Patent Publication Number: US-11648036-B2

Title: Suture system and method

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
     This application is a continuation of U.S. patent application Ser. No. 15/351,530, filed Nov. 15, 2016, which is a continuation of U.S. patent application Ser. No. 13/863,917 (now U.S. Pat. No. 9,492,200), filed Apr. 16, 2013. The entire disclosures of which are incorporated herein by reference. 
    
    
     FIELD 
     This disclosure relates to biological medical devices and methods, and particularly to biological medical suture systems and methods. 
     BACKGROUND 
     In many circumstances, it may be desirable to couple two or more bones or tissue segments together. For example, a bunion (hallux valgus) is a common deformity characterized by lateral deviation of the great toe (hallux) on the mesophalangeal joint (where the first metatarsal bone and hallux meet). One method of treating this deformity is to pull the great toe generally into proper alignment using a suture (or the like) disposed around the adjacent, pointer or index toe. In some applications, the two ends of the suture may need to be tied together. Additionally, torn or partially ligaments may be treated by suturing the ligament portions together. Unfortunately, many surgeons are uncomfortable tying knots because of the possibility of the knot becoming loose and/or the difficulty associated with tying a knot during a surgical procedure. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       Features and advantages of the present invention are set forth by description of embodiments consistent with the present invention, which description should be considered in conjunction with the accompanying drawings wherein: 
         FIG.  1    is a plan view of one embodiment of a suture construct consistent with one embodiment of the present disclosure; 
         FIG.  2    is a close up of region A in  FIG.  1   ; 
         FIG.  3    illustrates one embodiment of forming the passageways through the bones consistent with the present disclosure; 
         FIG.  4    illustrates one embodiment of the suture construct in combination with pull strands consistent with the present disclosure; 
         FIG.  5    illustrates the suture construct disposed within the passageways in the bone consistent with at least one embodiment of the present disclosure; 
         FIGS.  6 - 12    illustrate various embodiments of suture pins consistent with the present disclosure; 
         FIG.  13    illustrates one embodiment of the suture construct in combination with one embodiment of a pusher consistent with the present disclosure; 
         FIG.  14    illustrates the suture construct in a locked state consistent with at least one embodiment of the present disclosure; 
         FIGS.  15 - 18    illustrate various steps for forming a suture construct consistent with at least one embodiment of the present disclosure; 
         FIG.  19    illustrates another embodiment of suture system; 
         FIGS.  20  and  21    illustrate installation/reduction steps corresponding to the suture system illustrated in  FIG.  19   ; 
         FIG.  22    illustrates another embodiment of the pusher tubes consistent with the present disclosure; 
         FIG.  23    illustrates a further embodiment of the pusher tubes consistent with the present disclosure; 
         FIGS.  24  and  25    illustrates an embodiment of a suture system in combination with another embodiment of a suture pin for securing two bone fragments; 
         FIG.  26    illustrates an embodiment of a suture system in combination with the suture pin of  FIGS.  24  and  25    for securing two bones; 
         FIG.  27    illustrates a bottom perspective view of the suture pin of  FIGS.  24  and  25   ; 
         FIG.  28    illustrates a side view of the suture pin of  FIGS.  24  and  25   ; 
         FIG.  29    illustrates a bottom view of the suture pin of  FIGS.  24  and  25   ; 
         FIG.  30    illustrates an end view of the suture pin of  FIGS.  24  and  25   ; 
         FIG.  31    illustrates a cross-sectional view of one embodiment of a suture pin and a contractible loop extending through an opening in a passageway; and 
         FIG.  32    illustrates a cross-sectional view of the suture pin of  FIGS.  24  and  25    and a contractible loop extending through an opening in a passageway. 
     
    
    
     DETAILED DESCRIPTION 
     One embodiment of the present disclosure may feature suture systems and methods for coupling together two bones, bone segments, and/or tissue segments. The suture systems feature an all suture/thread construction which eliminates the need for the surgeon to tie knots during the surgical procedure. 
     By way of a brief overview explained in greater detail herein, one aspect of the present disclosure features a suture system which may be used for the treatment of hallux valgus (i.e., bunion); however, the suture system may also be used with other bones and/or may be used for the treatment of cracked and/or broken bone fragments. The suture system includes a suture construct having at least one reduction construct. The reduction construct includes a locking limb, a contractible loop, and an opposed loop disposed generally opposite to the contractible loop. The suture construct is configured to be selectively arranged in an expanded state/position and a reduced state/position. When in the expanded state/position, one or more of the contractible loops are passed through a respective passageway from through a first to the second bone or bone fragment until a portion of the contractible loop(s) extends beyond an opening in the second bone or bone fragment. A suture pin may be passed through the first (and optionally second contractible loop). To reduce/tighten the suture construct into the reduced state/position, the length/size of the opposed loop(s) is reduced thereby reducing the length/size of the first and second contractible loop(s) and biasing the first and second bones/bone fragments towards each other. Once the suture construct applies a desired amount of force to the bones/bone fragments in the reduced state, tension on the suture construct causes the opposed loop(s) to reduce against the locking limb(s), thereby locking, fixing, or otherwise securing the suture construct the reduced state. 
     With reference to  FIG.  1   , one embodiment of a suture construct  10  is generally illustrated. The suture construct  10  includes one or more reduction constructs (e.g., a first and optionally a second reduction construct  28 ,  30 ). As explained herein, the first and the second reduction constructs  28 ,  30  (which may have the same or different configuration) are configured to be selectively reduced in size and locked, fixed, or otherwise secured in the reduced formation to apply a compressive force. While the suture construct  10  is illustrated having two reduction constructs  28 ,  30  separated by a bridge  18 , it should be appreciated that a suture construct consistent with the present disclosure may include only one reduction construct  28 . 
