Patent Publication Number: US-2021169469-A1

Title: Insert holding device, suture holding device and method for connecting a suture to an insert for insertion into a bone

Description:
The invention relates to an insert holding device and a suture holding device for connecting a suture to an insert for insertion into a bone, a kit of parts comprising the insert holding device and the suture holding device, and a method for connecting a suture to an insert for insertion into a bone. In particular, the suture and the insert may be comprised in an implant for ligament repair in a human or animal joint, more particularly anterior cruciate ligament repair in a human or animal knee. 
     Implants for ligament repair comprising a flexible graft (e.g. an autograft from a patient hamstring) connected to at least one osteoconductive element (OCE) are known from the prior art (i.e. WO 2016/113142 A1). In addition, so-called bone-tendon-bone (BTB) grafts have been described in the prior art. 
     In such implants, the flexible graft replaces the torn or damaged ligament (e.g. the anterior cruciate ligament, ACL), and the osteoconductive element or bone graft is inserted into boreholes of associated bones (such as the tibia and/or femur in case of ACL repair). Therein, the purpose of the insert is to fix the implant in the bone and to facilitate ingrowth of bone cells leading to increased long-term stability of the implant. 
     In addition, so-called cortical fixation devices (CFD) are typically used to attach the implant on the outside of the borehole of the associated bone to apply sufficient tension to the flexible graft for replacing the function of the native ligament. Typical CFDs comprise a plate member to be positioned outside of the borehole, wherein sutures extending through the bone tunnel connect the plate member to the osteoconductive element or bone graft. 
     In clinical practice, attaching sutures to an insert for insertion into a bone (such as an OCE or a bone graft), in particular to connect the insert to a CFD or a flexible graft, is challenging for the surgeon, particularly since small components are handled. However, positioning the insert in the implant correctly is of great importance for achieving good biological performance. 
     Therefore, the objective of the present invention is to provide a means to facilitate attachment of sutures to an insert for insertion into a bone. 
     This objective is attained by the subject matter of independent claim  1  relating to an insert holding device, independent claim  9  relating to a suture holding device, independent claim  12  relating to a kit of parts, and independent claim  13  relating to a method for connecting a suture to an insert for insertion into a bone. 
     Embodiments of the present invention are described in dependent claims  2  to  8 ,  10  to  11 , and  14  to  15  and are described hereafter. 
     A first aspect of the invention relates to an insert holding device for connecting a suture to an insert for insertion into a bone, comprising a holding structure configured to releasably hold an insert for insertion into a bone, at least one first recess for receiving a first suture, and at least one second recess for receiving a looped second suture, wherein the at least one first recess and the at least one second recess are configured such that the first suture can be laid around the second suture and the insert, thereby connecting the second suture to the insert when the insert is held by the holding structure. 
     In particular, the at least one first recess is configured such that the first suture can be arranged around the insert when the insert is held by the holding structure. 
     By means of the holding structure and the first and second recess, the insert and the first and second sutures are pre-arranged, such that a surgeon may easily attach the second suture to the insert by laying the first suture around the insert and second suture and e.g. tying a knot of the first suture. 
     In the context of the present specification, the term ‘insert’ describes any component suitable to be inserted into a bone of a human or animal, in particular components comprising an osteoconductive and/or osteoinductive material. This includes bone grafts, such as xenografts and allografts, in other words natural bone material, as well as artificial osteoconductive and/or osteoinductive materials, such as e.g. tricalcium phosphate (TCP). 
     Therein the term ‘osteoinductive’ describes a material which is adapted to serve as a scaffold for new bone growth that is perpetuated by the native bone. The term ‘osteoconductive’ describes a material which is adapted to stimulate osteoprogenitor cells to differentiate into osteoblast, thereby facilitating new bone formation. 
     In the context of the present specification, the term ‘suture’ describes any elongated member which is suitable to be used for connecting components, particularly by sewing or knotting, to be implanted into the human or animal body. 
     The insert holding device can be manufactured from any suitable material, such as a metal or a polymer. For example, a foldable paper sheet, plastic sheet or polymer sheet may be used to produce the insert holding device. 
     In particular, the insert is adapted for use in an implant for anterior cruciate ligament repair, wherein the implant further comprises a flexible graft, particularly replacing the anterior cruciate ligament. More particularly, the implant further comprises a cortical fixation device comprising a plate member for applying tension to the flexible graft. 
     Due to its anatomical location, the anterior cruciate ligament (ACL) is subjected to potentially extreme forces during sports and other physical activities. Rupture of the ACL has been counted as the most frequent and severe of ligament injuries. Although several surgical options, including hamstring graft approach, bone patella tendon bone graft, etc. for ACL reconstruction have been practiced for the restoration of knee joint function, several unavoidable drawbacks exist, such as donor site morbidity, ligament laxity, mechanical mismatch, etc. 
     Clinically implemented graft fixation methods largely rely on tendon to bone ingrowth to provide long term ligament stability, with many requiring bone ingrowth to a non-osteoconductive graft. The non-osteoconductive nature of the graft material often critically limits the success of ACL repair. Failure of timely bone ingrowth can lead to “bone tunnel expansion”, and ultimately a failed reconstruction that may necessitate a revision surgery with large cost and burden to the patient. 
     To minimize bone tunnel expansion and to achieve an optimized attachment of a graft within the bone tunnel, an osteo-conductive element (OCE) can be used between bone tunnel and graft, resulting in a so-called “bony bridge”. Such an OCE has been described in patent application WO 2016/113142 A1. 
     In certain embodiments, the at least one first recess of the insert holding device is configured such that the first suture can be arranged in a straight line. In certain embodiments, the at least one second recess is configured such that the second suture can be arranged in a straight line. 
     In certain embodiments, the at least one first recess is configured such that the first suture can be arranged along a first axis when the first suture is received in the at least one first recess, wherein the at least one second recess is configured such that the second suture can be arranged along a second axis, when the second suture is received in the at least one second recess, wherein the first axis is non-parallel to the second axis and wherein the first axis is arranged at an angle of 30° to 150°, particularly 45° to 135°, more particularly 60° to 120°, most particularly 90°, in respect of the second axis. 
     In certain embodiments, the holding structure of the insert holding device comprises a slot for receiving the insert, a first wall and a second wall opposing the first wall, wherein the slot is delimited by the first wall and the second wall, and wherein the first wall and the second wall are adapted to releasably hold the insert within the slot by static friction. In other words, the insert is held in the slot by a press-fit. Alternatively, any other suitable means for holding the insert in place can be used as a holding structure. 
     In particular, the slot is open along the first axis, such that the insert can be slid in the slot along the first axis. 
     In certain embodiments, the first wall and/or the second wall comprises a flexible material having a Young&#39;s modulus of 10000 MPa or less, particularly 5000 MPa or less, more particularly 2000 MPa or less, most particularly 1800 MPa, according to DIN EN ISO 178:2013-09. Thus, due to the flexibility of the material, static friction with the insert is generated when the first and/or second wall is deformed by the insert in the slot. 
     In certain embodiments, the first wall and/or the second wall comprises or consists of polypropylene. 
     In certain embodiments the insert holding device comprises a force-generating element, for example a spring, such as a leaf spring, adapted to exert a force on the first and/or second wall. Thereby, static friction with the insert is generated when the insert is positioned in the slot. 
     In certain embodiments, the device further comprises a third wall and a fourth wall, wherein the third wall and the fourth wall are perpendicular to the first and second wall. In other words, the third wall and the fourth wall form a roof over the slot. 
     In certain embodiments, the insert holding device comprises a first surface and a second surface opposing the first surface. 
     In certain embodiments, the at least one first recess extends from the first surface of the insert holding device to the second surface of the insert holding device. In particular, this allows the first suture to be passed from the second surface through the at least one first recess to the first surface and around the insert when the insert is held by the holding structure of the insert holding device and back through the at least one first recess to the second surface in order to be laid around the second suture and the insert. 
     In certain embodiments, the at least one second recess extends from the first surface of the insert holding device to the second surface of the insert holding device. In particular, this allows the second suture to be passed from the second surface through the at least one second recess to the first surface and back through the at least one second recess to the second surface in order to be arranged around the insert. 
     In other words, the at least one first recess and the at least one second recess can be formed by through-holes or notches in the third surface (or edge) of the insert holding device. 
     In certain embodiments, the at least one first recess extends along the first axis, particularly between the first wall and the second wall. 
     In certain embodiments, the at least one first recess comprises a first end section, a second end section and a middle section connecting the first end section and the second end section. 
     In certain embodiments, the width of the first end section is greater than the width of the middle section, and the width of the second end section is greater than the width of the middle section. Therein, the term width refers to a maximum extension of the respective section measured perpendicular to the first axis. The greater width facilitates passing of the suture below the insert in the holding structure. 
     In certain embodiments, the insert holding device comprises a first recess, wherein the first recess extends along the first axis. In other words, the at least one first recess consists of the first recess (there is only one first recess). 
     In certain embodiments, the insert holding device comprises a first notch and a second notch (e.g. opposing the first notch), in particular extending along the first axis, wherein the first notch and the second notch are adapted to hold the first suture, such that the first suture can be arranged from the first notch over the at least one first recess to the second notch. 
     In certain embodiments, the insert holding device comprises a first notch and a second notch (e.g. opposing the first notch), in particular extending along the second axis, wherein the first notch and the second notch are adapted to hold the second suture, such that the second suture can be arranged from the first notch over the at least one second recess to the second notch. 
     In certain embodiments, the insert holding device comprises a first notch, a second notch, a third notch, and a fourth notch, wherein the first notch and the second notch are adapted to hold the first suture, such that the first suture can be arranged from the first notch over the at least one first recess to the second notch, and wherein the third notch and the fourth notch are adapted to hold the second suture, such that the second suture can be arranged from the third notch over the at least one second recess to the fourth notch. 
     In certain embodiments, the insert holding device comprises a first surface, a second surface facing away from the first surface, and a circumferential third surface connecting the first surface and the second surface. 
     In certain embodiments, the at least one second recess is open towards the third surface, such that the second suture can be received by, in particular inserted into, the at least one second recess from the third surface. 
     In certain embodiments, the insert holding device comprises two second recesses. In other words: the at least one second recess comprises or is constituted by two second recesses. 
     In certain embodiments, at least a part of the at least one first recess is positioned between the second recesses such that the second suture can be arranged between the second recesses above the at least one first recess on the first surface, such that the first suture can be laid around the second suture and the insert. 
     In certain embodiments, the two second recesses extend along the first axis. 
     In certain embodiments, the two second recesses are open towards the third surface. Thereby, the second suture can be arranged between the second recesses above the at least one first recess by inserting the second suture into the second recesses from the third surface (e.g. from the edge of the insert holding device). 
     In certain embodiments, the second recesses each comprise a width of 1 mm or less, particularly 0.5 mm or less. Therein, in particular, the width is measured along the second axis. Due to the small width, a certain amount of force has to be applied to move a surgical suture of typical width through the second recess, such that the suture is prevented from slipping out of the second recess. 
     In certain embodiments, the at least one second recess comprises a respective holding section for receiving the second suture and a respective entry section for moving the second suture towards the respective holding section, particularly from an opening in the third surface, wherein the respective holding section comprises a width, particularly along the second axis, which is larger than a width, particularly along the second axis, of the respective entry section. In particular, this prevents moving of the second suture back into the entry section. 
