Patent Publication Number: US-2012046747-A1

Title: Systems and methods for zipknot acl fixation

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
     This application is a continuation-in-part of: 
     U.S. patent application Ser. No. 12/828,856 filed 1 Jul. 2010, which carries Applicants&#39; docket no. MLI-77, and is entitled SYSTEM AND METHODS FOR ZIPKNOT ACL FIXATION. 
     U.S. patent application Ser. No. 12/828,856 claims the benefit of the following, which are incorporated herein by reference: 
     U.S. Provisional Patent Application No. 61/222,574 filed 2 Jul. 2009, which carries Applicants&#39; docket no. MLI-77 PROV, and is entitled ZIP KNOT ACL FIXATION BUTTON; 
     U.S. Provisional Patent Application No. 61/333,363 filed 11 May 2010, which carries Applicants&#39; docket no. MLI-84 PROV, and is entitled ZIP KNOT ACL FIXATION BUTTON; and 
     U.S. Provisional Patent Application No. 61/333,548 filed 11 May 2010, which carries Applicants&#39; docket no. MLI-85 PROV, and is entitled ZIP KNOT ACL FIXATION BUTTON. 
     The following are incorporated herein by reference: 
     U.S. patent application Ser. No. 11/001,866 filed 1 Dec. 2004, now U.S. Pat. No. 7,594,923, which carries Applicants&#39; docket no. MLI-17, and is entitled LINE LOCK SUTURE ATTACHMENT SYSTEMS AND METHODS; 
     U.S. patent application Ser. No. 10/936,376 filed 7 Sep. 2004, now U.S. Pat. No. 7,566,339, which carries Applicants&#39; docket no. MLI-15, and is entitled ADJUSTABLE LINE LOCKS AND METHODS; 
     U.S. patent application Ser. No. 10/459,375 filed 11 Jun. 2003, now U.S. Pat. No. 7,150,757, which carries Applicants&#39; docket no. 13447.35, and is entitled ADJUSTABLE LINE LOCKS AND METHODS; 
     U.S. patent application Ser. No. 11/112,814 filed 21 Apr. 2005, now U.S. Pat. No. 7,641,694, which carries Applicants&#39; docket no. MLI-23, and is entitled LINE LOCK GRAFT RETENTION SYSTEM AND METHOD; 
     U.S. patent application Ser. No. 11/125,885 filed 8 May 2005, now U.S. Pat. No. 7,722,644, which carries Applicants&#39; docket no. MLI-32, and is entitled COMPACT LINE LOCKS AND METHODS; and 
     U.S. patent application Ser. No. 11/142,933 filed 2 Jun. 2005, now abandoned, which carries Applicants&#39; docket no. MLI-33, and is entitled BONE IMPLANTS WITH INTEGRATED LINE LOCKS. 
    
    
     BACKGROUND OF THE INVENTION 
     1. The Field of the Invention 
     The present invention relates generally to anterior cruciate ligament (ACL) repair and the fixation of an ACL graft on the cortical side of the bone. The present invention may also be used for other suspensory fixation applications such as bone/tendon or bone/ligament attachment. 
     2. The Relevant Technology 
     Currently ACL repair requires cortical fixation using some type of fixation device that can retain a graft ligament passed through a bone tunnel while maintaining fixation on the cortical side of the bone. Currently there are buttons on the market that allow for fixation without passing through the bone tunnel. Knots tied on, around or through the button are used to hold the graft and the button in place. However, knots are known for reducing the strength of the fixation. 
     In addition, knots do not offer the amount of tension typically desired by physicians because in tying the knot tension is often relinquished in order to achieve a completed knot. Numerous devices have been developed to eliminate the need to tie knots as a way of securing a line. The devices that accomplish the same function as a knot, which is in part to secure a line to retain tension in a portion of the line, are typically referred to as line locks. These line locks can be used as a one-way directional slide to increase tension in a line without relinquishing that tension to tie a knot. 
     Current ACL repair systems will engage a graft and then fix the graft using knots tied to a body on the cortical side of the bone. Physicians either have to fix the graft using cord or line prior to passage through the bone tunnel and then readjust the tension, or pass the lines and cords through the bone tunnel without tension and then adjust the tension after pass through, again, tying knots to fix the graft to the cortical fixation device. 
     In addition currently physicians must choose a proper suture length and bight length of a sling to hold the graft. In this case the surgeon must have multiple sutures with multiple bight lengths available in the operating room (OR) and if the improper length is chosen first then the surgeon will be required to find a different suture length and bight length leading to more guess work and longer surgery times. 
     As the above described techniques illustrate, the existing systems and procedures for ACL repair may not be as effective as desired. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       Various embodiments of the present invention will now be discussed with reference to the appended drawings. It is appreciated that these drawings depict only typical embodiments of the invention and are therefore not to be considered limiting of its scope. 