     The suture construct  10  may be formed from a single piece of suture  12 , though it may also be formed from more than one piece of suture  12 . The suture  12  may include woven and non-woven sutures, either of which may be formed from one or more threads or fibers. The threads/fibers may all be the same material or may include two or more different materials. The suture  12  may optionally include one or more coatings such as, but not limited to, antimicrobial materials to reduce potential infection. The suture  12  may include absorbable or non-absorbable materials. The diameter of the suture  12  will depend on the intended application; however, the suture  12  may include, but is not limited to, a #2, #3, #4 and/or #5 suture as defined by the United State Pharmacopeia (U.S.P.), for example, a #4 suture. 
     With additional reference to  FIG.  2    (which shows a close-up of region A in  FIG.  1   ), the suture construct  10  includes the first and second reduction constructs  28 ,  30 , each separated by a bridge  18 . The first and second reduction constructs  28 ,  30  each include a first and a second knot  14 ,  16 . The first and second knots  14 ,  16  may include any type of knot which can form a loop  20 ,  22 , respectively. For example, one or more of the first and second knots  14 ,  16  may include splice (e.g., a sliding splice or the like), a slip knot, a running bowline, etc. Portions of the suture  12  are passed through a respective one of the loops  20 ,  22  to form the first and second reduction constructs  28 ,  30 . The first and second reduction constructs  28 ,  30  each include a contractible loop  32 ,  34  and a opposed loop  36 ,  38 , each of which are separated by the first and second loops  20 ,  22 , respectively. A first portion of each of the opposed loops  36 ,  38  extends through the loops  20 ,  22  from the contractible loops  32 ,  34 , respectively, and a second portion of each of the opposed loops  36 ,  38  extends through the loops  20 ,  22  and terminates at the first and second free ends  24 ,  26  of suture (also referred to as the first and second locking limbs  24 ,  26 ). A first portion of each of the contractible loops  32 ,  34  extends through the loops  20 ,  22  from the opposed loops  36 ,  38 , respectively, and a second portion of each of the contractible loops  32 ,  34  extends from and terminates at the loops  20 ,  22 . 
     Optionally, the first and second opposed loops  36 ,  38  may be temporarily retained in an expanded position (as generally illustrated in  FIGS.  1  and  2   ) using a first and second tab  40 ,  42 , respectively. The tabs  40 ,  42  may include, for example, folded pieces of metal (e.g., but not limited to, aluminum), plastic, suture, or the like configured to extend through the opposed loops  36 ,  38 , thereby preventing the opposed loops  36 ,  38  from being pulled through the first and second loops  20 ,  22 , respectively. 
     Turning now to  FIGS.  3 - 7   , embodiments illustrating how the suture system can be used to treat a medical condition are generally illustrated. With reference to  FIG.  3   , two generally parallel passageways  44 ,  45  are drilled through a first and second bone  46 ,  47  (e.g., the first and second metatarsus bones  46 ,  47 ). A drill guide  48  may be used to form the passageways  44 ,  45 . In particular, the drill guide  48  includes two drill bushings/openings  50   a ,  50   b  spaced apart from each other. The spacing of the bushings  50   a ,  50   b  is selected based on the size of the bones  46 ,  47  being drilled. In particular, the spacing may be selected such that the impact on the overall strength of the bones  46 ,  47  is minimized, thereby reducing the potential of damaging the bones  46 ,  47 . By way of example, the spacing may be selected within the range of 6-10 mm. It should also be appreciated that the spacing between the first and second splices  14 ,  16  should generally correspond to the spacing of the bushings  50   a ,  50   b.    
     In practice, the drill guide  48  may be placed against a portion of the second bone  47 . A first passing pin or drill bit  52   a  (e.g., but not limited to, a 1.2 mm passing pin) is advanced through the first bushing  50   a  of the drill guide  48  to form a first second portions  44   a ,  44   b  (collectively referred to as the first passageway  44 ) in the first and second bones  46 ,  47 , respectively. Similarly, a second passing pin or drill bit  52   b  is advanced through the second bushing  50   b  of the drill guide  48  to form a first second portions  45   a ,  45   b  (collectively referred to as the second passageway  45 ) in the first and second bones  46 ,  47 , respectively. The distal ends  53  of the first and second drill bits  52   a ,  52   b  extend beyond the first bone  46  and the proximal ends  55  have not passed through the second bone  47 . The first and second drill bits  52   a ,  52   b  optionally include a loop or snare  54   a ,  54   b  extending from the proximal ends  55 . 
     With the passageways  44 ,  45  having been formed, the suture construct  10  may then be advanced through the passageways  44 ,  45 . Turning now to  FIG.  4   , the suture construct  10  is illustrated in combination with two pull strands  56 . The pull strands  56  are disposed around a distal end of the first and second contractible loops  32 ,  34  and are configured to be releasably coupled to the first and second contractible loops  32 ,  34 . For example, the pull strands  56  may include a loop disposed around the first and second contractible loops  32 ,  34 . The pull strands  56  may also be tied or otherwise releasably secured to the first and second contractible loops  32 ,  34 . Optionally, the suture construct  10  includes a suture plate  58 . The suture plate  58  includes two apertures  60  spaced apart a distance generally corresponding to the distance between the two passageways  44 ,  45  and the spacing of the first and second knots  14 ,  16 . The suture plates  58  may have a “ FIG.  8   ” cross-section or may have a generally rectangular cross-section. 
     With reference to  FIGS.  3 ,  4 , and  5   , the pull strands  56  are configured to be coupled to the loops/snares  54   a ,  54   b  extending from the drill bits  52   a ,  52   b . The drill bits  52   a ,  52   b  are then retracted through the passageways  44 ,  45 , thereby advancing the pull strands  56  through the passageways  44 ,  45 . Once the pull strands  56  are beyond the first bone  46 , the pull strands  56  can be used to pull/advance a portion of the contractible loops  32 ,  34  through a respective one of the passageways  44 ,  45  (from the second bone  47  and then through the first bone  46 ) until a distal portion of the contractible loops  32 ,  34  extends beyond the first bone  46 . The contractible loops  32 ,  34  may be advanced through the passageways  44 ,  45  until the bridge  18  (or the optional suture plate  58 ) is proximate to or abuts against the second bone  47 , thereafter the pull strands  56  may be disconnected/released from the first and second contractible loop  32 ,  34  as generally illustrated in  FIG.  5   . 