     In certain embodiments, the entry section comprises a width of 0.5 mm or less, particularly 0.2 mm or less. 
     In certain embodiments, the insert holding device comprises a protrusion, particularly a pointed end, along the first axis, wherein the protrusion is positioned between the second recesses, such that the protrusion can be moved through the looped second suture, thereby inserting the second suture into the second recesses. In particular, the pointed end facilitates insertion into the looped second suture held by a suture holding device according to the second aspect. 
     In certain embodiments, the at least one first recess and the at least one second recess are open towards the first surface and closed towards the second surface. Therein, in particular, the at least one first recess is adapted to receive the first suture from the first surface, and the at least one second recess is adapted to receive the second suture from the first surface, wherein more particularly the holding structure of the insert holding device is adapted to hold the insert above the first suture and the second suture, such that the first suture can be arranged around the insert and the second suture, thereby connecting the second suture to the insert. Therein, in particular, the insert holding device comprises a first recess and a second recess, in other words, the at least one first recess consists of a (single) first recess and the at least one second recess consists of a (single) second recess. 
     In certain embodiments, the slot of the holding structure of the insert holding device is formed by blind hole which is open towards the first surface. In certain embodiments, the slot is positioned at an intersection between the at least one first recess and the at least one second recess, particularly between the first recess and the second recess. 
     In certain embodiments, the insert holding device comprises a groove for inserting the second suture, wherein the groove extends along the third surface of the insert holding device in a circumferential direction, and wherein the at least one second recess is connected to, particularly extends into, the groove. 
     In certain embodiments, the insert holding device comprises an upper portion and a lower portion, wherein the upper portion comprises the at least one first recess and the at least one second recess, particularly the first recess and the second recess, wherein particularly the third axis extends along a third axis which is perpendicular to the first axis and the second axis. 
     In certain embodiments, the upper portion comprises a respective first surface and a respective circumferential third surface, and the lower portion comprise a respective first surface, a second surface opposing the respective first surface, and a respective third circumferential surface connecting the first surface and the second surface of the lower portion. Therein, in particular, the second surface of the lower portion is the same as the second surface of the insert holding device. 
     In certain embodiments, the groove extending along the third surface of the insert holding device in a circumferential direction is positioned on the third surface of the upper portion, in particular adjacent to the first surface of the lower portion. 
     In certain embodiments, the upper portion and the lower portion are arranged along a third axis, wherein the upper portion comprises a first maximum extension perpendicular to the third axis, in particular a first diameter, and the second section comprises a second maximum extension perpendicular to the third axis, in particular a second diameter, wherein the first maximum extension is smaller than the second maximum extension. 
     In certain embodiments, the insert holding device comprises a circular cross-section in respect of the third axis. 
     In certain embodiments, the upper portion and the lower portion comprise a circular cross-section in respect of the third axis. Therein, in particular, the first maximum extension of the upper portion perpendicular to the third axis is the first diameter of the upper portion, and the second maximum extension of the lower portion perpendicular to the third axis is the second diameter of the lower portion. 
     In certain embodiments, the insert holding device comprises a planar geometry. In other words, the insert holding device comprises a sheet of material extending in a plane defined by the first axis and the second axis. 
     In certain embodiments, the insert holding device is folded from a sheet of material. Suitable materials for folding include paper sheets, plastic sheets or polymer sheets. 
     In certain embodiments, the sheet of material is configured to form the walls delimiting the slot when the flat sheet of material is folded. 
     In certain embodiments, the insert holding device is adapted to be mechanically connected to a suture holding device for holding at least the second suture, particularly according to the second aspect of the invention. 
     A second aspect of the invention relates to a suture holding device for connecting a suture to an insert for insertion into a bone comprising a first recess for inserting a flexible graft, a holding structure for positioning a looped second suture across the first recess, wherein the first recess is configured such that an insert for insertion into a bone held by the holding structure of an insert holding device, in particular according to the first aspect of the invention, can be positioned in or adjacent to the first recess and a first suture can be laid around the second suture and the insert, thereby connecting the second suture to the insert. 
     In certain embodiments, the suture holding device is configured to be assembled with an insert holding device according to the first aspect of the invention, such that the first suture can be laid around the second suture and the insert, thereby connecting the second suture to the insert, when the insert is held by the holding structure of the insert holding device and the suture holding device and the insert holding device are assembled. 
     In certain embodiments, the first recess of the suture holding device is configured such that a flexible graft (in particular a tendon graft, e.g. from a hamstring) can be passed through the first recess in order to connect the flexible graft to the second suture. 
     In certain embodiments, the suture holding device comprises a further holding structure for positioning a first suture across the first recess. 
     In certain embodiments, the holding structure of the suture holding device comprises a first protrusion and a second protrusion, wherein the first recess of the suture holding device is arranged between the first protrusion and the second protrusion, such that the second suture can be arranged from the first protrusion above the first recess towards the second protrusion. 
     In certain embodiments, the suture holding device comprises a first groove adapted to hold a plate member connected to the second suture, wherein the plate member is configured to be positioned on the outside of a borehole in a bone in order to apply tension to the second suture when the second suture extends from the plate member through the borehole. In particular, the plate member is comprised in a cortical fixation device. 
     In certain embodiments, the holding structure of the suture holding device further comprises a second recess adjacent to the first protrusion opposite the first recess of the suture holding device, wherein the holding structure comprises a third recess adjacent to the second protrusion opposite the first recess, wherein the second recess and the third recess are configured to receive the second suture. 
     In certain embodiments, the suture holding device comprises at least one groove for arranging at least one further suture (for example a passing suture and/or a flipping suture of a cortical fixation device) on the suture holding device. 
     In certain embodiments, the suture holding device comprises at least one hole for arranging at least one further suture (for example a passing suture and/or a flipping suture of a cortical fixation device) on the suture holding device. 
     In certain embodiments, the suture holding device comprises at least one notch for receiving the first suture, wherein the at least one notch is configured such that the first suture can be arranged across the first recess of the suture holding device. 
     A third aspect of the invention relates to a kit of parts comprising an insert holding device according to the first aspect of the invention and a suture holding device according to the second aspect of the invention, wherein the first recess of the suture holding device is configured such that an insert for insertion into a bone held by the holding structure of the insert holding device can be positioned in or adjacent to the first recess of the suture holding device, and a first suture can be laid around a second suture and the insert, thereby connecting the second suture to the insert, wherein the second suture is positioned across the first recess of the suture holding device by the holding structure of the suture holding device. 
     A fourth aspect of the invention relates to a method for connecting a suture to an insert for insertion into a bone, wherein an insert holding device, particularly according to the first aspect of the invention, is provided, and wherein an insert for insertion into a bone is received by a holding structure of the insert holding device, such that the holding structure releasably holds the insert, and wherein a first suture is received by at least one first recess of the insert holding device, and wherein a looped second suture is received by at least one second recess of the insert holding device, and wherein the first suture is laid around the second suture and the insert held by the holding structure of the insert holding device, thereby connecting the second suture to the insert. 
     In certain embodiments, the insert is subsequently removed from the holding structure of the insert holding device. 
     In certain embodiments, a flexible graft is connected to the insert, particularly after removing the insert from the holding structure of the insert holding device. Therein, in particular, the flexible graft is connected to the second suture, thereby connecting the flexible graft to the insert. For example, the flexible graft can be folded around the second suture and optionally stitched together at at least one stitching position. 
     In certain embodiments, the insert is first received by the holding structure of the insert holding device, wherein the second suture is subsequently received by the at least one second recess of the insert holding device, and wherein the first suture is subsequently received by the at least one first recess of the insert holding device. 
     In certain embodiments, the insert is first received by the holding structure of the insert holding device, wherein the first suture is subsequently received by the at least one first recess of the insert holding device, and wherein the second suture is subsequently received by the at least one second recess of the insert holding device. 
     In certain embodiments, the first suture is first received by the at least one first recess of the insert holding device, wherein the second suture is subsequently received by the at least one second recess of the insert holding device, and wherein the insert is subsequently received by the holding structure of the insert holding device. 
     In certain embodiments, the first suture is tied into a knot around the second suture and the insert, thereby connecting the second suture to the insert. 
     In certain embodiments, the first suture is passed from the first surface of the insert holding device to the second surface of the insert holding device through the first recess, passed below the insert in the holding structure of the insert holding device, passed below the first suture and passed back to the first surface through the first recess of the insert holding device, wherein subsequently the second suture is received by the at least one second recess of the insert holding device above the first suture, wherein in particular the first suture is inserted into the first notch and the second notch of the insert holding device. 
     In certain embodiments, the second suture is held by a holding structure of a suture holding device, particularly according to the second aspect of the invention, wherein the second suture is positioned across a first recess of the suture holding device, and wherein the insert held by the holding structure of the insert holding device is positioned in or adjacent to the first recess of the suture holding device, and wherein the first suture is laid around the second suture held by the holding structure of the suture holding device and the insert held by the holding structure of the insert holding device, thereby connecting the second suture to the insert. 
     In certain embodiments, the insert holding device is connected to the suture holding device when the first suture is laid around the second suture held by the holding structure of the suture holding device and the insert held by the holding structure of the insert holding device. 
     In certain embodiments, the insert holding device is removed from the suture holding device, wherein a flexible graft is inserted into the first recess of the suture holding device after removing the insert holding device from the suture holding device, and wherein the flexible graft is connected to the second suture, thereby connecting the flexible graft to the insert. For example, the flexible graft can be folded around the second suture and optionally stitched together at at least one stitching position. 
     In certain embodiments, the insert, the first suture, the second suture, and the flexible graft are removed from the suture holding device after connecting the flexible graft to the second suture, wherein the flexible graft is pulled, and wherein particularly the suture holding device is bent. In particular, the plate member is removed from the suture holding device after connecting the flexible graft to the second suture. 
     A fifth aspect of the invention relates to a method of manufacture of the insert holding device according to the first aspect of the invention, wherein a foldable sheet of material is provided, and wherein the material is folded to obtain the insert holding device. 
     In certain embodiments, at least one folding line is introduced into the sheet, particularly by indenting or heat treatment. 
     In certain embodiments, the first wall and the second wall delimiting the slot of the holding structure of the insert holding device are generated by folding segments of the sheet. 
     In certain embodiments, the third wall and the fourth wall delimiting the slot of the holding structure of the insert holding device are generated by folding segments of the sheet. 
    
