at each end of the unitary piece of suture to fix the ankle syndesmosis repair system  10  in a desired orientation. Optionally, the unitary piece of suture may be passed two or more times through each of the first, second, and third through holes  36 ,  38 ,  40  of the fibula bone plate  20 , each of the bone tunnels  98 ,  100 ,  102 , and each of the corresponding passageways  60 ,  62 ,  64  or buttons  66 ,  68 ,  70 . 
     In some instances, the surgeon may use the bone reduction clamp  700  with the ankle syndesmosis repair system  10  to aid in the accurate creation of the bone tunnels  98 ,  100 ,  102 . For example, during surgery, the surgeon may use the bone reduction clamp  700  to force the fibula and the tibia into a desired orientation prior to the creation of the bone tunnels  98 . This may be done by arranging the fibula  18  and the tibia  54  between the first arm  702  and the second arm  704 , and subsequently using the adjustment mechanism  706  to move the first arm  702  and the second arm  704  toward each other to clamp the fibula  18  and the tibia  54  in the desired orientation. As the first arm  702  and the second arm  704  come together, one of the first arm  702  and the second arm  704  applies pressure to the fibula  18  and the other of the first arm  702  and the second arm  704  applies pressure to the tibia  54 , pushing the fibula  18  and the tibia  54  into the desired orientation. 
     Once the fibula  18  and the tibia  54  have been clamped in the desired orientation, the surgeon may then create the first, second, and third bone tunnels  98 ,  100 ,  102  by passing the suture advancing device  80  through each of the first, second, and third guide holes  714 ,  715 ,  716  of the guide  710 . Accordingly, the first, second, and third guide holes  714 ,  715 ,  716  of the guide  710  may be aligned with each of the first, second, and third longitudinal axes  92 ,  94 ,  96  of the ankle syndesmosis repair system  10 . 
     Referring now to  FIG. 11A , the first length of suture  42  is shown within the first bone tunnel  98 . As illustrated in this non-limiting embodiment, a diameter  104  of the first length of suture  42  can be approximately 0.5 to 0.7 millimeters which may be 70% to 97% of an inside diameter  106  of the first bone tunnel  98 . However, the inside diameter of each of the first bone tunnels may be up to approximately 3.5 millimeters. Because the fibula buttons  45 ,  48 ,  52  and the tibia buttons  66 ,  68 ,  70  do not have to be passed through the various bone tunnels  98 ,  100 ,  102 , the suture advancing device  80  can be sized accordingly, allowing for the outside diameters of the first, second, and third lengths of suture  42 ,  46 ,  50  to each be approximately 70% to 97% of the inside diameters of the corresponding bone tunnels  98 ,  100 ,  102 . This ratio of outside diameter of the suture to the inside diameter of the corresponding bone tunnel provides a reduced amount of play in the ankle syndesmosis repair system  10  as compared to a system requiring clearance within the bone tunnels for passing a suture button. 
     Referring now to  FIG. 11B , a first length of suture  1042  and a second length of suture  1043  are shown within the first bone tunnel  98 . As illustrated, the diameter of each of the first length of suture  1042  and the second length of suture  1043  is approximately 35% to 48% of a diameter  1106  of the first bone tunnel  98 . This ratio of outside diameter of each of the pair of sutures to the inside diameter of the corresponding bone tunnel provides a reduced amount of play in the ankle syndesmosis repair system  10  as compared to a system requiring clearance within the bone tunnels for passing a suture button. 
     Referring now to  FIG. 12 , a jig mechanism  960  for guiding a suture advancing device  980  is shown. The jig mechanism  960  works as an assistant to an ankle syndesmosis repair system  910  for stabilizing the syndesmosis of an ankle. The system  910  includes a fibula engaging arrangement  912  and a tibia engaging region  914  coupled together by a first suture  916  and a second suture (not shown). 
     The fibula engaging arrangement  912  is dimensioned to engage a lateral surface of a fibula  918 . For example, the fibula engaging arrangement  912  comprises a fibula bone plate  920  configured to conform to the lateral surface of the fibula  918 . Additionally, the fibula bone plate  920  is configured to receive a plurality of bone screws  930 ,  934 . The plurality of bone screws  930 ,  934  are configured to secure the fibula bone plate  920  to the fibula  918 . 
     The suture advancing device  980  comprises an elongated shaft  982  extending along a longitudinal axis. The suture advancing device  980  may comprise, for example, a K-wire, or any other suitable suture advancing device. The suture advancing device  980  may comprise Nitinol or stainless steel. The suture advancing device  980  has a distal end  986  and a proximal end  988 . The distal end  986  terminates in a pointed tip  990 . The proximal end  988  includes an aperture  989  dimensioned to individually receive an end of a suture. 
     As illustrated, the suture advancing device  980  has a longitudinal length exceeding a transverse distance from an anteromedial surface of the tibia  954  to a posterolateral surface of the fibula  918  at the distal tibiofibular joint. As such, the suture advancing device  980  can form a bone tunnel extending from the posterolateral surface of the fibula  918  to the anteromedial surface of the tibia  954  when the suture advancing device  980  is moved through the fibula  918  and the tibia  954  at the distal tibiofibular joint. 
     In some non-limiting examples, the suture advancing device  980  may have a diameter in a range of 0.5 millimeters to 2.5 millimeters. For example, the suture advancing device  980  may have a diameter of approximately 1 millimeter. In some other non-limiting examples, the suture advancing device  980  may have a diameter in a range of 0.1 millimeters to 2.5 millimeters. 
     The jig mechanism  960  comprises a first tubular guide  962  and a second tubular guide  964 . The first tubular guide  962  includes a first tubular passageway  966  configured to slidably receive the shaft  982  of the suture advancing device  980 . The second tubular guide  964  includes a second tubular passageway  968  configured to slidably receive the shaft  982  of the suture advancing device  980 . The second tubular guide  964  also includes a suture removal slot  969  configured remove a suture from the second tubular passageway  968 . The first tubular guide  962  is attached to a first support  970  and the second tubular guide  964  is attached to a second support  972 . The first support  970  and the second support  972  are attached via a support spacer  974 , defining a distance between the first tubular guide  962  and the second tubular guide  964 . The first tubular passageway  966  has a first longitudinal axis and the second tubular passageway  968  has a second longitudinal axis. The support spacer  974  is configured such that the first axis and the second axis can be aligned to be substantially collinear. 
     The support spacer  974  is configured to vary in length according to a jig adjuster  976 . In one non-limiting example, the jig adjuster  976  may include a telescoping section of the support spacer  974  including threads, such that when the jig adjuster  976  is rotated in a first direction, the length of the support spacer  974  increases and when the jig adjuster  976  is rotated in a second direction, the length of the support spacer  974  decreases. As the support spacer  974  increases in length, the distance between the first tubular guide  962  and the second tubular guide  964  increases. 
     The first tubular passageway  966  and the second tubular passageway  968  are in alignment such that the suture advancing device  980  is compelled to travel along an intended axis when travelling between the first tubular guide  962  and the second tubular guide  964  while creating a bone tunnel. The suture advancing device  980  may have a diameter that is 80% of the diameter of the first tubular passageway  966  and the second tubular passageway  968  such that the suture advancing device  980  has restricted movement within the first tubular passageway  966  and the second tubular passageway  968 . In another non-limiting example, the suture advancing device  980  may have a diameter that is 85%, 90%, or 95% of the diameter of the first tubular passageway  966  and the second tubular passageway  968 . 
     The suture removal slot  969  may have a width such that a suture can pass through the suture removal slot  969  to be removed from the second tubular passageway  968  after the suture advancing device  980  has fully passed through the second tubular passageway  968 . The width of the suture removal slot  969  may also be configured such that the suture advancing device  980  is unable to be removed from the second tubular passageway  968  when the suture advancing device  980  has partially passed through the second tubular passageway  968 . 