     With the first and second contractible loops  32 ,  34  advanced through the passageways  44 ,  45 , the suture pin  62  ( FIG.  5   ) is then coupled to the first and second contractible loop  32 ,  34  such that the suture construct  10  forms an enclosed loop extending around a portion of the first and second bones  46 ,  47 . The enclosed loop suture construct is defined by the first and second contractible loops  32 ,  34 , the bridge  18 , and the suture pin  62 . According to one embodiment, the suture pin  62  is passed through the first and second contractible loops  32 ,  34  such that a portion of the first and second contractible loops  32 ,  34  is disposed around a portion of the suture pin  62 . Alternatively (or in addition), the suture pin  62  may be secured to the first and second contractible loops  32 ,  34  using one or more fasteners, clamps, or the like. 
     The suture pin  62  may have a length larger than the spacing between the two passageways  44 ,  45  in the first bone  46 . Having the length of the suture pin  62  greater than the spacing between the two passageways  44 ,  45  in the first bone  46  allows the first and second contractible loops  32 ,  34  to extend substantially parallel to the two passageways  44 ,  45 , thereby minimizing stress placed on the bones  46 ,  47  by the first and second contractible loops  32 ,  34 . For example, if the first and second contractible loops  32 ,  34  are not parallel to the passageways  44 ,  45 , then the first and second contractible loops  32 ,  34  will exert a force against the sideways of the passageways  44 ,  45  and/or the portion of bone between the passageways  44 ,  45 , causing the first and second contractible loops  32 ,  34  to dig into and damage the bones  46 ,  47 . 
     In addition to having a length greater than the spacing between the two passageways  44 ,  45  in the first bone  46 , the suture pin  62  may also have an overall width, diameter, or cross-section that is greater than the diameter of the passageways  44 ,  45  such that the suture pin  62  will not fit within the passageways  44 ,  45 . As explained herein, the suture pin  62  consistent with the present disclosure may be coupled to the first and second contractible loops  32 ,  34  after the first and second contractible loops  32 ,  34  have been advanced through the passageways  44 ,  45 . As a result, the suture pin  62  does not need to be advanced through the passageways  44 ,  45  and diameter of the passageways  44 ,  45  may be minimized (i.e., the diameter of the passageways  44 ,  45  need only be slightly larger than the overall cross-section of the first and second contractible loops  32 ,  34 ). As may be appreciated, the smaller diameter of the passageways  44 ,  45  minimizes the negative impact on the strength of the bones  46 ,  47  by reducing the amount of bone material that is removed. 
     Turning now to  FIGS.  6 - 12   , various embodiments of the suture pin  62  are generally illustrated. For example,  FIG.  6    generally illustrates a suture pin  62   a  having a generally elongated shape. The suture pin  62   a  may be formed from metal (e.g., but not limited to, stainless steel, titanium, aluminum, chromium cobalt, and/or any alloy thereof), plastic (e.g., but not limited to, polyether ether ketone (PEEK), polyethylene (PE) such as ultrahigh molecular weight polyethylene (UHMWPE) and high density polyethylene (HDPE), or the like), composite materials (e.g., reinforced plastics such as fiber-reinforced polymers, metal composites, ceramic composites, or the like), sutures (woven and/or non-woven suture), or the like. The suture pin  62   a  may have a generally consistent cross-section throughout its length. The suture pin  62   a  may have a generally circular cross-section and/or may have a non-circular cross-section (e.g., rectangular, oval, or the like). 
     With reference to  FIG.  7   , a suture pin  62   b  is illustrated having a main body  64 , an end region  66 , and at least one reduced portion  68  having a smaller cross-section compared to the main body  64  and/or the end region  66 . The reduced portion  68  may include a groove, slot, channel, or the like configured to aid in locating the first and second contractible loops  32 ,  34  with respect to the suture pin  66   b , and aid in preventing the suture pin  62   b  from becoming dislodged with respect to the first and second contractible loops  32 ,  34  (i.e., aid in securing the first and second contractible loops  32 ,  34  with respect to the reduced portion  68 ). The reduced portions  68  may extend radially around only a portion of the suture pin  62   b  (e.g., 180 degrees around, 90 degrees around, or the like) or may extend radially around the entire cross-section of the suture pin  62   b . The positions of the reduced portions  68  may be separated from each other a distance generally corresponding to the distance between the two passageways  44 ,  45  and the spacing of the first and second splices  14 ,  16 . While the suture pin  62   b  is illustrated having two reduced portions  68 , it should be appreciated that the suture pin  62   b  may include only one or may include more than two reduced portions  68  which are distributed along the length of the suture pin  62   b . Having more than two reduced portions  68  may allow the suture pin  62   b  to be used to different suture constructs  10  having different spacing between the first and second splices  14 ,  16 . 
     As generally illustrated in  FIGS.  8 - 12   , a suture pin  62  consistent with the present disclosure may also include one or more enlarged portions configured to aid in locating the first and second contractible loops  32 ,  34  with respect to the suture pin  66 , and aid in preventing the suture pin  62  from becoming dislodged with respect to the first and second contractible loops  32 ,  34  (i.e., aid in securing the first and second contractible loops  32 ,  34  with respect to the enlarged portions). The enlarged portions may be separated from each other a distance which is generally equal to or greater than the distance between the two passageways  44 ,  45  and the spacing of the first and second splices  14 ,  16 . 
     One embodiment of a suture pin  62   c  having an enlarged portion is generally illustrated in  FIG.  8   . More specifically, the suture pin  62   c  is formed from one or more pieces of suture (either woven or non-woven suture). The suture pin  62   c  includes enlarged portions  70  disposed at generally opposite end regions of a main body  64 . The enlarged portions  70  have a cross-section that is larger than the cross-section of the main body  64 . The overall width, diameter, or cross-section of the enlarged portions  70  may also be greater than the diameter of the passageways  44 ,  45  such that the suture pin  62   c  will not fit within the passageways  44 ,  45 . 