    
     
       The invention is further described by the following examples and figures, from which additional embodiments may be derived. Therein 
         FIG. 1  shows a schematic overview of anterior cruciate ligament repair according to the prior art; 
         FIG. 2  shows a schematic drawing of a cortical fixation device according to the prior art; 
         FIG. 3  shows a perspective view of a first embodiment of the insert holding device according to the invention; 
         FIG. 4  shows a perspective view of the first embodiment of the insert holding device, an insert for insertion into a bone, a first suture and a second suture; 
         FIG. 5  shows a top view of an intermediate product for generating an insert holding device according to the first embodiment; 
         FIG. 6  shows a perspective view of a first embodiment of a suture holding device according to the invention with a second suture and a cortical fixation device arranged on the suture holding device; 
         FIG. 7  shows a top view of the front surface of the suture holding device according to the first embodiment and a cortical fixation device arranged on the suture holding device; 
         FIG. 8  shows a top view of the back surface of the suture holding device according to the first embodiment and a cortical fixation device arranged on the suture holding device; 
         FIG. 9  shows a perspective view of an assembly between an insert holding device according to the first embodiment and a suture holding device according to the first embodiment; 
         FIG. 10  shows a perspective view of a second embodiment of the insert holding device according to the invention; 
         FIG. 11  shows a schematic of a method for connecting a suture to an insert using the insert holding device according to the second embodiment; 
         FIG. 12  shows a perspective view of a second embodiment of the suture holding device according to the invention. 
     
    
    