     The surgeon may first fix the fibula bone plate  920  onto the lateral side of the fibula  918 . The surgeon may then use the jig mechanism  960  to align the first tubular guide  962  with the lateral side of the fibula  918  and the second tubular guide  964  with the medial side of tibia the  954  by adjusting the length of the support spacer  974  via the jig adjuster  976 . The jig adjuster  976  may be tightened such that a slight perturbation to the jig mechanism  960  will not affect the alignment of the first tubular guide  962  with the lateral side of the fibula  918  and the second tubular guide  964  with the medial side of the tibia  954 . The surgeon may then insert the suture advancing device  980 , equipped with a first suture  916  received through the aperture  989 , into the first tubular passageway  966  and begin to form a first bone tunnel  992  extending from the posterolateral surface of the fibula  918  to the anteromedial surface of the tibia  954 , such that the suture advancing device exits the tibia  954  and continues through the second tubular passageway  968  of the jig mechanism  960 . 
     Once the first bone tunnel  992  is created, the jig mechanism  960  can be advanced via the jig adjuster  976  to shift the position of the first tubular guide  962  on the lateral side of the fibula  918  and the second tubular guide  964  on the medial side of the tibia  954  in preparation for a second bone tunnel  994 , separated by a first bone bridge  995 . The jig adjuster  976  may be again tightened such that a slight perturbation to the jig mechanism  960  will not affect the alignment of the first tubular guide  962  with the lateral side of the fibula  918  and the second tubular guide  964  with the medial side of the tibia  954 . The suture advancing device  980  may be advanced and inserted into the second tubular passageway  968  and begin to form the second bone tunnel  994  extending from the anteromedial surface of the tibia  954  to the posterolateral surface of the fibula  918  such that the suture advancing device exits the fibula  918  and continues through the first tubular passageway  966  of the jig mechanism  960 . Once the second bone tunnel  994  is created, the first suture  916  may be removed from the second tubular guide  964  via the suture removal slot  969 . The surgeon may then temporarily remove the jig mechanism  960  and secure the first suture  916  under tension at opposite ends using a fibula button  952 . 
     Once the second bone tunnel  994  is created, the surgeon may then use the jig mechanism  960  to align the first tubular guide  962  with the lateral side of the fibula  918  and the second tubular guide  964  with the medial side of tibia the  954  by adjusting the length of the support spacer  974  via the jig adjuster  976  in preparation for a third bone tunnel  996 , separated by a second bone bridge  997 . The jig adjuster  976  may be tightened such that a slight perturbation to the jig mechanism  960  will not affect the alignment of the first tubular guide  962  with the lateral side of the fibula  918  and the second tubular guide  964  with the medial side of the tibia  954 . The surgeon may then insert the suture advancing device  980 , equipped with a second suture  917  received through the aperture  989 , into the first tubular passageway  966  and begin to form the third bone tunnel  996  extending from the posterolateral surface of the fibula  918  to the anteromedial surface of the tibia  954 , such that the suture advancing device exits the tibia  954  and continues through the second tubular passageway  968  of the jig mechanism  960 . 
     Once the third bone tunnel  996  is created, the jig mechanism  960  can be advanced via the jig adjuster  976  to shift the position of the first tubular guide  962  on the lateral side of the fibula  918  and the second tubular guide  964  on the medial side of the tibia  954  in preparation for a fourth bone tunnel (not shown), separated by a third bone bridge (not shown). The jig adjuster  976  may be again tightened such that a slight perturbation to the jig mechanism  960  will not affect the alignment of the first tubular guide  962  with the lateral side of the fibula  918  and the second tubular guide  964  with the medial side of the tibia  954 . The suture advancing device  980  may be advanced and inserted into the second tubular passageway  968  and begin to form the fourth bone tunnel extending from the anteromedial surface of the tibia  954  to the posterolateral surface of the fibula  918  such that the suture advancing device exits the fibula  918  and continues through the first tubular passageway  966  of the jig mechanism  960 . Once the fourth bone tunnel is created, the second suture  917  may be removed from the second tubular guide  964  via the suture removal slot  969 . The surgeon may then remove the jig mechanism  960  and secure the second suture  917  under tension at opposite ends using a fibula button  952 . 
     Thus, the invention provides systems and methods for treating and repairing ankle syndesmosis. More particularly, the invention provides a system for multi-level, multi angle stabilization of the ankle syndesmosis of a subject. 
     Although the present invention has been described in detail with reference to certain embodiments, one skilled in the art will appreciate that the present invention can be practiced by other than the described embodiments, which have been presented for purposes of illustration and not of limitation. Therefore, the scope of the appended claims should not be limited to the description of the embodiments contained herein.