     The enlarged portions  70  may be formed by forming one or more knots (such as, but not limited to, an overhand knot, half hitch knot, square knot, half knot, or the like). The knots may be made from the same piece of suture as the main body  64 , and/or may include additional pieces of suture. A benefit to a suture pin having an all-suture construction is that is minimizes the amount of different materials used by the suture system. Additionally, tissue may grow into the suture material, thereby reducing the possibility of the suture pin  62   c  from migrating with respect to the first and second contractible loops  32 ,  34 . 
     Another embodiment of a suture pin  62   d  having enlarged portions  70  is generally illustrated in  FIG.  9   . The suture pin  62   d  may be similar to the suture pin  62   c , however, the suture pin  62   d  includes a rigid element/member  72  over which the suture  74  is woven, tied, or otherwise secured around. For example, the rigid element  72  may include an elongated member (e.g., a pin or the like as generally described in  FIGS.  6 ,  7 , and  10 - 12   ). The combination of the rigid element  72  and the suture element  74  may increase the structural rigidity of the suture pin  62   d , thereby facilitating the assembly of the suture system during the surgical procedure. Additionally, the combination of the rigid element  72  and the suture element  74  may increase the overall strength of the suture pin  62   d , and may also allow for tissue growth into the suture element  74  as discussed herein. 
     Other embodiments of a suture pin  62   e - 62   g  having enlarged portions  70  are generally illustrated in  FIGS.  10 - 12   . The suture pins  62   e - 62   g  include a generally elongated main body  64  having enlarged portions  70  disposed about the proximal end regions. The main body  64  and the enlarged portions  70  may be formed as an integral component (e.g., pieces bonded together, which may be made from the same or different materials) or may be formed as a unitary component (i.e., formed as a single component from the same material). The suture pins  62   e - 62   g  may be formed from metal (e.g., but not limited to, stainless steel, titanium, aluminum, chromium cobalt, and/or any alloy thereof), plastic (e.g., but not limited to, polyether ether ketone (PEEK), polyethylene (PE) such as ultrahigh molecular weight polyethylene (UHMWPE) and high density polyethylene (HDPE), or the like), or composite materials (e.g., reinforced plastics such as fiber-reinforced polymers, metal composites, ceramic composites, or the like). 
     The enlarged portions  70  may have a generally “T” shaped or disc-shaped protrusion extending generally radially outward as generally illustrated in  FIG.  10    or a may have a generally “L” shaped protrusion extending generally radially outward as generally illustrated in  FIG.  11   . While the protrusions are illustrated extending radially outward at approximately 90 degrees from the body portion  64 , it should be appreciated that the protrusions may extend radially outwardly at an angle A from the body portion  64  in the range of 10 degrees to 170 degrees. Additionally, while the protrusions are illustrated having a generally planar or linear shape, it should be understood that the protrusions may have a non-linear or non-planar shape such as a curved or arcuate shape. The enlarged portions  70  may also have a generally circular or cross-section, spherical shape, and/or may have a non-circular cross-section (e.g., rectangular, oval, or the like) as generally illustrated in  FIG.  12   . 
     Turning back to  FIG.  5   , with the suture pin  62  extending between the first and second contractible loops  32 ,  34 , the first and second contractible loops  32 ,  34  may be pulled away from the first bone  46  to urge the suture pin  62  against the first bone  46 , thereby aiding in maintaining the suture pin  62  within the first and second contractible loops  32 ,  34 . The first and second tabs  40 ,  42  are removed from the first and second opposed loops  36 ,  38  and a pusher  76  is advanced through the first and second opposed loops  36 ,  38  as generally illustrated in  FIG.  13   . 
     The pusher  76  is configured to aid in reducing/tightening the suture system and to urge the first and second bones  46 ,  47  towards each other. According to one embodiment, the pusher  76  includes a pivoting section  78  which is advanced through the first and second opposed loops  36 ,  38  and a pull snare  77  extending outward beyond the distal end  79  of the pivoting section  78 . The pivoting section  78  optionally extends at an angle from an arm section  80 . While the angle between the pivoting section  78  and the arm section  80  is illustrated at approximately 90 degrees, it should be appreciated that the angle therebetween will depend on the application and the surgeon&#39;s preference and may, for example, be in the range of 45 to 135 degrees. The pusher  76  also optionally includes a handle portion  82  coupled to the arm section  80  to aid in gripping the pusher  76 . 
     To reduce/tighten the suture system, the surgeon pulls the locking limbs  24 ,  26  of the suture construct  10  away from the second bone  47  while simultaneously urging the pusher  76  towards the second bone  47 , thereby reducing the length of the first and second contractible loops  32 ,  34  and applying a compressive force through the first and second contractible loops  32 ,  34 , the bridge  18  (and the optional suture plate  58 ), and suture pin  62  to bias the first and second bones  46 ,  47  towards each other. More specifically, the length of the locking limbs  24 ,  26  of the suture construct  10  is extended as a portion of the suture  12  is pulled from the first and second contractible loops  32 ,  34  and through the opposed loops  36 ,  38 . The pusher  76  prevents the opposed loops  36 ,  38  from self-collapsing as the locking limbs  24 ,  26  are pulled and effectively acts as a pulley. 
     Once the suture system applies a desired amount of force to urge the first and second bones  46 ,  47  towards each other, the locking limbs  24 ,  26  of the suture construct  10  are advanced into and captured by the pull snare  77  extending out from the distal end  79  of the pusher  76 . The pusher  76  is then retracted through the first and second opposed loops  36 ,  38 , causing a least a portion of the locking limbs  24 ,  26  to pass through the opposed loops  36 ,  38  as generally illustrated in  FIG.  14   . The tension on the suture construct  10  causes the opposed loops  36 ,  38  to reduce against the locking limbs  24 ,  26 , thereby locking the suture construct  10  and preventing the suture construct  10  from loosening. Once the suture construct  10  is locked, excess lengths of the locking limbs  24 ,  26  may be trimmed proximate to the opposed loops  36 ,  38 . 