       FIG. 1  shows a schematic overview of an example of anterior cruciate ligament repair in a human knee by means of an implant I according to the prior art. The implant I comprises a flexible graft  900  connected at a first end  901  and a second end  902  to a respective insert  300 . The inserts  300  (as well as a part of the flexible graft  900 ) are positioned in boreholes B of the tibia T and femur F, respectively. Furthermore, each insert  300  is connected to a respective looped second suture  500  of a respective cortical fixation device  520  by means of a first suture  400  laid around the respective insert  300  and the respective second suture  500 . The cortical fixation devices  520  further comprise respective plate members  510  which are connected to the looped second sutures  500 . The plate members  510  are positioned on the outside of the respective boreholes B of the tibia T and femur F. 
     The implant I thus extends from the outside of the tibia T bone through the borehole B of the tibia T, the joint space and the borehole B of the femur F to the outside of the femur F bone, wherein the flexible graft  900  replaces the native anterior cruciate ligament. Tension can be applied to the flexible graft  900  by pulling on the second sutures  500  between the plate members  510  and the inserts  300 , wherein the plate members  510  prevent the ends of the second sutures  500  from being pulled into the respective borehole B when tension is applied to the flexible graft  900 . 
     Typically, the flexible graft  900  is an autograft comprising segments cut from a patient&#39;s hamstring tendon. 
     In particular, the insert  300  comprises an osteoconductive and/or osteoinductive material, such that ingrowth of bone cells into the implant I occurs, improving the stability of the implant I. Such an insert  300  is also termed “osteoconductive element”. Alternatively, the insert  300  may be constituted by a bone block, preferably an autograft. In this case, the resulting implant I is termed “bone-tendon-bone autograft”. 
     A schematic drawing of a typical plate member  510  of a cortical fixation device  520  for fixing an implant I (such as shown in  FIG. 1 ) is depicted in  FIG. 2 . The plate member  510  comprises a first hole  511  and a second hole  512  for receiving a second suture  500 , for example to connect the plate member  510  to the insert  300 . As shown in  FIG. 2 , the second suture  500  is arranged in a closed loop L 1  and an open loop L 2 . 
     Furthermore, the plate member  510  comprises a third hole  513  for receiving a pulling suture  700  and a fourth hole  514  for receiving a flipping suture  800 . The third hole  513  and the fourth hole  514  are positioned adjacent to opposing ends of the plate member  510  along a longitudinal axis L of the plate member  510 . The pulling suture  700  can be used to pull the plate member  510  through a borehole B of the femur F and/or tibia T bone, wherein the longitudinal axis L of the plate member  510  is parallel to the borehole B. After the plate member  510  has reached the outside of the borehole B, the plate member  510  can be rotated by pulling the flipping suture  800 , such that the longitudinal axis L is perpendicular to the borehole B. In this configuration, the plate member  510  prevents the end of the second suture  500  from being pulled into the borehole B when tension is applied to the flexible graft  900  (see also  FIG. 1 ). 
       FIG. 3  shows a first example of an insert holding device  100  according to the invention, which is configured to assist in connecting a second suture  500  of a cortical fixation device  520  to an insert  300  (i.e. an osteoconductive element) of an implant for anterior cruciate ligament repair. The insert holding device  100  comprises a flat sheet of material having a first surface  101  and a second surface  102  opposing the first surface  101 , wherein the first surface  101  and the second surface  102  are connected by a third, circumferential, surface  103  formed by an edge of the sheet of material. 
     Furthermore, the insert holding device  100  comprises a holding structure  110  for receiving an insert  300 , wherein the holding structure  110  comprises a first wall  112 , a second wall  113  opposing the first wall  112 , and a third wall  114  and a fourth wall  115  extending parallel to the first surface  101  and perpendicular to the first wall  112  and the second wall  113 . The first wall  112  is connected to the third surface  103  (edge) of the insert holding device  100  by means of a first strut  116 , and the second wall  113  is connected to the third surface  103  by means of a second strut  117  opposite the first strut  116 . 
     The first wall  112 , the second wall  113 , the third wall  114  and the fourth wall  115  form a slot  111  for receiving the insert  300 , wherein the first and the second wall  112 , 113  form side walls of the slot  111  and the third and the fourth wall  114 , 115  form a roof of the slot  111 . The slot  111  is open along a first axis A 1  of the insert holding device  100 , such that an insert  300  can be slid in the slot  111  along the first axis A 1 . 
     In particular, the first wall  112  and the second wall  113  are formed from a flexible material, and the distance between the first wall  112  and the second wall  113  is chosen such that an insert  300  of appropriate dimensions is held in the slot  111  by static friction (press-fit) between the first wall  112 , the second wall  113  and the insert  300  when no external force is applied, but can be easily removed from the slot  111  by applying a force along the first axis A 1  (for instance by hand). Optionally, the third and fourth wall  114 , 115  forming the roof of the slot  111  can also be adapted to generate static friction to hold the insert  300  in the slot  111 . 
     Alternatively, the insert holding device  100  may comprise at least one force-generating element (e.g. a leaf spring) adapted to exert a force on an insert  300  in the slot  111 , wherein the force acts perpendicular to the first axis A 1 . In this manner, a press-fit of the insert  300  in the slot  111  may be achieved with first and second walls  112 , 113  from a less flexible material. 
     As shown in  FIG. 3 , the insert holding device  100  further comprises a first recess  120  formed by a through-hole extending along the first axis A 1  between the first wall  112  and the second wall  113  of the holding structure  110 . The first recess  120  comprises opposing first and second end sections  121   a , 121   b  connected by a middle section  122 . Therein, the width of the end sections  121   a , 121   b  (the maximum extension perpendicular to the first axis A 1 ) is greater than the width of the middle section  122 . In other words, the first recess  120  is dumbbell-shaped. 
     Furthermore, the insert holding device  100  comprises a first notch  141  and a second notch  142  opposing the first notch  142 , wherein the first notch  141  and the second notch  142  are arranged along the first axis A 1  in line with the first recess  120 . The first and second notch  141 , 142  are configured to receive a first suture  400  and hold the first suture  400  in place when the first suture  400  is arranged along the first recess  120 . The first suture  400  can be received in the first and second notch  141 , 142  by inserting the first suture  400  from the third surface  103  of the insert holding device  100 , in other words from its edge. In particular, the first and second notch  141 , 142  are narrow enough, such that a certain force has to be applied to insert the first suture  400  into the first and second notch  141 , 142 , wherein the first suture  400  is held by static friction once inserted into the first and second notch  141 , 142 . 
     In addition, the insert holding device  100  according to the example shown in  FIG. 3  to  FIG. 5  comprises two second recesses  130  formed by parallel notches extending along the first axis A 1  on either side of the first recess  120 . The second recesses  130  each comprise a respective entry section  131  and a respective holding section  132 . Therein, the entry sections  131  are open towards the third surface  103  (edge) and separate a pointed end  160  of the insert holding device  100  into a middle segment  161  and two side segments  162 . A second suture  500  may be inserted from the third surface  103  into the entry sections  131  and moved along the entry sections  131  into the holding sections  132 . The holding sections  132  are arranged along a second axis A 2 , which is perpendicular to the first axis A 1 , and wherein the second axis A 2  intersects the first recess  120 . Therefore, when the second suture  500  is arranged in a straight line from one of the holding sections  132  across the first surface  101  of the insert holding device  100  to the other holding section  132 , the second suture  500  extends above the first recess  120 . 