         FIG. 1  illustrates a perspective view of a device with a neck and head of the plate, a plurality of passageways through a body of the plate, a line routed through the plurality of passageways, a primary filament and a secondary filament; 
         FIG. 2  illustrates a side view of the device of  FIG. 1  with the line routed through the plurality of passageways and a primary and secondary filament; 
         FIG. 3  illustrates a perspective view of the device of  FIG. 1  with a plate, the plate with a head, neck, body and a plurality of passageways and the line routed through the plurality of passageways with a primary and secondary filament, the secondary filament routed differently than in  FIGS. 1 and 2 ; 
         FIG. 4  illustrates perspective view of the device of  FIG. 1  with a plate, the plate with a head, neck, body and a plurality of passageways and the line routed through the plurality of passageways with a primary and secondary filament, the secondary filament routed differently than in  FIGS. 1 and 3 ; 
         FIG. 5  illustrates a perspective view of the device of  FIG. 1  with a plate, the plate with a head, neck, body and a plurality of passageways and the line routed through the plurality of passageways with a primary and secondary filament, the secondary filament routed differently than in  FIGS. 1 ,  3  and  4 ; 
         FIG. 6  illustrates a perspective view of the device of  FIG. 1  with a plate, the plate with a head, neck, body and a plurality of passageways and the line routed through the plurality of passageways with only a primary filament routed differently than in  FIGS. 1 ,  3 ,  4  and  5 ; 
         FIG. 7  illustrates a perspective view of an alternate embodiment of  FIG. 1  with a neck, a head and a body of the plate, the body with a plurality of passageways and a line routed through the plurality of passageways, and a plurality of grooves, the line comprising a first loop or eyelet at one end; 
         FIG. 8  illustrates a perspective view of an alternate embodiment of the device of  FIG. 1 , with a plate having a head, a neck and a body, the body with a plurality of passageways and a line routed through the plurality of passageways, and a crimp on the neck of the plate; 
         FIG. 9  illustrates a perspective view of an alternate embodiment of the device of  FIG. 1 , with a plate having a head, a neck and a body, the body with a plurality of passageways and a line routed through the plurality of passageways, and hole passing longitudinally through the neck from a lateral passageway with an opening allowing a filament to be looped around the line and two pins holding the line in place across the opening; 
         FIG. 10  illustrates a perspective view of an alternate embodiment of the device of  FIG. 1 , with a plate having a head, a neck and a body, the body with a plurality of passageways and a line routed through the plurality of passageways, one of the passageways on the neck of the plate and a loop of the line wrapped around the neck and a filament passing through the neck passageway and looped around the line so the filament is retained by the line; 
         FIG. 11  illustrates a perspective view of an alternate embodiment of the plate of  FIGS. 1-7 , with the plate having a head, a neck and a body, the body with a plurality of passageways for receiving at least one line, without the line depicted; 
         FIG. 12  illustrates a bottom perspective view of the plate of  FIG. 11 , with the plate having a head, a neck and a body, the body with a plurality of passageways for receiving at least one line; 
         FIG. 13  illustrates a perspective view of an alternate embodiment of the plate of  FIGS. 1-7 , with the plate having a head, a neck and a body, the body with a plurality of passageways for receiving at least one line, without the line depicted; 
         FIG. 14  illustrates a bottom perspective view of the plate of  FIG. 13 , with the plate having a head, a neck and a body, the body with a plurality of passageways for receiving at least one line and curved ends of the passageways adjacent to one another; 
         FIG. 15  illustrates a bottom perspective view of the plate of  FIG. 13 , with the plate having a head, a neck and a body, the body with a plurality of passageways for receiving at least one line and curved ends of the passageways separated by a portion of the body of the plate; 
         FIG. 16  illustrates a perspective view of an alternate embodiment of the plate of  FIGS. 1-7 , with the plate having a head, a neck and a body, the body with a plurality of passageways for receiving at least one line, without the line depicted; 
         FIG. 17  illustrates a bottom perspective view of the plate of  FIG. 16 , with the plate having a head, a neck and a body, the body with a plurality of passageways for receiving at least one line; 
         FIG. 18  illustrates a perspective view of an alternate embodiment of the plate of  FIGS. 1-7 , with the plate having a head, a neck, resembling a single post, and a body, the body with a plurality of passageways for receiving at least one line, without the line depicted; 
         FIG. 19  illustrates a perspective view of an alternate embodiment of the plate of  FIGS. 1-7 , with the plate having a head, a neck and a body, the body with a plurality of passageways for receiving at least one line, and at least one deep groove extending from the end of the head to at least one of the plurality of passageways for receiving a line, without the line depicted; 
         FIG. 20  illustrates a perspective view of an alternate embodiment of the plate of  FIGS. 1-7 , with the plate having a head, a neck and a body, the body with a plurality of passageways for receiving at least one line, and a cut out extending from the head toward the neck for receiving a line, without the line depicted; 
         FIG. 21  illustrates a top perspective view of an alternate embodiment of a line lock, with the plate having an elongated body, the body with a plurality of passageways, the plate also having two dogbone features. 
         FIG. 22  illustrates a bottom perspective view of the line lock of  FIG. 21 . 
         FIG. 23  illustrates a top perspective view of the line lock of  FIG. 21 , having a line mounted on the plate with two free ends and an adjustable loop that extend outwards from the bottom surface of the body. 
         FIG. 24  illustrates a bottom perspective view of the line lock of  FIG. 23 . 
     
    
    
     DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS 
     The present device provides a means for “locking” a line or suture at a length without using a knot, such knots capable of reducing its strength. The invention allows for adjustment of the line/suture/sling length on the back table, reducing the need for multiple sizes or parts. Because of the adjustable nature the tolerance/error band on the line length is lower than competitive devices that use a fixed size and/or length line. Parts of this device may include a zip knot or “wrap” along with plate geometry and hole patterns for routing of a line. The device may also include a loop/cinch with a first loop or lead loop. Other features may include adjustability of a single free end or multiple free ends. Furthermore a first or primary filament and second or secondary filament configurations may be used to flip the plate to secure the device against a bone. 
     One embodiment is a rectangular piece/plate with rounded ends. One of the ends has a “dogbone” feature for lines and filaments to wrap around. The dogbone feature may comprise two cutouts toward one end of the plate on opposing sides, forming a neck, which give the structure its name as featured in the  FIGS. 1-14  and  17 - 21 .  FIGS. 15-16  show what may be a dogbone feature, however the dogbone feature may be less pronounced than in the other figures. There may be four holes in the plate; two on each end, and two holes more centrally located in the plate. A line which may be a suture, a cord, or a filament material is passed through the holes to create an adjustable loop/sling to hold an ACL graft or other biological material. The graft line material is fixed to the dogbone end via a looping technique that secures the line to the plate and simultaneously provides a first loop that is configured to be pulled on directly or have a filament passed through this first loop. Such a looping technique may include those as described in U.S. Pat. Nos. 7,594,923, 7,566,339 and 7,150,757 which are herein incorporated by reference. This first loop can be pulled on directly or via secondary filaments to pull or position the plate through a tunnel or hole. A non-looped end, or a free end, of the line material passes around the plate and back under itself to form a self-locking wrap. When the free end of the line is pulled, the adjustable loop, or sling, can be shortened. When the adjustable loop is pulled on, the self-locking wrap cinches itself tighter. 
     The plate is designed to fit through a bone tunnel and can be inserted via any preferred approach (e.g., medial portal or trans-tibial approaches). A first or primary filament may have a first filament loop created along its length a specified distance from its mid-length, the loop may be stationary but may also move along the length of the first filament. The first filament may have a stationary feature, which may be a knot, at the filament&#39;s mid-length. A section of the first filament is looped through the plate body on one side. The secondary filament may pass through the body of the plate or through the first loop of the line. A second filament may be passed through one of the central holes in the body of the plate which may be the same hole that the first loop of the line is passed through. The second or secondary filament may also pass through the first filament loop. The second filament may be fixed to the plate at any specified distance from the central plate hole such as passing the second filament around the dogbone feature of the plate or around the plate in general or through any of the other plate holes. The colors and lengths of the filaments may be configured to ensure the primary filament through the plate hole will be pulled through the bone tunnel to pull up the button past the cortical wall, with the secondary filament parallel with the first loop and graft. Once the plate clears the bone tunnel, the secondary filament is pulled on either trans-tibially or from a medial portal to flip the plate so that the plate is perpendicular to the tunnel and anchors against the bone (plate contact area larger the bone tunnel area). After plate installation one end of the primary filament is pulled through the plate, simultaneously pulling the secondary filament from the bone tunnel and central hole in the body of the plate. The secondary filament is pulled from the plate. 
     One will appreciate that the secondary filament is not required to pass through a first filament loop and thus the secondary filament may not be removed in conjunction with removal of the primary filament. The secondary filament may pass through the bone tunnel and after installation of the plate the secondary filament may be removed through the plate similar to the primary filament. 
     This device may be used to hold an ACL graft and the graft may be soft or hard tissue. In addition this device is not limited to the ACL or knee and may have other applications in other parts of the body, such as the shoulder, elbow and ankle. 
     In an aspect of the technology for retaining a graft, the system includes a plate having a body formed of biocompatible material. The body has an elongated shape, and the body substantially bounds a plurality of passageways. The body also includes a first neck extending from a first end of the body, the first neck thinner than the body in at least one plane, and a first head extending from the first neck, the first head thicker than the first neck in at least one plane. The body also includes a continuous line routed through the plurality of passageways of the body, the line comprising a first compression section, a first free end and an adjustable loop. The first free end is drawable along a first pathway defined by the routing of the line only along a first direction. A first length of the loop is adjusted by drawing the first free end along the first direction. 
     In an embodiment of the system, the plate has a first surface and a first portion, wherein the first neck extends from the first portion, and wherein the first free end and the adjustable loop extend from the first surface of the body. 
     In another embodiment, the adjustable loop is immediately adjacent to the first compression section. 
     In yet another embodiment, the plate body includes a first dog bone feature. The first dog bone feature includes the first neck and the first head. 
     In yet another embodiment, a portion of the line encircles the first neck. 
     In yet another embodiment the plate comprises at least one edge, wherein at least a portion of the edge is rounded and the rounded edge portion contacts the line. 
     In yet another embodiment, the rounded edge portion is located on at least one passageway. 
     In yet another embodiment, the body comprises four substantially bounded passageways. 
     In yet another embodiment, the plate includes a second portion opposite the first portion, a top surface that extends between the first portion and the second portion, and a bottom surface opposite the top surface. Further, the body includes a first side that extends between the first portion and the second portion, and between the top surface and the bottom surface. The body also includes a second side opposite the first side. The first neck has a first side that extends between the top surface and the bottom surface, and a second side opposite the first side. The line is routed through a first passageway, across the top surface of the plate toward the second side of the first neck, besides the second side of the first neck towards the bottom of the plate, across the bottom surface of the plate towards the first side of the first neck, along the first side of the first neck towards the top surface of the plate, and through a second passageway so that the line crosses itself to form the first compression section. The line is coupled to the plate so that the first free end and the adjustable loop extend from the bottom surface of the plate. 
     In yet another embodiment, the first neck is tapered. 
     In yet another embodiment, the continuous line includes a second compression section and a second free end, wherein the second free end is drawable along a second pathway defined the routing of the line only along a second direction. The first length of the loop is adjusted by drawing the second free end along a second direction. 
     In yet another embodiment, the body has a second neck extending from the second portion, the second neck thinner than the body in at least one plane and a second head extending from the second neck, the second head thicker than the first neck in at least one plane. 
     In yet another embodiment, the second neck and second head are contained in a second dogbone feature. 
     In yet another embodiment, the second neck has a first side that extends between the top surface and the bottom surface, and a second side opposite the first side. The line is routed through a third passageway, across the top surface of the plate toward the second side of the second neck, beside the second side of the second neck towards the bottom of the plate, across the bottom surface of the plate towards the first side of the second neck, along the first side of the second neck towards the top surface of the plate, and through a fourth passageway so that the line crosses itself to form the second compression section. The line is coupled to the plate so that the second free end and the adjustable loop extend from the bottom surface of the plate. 
     In yet another embodiment, the graft is placed over the adjustable loop. When the graft is over the adjustable loop and tension is applied to the graft, the line compresses itself against the body at the first compression section so that the length of the adjustable loop becomes fixed. 
     Referring to  FIGS. 1-5 , a fixation device  10  is portrayed with a plate  11 , a line  24  and filaments  44 ,  46 . The plate  11  may be substantially rectangular and may comprise a body  12  which may have rounded first end  16  and a rounded second end  18 . The body may include a plurality of passageways  14  configured to receive the line  24  and first and second filaments  44 ,  46 . The plurality of passageways  14  may be partially or entirely bounded by the plate  11 . The plate may also comprise a neck  20  extending longitudinally from the first end  16  of the body  12 ; however, the neck  20  may extend from either the first end  16  or the second end  18 , or both. The neck  20  may be thinner than the body  12  of the plate  11  in at least one plane or the neck  20  may have a smaller circumference than the body l 2  of the plate  11 . Extending longitudinally from the neck is a head  22  which may be thicker than the neck  20  in at least one plane or may have a greater cross-sectional diameter in at least one plane than the neck  20 . The head  22  may also extend from the neck in at least one plane substantially perpendicular to the neck  20 . The head  22  may have a substantially similar thickness as the body  12  of the plate or may have a substantially similar cross-sectional diameter in at least one plane as the body  12  of the plate  11 . The neck  20  and head  22  of the plate  11  create a dogbone  34  feature on one end of the plate  11 . The head  22  may be rounded on the end opposite the neck  20 . 
     The plate  11  may also comprise grooves  36  throughout the plate. The grooves  36  may extend between passageways  14  or between a passageway  14  and a periphery  40  of the plate  11  or even grooves  36  from between the head  22  and neck  20  and the neck  20  and the body  12 . The grooves  36  may also reside on the top, sides or bottom of the plate  11 . The plate  11  is designed to fit through a bone tunnel and can be inserted via any preferred approach (e.g., medial portal or trans-tibial approaches). The plate may be comprised of biocompatible materials including but not limited to titanium, stainless steel, cobalt chrome, PEEK, PLLA, polymer/ceramic composites, polymers, co-polymers, or alloys or a combination of those mentions herein. In addition any material used for the plate may also be coated with bioactive or supportive materials. 
     The plurality of passageways  14  may be generally rounded and are capable of receiving at least one line. The plurality of passageways  14  may comprise four passageways that are configured to receive the line  24  and are shaped and patterned for the routing of the line through the passageways  14 . The passageways  14  may be substantially on the body  12  of the plate  11 ; however in an alternate embodiment the neck  20  may also comprise passageway  14 . Of the four passageways those disposed more laterally may comprise a more ovoid shape and those passageways disposed more medially may comprise a more triangular or tear-drop shape. The shapes of the plurality of passageways  14  is to enhance the routing and self-locking of the line  24  to the plate  11 . The tear-drop shape of at least one of the plurality of passageways  14  may further enhance the locking of the line  24  for the adjustable loop  29 . The ovoid shape of at least one of the plurality of passageways  14  may allow for multiple passes of the line  24  through the same passageway while minimizing total passageway area. The plurality of passageways  14  may also taper or enlarge from the top to the bottom of the plate  11  or the plurality of passageways  14  may taper or enlarge from the bottom to the top of the plate  11 . 
     The neck  20  is a smaller circumference than the body  12 , or is thinner than the body in at least one plane, to maintain the line  24 . The smaller circumference may also provide protection of the lines as they pass through the cutouts that create the neck to prevent the lines from rubbing against the walls of a bone tunnel when passing the plate  11  through the bone tunnel. 
     The head  22  of the plate  11  may comprise flanges or fins  42  which extend back toward the body  12  of the plate  11 . These flanges  42  may add greater security of the line  24  and the second filament  46  preventing withdrawal of the second filament  46  or the line  24  over the head  22 . The flanges  42  may also provide added protection of the line  24  and second filament  46  while passage of the plate through the bone tunnel. 
     The line  24  of the device  10  is routed through the passageways  14  to create a self-locking slide. The line  24  may be comprised of metal, polymer, composite or suture and may be woven or braided. The line may comprise a first portion, which may be a first working portion  26 , and a second portion, which may be a second working portion  30 . Both of the first and second working portions  26 ,  30  may have free ends. Between the first working portion  26  and the second working portion  30  is an intermediate portion  28  which may comprise an adjustable loop  29 . The first working portion  26  is routed along a first pathway. The first pathway may comprise routing the first working portion up through a first medially located passageway  14   a , through at least one of the grooves  36 , down through a first laterally located passageway  14   c , around the neck  20 , up through the first laterally located passageway  14   c  and passed underneath the portion of the line around the neck  20 . The neck  20  may comprise a neck groove  32  that the line passes through underneath the portion of the line  24  that is wrapped around the neck  20 . A first compression section  25  is formed with the line passing underneath the portion of the line that passes around the neck  20  wherein when the first working portion  26  is pulled tight the compression section  25  pushes a portion of the line against the neck groove  32  of the neck  20  self-locking the line  24  against the plate  11 . This compression section  25  of the line creates a one-way slide allowing for the first working portion  26  to be advanced only along one direction, the one direction defined by the routing of the first working portion  26 . 
     The second working portion  30  is routed along a second pathway. The second pathway may comprise routing the second working portion up through the first medially located passageway  14   a , passed over the top of a periphery groove  38 , the periphery groove  38  extending from a second medially located passageway  14   b  to the periphery  40  of the plate. The second working portion  30  is then passed down through the second laterally located passageway  14   d , up through the second medially located passageway  14   b  and underneath the portion of the line  24  that passed over the periphery groove  38 . A second compression section  27  is formed with the line passing underneath the portion of the line that passes over the top of the periphery groove  38  wherein when the second working portion  28  is pulled tight the compression section  27  pushes a portion of the line against the periphery groove  38  of the plate  11  self locking the line against the plate  11 . This compression section  27  of the line creates a one-way slide allowing for the second working portion  30  to be advanced only along one direction, the one direction defined by the routing of the second working portion  30 . 
     The adjustable loop  29  of the intermediate portion  28  of the line  24  is configured to hold a graft (not shown). The graft may be an ACL graft and may be a soft or hard tissue. The graft is looped around the adjustable loop  29  to retain the graft. By pulling on either the first working portion  26  or the second working portion  30 , or both, the adjustable loop  29  reduces in size pulling the graft closer to the plate  11 . The adjustable loop  29  is unable to increase in size after the graft is captured by the adjustable loop  29  and the line  24  is routed through the plate  11  because the routing of the line  24  forms a one-way slide so only reduction of the adjustable loop  29  occurs. 
     The first filament  44  passes through the second laterally positioned passageway  14   d  and is used to pull the plate  11  through the bone tunnel along a longitudinal axis of the plate  11 . The second filament  46  may be routed around the neck  20 , creating a loop around the neck  20 , of the plate  11  and then passed through the second medially positioned passageway  14   b . The second filament  46  is used to toggle the plate  11  after the plate  11  passes through the bone tunnel. After passing through the bone tunnel the second filament  46  may remain in the bone tunnel. The second filament  46  is pulled and the plate  11  toggles so that the longitudinal axis of the plate  11  is perpendicular to the bone tunnel. After the plate  11  is positioned on a cortical side of a bone the first and second filaments  44 ,  46  may be removed by pulling on one end of each filament. After positioning of the plate  11  the first working portion  26  or the second working portion  30 , or both, are pulled to reduce the size of the adjustable loop  29  thereby creating greater tension in the graft and further cinching the plate  11  against the cortical side of the bone. 
     The routing of the second filament  46  may be done in a plurality of ways. Referring to  FIG. 3 , the second filament  46  may be routed around the neck  20 , creating a loop around the neck  20 , similar to the embodiment in  FIG. 1 . The second filament  46  then passes through the second laterally positioned passageway  14   d . The same effect is achieved with this routing as that previously described in that the second filament  46  is used to toggle the plate  11  after passing through the bone tunnel. Similar to the previous routing, after passing through the bone tunnel the second filament  46  may remain in the bone tunnel. After the plate  11  is positioned on the cortical side of the bone the second filament  46  is removed. 
     Referring to  FIG. 4 , the second filament  46  may be routed around the neck  20 , creating a loop around the neck  20 , and then the second filament passed slidably through a first filament loop  48  of the first filament  44 . The first filament loop  48  may be static. The second filament  46  may then be routed through any of the plurality of passageways  14 . After passage of the plate  11  through the tunnel the second filament  46  is again used to toggle the plate  11  so that the longitudinal axis of the plate is perpendicular to the bone tunnel. Similar to the previously described routing, after passing through the bone tunnel the second filament  46  may remain in the bone tunnel. After positioning of the plate  11 , the first filament  44  may be removed thereby removing the second filament  46  as well because the second loop is still within the first filament loop  48 . 
     Referring to  FIG. 5 , the second filament  46  may be routed through any of the plurality of passageways  14  creating a loop around the intended passageway. The filament is then routed through the first filament loop  48  of the first filament  44 . The second filament  46  may then be routed through any of the plurality of passageways  14 . Once the plate  11  clears the bone tunnel, the second filament  46  is pulled on (trans-tibially or from the medial portal) to flip the plate so that the plate  11  is perpendicular to the bone tunnel and anchors against the bone with the plate contact area being larger than the bone tunnel. Similar to the previously described routing, after passing through the bone tunnel the second filament  46  may remain in the bone tunnel. Similar to the removal of the first filament  44  in the preceding paragraph, after positioning of the plate  11 , the first filament  44  may be removed thereby removing the second filament  46  as well because the second loop is still within the first filament loop  48 . 
     After the plate  11  is secured against the cortical bone, the filaments  44 ,  46  are removed and the plate  11  is cinched and the adjustable loop  29  adjusted to the appropriate length and tension the free ends of the first and second working portions  26 ,  30  may be cut to shorter lengths. 
     Referring to  FIG. 6 , all of the features previously disclosed are substantially the same; however only a one filament, the first filament  44 , is used and passed through the more centrally located first medial passageway  14   a . The first filament  44  passes through the first medial passageway  14   a . The plate  11  is inserted in a longitudinal direction, substantially parallel to the axis of the bone tunnel, into the bone tunnel. Pulling on the first filament through the bone tunnel the plate  11  passes through the bone tunnel and after clearing the cortical side of the bone the plate  11  toggles automatically, wherein the longitudinal direction of the plate is substantially perpendicular to the axis of the bone tunnel. Because of the placement of the first filament  44  through the first medial passageway  14   a , the plate  11  naturally tends to return to a non-parallel state between the plate  11  and the bone tunnel. In this embodiment a second filament is not needed to toggle the plate  11 . 
     Referring to  FIG. 7 , all of the features previously disclosed are substantially the same to this embodiment with the exception of the first working portion  26  may comprise a first loop  50  instead of a free end. The first loop  50  may be an eyelet. The first loop  50  may be woven or braided into the cord or the first loop  50  may be a thicker cord with separate fibers of the cord. The first loop  50  may also use an adhesive in the fibers to help maintain the structure of the loop. The first loop  50  may also be created by using the free end of the first working portion  26  and crimping the free end with a crimp (not shown) to another portion of the first working portion  26  to create a loop. The crimp could be metal, polymer or any other biocompatible materials strong enough to hold the line  24  to form the first loop  50 . The first loop  50  may be held tightly against the plate  11  or may be kept at a distance from the plate  11 . 
     The first loop  50  may be configured to receive the second filament  46 . The second filament  46  is looped through the first loop  50  and is used to toggle the plate  11  after passage through the bone tunnel. The second filament  46  through the first loop  50  provides certain advantages when pulling the plate  11  through the bone tunnel including increased slidability of the second filament  46  and may provide an offset distance from the plate  11  to improve flipping of the plate  11 . Furthermore the first loop  50  may allow for slidability of the second filament  50  preventing the second filament  46  from getting stuck or damaged between the plate  11  and the bone. 
     Referring to  FIG. 8 , a device  10  is depicted with a slight different head  22  extending from the neck  20 . In this embodiment the head  22  may not include the flanges or fins  42  as depicted in the previous embodiments ( FIGS. 1-7 ). Furthermore, this embodiment may include a crimp  52  on the dogbone end  34 , wherein the first working portion  26  of the line  24  passes through the neck groove  32  and is secured to the plate  11  on the neck  22  or the dogbone end  32  through the use of the crimp  52 . The crimp  52  would substantially encircle the neck  20  and the first working portion  26  of the line  24  to the plate  11 . The crimp  52  may be comprised of any biocompatible material including polymer, composite or metal. A further distinguishing feature of this embodiment is that the first working portion  26  may or may not be routed in the same or similar manner as the routing in the previous embodiment ( FIGS. 1-7 ). With the  FIG. 8  embodiment the first working portion  26  may simply pass up through the first medial passageway  14   a  but may not pass completely back down and through the first lateral passageway  14   c , but rather simply pass through the neck groove  32  and then be secured to the plate  11  with the crimp  52 . The second working portion  30  of the line  24  is routed in substantially the same manner as described in the previous embodiments described in  FIGS. 1-7  with the same routing of the line  24 , the same adjustable loop  29  of the intermediate portion  28  and the second compression section  27  which holds a portion of the line  24  to create a one-way slide. 
     First and second filaments  44 ,  46  (not shown in  FIG. 8 ) may be routed around and through the plate  11  in any manner as previously described herein. Likewise inserting the plate  11  into the bone tunnel, passing the plate  11  through the bone tunnel, toggling the plate  11  after passage through the bone tunnel, cinching the plate to the cortical side of the bone and removing the filaments  44 ,  46  from the plate may all be accomplished in any of the ways as previously described herein. 
     Referring to  FIG. 9 , a device  10  is depicted with the nearly the same plate  11  configuration as that of  FIG. 8 ; however, in this embodiment there is a neck hole  54  that passes from the first lateral passageway  14   c  through the neck  20  and out of the head  22 . The neck  20  may include an opening with two transverse pins  54 . The first working portion  26  of the line  24  may pass through the neck hole  54  wherein a portion of the first working portion  26  is exposed in a neck opening  56 . The neck opening  56  may be defined by two transverse pins  54  that are substantially perpendicular to the longitudinal axis of the plate  11 . The transverse pins  54  may retain the line  24  and prevent it from withdrawal from the plate  11 . The first filament  44  (not shown in  FIG. 9 ) may be passed through at least one of the plurality of passageways  14 . The second filament  46  may pass around the exposed portion of the first working portion  26  in the neck opening  56  and is retained by the exposed portion of the first working portion  26 . The first filament  44  (not shown in  FIG. 9 ) may be passed through at least one of the plurality of passageways  14 . The second working portion  30  of the line  24  is routed in substantially the same manner as described in the previous embodiments described in  FIGS. 1-7  with the same routing of the line  24 , the same adjustable loop  29  of the intermediate portion  28  and the second compression section  27  which holds a portion of the line  24  to create a one-way slide. 
     A method of inserting the plate  11  into the bone tunnel, passing the plate  11  through the bone tunnel, toggling the plate  11  after passage through the bone tunnel, cinching the plate  11  to the cortical side of the bone and removing the filaments  44 ,  46  from the plate may be accomplished in any of the ways as previously described herein. 
     Referring to  FIG. 10 , a device  10  is depicted with the plurality of passageways  14  as previously described; however, in this embodiment one of the plurality of passageways is positioned in the neck  20  of the plate  11 . The second working portion  30  of the line  24  is routed in substantially the same manner as described in the previous embodiments described in  FIGS. 1-7  with the same routing of the line  24 , the same adjustable loop  29  of the intermediate portion  28  and the second compression section  27  which holds a portion of the line  24  to create a one-way slide. The first working portion  26  of the line  24  includes the first loop  50  as described in  FIG. 7 . In this embodiment the first loop  50  is not secured to the plate through a first compression section  25  as previously described; rather, the first loop  50  is lassoed around the neck  20 . The second filament  46  is then able to pass through the passageway in the neck, the first lateral passageway  14   c , and loop around the first loop  50 , the first loop  50  retaining the second filament. The first filament  44  is passed through the second lateral passageway  14   d  and the filaments  44 ,  46  are used to pass the plate  11  and toggle the plate  11  in any manner as previously described herein. It will be appreciated that the first filament  44  may pass through any of the remaining plurality of passageways  14  of the plate  11  except for the first lateral passageway  14   c.    
     Alternate embodiments of the plate are depicted in  FIGS. 11-21 . In each of the  FIGS. 11-21  the line  24  has not been shown neither do the figures show the first and second filaments  44 ,  46 . It should be understood that the line  24  and filaments  44 ,  46  may be used for those embodiment described and illustrated for  FIGS. 11-21  in the same manner as any previously disclosed embodiment in the paragraphs and illustrations above. For the avoidance of doubt, the line may comprise two free ends or one free end and a loop or further still one free end and another securing means as described above such as crimps, pins, loops or clamps. In addition each of these embodiments may comprise a looped end on the first working portion  26  and a free end on the second working portion  30  as set forth above. 
     Referring to  FIGS. 11-12 , the plate  11  is the same as shown in  FIGS. 8 and 9  without the line  24  and the first and second filaments  44 ,  46  depicted. The line  24  and filaments  44 ,  46  may be used in this embodiment in any of the previously described methods found herein. 
     The features in this embodiment are very similar to the previous embodiment of the plate in  FIGS. 1-7  with the exception that the plurality of passageways  14  may have slightly different shapes where the substantially triangular or tear-drop shaped passageways may have other bends and the ovoid passageways may be more circular. Other distinguishing features of this embodiment of the plate  11  are the shape and features of the head  22  of the dogbone  34  feature. Like the previous embodiment the head  22  has a greater cross-sectional diameter than the neck  20  in at least one plane. Whereas the previous embodiment may have comprised flanges or fins  42  extending back toward the body  12  of the plate  11  giving the dogbone feature  34  an almost anchor like look, this embodiment does not require the fins  42  but rather the head  22  may only extend outward from the neck  20  in at least one plane perpendicular to the longitudinal axis of the plate  11 . The head  22  may also be rounded on one end opposite from the neck  20 . The same features found in the previous embodiment hold true for this embodiment in that there are grooves  36  which may pass between the plurality of passageways and this embodiment may also include a periphery groove  38  extending from one of the second medially passageway  14   b  to the periphery  40  to receive the second working portion  30  of the line  24 . 
     Referring to  FIGS. 13-15 , the plate  11  may include similar features as the previously described plates with passageways and grooves; however, in this embodiment the neck  20  may be shorter than in the previous embodiments and the head  22  extending from the neck  20  creating the dogbone feature  34  has previously set forth. The head  22  may have a larger circumference than the neck  20  but smaller than the body  12  of the plate  11 . 
     Referring to  FIG. 14 , the plurality of passageways  14  may comprise curved ends  58  that allow for easy passage of the line  24  through the plurality of passageways  14 . The curved ends  58  of the plurality of passageways  14  may extend into each other as depicted between the first medial passageways  14   a  and second medial passageway  14   b . Alternately, as depicted in  FIG. 15  between the first medial passageways  14   a  and second medial passageway  14   b , the curved ends  58  may be separated by part of the body  12  of the plate  11 . 
     Referring to  FIGS. 16-17 , this alternate plate  11  embodiment comprises substantially all of the features as previously described herein with a neck  20  and head  22  creating a dogbone feature  34 . The neck may have a substantially smaller cross-sectional diameter than the body  12  of the plate  11  and the head  22  may have a larger circumference than the neck  11 ; however the head  22  may have a smaller cross sectional diameter in at least one plane than the body  12  of the plate  11 . The shapes of the plurality of passageways  14  may be substantially the same as the previous embodiments with the lateral passageways  14   c ,  14   d  maintaining a substantially ovoid or circular shape and the medial passageways  14   a ,  14   b  maintaining a substantially triangular or tear-drop shape. 
     Referring to  FIG. 18 , this alternate embodiment of the plate  11  may comprise features substantially similar to those already described herein. However, the neck  20  and head  22  may of the dogbone feature  34  may have substantially the same cross-sectional diameter in at least one plane. The neck  20  extends from at least one end of the body  12  of the plate  11  and the head  22  extends from the neck  20  but the extension may look like a singular post extending from the body  12  of the plate  11  rather than a dogbone feature  34  as previously recited. The use of this embodiment remains the same in that the routing of the line  24  and the use of the first and second filaments  44 ,  46  remains may be used in any of the previously described methods. 
     Referring to  FIG. 19 , this alternate embodiment of the plate  11  may comprise features substantially similar to those already described herein. In this embodiment, however, the neck  20  and head  22  may comprise a deep groove  60  extending from one end of the head  20  to the first lateral passageway  14   c . The deep groove  60  may provide easier passage of the first working portion  26  of the line  24  underneath the compression section  25 . 
     Referring to  FIG. 20 , this alternate embodiment of the plate  11  may comprise features substantially similar to those already described herein. However, a cutout  62  may extend from the head  22  toward the neck  20 . The cutout  62  may provide easier passage of the first working portion  26 . 
     Depicted in  FIG. 21  is another embodiment of a line lock  100  incorporating several features previously described in this application. Line lock  100  includes an elongated body  110 . The elongated body may have a top surface  114  and an opposing bottom surface  116 . The top surface  114  and bottom surface  116  both extend between a first end  118  and an opposing second end  120 . In the example depicted, the body  110  has a substantially rectangular configuration; however, the body  110  can be any desired polygonal or irregular conformation, similar to previous embodiments. The body  110  may also have a first side  122  and an opposing second side  124 . The first side  122  and opposing second side  124  extend between the first end  118  and the second end  120 , and also extend between the top surface  114  and the bottom surface  116 . At least one of the ends  118 ,  120  may contain a dog bone feature. In the embodiment shown, first end  118  contains a first dog bone feature  132  and second end  120  contains an opposing, symmetrical second dog bone feature  134 , however, the dog bone features may be of differing shapes and orientations. 
     As depicted in  FIGS. 21-24 , body  110  may contain a plurality of passageways that extend between the top surface  114  and the bottom surface  116 . The passageways may be configured to receive at least one line. In the example shown, the body  110  contains four substantially circular passageways: an exterior first passive passageway  135 , an exterior second passive passageway  136 , an interior first active passageway  137  and an interior second active passageway  138 . The active passageways may also be referred to as working passageways. The two exterior or outboard passive passageways  135 ,  136  may be positioned closer to the first side  122  of the body  110 , while the two interior or central working passageways  137 ,  138  may be positioned closer to the second side  124  of the body  110 . Each of the passageways may include a circumferential fillet,  191 ,  192 ,  193 ,  194  that is disposed toward the top surface  114  of the body  110 . The passageways  135 ,  136 ,  137 ,  138  may also include a portion where an edge radius is larger than the circumferential fillet. This edge portion may lean outward from the passageway. This portion may also be referred to as a tapered keyway. In the example shown, the first working passageway  137  contains a first tapered keyway  148  and the second working passageway  138  contains a second tapered keyway  149 . 
     As shown best in  FIGS. 21 and 22 , the first dog bone feature  132  may include a first top surface  131  and a first bottom surface  133 . The first dog bone feature  132  may also include a first neck  150 , which may extend outward between the first end  118  of the body  110  and a first enlarged head  152 . The neck  150  may be thinner than the body  110  and tapered on one side so that a first side of the neck  158  extends between the first end  118  of the body  110  and enlarged head  152  at an acute angle relative to the first side  122  of the body  110 . An opposing second side  160  of the neck  150  may lie parallel to the second side  124  of the body  110 . A first step feature  162  may be located at the corner where the first neck  150  is connected to the body  110 . Adjacent to the first step feature  162 , a first rounded edge  164  may be located on the first end  118  of the body  110  to reduce resistance along the line pathway. The rounded edge  164  may resemble tapered keyways  148 ,  149 . In the embodiment shown, the enlarged head  152  is substantially T-shaped. The opposing ends of the T-cross bar may curve inward toward the body  110 , which may provide added security of the line, preventing withdrawal of the line over the enlarged head  152 . Located between the curved ends of the T-cross bar and the neck of the enlarged tab element may be two semi-circular alcoves. In the example shown, the second dog bone feature  134  is symmetrical to first dog bone feature  132 , including a second top surface  141  and a second bottom surface  143 . Like the first dog bone feature  132 , the second dog bone feature may also include a second neck  154  that may extend between the second end of the body  120  and a second enlarged head  156 , having a first side  157  that extends between the second end  120  and the second enlarged head  156  at an acute angle relative to the first side  122  of the body  110  and a second side  159  that extends parallel to the second side  124  of the body  110 . A second step feature  163  and a second rounded edge  165  may also be located on the second end  120  of the body  110  where the second neck  154  connects to the second end  120  of the body  110 . 
     As depicted in  FIGS. 23 and 24 , a line  164  is adjustably mounted on the line lock  100 . The line includes a standing portion  170  in the form of an adjustable loop, which extends outwardly from the bottom surface  116  of the body  110 . The line may also include at least one working portion. In the example shown, the line includes a first working portion  171  and a second working portion  180 . The first working portion  171  may include a first compression section  172  where the line passes over itself to compress the line against the body  110 . The first working portion may also include a first free end  174  that may be independently adjusted and extends outward from the bottom surface  116  of the body  110 , and a first intermediate portion  194  of the line that may contact the first neck  150  of the first dogbone feature. The second working portion  180  may include a second compression section  182 , a second free end  184  that may be independently adjusted and extends outward from the bottom surface  116  of the body  110 , and a second intermediate portion  195  of the line that may contact the second neck  154  of the second dog bone feature  134 . 
     In the configuration shown in  FIGS. 23 and 24 , the first working portion  171  may be routed along a first pathway. The first pathway may include routing the first working portion  171  through a centrally located active passageway  137  from the bottom surface  116  towards the top surface  114  of the body  110 , then across the top surface  114  of the body  110  towards the first end  118 . The line then passes from the first top surface  131  of the first neck  150  towards the second bottom surface  133  of the first neck  150  then passing back towards the first top surface  131 , forming a loop around the first neck  150  of the first dog bone feature  132 . The line then passes over itself on the top surface  114  of the body  110  to provide a first compression section  172  and downward from the top surface  114  towards the bottom surface  116  through the first outer passive passageway  135  where it becomes the standing portion  170 . The second working portion may be routed symmetrically on the opposing second end  120  of the body  110 . 
     An example of a method of use will now be described in the context of securing a graft ligament in a bone tunnel. The graft may be a soft tissue graft, such as a hamstring tendon graft. The graft may be placed over the standing loop  170  of the line  164  of line lock  100 . The line lock  100  may then be oriented in an insertion position such that it lies parallel to a bone tunnel. For example, the length of the body may be aligned so that it is parallel to an axis that extends the length of the tunnel. The line lock  100  may be passed through the bone tunnel in the orientation position. The line lock  100  may then be transitioned into an engaged position in which it is oriented perpendicular to the bone tunnel and positioned such that it becomes seated firmly against the bone. For example, the length of the body may be positioned such that it is situated perpendicular to the tunnel axis. In this position, line lock  100  may be oriented such that it contacts an exterior surface of bone. The adjustable loop  170 , free ends  174 ,  184 , and the secured graft may extend out of the bone tunnel and in fact, may extend outside of the patient. For example, the adjustable loop  170  secured to a graft, and/or the free ends  174 ,  184  may extend through an anterior medial portal or distal tibial tunnel so that these elements are accessible to the surgeon. The line  164  of line lock  100  may then be adjusted in one of the following ways to secure the graft: 
     1. Both of the free ends  174 ,  184  may be adjusted simultaneously by pulling outward from the bottom surface  116  of the body  110  so that the length of the adjustable loop  170  is changed to a desired length.
 
2. Pulling on the free ends  174 ,  184  one at a time in an alternating fashion to change the length of the adjustable loop  170  to a desired length.
 
3. Pulling on only on one of the free ends in order to change the length of the adjustable loop  170 .
 
     Other characteristics which are not depicted in the figures may include other means of securing the second working portion of line in addition to the use of the compression section and routing of the lines to create a one-way slide. On the end opposite the dogbone feature of the plate a slot may extend from the opposite end into the body of the plate where in the slot gets wider as it moves further from the periphery of the plate. The slot may be configured to receive and pinch a line keeping the line substantially static after the appropriate length and tension of the line is determined. Other means for additional security may be the use of a cleat or locking feature extending from the plate opposite the dogbone feature. The cleat may be used to tie off the free end of the line after the appropriate length and tension of the line is determined. 
     All of the embodiments illustrated and described herein may have features mixed and matched to create a plate of physician&#39;s choice. The plurality of passageways  14  may be spaced apart at greater or lesser distance from one another. Similarly the plurality of passageways  14  may reside nearer or further from the periphery  40  of the plate  11 . Each of the plurality of passageways  14  may be smaller or larger so long as they are capable of receiving at least one line and/or filament. 
     The present invention may be embodied in other specific forms without departing from its spirit or essential characteristics. For example, above are described various alternative examples of plates and securing of lines as well as routing of the line and the routing of filaments. It is appreciated that various features of the above-described examples can be mixed and matched to form a variety of other combinations and alternatives. It is also appreciated that this system should not be limited to simply ACL repair and fixation. This system may also be used to secure other ligaments, tendons or soft or hard tissue. As such, the described embodiments are to be considered in all respects only as illustrative and not restrictive. The scope of the invention is, therefore, indicated by the appended claims rather than by the foregoing description. All changes which come within the meaning and range of equivalency of the claims are to be embraced within their scope.