     Turning now to  FIGS.  15 - 18   , the steps for forming one embodiment of a suture construct  10  consistent with one embodiment of the present disclosure is generally illustrated. With reference to  FIG.  15   , a length of suture  12  is provided and the spacing between the first and second knots  14 ,  16  is determined based on the desired spacing between the first and second passageways  44 ,  45 . Turning now to  FIG.  16   , the first and second knots  14 ,  16  are formed in the suture  12  (for example, but not limited to, using any splicing technique known to those skilled in the art) and are separated by the bridge  18 . The first and second loops  20 ,  22  are also formed as a result of forming the first and second knots  14 ,  16 , respectively. Intermediate portions  84 ,  86 ,  FIG.  17   , of the suture  12  are then passed through the first and second loops  20 ,  22  to form the first and second contractible loops  32 ,  34  and the first and second opposed loops  36 ,  38  as generally illustrated in  FIG.  18   . 
     With reference to  FIG.  19   , another embodiment of a suture system  1   a  is generally illustrated. The suture system  1   a  includes a suture construct  10   a , a first and a second pusher tubes  100 ( 1 ),  100 ( 2 ), a suture pin  62  (not shown for clarity), and optionally a suture plate  58  (also not shown for clarity). The suture construct  10   a  is similar to the suture construct  10  described herein, except that the first and second opposed loops  36 ,  38  have been lengthened, the locking limbs  24 ,  26  of the suture  12  have been advanced through the opposed loops  36 ,  38 , and the lumens  101 ( 1 ),  101 ( 2 ) of the pusher tubes  100 ( 1 ),  100 ( 2 ) have been advanced over a portion of the opposed loops  36 ,  38  such that a distal portion  102 ( 1 ),  102 ( 2 ) of the opposed loops  36 ,  38  extends beyond a distal end  104 ( 1 ),  104 ( 2 ) of the pusher tubes  100 ( 1 ),  100 ( 2 ). The proximal ends  106 ( 1 ),  106 ( 2 ) of the pusher tubes  100 ( 1 ),  100 ( 2 ) are proximate to and/or abuts against the splice snares  20 ,  22  and/or the splices  14 ,  16 , respectively. Optionally, the “hot side”  108 ( 1 ),  108 ( 2 ) of the opposed loops  36 ,  38  may be marked, for example, using one or more marking indicia, tabs  110  or the like. As used herein, the term “hot sides” of the opposed loops  36 ,  38  refers to the portions of the opposed loops  36 ,  38  which pass through the first and second loops  20 ,  22  from the first and second contractible loops  32 ,  34  when the first and second contractible loops  32 ,  34  are reduced in size. 
     The suture construct  10   a  of the system  1   a  is installed in the first and second bones  46 ,  47  in a manner similar to the suture construct  10 . For the sake of brevity, all of the installation steps of the suture system  1   a  have not been repeated, and reference is made to the remainder of the instant application. Specifically, the passageways  44 ,  45  may be formed in the bones  46 ,  47  and the contractible loops  32 ,  34  are advanced through a respective one of the passageways  44 ,  45  (from the second bone  47  and then through the first bone  46 ) until a distal portion of the contractible loops  32 ,  34  extends beyond the first bone  46  in the same manner as described herein. The contractible loops  32 ,  34  may be advanced through the passageways  44 ,  45  until the bridge  18  (or the optional suture plate  58 ) is proximate to or abuts against the second bone  47 . With the first and second contractible loops  32 ,  34  advanced through the passageways  44 ,  45 , a suture pin  62  is then coupled to the first and second contractible loops  32 ,  34  such that the suture construct  10  forms an enclosed loop extending around a portion of the first and second bones  46 ,  47  in the same manner described herein. With the suture pin  62  extending between the first and second contractible loops  32 ,  34 , the first and second contractible loops  32 ,  34  may be pulled away from the first bone  46  to urge the suture pin  62  against the first bone  46 , thereby aiding in maintaining the suture pin  62  within the first and second contractible loops  32 ,  34 . 
     Whereas the reduction of the suture construct  10  utilized a pusher  76 , the installation and reduction of the suture construct  10   a  replaces the pusher  76  and utilizes one or more pusher tubes  100 ( 1 ),  100 ( 2 ) instead. More specifically, with the suture pin  62  extending between the first and second contractible loops  32 ,  34  and urged against the first bone  46 , the user grasps the hot sides  108 ( 1 ),  108 ( 2 ) (for example, using a gripper, grasper, forceps,  112  or the like as generally illustrated in  FIG.  20   ) of the opposed loops  36 ,  38  and pulls the hot sides hot sides  108 ( 1 ),  108 ( 2 ) through the pusher tubes  100 ( 1 ),  100 ( 2 ) and distally or away from the contractible loops  32 ,  34  (for example, but not limited to, rotating or twisting the forceps  112  against a distal end  104 ( 1 ),  104 ( 2 ) of the pusher tubes  100 ( 1 ),  100 ( 2 ) as generally illustrated in  FIG.  21   ). The pusher tubes  100 ( 1 ),  100 ( 2 ) may have a length sufficient to allow the surgeon to operate on the distal ends  104 ( 1 ),  104 ( 2 ) outside of the patient&#39;s tissue. 