     The width (maximum extension measured perpendicular to the first axis A 1 ) of the entry sections is smaller than the width of the respective holding sections  132 . In particular, the width of the entry sections  131  is such that a certain amount of force has to be applied to insert the second suture  500  into the entry sections  131  (see  FIG. 4 ). In this manner, the second suture  500  can be prevented from moving back from the holding sections  132  into the entry sections  131 . 
     In particular, as illustrated in  FIG. 4 , for attaching the first suture  500  to the insert  300 , the insert  300  is first inserted into the slot  111  of the holding structure  110  of the insert holding device  100 . Subsequently, the first suture  400  is passed through the first end section  121   a  of the first recess  120  from the first surface  101  to the second surface  102 , passed below the insert  300  held by the holding structure  110 , and passed through the second end section  121   b  of the first recess  120  back from the second surface  102  to the first surface  101 . In case the optional first and second notch  141 , 142  is provided, the first suture  400  can subsequently be fixed by inserting the first suture  400  into the first and second notch  141 , 142  (see  FIG. 9 ). Passing the first suture  400  through the first recess  120  is facilitated by the increased width of the end sections  121   a , 121   b  of the first recess  120 . Next, a second suture  500  is inserted through the entry sections  131  into the holding sections  132  of the second recesses  130 , such that the second suture  500  extends above the first suture  400  across the first recess  120 . Therein, in particular, the second suture  500  is connected to a plate member  510  of a cortical fixation device  520 . Finally, the first suture  400  is laid around the insert  300  held by the holding structure  110  and around the second suture  500  held by the second recesses  130 , straightened and tied into a knot, thereby connecting the insert  300  to the second suture  500 . Alternatively to tying of a knot, the first suture  400  can be fixed by other means, such as e.g. gluing. 
     Of course, in case the first suture  400  has been fixed by insertion into the first and second notch  141 , 142 , the first suture  400  has to be removed from the first and second notch  141 , 142  prior to laying the first suture  400  around the insert  300  and the second suture  500  and tying the knot. 
     The insert holding device  100  according to the invention facilitates connecting the insert  300  to the second suture  500 , since the insert  300 , the second suture  500 , and (optionally) also the first suture  400  can be secured on the insert holding device  100  in an arrangement allowing fast and easy connection by means of the first suture  400 . 
     After joining of the insert  300  and the second suture  500 , the insert holding device  100  can be removed and the insert  300  can be connected to a flexible graft  900  to generate an implant I, in particular for anterior cruciate ligament repair, in a manner known from the prior art (see  FIG. 1 ). 
       FIG. 5  illustrates a method of manufacture of the insert holding device  100  shown in  FIG. 3  and  FIG. 4 . In this embodiment, the device  100  consists of a flat sheet of material, into which folding lines  118  are introduced (e.g. by indenting or heat treatment). The folding lines  118  are indicated by dashed lines, whereas cutting lines are indicated by solid lines. In order to generate the first wall  112  and the second wall  113  (see  FIG. 3  and  FIG. 4 ), two essentially rectangular segments of the sheet are cut out at three sides and a folding line  118  is generated at a fourth side extending along the first axis A 1  on the inside of the respective rectangular segment. Additionally, respective slits  119  are cut out in the center of the rectangular segments. The rectangular segments are then folded inside towards the first surface  101  in order to generate the first and second wall  112 , 113 . 
     Further fold  118  lines are generated to delimit segments constituting the first and second struts  116 , 117 , and the third and fourth wall  114 , 115 . The segments constituting the struts  116 , 117  are then folded inside towards the first surface  101 , the segment constituting the third wall  114  is inserted into the slit  119  of the first wall  112 , and the segment constituting the fourth wall  115  is inserted into the slit  119  of the second wall  113 . 
     The fold lines  118  on the side segments  162  of the pointed end  160  can be used to fold the side segments upwards in order to facilitate joining of the insert holding device  100  with the suture holding device  200  described below (see  FIG. 7 ). Folding the side segments  162  upwards is advantageous to prevent locking the insert holding device  100  on the suture holding device  200 . 
     Optionally, the above-described insert holding device  100  can be combined with a suture holding device  200  according to the present invention as depicted in  FIG. 6  and  FIG. 7 . 
     As shown in  FIG. 6 , the suture holding device  200  consists of a flat sheet of material extending in a plane defined by a first axis A 1  and a second axis A 2  which is perpendicular to the first axis A 1 . The suture holding device  200  has a front surface  201 , a back surface  202  opposing the front surface  201 , and a circumferential edge  203  connecting the front surface  201  and the back surface  202 . 
     Furthermore, the suture holding device  200  comprises a first recess  210  comprising a slot section  211  and a circular section  213  connected at a neck  212 . The first recess  210  is positioned adjacent to a holding structure  220  for arranging a second suture  500  across the first recess  210  along the second axis A 2 . 
     The holding structure  220  comprises a first protrusion  221  and a second protrusion  222  opposite the first protrusion  221 , wherein the slot section  211  of the first recess  210  is positioned between the first and the second protrusion  221 , 222 . The protrusions  221 , 222  each comprise a triangular shape, wherein the protrusions  221  each comprise an inner edge adjacent to the slot section  211 , wherein the inner edges are arranged at an acute angle in respect of the first axis A 1 , such that the width of the slot section  211  (measured along the second axis A 2 ) decreases towards the circular section  213  of the first recess  210 , thereby forming a neck  212  at the narrowest position. 
     A second recess  231  is positioned adjacent to the first protrusion  221  opposite the slot section  211 , and a third recess  232  is positioned adjacent to the second protrusion  222  opposite the slot section  211 . 
       FIG. 6  further shows a part of a looped second suture  500  held by the holding structure  220 . The second suture  500  extends from the back surface  202  through the second recess  231  to the front surface  201 , across the first protrusion  221 , the neck  212  of the first recess  210  and the second protrusion  222 , and back to the back surface  202  through the third recess  232 . To obtain the configuration shown in  FIG. 6 , the second suture  500  can be inserted into the second and third recess  231 , 232  from the edge  203  of the suture holding device  200  along the first axis A 1 . This has the advantage that a second suture  500  arranged in a closed loop (e.g. as part of a cortical fixation device  520 ) can be received by the holding structure  220  without opening the loop. 
     Furthermore, the suture holding device  200  comprises a first groove  240  for receiving a plate member  510 , particularly a plate member  510  of a cortical fixation device  520  as described above and depicted in  FIG. 2 . The first groove  240  of the suture holding device  200  is positioned opposite the first holding structure  220  along the first axis A 1 . When the plate member  510  is connected to the second suture  500 , a closed loop of the second suture  500  extending between the holding structure  220  and the plate member  510  in the first groove  240  on the back surface  202  of the suture holding device  200  can be tightened and thereby fixed on the suture holding device  200 . 
     Moreover, according to the embodiment shown in  FIG. 6 , the suture holding device  200  comprises a second groove  250 , a third groove  260 , a fourth groove  270 , and an opening  280 . The third and the fourth groove  260 , 270  are positioned opposite to each other along the first axis A 1  on a side of the suture holding device  200  in respect of the holding structure  220  The second groove  250  is positioned between the third and the fourth groove  260 , 270  and extends along the second axis A 2  on the side of the suture holding device  200 . The opening  280  is positioned between the first recess  210  and the first groove  240 . 