     As may be appreciated, pulling the hot sides  108 ( 1 ),  108 ( 2 ) of the opposed loops  36 ,  38  causes the length of the contractible loops  32 ,  34  to be reduced since the hot sides  108 ( 1 ),  108 ( 2 ) are slidably coupled to the contractible loops  32 ,  34  through the loops  20 ,  22 . Reducing the lengths of the opposed loops  36 ,  38  applies a compressive force through the first and second contractible loops  32 ,  34 , the bridge  18  (and the optional suture plate  58 ), and suture pin  62  to bias the first and second bones  46 ,  47  towards each other. Once the desired amount of compressive force is applied to the bones  46 ,  47 , the suture construct  10   a  may be temporally maintained in the compressed state by urging the pusher tubes  100 ( 1 ),  100 ( 2 ) against the loops  20 ,  22  and/or the knots  14 ,  16 , and the tension on the hot sides  108 ( 1 ),  108 ( 2 ) (e.g., by means of the forceps  112 ) may be temporarily eliminated. While urging the pusher tubes  100 ( 1 ),  100 ( 2 ) against the loops  20 ,  22  and/or the knots  14 ,  16 , the user may then pull on the locking limbs  24 ,  26  of the suture construct  10   a . As noted above, the locking limbs  24 ,  26  are already passed through the opposed loops  36 ,  38 . As the user pulls on the locking limbs  24 ,  26 , the length of the opposed loops  36 ,  38  decreases until the opposed loops  36 ,  38  are compressed against the locking limbs  24 ,  26  extending therethrough. The tension on the suture construct  10   a  causes the opposed loops  36 ,  38  to reduce against the locking limbs  24 ,  26 , thereby locking the suture construct  10   a  and preventing the suture construct  10   a  from loosening. Once the suture construct  10   a  is locked, excess lengths of the locking limbs  24 ,  26  may be trimmed proximate to the opposed loops  36 ,  38 . 
     The pusher tubes  100 ( 1 ),  100 ( 2 ) optionally include one or more outriggers  114  extending generally outward from the distal ends  104 ( 1 ),  104 ( 2 ) of the pusher tubes  100 ( 1 ),  100 ( 2 ), for example, outwardly from the longitudinal axis of the pusher tubes  100 ( 1 ),  100 ( 2 ) as generally illustrated in  FIG.  21   . The outriggers  114  may facilitate pulling the hot sides  108 ( 1 ),  108 ( 2 ) of the opposed loops  36 ,  38  through the pusher tubes  100 ( 1 ),  100 ( 2 ). More specifically, the outrigger  114  is configured to provide an increased area against which the forceps or other grasper  112  may contact against. 
     With reference to  FIG.  22   , the pusher tubes  100 ( 1 ),  100 ( 2 ) may include a plurality of outriggers  114 ( 1 )- 114 ( n ) extending generally outwardly from the distal ends  104 ( 1 ),  104 ( 2 ) of the pusher tubes  100 ( 1 ),  100 ( 2 ). For example, the pusher tubes  100 ( 1 ),  100 ( 2 ) may include a first and a second outrigger  114 ( 1 ),  114 ( n ) which extend outward from generally opposite sides of the pusher tubes  100 ( 1 ),  100 ( 2 ), e.g., the first and second outriggers  114 ( 1 ),  114 ( 2 ) to form a cradle-like structure configured to reduce and/or prevent the forceps/graspers  112  from slipping off the distal ends  104 ( 1 ),  104 ( 2 ) of the pusher tubes  100 ( 1 ),  100 ( 2 ) as the forceps/graspers  112  are rotated or twisted. For example, the first and second outriggers  114 ( 1 ),  114 ( 2 ) may be disposed approximately 180 degrees from each other. It should be appreciated, however, that the first and second outriggers  114 ( 1 ),  114 ( 2 ) may be disposed at any other angle relative to each other to form a crook. For example, the first and second outriggers  114 ( 1 ),  114 ( 2 ) may be disposed at an angle less than 180 degrees relative to each other, for example, an obtuse angle as generally illustrated in  FIG.  23   . 
     Optionally, one or more of the proximal ends  160 ( 1 ),  106 ( 2 ) of the pusher tubes  100 ( 1 ),  100 ( 2 ) may include a taper  116  to aid in visualization of the tip. Additionally, the pusher tubes  100 ( 1 ),  100 ( 2 ) may optionally include one or more apertures  118 . The apertures  118  may facilitate sterilization of the pusher tubes  100 ( 1 ),  100 ( 2 ) by allowing the sterilization medium to more easily flow through the lumens  101 ( 1 ),  101 ( 2 ) of the pusher tubes  100 ( 1 ),  100 ( 2 ) and/or may facilitate molding of the pusher tubes  100 ( 1 ),  100 ( 2 ) by allowing pins to be aligned through the apertures  118  to aid in aligning a centering pins disposed through the lumens  101 ( 1 ),  101 ( 2 ). 
     The pusher tubes  100 ( 1 ),  100 ( 2 ) facilitate the reduction of the suture construct  10   a . In particular, the pusher tubes  100 ( 1 ),  100 ( 2 ) allow the user to pull the suture  12  (e.g., the hot sides  108 ( 1 ),  108 ( 2 )) from the opposed loops  36 ,  38  linearly through the first and second loops  20 ,  22 , thereby allowing a user to more easily apply a much greater amount of compressive force through the suture system  1   a . Moreover, rotating/twisting the hot sides  108 ( 1 ),  108 ( 2 ) using the forceps  112  on the distal ends  104 ( 1 ),  104 ( 2 ) of the pusher tubes  100 ( 1 ),  100 ( 2 ) creates a mechanical advantage (e.g., a pulley-like effect) which greatly increases the amount of compressive force which may be applied through the suture system  1   a.    
     Turning now to  FIGS.  24 - 30   , another embodiment of a suture pin  62   h  is generally illustrated. In particular,  FIGS.  24  and  25    generally illustrate one embodiment of a suture construct  10   a  in combination with the suture pin  62   h  for securing two bone fragments  125   a ,  125   b .  FIG.  26    generally illustrates one embodiment of a suture construct  10   a  in combination with the suture pin  62   h  for securing two bones  46 ,  47 .  FIGS.  27 - 30    generally illustrate various views of the suture pin  62   h . As will described in more detail herein, the suture pin  62   h  reduces the amount of friction and/or force required to reduce the suture construct, thereby providing a greater tactile feel to the surgeon, minimizing potential damage to the bones/bone fragments, and/or providing sufficient strength/rigidity to the suture pin to prevent damage/failure of the suture pin while reducing the suture construct. 
     As may be appreciated, the main body of the suture pin should be strong enough to prevent failure when reducing the suture construct. Put another way, if the suture pin is not strong enough, then the forces exerted against the suture pin by the suture construct will excessively bend the suture pin causing an unacceptable amount of deformation of the suture pin which can lead to bone damage or failure of the suture pin. As the cross-sectional thickness of the suture pin is increased, however, the main body of the suture pin begins to close/cover-over the opening in the bone defined by the passageway therethrough. An example of this is illustrated in  FIG.  31   . In particular, a cross-section of a suture pin  62  and the opening  120  of passageway  44  in the bone  46  is generally illustrated. The suture pin  62  includes a rectangular main body  64  over which the contractible loop  32  slides. Because the cross-sectional thickness of the main body  64  (i.e., the portion of the suture pin which extends across the opening  120 ) is larger than the diameter of the opening  120  to provide sufficient strength to the suture pin  62 , the main body  64  will cover or block the opening  120 . As the main body  64  blocks the opening  120 , the contractible loop  32  is forced to travel between the main body  64  and the opening  120  and/or the contractible loop  32  is forced to cut a groove into the bone  46  in the area proximate to the opening  120  when the suture construct is reduced. Consequently, the suture pin  62  significantly increases the friction/resistance and reduces the tactile feel when reducing the suture construct. 
     In addition, the rectangular cross-section of the main body  64  significantly increases the amount of friction when reducing the suture construct. In particular, because the contractible loop  32  is forced to travel between the main body  64  and the opening  120 , the contractible loop  32  must slide across the four corners  122   a ,  122   b ,  122   c    122   d  of the main body  64  as well as two portion portions  124   a ,  124   b  of the perimeter of the opening  120 . The four corners  122   a ,  122   b ,  122   c    122   d  and portions  124   a ,  124   b  generate a very high stress and/or friction concentrations, thereby increasing the overall amount of force necessary to slide the contractible loop  32  when reducing the suture construct. 
     Referring back to  FIGS.  24 - 30   , the suture pin  62   h  is configured to minimize and/or eliminate the above described issues. In particular, the suture pin  62   h  includes a main body  64  having a generally circular cross-section extending between a first and a second enlarged portion  70 . The main body  64  may include a length which is greater than the spacing of the bridge  18  to compensate for non-parallel passageways  44 ,  45 . For example, for a bridge having a length of 10 mm, the main body  64  may include a length of 17 mm to 20 mm. The diameter of the main body  64  should be selected to prevent an undesirable amount of deformation and/or failure of the suture pin  62   h  based on the intended use of the suture construct. By way of an example, a suture pin  62   h  constructed from a titanium alloy used with a suture construct having a #4 suture to treat hallux valgus may include a main body  64  having a diameter of approximately 1 mm (which may be approximately equal to the diameter of the passageway  44 ). It should be appreciated, thought, that this is just an example, and that the diameter of the main body  64  of the suture pin  62   h  will depend on the intended application as well as the intended forces exerted by the suture system during reduction. 
     With reference to  FIG.  32   , a cross-section of the main body  64  of the suture pin  62   h  is illustrated along with the contractible loop  32  extending through the opening  120  of the passageway  44 . Depending on the diameter of the main body  64 , the suture pin  62   h  may eliminate the friction points (e.g., when the diameter of the main body  64  is less than the diameter of the opening  120  of the passageway  44 ) or may have only two friction points  104   a ,  124   b  which correspond to the locations where the contractible loop  32  passes between the main body  64  and the opening  120  (e.g., when the diameter of the main body  64  is equal to or greater than the diameter of the opening  120  of the passageway  44 ). The generally circular cross-section of the main body  64  acts as a pulley, thereby allowing the contractible loop  32  to slide smoothly around a portion of the perimeter of the main body  64  (e.g., greater than or equal to 180 degrees around the main body  64 ) as the contractible loop  32  is reduced. As a result, the suture pin  62   h  with a main body  64  having a generally circular cross-section reduces the amount of friction and/or force required to reduce the suture construct. Additionally, the reduction in friction points allows the suture pin  62   h  to provide a greater tactile feel to the surgeon and minimizes potential damage to the bones/bone fragments. Moreover, the overall strength of the suture pin  62   h  may be increased while preventing/minimizing the suture pin  62   h  from covering/blocking the opening  120  of the passageway  44 . 
     With reference again to  FIGS.  24 - 30   , the enlarged portions  70  of the suture pin  62   h  may include a bone facing surface  126  having a generally concaved contour. The concaved contour is configured to allow the bone facing surface  126  to generally conform to the bone surface, e.g., to allow the bone facing surface  126  to sit generally congruent with the bone face. The concaved bone facing surface  126  helps distribute the forces exerted by the suture system more evenly across the bone  46  and also helps position the suture pin  62   h  during assembly/implanting of the suture system within passageway(s)  44 ,  45 . 
     One or more of the enlarged portions  70  of the suture pin  62   h  may also feature one or more shoulders  127  extending outwardly beyond the main body  64 . For example, the shoulders  127  may form a generally an arrowhead-like shape which extend outward and generally towards the opposite end (though the shoulders  127  may extend outward generally perpendicularly from the main body  64  or outward generally away from the opposite end). As discussed herein, the enlarged portions  70  may aid in keeping the contractible loop(s)  32 ,  34  disposed on the main body  64  during assembly/implanting of the suture system within passageway(s)  44 ,  45 . 
     While the main body  64  is described having a generally circular cross-section, it may be appreciated that the main body  64  may also include a generally oval cross-section. Additionally, while the entire main body  64  is illustrated having a generally circular, it may be appreciated that only the portions or regions of the main body  64  over which the contractible loop(s)  28 ,  30  slide when reducing the suture construct may have a generally circular or oval cross-section. Moreover, while the suture pin  62   h  is illustrated having a first and a second enlarged portion  70 , it may be appreciated that the main body  64  may extend between one or more reduced portions as disclosed herein. 