     A cortical fixation device  520  (see  FIG. 2 ) comprising a second suture  500  (also termed graft suture) for connecting a plate member  510  to a flexible graft  900 , a pulling suture  700  for pulling the plate member  510  through a borehole B of a bone, and a flipping suture  800  for flipping the plate member  510  outside of the borehole B can be arranged on the suture holding device  200  according to the embodiment shown in  FIG. 6  as described below and illustrated in  FIG. 7  and  FIG. 8 . 
     As shown in  FIG. 7  and  FIG. 8 , the second suture  500  is arranged on a plate member  510  in a closed loop L 1  and an open loop L 2  as shown in  FIG. 2 , wherein the second suture  500  extends twice through the first hole  511  and the second hole  512  of the plate member  510 . The pulling suture  700  is arranged in the third hole  513  of the plate member  510  and the flipping suture is arranged in the fourth hole  514  of the plate member  510 . In order to fix the cortical fixation device  520  on the suture holding device  500 , the closed loop L 1  is inserted in the second and third recess  231 , 232  of the holding structure  220  of the suture holding device  200 , such that the second suture  500  extends across the neck  212  of the first recess  210 , and the plate member  510  is inserted into the first groove  240  of the suture holding device  200 , such that the plate member  510  is arranged on the front side  201  of the suture holding device  200  and the closed loop L 1  extends from the first hole  511  of the plate member  510  to the second recess  231  on the back surface  202  of the suture holding device  200 , across the first protrusion  221 , the neck  212  of the first recess  210  and the second protrusion  222  on the front surface  201  of the suture holding device  200 , and from the third recess  232  back to the second hole  512  of the plate member  510  on the back surface  202  of the suture holding device  200 . The closed looped L 1  can be tightened by pulling the ends of the open loop L 2  in order to tightly fix the closed loop L 1  on the suture holding device  200 . 
     One end of the open loop L 2  is then arranged from the plate member  510  to the third recess  232  on the back surface  202 , across the neck  212  of the first recess  210  to the second recess  231  on the front surface  201 , and from the second recess  231  to the second groove  250  on the back surface  202  of the suture holding device  200 . The other end of the open loop L 2  is arranged from the plate member  510  to the second groove  250  on the back surface  202  of the suture holding device  200 . Subsequently, the first and the second end of the open loop L 2  are arranged from the second groove  250  to the third groove  260  on the front surface  201 , from the third groove  260  to the fourth groove  270  on the back surface  202 , from the fourth groove  270  to the opening  280  on the front surface  201 , and through the opening  280  to the second surface  202  of the suture holding device  200 . 
     The pulling suture  700  and the flipping suture  800  are arranged from the plate member  510  to the second groove  250  on the back surface  202 , from the second groove  250  to the third groove  260  on the front surface  201 , from the third groove  260  to the fourth groove  270  on the back surface  202 , from the fourth groove  270  to the third groove  260  on the front surface  201 , again from the third groove  260  to the fourth groove  270  on the back surface  202 , from the fourth groove  270  to the opening  280  on the front surface  201  and through the opening  280  to the back surface  202  of the suture holding device  200 . 
     The final configuration of the sutures on the front surface  201  of the suture holding device  200  is depicted in  FIG. 7 , and the final configuration of the sutures on the back surface  202  of the suture holding device  200  is depicted in  FIG. 8 . 
       FIG. 9  illustrates how the suture holding device  200  according to  FIG. 6  to  FIG. 8  can be combined with an insert holding device  100  according to the embodiment of the invention depicted in  FIG. 1  to  FIG. 4 . 
     The insert  300  is first received by the holding structure  110  of the insert holding device  100  (e.g. inserted into the slot  111 ), and the first suture  400  is received by the first recess  120  of the insert holding device  100  as described above. In detail, the first suture  400  is passed from the first surface  101  of the insert holding device  100  through the first end section  121   a  of the first recess  120  to the second surface  102 , passed below the insert  300  towards the second end section  121   b  of the first recess  120 , and passed through the second end section  121   b  back to the first surface  101 . Optionally, as shown in  FIG. 9 , the first suture  400  is inserted into the first notch  141  and the second notch  142  (see  FIG. 5 ) to fix and secure the first suture  400  on the insert holding device  100 . 
     Next, the second suture  500  is arranged on the holding structure  220  of the suture holding device  200  as described above ( FIG. 6  to  FIG. 8 ), such that the second suture  500  extends above the neck  212  of the first recess  210  of the suture holding device  200 . 
     Subsequently, the insert holding device  100  is assembled with the suture holding device  200  as shown in  FIG. 9 . Therein, the pointed end  160  (see  FIG. 4 ) of the insert holding device  100  is slid on the front surface  201  of the suture holding device  200 , wherein the first axis A 1  of the insert holding device  100  (see  FIG. 4 ) is parallel to the first axis A 1  of the suture holding device  200  (see  FIG. 6 ), such that the middle segment  161  of the pointed end  160  is arranged below the second suture  500  on the holding structure  210  of the suture holding device  200 . In this manner, the second suture  500  is received by the second recesses  130  of the insert holding device  100 . 
     The pointed end  160  facilitates positioning of the middle segment  161  below the second suture  500  on the holding structure  210  of the suture holding device  200 . 
     In addition, the arrow shape of the side segments  162  indicates the direction of joining the insert holding device  100  with the suture holding device  200 . 
     When the insert holding device  100  and the suture holding device  200  have been joined as shown in  FIG. 9 , the second suture  500  lays on top of the first suture  400 , such that the second suture  500  can be connected to the insert  300  by laying the first suture  400  around the second suture  500  and the insert  300  and e.g. tying a knot into the first suture  400 . After this step, the insert holding device  100 , the suture holding device  200 , and the insert  300  connected to the second suture  500  (and the cortical fixation device  520  attached thereto) can be disassembled, and the cortical fixation device  520  can e.g. be connected to the flexible graft  900 . 
     After this step, the insert holding device  100  can be firstly removed from the suture holding device  200 . Therein, the insert  300  is moved out of the slot  111 , and stays attached to the suture  500 . Then, a flexible graft  900  (see  FIG. 1 ) can be put through the first recess  210  (particularly through the circular section  213  of the first recess), thereby inserting the flexible graft  900  into the first loop L 1  of the second suture  500  (see  FIG. 2 ), and folded to attach the flexible graft  900  to the insert  300 . Optionally, the flexible graft  900  can be stitched together at a first stitching position  903  and a second stitching position  904  of the flexible graft  900  to secure the flexible graft  900  on the insert  300 . 
     Finally, the whole implant comprising the insert  300 , the first suture  400 , the second suture  500 , the plate member  510 , and the flexible graft  900  can be removed from the suture holding device  200  by pulling the flexible graft  900  and slightly bending the suture holding device  200  on the back surface  202 . 
       FIG. 10  shows a second embodiment of the insert holding device  100  according to the invention. The insert holding device  100  comprises an upper portion  104  and a lower portion  105  arranged along a third axis A 3 . Both the upper portion  104  and the lower portion  105  have a cylindrical shape with a circular cross-section in respect of the third axis A 3 , wherein the diameter of the upper portion  104  is smaller than the diameter of the lower portion  105 . The upper portion  104  comprises a first surface  101   a  perpendicular to the third axis A 3  and a circumferential third surface  103   a , and the lower portion  105  comprises a first surface  101   b  perpendicular to the third axis A 3 , a second surface  102  opposing the first surface  101   b , and a circumferential third surface  103   b.    
     The insert holding device  100  comprises a holding structure  110  comprising a slot  111  extending along a second axis A 2  perpendicular to the third axis A 3  on the first surface  101   a  of the upper portion  104  delimited by a first wall  112  and a second wall  113 . Therein, the material of the walls  112 , 113  and the distance between the first wall  112  and the second wall  113  are chosen such that an insert  300  can be held in position by static friction between the first wall  112 , the second wall  113  and the insert  300  when inserted into the slot  111 , and easily removed from the slot (press-fit). For instance, the first wall  112  and the second wall  113  may comprise a flexible material which is compressed when the insert  300  is inserted into the slot  111 . 
     Furthermore, the holding device  100  comprises a first recess  120  and a second recess  130  on the first surface  101   a  of the upper portion  104 , wherein the first recess  120  extends along a first axis A 1  perpendicular to the second axis A 2  and the third axis A 3 , and the second recess  130  extends along the second axis A 2 . In other words, the first and the second recess  120  are formed by a cross-shaped slot on the upper portion  104 . 
     In the example depicted in  FIG. 10 , the slot  111  of the holding structure  110  overlaps with and forms part of the second recess  130 . Alternatively, the slot  111  may form part of the first recess  120 . Along the third axis A 3 , the first recess  120  and the second recess  130  extend towards the first surface  101   b  of the lower portion  105 . In other words, the first recess  120  and the second recess  130  comprise the same height as the upper portion, and the first surface  10   b  of the lower portion  105  forms the bottom of the first and second recess  120 , 130 . A conical recess  170  (or a recess having any other shape, such as a rectangular milled recess) may be provided around the slot  111  to facilitate insertion of the insert  300  into the slot  111 . The third surface  103   a  of the upper portion  104  further comprises a groove  150  which extends circumferentially in respect of the third axis A 3 . 
       FIG. 11  schematically depicts an example of the use of the insert holding device  100  according to the embodiment shown in  FIG. 10  for connecting a second suture  500  (e.g. of a cortical fixation device  520 , see  FIG. 2 ) to an insert  300  (e.g. an osteoconductive element or a bone graft). In a first step ( FIG. 11A ), a first suture  400  is placed in the first recess  120  of the insert holding device  100 . According to a second step ( FIG. 11B ), a looped second suture  500  connected to a plate member  510  of a cortical fixation device  520  (see  FIG. 2 ) is gripped by a surgical tool  600 . As shown in  FIG. 11C , the loop of the second suture  500  is then inserted into the second recess  130  of the insert holding device  100 , and the loop is partially inserted into the circumferential groove  150  which facilitates holding the second suture  500  in place by means of the tool  600 . Subsequently, as depicted in  FIG. 12C , the insert  300  is placed in the slot  111  above the first suture  400  and the second suture  500  and held in position by the holding structure  110 . Finally, as shown in  FIG. 12D , the first suture  400  is tied into a knot, thereby connecting the second suture  500  to the insert  300 . 
       FIG. 12  depicts a further embodiment of the suture holding device  200  according to the invention which can be used together with the insert holding device  100  according to  FIG. 10 . The suture holding device  200  is formed from a flat sheet of material arranged in a plane defined by a first axis A 1  and a second axis A 2 , wherein the suture holding device  200  comprises a front surface  201  and a back surface  202  opposing the front surface  201 . Furthermore, the suture holding device  200  comprises a circular-shaped central first recess  210  and a holding structure  220  comprising a first through-hole  224  and a second through-hole  225  arranged along the second axis A 2  in line with the first recess  210 . 
     The suture holding device  200  further comprises a first hole  281 , a second hole  282 , a third hole  283 , a fourth hole  284 , and a fifth hole  285  arranged essentially along a semi-circle around the first recess  210 . Moreover, the suture holding device  200  comprises a first notch  287  and a second notch  288  in opposing edges, wherein the first and the second notch  287 , 288  are arranged along the first axis A 1  in line with the first recess  210 . In addition, a third notch  291  and a fourth notch  292  are provided in a further edge of the suture holding device  200 , wherein a flap  290  is positioned between the third notch  291  and the fourth notch  292 . 
     A second suture  500  can be arranged on the front surface  201  of the suture holding device  200  from the third notch  291  to the first hole  281 , through the first hole  281  to the back surface  202  of the suture holding device  200 , on the back surface  202  from the first hole  281  to the second hole  282 , through the second hole  282  to the front surface  201 , on the front surface  201  from the second hole  282  to the third hole  283 , through the third hole  283  to the back surface  202 , on the back surface  202  to the fourth hole  284 , through the fourth hole  284  to the front surface  201 , on the front surface  201  to the fifth hole  285 , through the fifth hole  285  to the back surface  202 , on the back surface  202  to the first through-hole  224  of the holding structure  220 , through the first through-hole  224  to the front surface  201 , on the front surface  201  across the first recess  210  to the second through-hole  225  of the holding structure  220 , through the second through-hole  225  to the back surface  202 , on the back surface  202  to the sixth hole  286 , through the sixth hole  286  to the front surface  201 , and on the front surface  201  back to the first hole  281 , resulting in a closed loop L 1  of the second suture  500 . The second suture  500  can then be passed along in parallel to the closed loop L 1  back to the sixth hole  286  and on the front surface  201  from the sixth hole  286  to the second notch  292 , resulting in an additional open loop L 2  of the second suture  500  (see  FIG. 2 ). 
     This results in the second suture  500  being fixed on the suture holding device  200  and arranged across the first recess  210  along the second axis A 2 . Of course, instead of the first to sixth hole  281 - 286  and the third and fourth notch  291 , 292 , other suitable means of fixing the second suture  500  on the suture holding device  200  may be used. 
     A first suture  400  may be arranged between the first notch  287  and the second notch  288  across the first recess  210 , in particular above the second suture  500 . 
     Four second recesses  293  on opposing edges of the suture holding device  200  may match the surface of the insert holding device  100  ( FIG. 10 ,  FIG. 11  A) to facilitate handling of the sutures  400 , 500  during placement on the insert holding device  100  ( FIG. 10 ,  FIG. 11  A). 
     The suture holding device  20  according to  FIG. 12  can be combined with the insert holding device  100  according to  FIG. 10  by placing the suture holding device  200  on top of the insert holding device  100  such that at least the upper portion  104  of the insert holding device  100  is positioned in the first recess  210 , such that the first axis A 1  of the insert holding device  100  is parallel to the first axis A 1  of the suture holding device  200 , and the second axis A 2  of the insert holding device  100  is parallel to the second axis A 2  of the suture holding device  200 . 
     In this manner, the first suture  400  may be easily be inserted into the first recess  120  of the insert holding device  100 , and the second suture  500  may be easily inserted into the second recess  130  of the insert holding device  100 . Subsequently, the insert  300  can be placed into the slot  111  of the holding structure  110  of the insert holding device  100 , and the first suture  400  can be laid around the insert  300  and the second suture  500  (and e.g. tied into a knot), thereby connecting the second suture  500  to the insert  300 . 
     Optionally, the diameter of the first recess  210  may be chosen according to the diameter of the upper portion  104  of the insert holding device  100 , such that only the upper portion  104  is inserted into the first recess  210 , and the suture holding device  200  rests on the first surface  101   b  of the lower portion  105  of the insert holding device  100 . This facilitates assembly of the insert holding device  100  and the suture holding device  200 . 
     A position reference hole  294  on the suture holding device  200  may be aligned with a marking (not shown) of the insert holding device  100  during assembly of the parts in order to position the first axis A 1  of the insert holding device  100  parallel to the first axis A 1  of the suture holding device  200 . 
     
       
         
           
               
             
               
                   
               
               
                 List of reference numbers 
               
               
                   
               
             
            
               
                   
               
            
           
           
               
               
               
            
               
                   
                 Insert holding device 
                 100 
               
               
                   
                 First surface 
                 101, 101a, 101b 
               
               
                   
                 Second surface 
                 102 
               
               
                   
                 Third surface 
                 103, 103a, 103b 
               
               
                   
                 Upper portion 
                 104 
               
               
                   
                 Lower portion 
                 105 
               
               
                   
                 Holding structure of the insert holding device 
                 110 
               
               
                   
                 Slot 
                 111 
               
               
                   
                 First wall 
                 112 
               
               
                   
                 Second wall 
                 113 
               
               
                   
                 Third wall 
                 114 
               
               
                   
                 Fourth wall 
                 115 
               
               
                   
                 First strut 
                 116 
               
               
                   
                 Second strut 
                 117 
               
               
                   
                 Folding line 
                 118 
               
               
                   
                 Slit 
                 119 
               
               
                   
                 First recess 
                 120 
               
               
                   
                 First end section 
                 121a 
               
               
                   
                 Second end section 
                 121b 
               
               
                   
                 Middle section 
                 122 
               
               
                   
                 Second recess 
                 130 
               
               
                   
                 Entry section 
                 131 
               
               
                   
                 Holding section 
                 132 
               
               
                   
                 First notch 
                 141 
               
               
                   
                 Second notch 
                 142 
               
               
                   
                 Groove of the insert holding device 
                 150 
               
               
                   
                 Pointed end 
                 160 
               
               
                   
                 Middle segment 
                 161 
               
               
                   
                 Side segment 
                 162 
               
               
                   
                 Conical recess 
                 170 
               
               
                   
                 Suture holding device 
                 200 
               
               
                   
                 Front surface 
                 201 
               
               
                   
                 Back surface 
                 202 
               
               
                   
                 Edge 
                 203 
               
               
                   
                 First recess of the suture holding device 
                 210 
               
               
                   
                 Slot section 
                 211 
               
               
                   
                 Neck 
                 212 
               
               
                   
                 Circular section 
                 213 
               
               
                   
                 Holding structure of the suture holding device 
                 220 
               
               
                   
                 First protrusion 
                 221 
               
               
                   
                 Second protrusion 
                 222 
               
               
                   
                 First through-hole 
                 224 
               
               
                   
                 Second through-hole 
                 225 
               
               
                   
                 Second recess 
                 231 
               
               
                   
                 Third recess 
                 232 
               
               
                   
                 First groove 
                 240 
               
               
                   
                 Second groove 
                 250 
               
               
                   
                 Third groove 
                 260 
               
               
                   
                 Fourth groove 
                 270 
               
               
                   
                 Opening 
                 280 
               
               
                   
                 First hole 
                 281 
               
               
                   
                 Second hole 
                 282 
               
               
                   
                 Third hole 
                 283 
               
               
                   
                 Fourth hole 
                 284 
               
               
                   
                 Fifth hole 
                 285 
               
               
                   
                 Sixth hole 
                 286 
               
               
                   
                 First notch of the suture holding device 
                 287 
               
               
                   
                 Second notch of the suture holding device 
                 288 
               
               
                   
                 Flap 
                 290 
               
               
                   
                 Third notch of the suture holding device 
                 291 
               
               
                   
                 Fourth notch of the suture holding device 
                 292 
               
               
                   
                 Second recess of the suture holding device 
                 293 
               
               
                   
                 Position reference hole 
                 294 
               
               
                   
                 Insert 
                 300 
               
               
                   
                 First suture 
                 400 
               
               
                   
                 Second suture 
                 500 
               
               
                   
                 Plate member 
                 510 
               
               
                   
                 First hole 
                 511 
               
               
                   
                 Second hole 
                 512 
               
               
                   
                 Third hole 
                 513 
               
               
                   
                 Fourth hole 
                 514 
               
               
                   
                 Cortical fixation device 
                 520 
               
               
                   
                 Tool 
                 600 
               
               
                   
                 Pulling suture 
                 700 
               
               
                   
                 Flipping suture 
                 800 
               
               
                   
                 Flexible graft 
                 900 
               
               
                   
                 First end 
                 901 
               
               
                   
                 Second end 
                 902 
               
               
                   
                 First stitching position 
                 903 
               
               
                   
                 Second stitching position 
                 904 
               
               
                   
                 First axis  
                 A 1   
               
               
                   
                 Second axis 
                 A 2   
               
               
                   
                 Third axis 
                 A 3   
               
               
                   
                 B 
                 Borehole 
               
               
                   
                 I 
                 Implant 
               
               
                   
                 F 
                 Femur 
               
               
                   
                 T 
                 Tibia 
               
               
                   
                 L 
                 Longitudinal axis 
               
               
                   
                 L 1   
                 Closed loop 
               
               
                   
                 L 2   
                 Open loop