     Variations of the suture system and suture construct described herein are considered to be part of this disclosure. For example, while the suture construct the suture construct described above is generally symmetrical about the bridge (e.g., the suture construct is illustrated having first and second knots, first and second loops, first and second contractible loops, and first and second opposed loops separated by the bridge), the bridge section may be eliminated and the suture construct may feature only one half of the remaining construct (i.e., a single reduction construct). More specifically, the suture construct may alternatively include only one knot, one loop, one contractible loop, and one opposed loop. The contractible loop may be passed through a single passageway formed through the first and second bones. A first suture pin may be disposed through a distal end of the contractible loop against the first bone and a second splice pin may be disposed through a proximal end of the contractible loop against the second bone. The suture construct may then be tightened by pulling on the locking limb of the suture using a pusher or pusher tube as generally described herein. Once the desired amount of force is applied by the suture construct, the tension on the suture construct causes the opposed loop to reduce against the locking limb, thereby locking the suture construct and preventing the suture construct from loosening. Once the suture construct is locked, the locking limb may be trimmed proximate to the opposed loop. 
     One or more of the suture systems consistent with the present disclosure provide numerous advantages. For example, the suture systems may include an all thread (suture) repair device which does not require the surgeon to tie any knots, welds, or the like in order to secure and/or draw the suture system tight. The elimination of knots is significant because many surgeons are uncomfortable tying knots due to the possibility of the knot becoming loose and/or the difficulty associated with tying a knot during a surgical procedure. Additionally, welding increases the possibility of accidental collateral damage to surrounding tissue and may be difficult during a surgical procedure. 
     Additionally, the suture systems consistent with the present disclosure eliminate the need to pass buttons, pledgets, or the like through passageways formed in the bone. As a result, the passageways formed in the bone may have a smaller diameter and may minimize the potential of causing incidental complications (such as, but not limited to, damaging the bones during drilling and/or cracking the bones after installation). 
     The suture systems consistent with the present disclosure also provide an “equilibrium” construct. More specifically, the suture systems consistent with the present disclosure distribute the compressive force generated by the suture system evenly across the entire suture system. In contrast, other suture systems utilize two separate and distinct sutures. Consequently, one suture may exert more compressive force than the other suture. This uneven compressive force may place additional stress on the tissue and/or bones, and may lead to the tissue or bones failing. 
     According to one aspect, the present disclosure features a suture system including a suture construct having a first reduction construct configured to be selectively arranged in an expanded state and a reduced state. The first reduction construct includes a first locking limb, a first contractible loop, and a first opposed loop disposed generally opposite to the first contractible loop, wherein reduction of the first opposed loop contracts the first contractible loop from the expanded state into the reduced state and secures the suture construct in the reduced state. The suture construct may also include a second reduction construct. 
     According to another aspect, the present disclosure features a suture system including a first and a second reduction construct separated by a bridge. Each of the reduction constructs features a knot defining a loop, a contractible loop and an opposed loop separated by the loop, and a locking limb extending from the loop and the opposed loop. Each of the reduction constructs is configured to be selectively reduced from an expanded state to a reduced state by reducing a length of the contractible loop by urging the locking limb through the loop from the opposed loop, thereby advancing a portion of the contractible loop through the loop and into the opposed loop. 
     According to yet another aspect, the present disclosure features a suture system including a first and a second reduction construct separated by a bridge. Each of the reduction constructs is configured to be selectively arranged in an expanded state and a reduced state and each includes a locking limb, a contractible loop, and an opposed loop disposed generally opposite to the contractible loop. Reduction of the opposed loop contracts the contractible loop from the expanded state into the reduced state and secures the suture construct in the reduced state. 
     According to yet a further aspect, the present disclosure features a suture pin including a first and a second enlarged portion and an elongated body portion extending between the first and the second enlarged portion. The elongated body portion has a generally circular cross-section. The first and the second enlarged portion have a cross-section which greater than a cross-section of the elongated body portion. 
     According to another aspect, the present disclosure features a method for securing two bones together using a suture system. The method includes forming a first and a second passageway, each extending through a first and a second bone; advancing a distal portion of a first and a second contractible loop through a respective one of the first and the second passageways until the distal ends extend beyond the first bone, wherein proximal regions of the first and the second contractible loops are separated by a bridge, the bridge being disposed proximate to the second bone; advancing a suture plate through the distal portion of the first and the second contractible loops extending beyond the first bone; and reducing the first and the second contractible loops disposed within the first and the second passageways by advancing a first and a second locking limb from a first and a second opposed loop and through a first and a second loop, respectively, thereby advancing portions of the first and second contractible loops through the first and the second loops and into the first ands second opposed loops. 
     According to yet a further aspect, the present disclosure features a method for forming a suture construct. The method includes providing a length of suture; forming a first and a second knot and a first and a second loop, respectively, in the suture, the first and second knots being separated by a bridge; and passing intermediate portions of the suture through the first and the second loops to form a first and a second contractible loop and a first and a second opposed loop, respectively, wherein a first and a second locking limb extends from the first and the second opposed loops through the first and the second loops, respectively. 
     It should be appreciated that various features of the different embodiments described herein may be combined together. 
     While the principles of the present disclosure have been described herein, it is to be understood by those skilled in the art that this description is made only by way of example and not as a limitation as to the scope of the invention. The features and aspects described with reference to particular embodiments disclosed herein are susceptible to combination and/or application with various other embodiments described herein. Such combinations and/or applications of such described features and aspects to such other embodiments are contemplated herein. Other embodiments are contemplated within the scope of the present invention in addition to the exemplary embodiments shown and described herein. Modifications and substitutions by one of ordinary skill in the art are considered to be within the scope of the present invention, which is not to be limited except by the following claims. 
     All definitions, as defined and used herein, should be understood to control over dictionary definitions, definitions in documents incorporated by reference, and/or ordinary meanings of the defined terms. 
     The indefinite articles “a” and “an,” as used herein in the specification and in the claims, unless clearly indicated to the contrary, should be understood to mean “at least one.” 
     The phrase “and/or,” as used herein in the specification and in the claims, should be understood to mean “either or both” of the elements so conjoined, i.e., elements that are conjunctively present in some cases and disjunctively present in other cases. Other elements may optionally be present other than the elements specifically identified by the “and/or” clause, whether related or unrelated to those elements specifically identified, unless clearly indicated to the contrary. 
     All references, patents and patent applications and publications that are cited or referred to in this application are incorporated in their entirety herein by reference. 
     Additional disclosure in the format of claims is set forth below: