Patent Publication Number: US-2020297338-A1

Title: Method and apparatus for soft tissue fixation

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
     This application is a divisional of U.S. patent application Ser. No. 13/098,927 filed on May 2, 2011, which is a continuation-in-part of U.S. patent application Ser. No. 12/196,398 filed on Aug. 22, 2008, now U.S. Pat. No. 7,959,650 issued on Jun. 14, 2011, which is a continuation-in-part of (a) U.S. patent application Ser. No. 11/541,506 filed on Sep. 29, 2006, now U.S. Pat. No. 7,601,165 issued on Oct. 13, 2009; (b) U.S. patent application Ser. No. 11/935,681 filed on Nov. 6, 2007, now U.S. Pat. No. 7,905,903 issued on Mar. 15, 2011; and (c) U.S. patent application Ser. No. 11/784,821 filed on Apr. 10, 2007. 
     This application is a divisional of U.S. patent application Ser. No. 13/098,927 filed on May 2, 2011, which is a continuation-in-part of U.S. patent application Ser. No. 12/938,902 filed on Nov. 3, 2010, now U.S. Pat. No. 8,597,327 issued on Dec. 3, 2013, which is a continuation-in-part of U.S. patent application Ser. No. 12/915,962 filed on Oct. 29, 2010, now U.S. Pat. No. 8,562,647 issued on Oct. 22, 2013, which is a continuation-in-part of U.S. patent application Ser. No. 12/719,337 filed on Mar. 8, 2010, which is a continuation-in-part of U.S. patent application Ser. No. 12/489,168 filed on Jun. 22, 2009, now U.S. Pat. No. 8,361,113 issued on Jan. 29, 2013, which is a continuation-in-part of U.S. patent application Ser. No. 12/474,802 filed on May 29, 2009, now U.S. Pat. No. 8,088,130 issued on Jan. 3, 2012, which is a continuation-in-part of (a) U.S. patent application Ser. No. 12/196,405 filed on Aug. 22, 2008, now U.S. Pat. No. 8,128,658 issued on Mar. 6, 2012; (b) U.S. patent application Ser. No. 12/196,407 filed on Aug. 22, 2008, now U.S. Pat. No. 8,137,382 issued on Mar. 20, 2012; (c) U.S. patent application Ser. No. 12/196,410 filed on Aug. 22, 2008, now U.S. Pat. No. 8,118,836 issued on Feb. 21, 2012; and (d) a continuation-in-part of U.S. patent application Ser. No. 11/541,506 filed on Sep. 29, 2006, now U.S. Pat. No. 7,601,165 issued on Oct. 13, 2009. 
     This application is a divisional of U.S. patent application Ser. No. 13/098,927 filed on May 2, 2011, which is a continuation-in-part of U.S. patent application Ser. No. 12/788,978 filed on May 27, 2010. 
     This application is a divisional of U.S. patent application Ser. No. 13/098,927 filed on May 2, 2011, which is a continuation-in-part of U.S. patent application Ser. No. 12/702,067 filed on Feb. 8, 2010, which is a continuation of U.S. patent application Ser. No. 11/541,505 filed on Sep. 29, 2006, now U.S. Pat. No. 7,658,751 issued on Feb. 9, 2010. 
     This application is a divisional of U.S. patent application Ser. No. 13/098,927 filed on May 2, 2011, which is a continuation-in-part of U.S. patent application Ser. No. 12/570,854 filed on Sep. 30, 2009, now U.S. Pat. No. 8,303,604 issued on Nov. 6, 2012, which is a continuation-in-part of: (a) U.S. patent application Ser. No. 12/489,181 filed on Jun. 22, 2009, now U.S. Pat. No. 8,298,262 issued on Oct. 30, 2012; (b) U.S. patent application Ser. No. 12/014,399 filed on Jan. 15, 2008, now U.S. Pat. No. 7,909,851 issued on Mar. 22, 2011, which is a continuation-in-part of U.S. patent application Ser. No. 11/347,661 filed on Feb. 3, 2006, now U.S. Pat. No. 7,749,250 issued on Jul. 6, 2010; and (c) U.S. patent application Ser. No. 12/014,340 filed on Jan. 15, 2008, now U.S. Pat. No. 7,905,904 issued on Mar. 15, 2011. 
     The entire disclosures of the aforementioned references are expressly incorporated herein by reference. 
    
    
     FIELD 
     The present disclosure relates to methods and apparatuses for securing soft tissue using a flexible suture construct and, more particularly, to flexible suture constructs including adjustable loops. 
     BACKGROUND 
     This section provides background information related to the present disclosure which is not necessarily prior art. 
     Surgical procedures are often performed on a body, for example, a human body or anatomy, to repair or replace various portions thereof. For example, the soft tissues of the body may need to be reattached to bones or a tear in the soft tissue may need repaired due to trauma, overuse, surgical intervention, or disease. 
     Soft tissues can be reattached to a bone or repaired using fastening devices such as screws, staples, and various types of suture anchors. Soft tissues are often fixed to various positions on the bone. For example, to replace a natural tendon fixation point or to replace the tendon itself, it may be desired to fix a graft to a selected bone area. One method of fixing a soft tissue to the selected area is to pass one end of a suture through a selected portion of the soft tissue to form a knot and fix another end of the suture to a selected area on the bone with a suture anchor. The present teachings provide surgical methods and apparatuses for improving engagement between a suture construct and a soft tissue. 
     SUMMARY 
     This section provides a general summary of the disclosure, and is not a comprehensive disclosure of its full scope or all of its features. 
     The present teachings provide surgical methods of attaching a first tissue to a second tissue. In one example, an exemplary method can include passing at least two adjustable loops through at least the first tissue to extend from an outer surface of the first tissue opposite a tissue engaging surface facing the second tissue, and attaching the two adjustable loops to a first selected area of the second tissue. The method can further include positioning a locking member within the two adjustable loops such that the locking member extends between the two adjustable loops adjacent the outer surface, engaging the locking member with the outer surface by drawing the two adjustable loops towards the outer surface, and compressing the first tissue between the locking member and the second tissue by tensioning the two adjustable loops. 
     In another example, the method can include attaching a suture anchor including a flexible construct to the second tissue, wherein the flexible construct extends from the suture anchor and includes at least two self-locking adjustable loops and tensioning members extending from the two adjustable loops. The method can further include passing the at least two self-locking adjustable loops and the tensioning members through the first tissue to extend from an outer surface of the first tissue opposite a tissue engaging surface facing the second tissue. The method can further include positioning an elongated locking member within the two self-locking adjustable loops such that the locking member extends between the two self-locking adjustable loops adjacent the outer surface. The method can further include cinching the two self-locking adjustable loops around the locking member by selectively pulling on the tensioning members, engaging the locking member with the outer surface of the first tissue, and compressing the first tissue between the locking member and the second tissue by selectively pulling on the tensioning members. 
     In another example, the method can include attaching a self-locking, first adjustable loop to a first anchor at a first end of the first adjustable loop and a second anchor at a second end of the first adjustable loop, wherein the first adjustable loop includes a first tensioning member. The method can further include attaching a self-locking, second adjustable loop to a third anchor at a first end of the second adjustable loop and a fourth anchor at a second end of the second adjustable loop, wherein the second adjustable loop includes a second tensioning member. The method can further include passing the first ends of the first and second adjustable loops through separate apertures in the first tissue to extend from an outer surface of the first tissue opposite a tissue engaging surface facing the second tissue. The method can further include attaching the first and third anchors to the second tissue in a first selected area overlapping the first tissue, and attaching the second and fourth anchors to the second tissue in a second selected area spaced apart from the first selected area. The method can further include positioning a locking member between the outer surface and the first and second adjustable loops, and engaging the first and second adjustable loops with the locking member by pulling on the first and second tensioning members. The method can further include engaging the locking member with the outer surface of the first tissue, and compressing the first tissue between the locking member and the second tissue by pulling on the first and second tensioning members. The second selected area can be disposed adjacent an end of the first tissue. 
     The present teachings also provide tissue fixation apparatuses that can be used to attach a first tissue to a second tissue. In one example, an exemplary tissue fixation apparatus can include a flexible construct and an elongated locking member. The flexible construct can include at least two adjustable loops, tensioning members, and an anchor. The two adjustable loops can be configured to pass through the first tissue, and to be spaced apart along an outer surface of the first tissue in a first direction. The tensioning members can extend from the two adjustable loops, and can be configured to reduce the two adjustable loops from a first size to a second size. The anchor can be configured to attach the flexible construct to the second tissue in a first selected area of the second tissue. The locking member can be configured to be received within the two adjustable loops at the first size, and to engage the two adjustable loops at the second size. 
     Further areas of applicability will become apparent from the description provided herein. The description and specific examples in this summary are intended for purposes of illustration only and are not intended to limit the scope of the present disclosure. 
    
    
     
       DRAWINGS 
       The drawings described herein are for illustrative purposes only of selected embodiments and not all possible implementations, and are not intended to limit the scope of the present disclosure. 
         FIGS. 1-3  are fragmentary side views illustrating an exemplary tissue fixation device and method for affixing two tissues together using the tissue fixation device according to the present teachings; 
         FIGS. 4-6  are fragmentary environmental perspective views illustrating an exemplary method of using the tissue fixation device shown in  FIGS. 1-3  to affix a rotator cuff to a humerus; 
         FIG. 7  is a perspective view illustrating an exemplary locking member according to the present teachings; 
         FIG. 8  is a fragmentary top view illustrating another exemplary locking member according to the present teachings; 
         FIG. 9  is a fragmentary top view illustrating another exemplary locking member according to the present teachings; 
         FIG. 10  is a top view illustrating an exemplary adjustable locking member according to the present teachings; 
         FIG. 11  is a top view illustrating another exemplary adjustable locking member according to the present teachings; 
         FIG. 12  is a top view illustrating another exemplary adjustable locking member according to the present teachings; 
         FIG. 13  is a top view illustrating another exemplary adjustable locking member according to the present teachings; 
         FIG. 14  is a top view illustrating another exemplary adjustable locking member according to the present teachings; 
         FIG. 15  is a fragmentary side view illustrating an exemplary method for coupling a locking member to a flexible suture construct according to the present teachings; 
         FIG. 16  is a fragmentary side view illustrating another exemplary method for coupling a locking member to a flexible suture construct according to the present teachings; 
         FIG. 17  is a fragmentary environmental perspective view illustrating another exemplary method for affixing a rotator cuff to a humerus using another tissue fixation device according to the present teachings; 
         FIG. 18  is a fragmentary environmental perspective view illustrating another exemplary method for affixing a rotator cuff to a humerus using another tissue fixation device according to the present teachings; 
         FIG. 19  is a fragmentary environmental perspective view illustrating another exemplary method for affixing a rotator cuff to a humerus using another tissue fixation device according to the present teachings; 
         FIG. 20  is a fragmentary environmental perspective view illustrating another exemplary method for affixing a rotator cuff to a humerus using another tissue fixation device according to the present teachings; 
         FIG. 21  is an environmental perspective view illustrating another exemplary method for affixing two tissues together using another tissue fixation device according to the present teachings; 
         FIG. 22  is a view illustrating a flexible loop construct according to the present teachings; and 
         FIGS. 23-24  are fragmentary environmental perspective views illustrating another exemplary tissue fixation device and method of using the tissue fixation device for affixing a rotator cuff to a humerus. 
     
    
    
     Corresponding reference numerals indicate corresponding parts throughout the several views of the drawings. 
     DETAILED DESCRIPTION 
     Example embodiments will now be described more fully with reference to the accompanying drawings. 
     With particular reference to  FIGS. 1-3 , an exemplary tissue fixation device (TFD)  10  for affixing a first tissue  12  to a second tissue  14  is shown. The first tissue  12  and the second tissue  14  can be independently selected from soft tissue or bone to provide any one of a soft tissue-to-bone, a soft tissue-to-soft tissue, or a bone-to-bone connection. For purposes of the example shown in  FIGS. 1-3 , a soft tissue-to-bone connection is described. Various components of the TFD  10  are described first and then various surgical methods for affixing the first tissue  12  to the second tissue  14  using the TFD  10  are described. 
     Generally, the TFD  10  can be composed of various biocompatible materials, including bioresorbable and non-bioresorbable materials. The TFD  10  can include a flexible suture construct  20 , a suture anchoring member  22 , and a locking member  24 . Generally, the suture construct  20  can be formed of a monofilament, a braided fiber or strand, or other flexible member or suture used to affix the tissues  12 ,  14 . The suture construct  20  can include at least two adjustable loops  30 ,  32  and at least one tensioning member  34 . In various implementations, as illustrated by the examples discussed below, a tensioning member  34  may be provided for each of the loops  30 ,  32 . Additionally, the loops  30 ,  32  and the tensioning member or members  34  can be formed from a single suture construct. 
     Together, the loops  30 ,  32  and the tensioning member or members  34  can cooperate to cinch the loops  30 ,  32  and to create tension in the suture construct  20 . In this way, the loops  30 ,  32  and the tensioning member or members  34  can cooperate to draw and/or compress the tissues  12 ,  14  together. The loops  30 ,  32  can be adapted to both receive and engage the locking member  24 . In various implementations, the loops  30 ,  32  can be self-locking adjustable loops, as illustrated by the examples discussed below. Together, the loops  30 ,  32  and the locking member  24  can cooperate to engage a major or outer surface  36  of the first tissue  12  opposite a tissue engaging surface  38  to be engaged with the second tissue  14 . The tensioning member or members  34  can be configured to adjust the suture construct  20  between an untensioned state and a tensioned state. 
     The loops  30 ,  32 , the tensioning member or members  34 , and/or the suture anchoring member  22  can be created using various surgical methods and suture constructs. For example, whip and/or mattress stitching methods employing a suture thread can be used. As another example, self-locking adjustable loop suture constructs can be employed. Exemplary self-locking adjustable loop suture constructs are disclosed in commonly assigned U.S. Pat. Nos. 7,658,751 and 7,601,165, the entire disclosures of which are expressly incorporated herein by reference. 
     According to the example shown in  FIGS. 1-3 , the suture construct  20  can include a braided body  40  and tensioning strands  42 ,  44  that form self-locking adjustable loops  30 ,  32  and separate tensioning members  34  for each of the loops  30 ,  32 . The braided body  40  and the tensioning strands  42 ,  44  can be formed in a single suture construct using a braiding process for braiding fibers composed of a biocompatible material. The braided body  40  can define a longitudinal passage  50  and apertures  52 ,  54  longitudinally spaced along and in communication with the longitudinal passage  50 . The apertures  52 ,  54  can be created during the braiding process as loose portions between pairs of fibers. The tensioning strands  42 ,  44  can be created using one or more of the fibers used to create the braided body. In this way, the tensioning strands  42 ,  44  can be integral to the braided body  40 . 
     An end  56  of the tensioning strand  42  can be inserted through the aperture  52  and passed through the longitudinal passage  50  and out the aperture  54  to create the loop  30 . Similarly, an end  58  of the tensioning strand  44  can be inserted through the aperture  54  and passed through the longitudinal passage  50  and out the aperture  52  to create the loop  32 . Sizes or diameters of the loops  30 ,  32  can be adjusted by retracting or advancing the tensioning strands  42 ,  44 , respectively, within the longitudinal passage  50 . 
     The suture anchoring member  22  can be configured to affix the suture construct  20  to the second tissue  14 . In various implementations, the suture anchoring member  22  can be created by the suture construct  20  alone, or in combination with, a separate component. According to the example shown in  FIGS. 1-3 , the suture anchoring member  22  can be a separate fastener or suture anchor  60  including external threads  62  configured to threadingly engage the second tissue  14  and an eyelet  64  configured to receive the braided body  40 . It should be understood that the suture anchor  60  is merely exemplary in nature, and that other suture anchors can be used. For example, threaded or non-threaded suture anchors can be used. The suture anchor  60  can be composed of various bioresorbable materials such as, for example, the LactoSorb® material available from Biomet Sports Medicine, LLC of Warsaw, Ind. Alternately, or additionally, the suture anchor may be composed of other non-bioresorbable materials, such as, for example, titanium-based materials. Various bioresorbable and non-bioresorbable, soft and hard suture anchors are available from, for example, Biomet Sports Medicine, LLC of Warsaw, Ind. 
     The locking member  24  can be an elongated member that is received within each of the loops  30 ,  32 , and that spans a lateral distance between the loops  30 ,  32 . The locking member  24  can be further configured to engage and thereby restrain the loops  30 ,  32  from pulling through the first tissue  12  and to maintain the lateral distance between the loops  30 ,  32 , when the suture construct  20  is in the tensioned state. For example, the locking member  24  can be constructed to have a predetermined strength for a period after implantation for resisting pull through by the loops  30 ,  32 . The locking member  24  can be further sized to provide a predetermined bearing surface for distributing compressive loads to the first tissue  12  generated by the suture construct  20  in the tensioned state. More specifically, the locking member  24  can transmit compressive loads received from the loops  30 ,  32  to the first tissue  12 . 
     Generally, the locking member  24  can be composed of various bioresorbable or non-bioresorbable materials. The locking member  24  can include flexible and/or semi-rigid sections that enable the locking member  24  to conform to the outer surface  36  of the first tissue  12 , yet distribute the compressive loads to the first tissue  12  in a predetermined manner. According to the example shown in  FIGS. 1-3 , the locking member  24  can be a length of a flexible strip of surgical fabric such as, for example, surgical tape. The surgical tape can include braided fibers. The locking member  24  can be cut to a predetermined length and/or cut to a custom length during a surgical procedure based on a particular patient. 
     With additional reference to  FIGS. 4-6 , an exemplary surgical method for affixing the tissues  12 ,  14  together using the TFD  10  according to the present teachings will now be described. For exemplary purposes, the method includes affixing a rotator cuff  70  to a humerus  72 . In various implementations, the TFD  10  and the corresponding method can include two or more suture constructs, such as the suture construct  20 , with a single locking member, such as the locking member  24 . As illustrated in  FIGS. 4-6 , the TFD  10  can further include a second suture construct  20 ′ substantially similar to the suture construct  20 . The second suture construct  20 ′ can be coupled to the second tissue  14  via a second suture anchoring member  22 ′ substantially similar to the suture anchoring member  22 . For purposes of the following description, corresponding reference numerals are used to indicate corresponding parts of the suture constructs  20 ,  20 ′ throughout the several views of the drawings. 
     With continued reference to  FIGS. 1-6 , the method can include preparing the humerus  72  to receive suture anchoring members  22 ,  22 ′ in a selected area where the rotator cuff  70  is to be attached. The humerus  72  can be prepared by creating threaded holes in the humerus  72  in selected areas, each at a desired angle of insertion. The threaded holes can be created to a depth that enables the suture anchoring members  22 ,  22 ′ and/or portions of the suture constructs  20 ,  20 ′ to be located beneath an outer surface of the humerus  72 . 
     Next, suture constructs  20 ,  20 ′ can be coupled to the humerus  72  via the suture anchoring members  22 ,  22 ′, respectively. The suture constructs  20 ,  20 ′ can be coupled to the suture anchoring members  22 ,  22 ′ prior to, at the same time, or after securing the suture anchoring members  22 ,  22 ′ to the humerus  72 . According to the examples shown in  FIGS. 1-6 , the suture construct  20  can be coupled to the suture anchoring member  22  prior to threadingly engaging the suture anchoring member  22  with the humerus  72 . More particularly, tensioning strand  42  can be inserted through the eyelet  64  until the braided body  40  is approximately centered within the eyelet  64 . Next, the tensioning strands  42 ,  44  can be passed through the longitudinal passage  50  to create the loops  30 ,  32  as discussed above. The suture construct  20 ′ can be coupled to the suture anchoring member  22 ′ and subsequently to the tissue  14  in a similar manner. 
     Next, with particular reference to  FIG. 4 , the loops  30 ,  32  and tensioning strands  42 ,  44  can be passed through incisions or apertures  80 ,  82  formed into the rotator cuff  70 . Similarly, the loops  30 ′,  32 ′ and tensioning strands  42 ′,  44 ′ can be passed through apertures  84 ,  86  of the rotator cuff  70 . The apertures  80 ,  82 ,  84 ,  86  can be spaced apart and can extend generally parallel to one another as shown. In various implementations, one or more of the tensioning strands  42 ,  44 ,  42 ′,  44 ′ can be passed between the tissues  12 ,  14 , rather than through the corresponding apertures  80 ,  82 ,  84 ,  86 . The apertures  80 ,  82 ,  84 ,  86  can be created prior to or at the same time as the passing of the corresponding loops  30 ,  32 ,  30 ′,  32 ′ and the tensioning strands  42 ,  44 ,  42 ′,  44 ′. The loops  30 ,  32 ,  30 ′,  32 ′ and tensioning strands  42 ,  44 ,  42 ′,  44 ′ can be passed using a separate needle or other suitable suture passer or device. For example, suitable devices include devices sold under the trade names “BiPass™”, SpeedPass™”, and “ArthroPass™”, all made by Biomet Sports Medicine, LLC of Warsaw, Ind. 
     The loops  30 ,  32 ,  30 ′,  32 ′ can be passed such that distal ends of the loops  30 ,  32 ,  30 ′,  32 ′ are spaced apart along a major or outer surface  88  of the rotator cuff  70 . The loops  30 ,  32 ,  30 ′,  32 ′ can be spaced apart along a line or axis  89  to face or open towards each other as shown. The loops  30 ,  32 ,  30 ′,  32 ′ can be spaced apart to span a selected area of the rotator cuff  70  to be attached to the humerus  72 . The tensioning strands  42 ,  44 ,  42 ′,  44 ′ can be passed through the same apertures  80 ,  82 ,  84 ,  86  as the corresponding loops  30 ,  32 ,  30 ′,  32 ′ as shown, or through separate, spaced apertures as discussed in further detail below. Next, as shown between  FIGS. 4-5 , the locking member  24  can be passed through and positioned within each of the loops  30 ,  32 ,  30 ′,  32 ′. Sizes or diameters of the loops  30 ,  32 ,  30 ′,  32 ′ can be adjusted to enable the locking member  24  to be passed through the loops  30 ,  32 ,  30 ′,  32 ′. The diameters can be adjusted as discussed above prior to or when positioning the locking member  24 . 
     With the locking member  24  thus positioned, the tensioning strands  42 ,  44 ,  42 ′,  44 ′ can be selectively pulled to cinch the loops  30 ,  32 ,  30 ′.  32 ′ around the locking member  24  and to draw the locking member  24  into engagement with the rotator cuff  70 . With the locking member  24  engaged, the tensioning strands  42 ,  44 ,  42 ′,  44 ′ can be further pulled to further close and tension the loops  30 ,  32 ,  30 ′,  32 ′ and draw the locking member  24  towards the suture anchoring members  22 ,  22 ′. Further drawing the locking member  24  can draw the rotator cuff  70  in close proximity with the humerus  72  and subsequently compress the rotator cuff  70 , thereby creating tension in the suture constructs  20 ,  20 ′. More specifically, the rotator cuff  70  can be drawn into a desired relationship with the humerus  72 .  FIGS. 1 and 4  illustrate the suture constructs  20 ,  20 ′ in an untensioned state.  FIGS. 2, 3, and 5  illustrate the suture constructs  20 ,  20 ′ in a tensioned state. 
     Tension in the loops  30 ,  32 ,  30 ′,  32 ′ can be retained by the self-locking features of the constructs  20 ,  20 ′ without continuing to pull on the tensioning strands  42 ,  44 ,  42 ′,  44 ′. Although not specifically shown, with the rotator cuff  70  and the humerus  72  in the desired relationship, one or more of the tensioning strands  42 ,  44 ,  42 ′,  44 ′ can be cut to a desired length, for example, flush to the outer surface  88 . In this way, excess length can be removed. Alternately, the tensioning strands  42 ,  44 ,  42 ′,  44 ′ can be drawn past an end of the rotator cuff  70  and attached to a selected area of the humerus  72  as shown in  FIG. 6 . More particularly, the tensioning strands  42 ,  44 ,  42 ′,  44 ′ can be drawn and attached so as to extend in a direction generally parallel to a direction in which the rotator cuff  70  contracts during muscle action. Tensioning strands  44 ,  44 ′ can be drawn around the locking member  24  and positioned to adjoin the loops  32 ,  32 ′, respectively, as shown. 
     The tensioning strands  42 ,  44 ,  42 ′,  44 ′ can be attached using another suture anchoring member  90  substantially similar to the suture anchoring member  22 . The tensioning strands  42 ,  44 ,  42 ′,  44 ′ can be coupled to the suture anchoring member  90  by passing the tensioning strands  42 ,  44 ,  42 ′,  44 ′ through an eyelet  92  of the suture anchoring member  90  and creating a knot  94 . The humerus  72  can be prepared to receive the suture anchoring member  90  in substantially the same manner as the suture anchoring members  22 ,  22 ′. 
     With particular reference to  FIGS. 7-14 , various other exemplary configurations of the locking member  24  according to the present teachings are shown.  FIGS. 7-9  illustrate various flexible, elongated, and generally thin, flat configurations that can be cut to a desired length and/or width from a larger stock of material prior to and/or during a surgical procedure. With particular reference to  FIG. 7 , an exemplary locking member  100  can include monofilament fibers  102 ,  104  connected along a length by a fabric of intertwined threads, or braided fabric  106 . The monofilament fibers  102 ,  104  can have diameters greater than a thickness of the braided fabric  106 . The braided fabric  106  can circumscribe the monofilament fibers  102 ,  104  and include a central section  108  that spans a width between the monofilament fibers  102 ,  104 . The locking member  100  can be oriented between adjacent loops (e.g., loops  30 ,  32 ) of a suture construct so that the monofilament fibers  102 ,  104  span a distance between the loops. Alternately, the locking member  100  can be oriented so that the central section  108  spans the distance between the loops and the larger side sections created by the monofilament fibers  102 ,  104  engage opposite sides of the loops. In this way, the monofilament fibers  102 ,  104  can provide a loop engaging feature for fixing ends of the locking member  100  relative to the loops and/or for fixing the distance between the loops. 
     Referring now to  FIG. 8 , another exemplary locking member  120  can include outwardly extending edges or protrusions  122 ,  124  that create peripheral recesses along a length that are configured to engage two or more loops (e.g., loops  30 ,  32 ) of a suture construct. At least two protrusions  122 ,  124  can be provided to fixedly position the loops and thereby maintain a distance between the loops when the loops are engaged. The protrusions  122 ,  124  can extend at an angle, for example towards each other, to create barbs or hooks as shown for engaging and securely holding the loops at a separated distance. In an exemplary construction, the locking member  120  can include monofilament fibers  126  connected along a length by a braided fabric  128  in a substantially similar way as the locking member  100 . The protrusions  122 ,  124  can be created using various methods. For example, the protrusions  122 ,  124  can be created during the braiding process used to create the braided fabric  128 . As another example, a cutting process, for example a die cutting process, can be used to create the protrusions  122 ,  124 . 
     Referring now to  FIG. 9 , another exemplary locking member  140  can include a length or strip of a non-woven bio-textile  142 , such as, for example, the Scaftex® materials offered by Biomedical Structures of Warwick, R.I. Non-woven bio-textiles can be manufactured from a variety of synthetic, absorbable polymeric fibers, including polyglycolic acid (PGA), poly-L-lactide (PLLA), poly DL-lactide-co-glycolide acid (PLGA), blends, and other fibers. The bio-textile  142  can include first regions  144  having a higher density than second regions  146 . The first and second regions  144 ,  146  can have a predetermined and regular arrangement with respect to a broad or major surface of the locking member  140  configured to engage loops of a suture construct. The bio-textile  142  can be die cut from a sheet to include peripheral depressions  148  along opposite sides configured to engage the loops of the suture construct. The peripheral depressions  148  can adjoin the higher density first regions  144 . In this way, the loops can engage and be retained in higher density regions specifically suited to restrain the loops from pulling through the adjoining tissue. 
       FIGS. 10-14  illustrate various adjustable locking members according to the present teachings. Generally, the locking members are flexible and elongate configurations created using various adjustable loop constructions. The adjustable loop constructions can enable adjustments to sizes or diameters of one or more loop sections and an overall length of the locking members prior to and during a surgical procedure. The adjustments can further enable loop engaging members at opposite ends of the locking members to be brought into engagement with one or more loops of a suture construct. The loop engaging members can be deformable between a first configuration when the locking members are untensioned and/or unengaged with loops of a suture construct and a second configuration facilitating engagement between the locking members and the loops. Additional suitable adjustable loop constructions are disclosed in commonly assigned U.S. patent application Ser. No. 11/541,506, the entire disclosure of which is expressly incorporated herein by reference. 
     With particular reference to  FIG. 10 , an exemplary adjustable locking member  160  can include an adjustable loop construct including a sleeve  162 , a fiber or strand  164 , and sleeves  166 ,  168 . The sleeve  162  can have a braided construction and can define a longitudinal passage  170  and apertures  172 ,  174 . The strand  164  can be wrapped into a single loop or coil passing through the longitudinal passage  170  and the sleeves  166 ,  168  as shown to create adjustable loop sections that extend from opposite ends of the sleeve  162 . Ends  176 ,  178  of the strand  164  can pass through the apertures  172 ,  174  and can be used as tensioning members used to adjust sizes or diameters of the adjustable loop sections and thereby adjust an overall length of the locking member  160  or, more specifically, a distance between the sleeves  166 ,  168 . The sleeves  166 ,  168  can have a braided construction similar to the sleeve  162  and can function as loop engaging members. 
     Referring now to  FIG. 11 , another exemplary adjustable locking member  180  can include an adjustable loop construct including a fiber or strand  182  and sleeves  184 ,  186 . The strand  182  can be wrapped into a single loop or coil passing through the sleeves  184 ,  186  as shown to create an adjustable closed loop configuration. Ends  188 ,  190  of the strand  182  can extend through the sleeves  184 ,  186  and exit at opposite ends of the sleeve  184 . A size or diameter of the loop or coil and an overall distance between the sleeves  184 ,  186  can be adjusted by pulling on one or both the first and second ends  188 ,  190 . The sleeves  184 ,  186  can include flexible sections to facilitate adjustments and/or semi-rigid sections to maintain a predetermined curvature or diameter of the sleeves  184 ,  186  after the adjustments. The sleeves  184 ,  186  can also function as loop engaging members deformable between a first configuration and a second configuration. The first configuration can be a first shape configured to maintain an overall shape of the locking member  180  prior to engaging the locking member  180  with loops of a suture construct, for example, the shape shown in  FIG. 11 . The second configuration can be a second shape different from the first shape configured to facilitate engagement between the locking member  180  and the loops of the suture construct, for example, the cinched shape shown in  FIG. 16  and discussed below. 
     Referring now to  FIG. 12 , another exemplary adjustable locking member  200  can include a self-locking adjustable loop construct formed from a braided suture construct. The locking member  200  can include a braided body  202 , fibers or strands  204 ,  206 , and sleeves  208 ,  210 . The braided body  204  can have a longitudinal passage  212  and apertures  214 ,  216 . The longitudinal passage  212  and the apertures  214 ,  216  can be sized relative to the strands  204 ,  206  to provide the self locking feature. A first end  217  of the strand  204  can be passed through the sleeve  208 , then through the aperture  214  and the longitudinal passage  212  and out the aperture  216  to create a first self-locking adjustable loop at one end of the adjustable locking member  200 . A second end  219  of the strand  206  can be passed through the sleeve  210 , then through the aperture  216  and the longitudinal passage  212  and out the aperture  214  to create a second self-locking adjustable loop at an opposite end. 
     The apertures  214 ,  216  can be loose portions between pairs of fibers forming the braided body  204 . While two apertures  214 ,  216  are shown, additional apertures can be provided so that each of the strands  204 ,  206  can be passed through separate apertures to create the adjustable loops. Sizes or diameters of the adjustable loops can be separately adjusted by selectively pulling on the first and second ends  217 ,  219 . By adjusting the diameter of one or both of the loops, an overall length of the adjustable locking member  200  and, more particularly, a distance between the sleeves  208 ,  210  can be adjusted. 
     Referring now to  FIG. 13 , another exemplary adjustable locking member  220  can include an adjustable loop construct including a tubular body  222 , a fiber or strand  224 , and sleeves  226 ,  228 . The strand  224  can be wound in a single loop or coil passing through the tubular body  222  and the sleeves  226 ,  228 , as shown, to create two adjustable loop sections extending from opposite ends of the tubular body  222 . First and second ends  230 ,  232  of the strand  224  can pass through the tubular body  222  to exit at one of the opposite ends. The first end  230  can be a free end that functions as a tensioning member that can be pulled to simultaneously adjust sizes or diameters of the adjustable loop sections and thereby adjust a distance between the sleeves  226 ,  228 . The second end  232  can be tied in a knot  234  that engages the tubular body  222  to prevent the second end  232  from pulling through the tubular body  222  when making adjustments. 
     Referring now to  FIG. 14 , another exemplary adjustable locking member  240  can include an adjustable loop construct including a fiber or strand  242  and sleeves  244 ,  246 . The strand  242  can be wound into a single loop or coil passing through the sleeves  244 ,  246 , as shown, to create an adjustable closed loop configuration similar to that of the locking member  180  discussed above. First and second ends  248 ,  250  can exit opposite ends of the sleeve  244 . The first end  248  can be a free end that functions as a tensioning member. The second end  250  can be tied in a knot  252  that engages the sleeve  244  to prevent the second end  250  from pulling through the sleeve  244  when pulling on the first end  248  to make adjustments. 
     With particular reference to  FIG. 15 , another TFD  300  and surgical method for using the TFD  300  for affixing the first tissue  12  to the second tissue  14  is shown. The TFD  300  and the method illustrate alternate features that can be employed to engage a locking member with two or more loops of a suture construct, according to the present teachings. For exemplary purposes, the TFD  300  can include the suture constructs  20 ,  20 ′ and the suture anchoring members  22 ,  22 ′. The TFD  300  can further include a locking member  310 . The locking member  310  can incorporate one or more features of the locking members  24 ,  100 ,  120 ,  140 ,  160 ,  180 ,  200 ,  220 ,  240  discussed above. According to the example shown in  FIG. 15 , the locking member  310  can be a fiber or strand  320  having first and second ends  322 ,  324 . 
     With continued reference to  FIG. 15 , an exemplary method of using the TFD  300  can include coupling the suture constructs  20 ,  20 ′ to the second tissue  14  and passing the loops  30 ,  32 ,  30 ′,  32 ′ through the first tissue  12  in substantially the same manner as described above for the TFD  10 . Next, with the suture constructs  20 ,  20 ′ in an untensioned state, the first end  322  can be passed through a first end loop, for example, the loop  30 ′, and then successively through the remaining loops  32 ′,  32 ,  30  in that order. Next, the strand  320  can be wrapped around a second end loop, here, the loop  30 , by pulling the first end  322  back towards the adjacent loop  32 . Next, the first end  322  can be successively passed back through the loops  32 ,  32 ′,  30 ′ in that order. 
     Once the strand  320  is routed through the loops  30 ,  32 ,  30 ′,  32 ′ in the foregoing manner, the tensioning strands  42 ,  44 ,  42 ′,  44 ′ can be selectively pulled to cinch the loops  30 ,  32 ,  30 ′,  32 ′ around the strand  320  and to draw the strand  320  into engagement with the first tissue  12 . With the strand  320  engaged, a distance between the loops  30 ,  30 ′ can be adjusted by manipulating (e.g., pulling) one or both the first and second ends  322 ,  324 . Next, the first and second ends  322 ,  324  can be secured together using a knot  326  that functions as a loop engaging member that engages the loop  30 ′ and thereby inhibits the loops  30 ,  30 ′ from separating during subsequent steps. 
     Next, the tensioning strands  42 ,  44 ,  42 ′,  44 ′ can be further selectively pulled to draw the loops  30 ,  32 ,  30 ′,  32 ′ and the strand  320  towards the suture anchoring members  22 ,  22 ′. Further drawing the loops  30 ,  32 ,  30 ′,  32 ′ can draw the first tissue  12  in close proximity with the second tissue  14  in a desired relationship, and subsequently compress the first tissue  12 , thereby creating tension in the suture constructs  20 ,  20 ′.  FIG. 15  illustrates the suture constructs  20 ,  20 ′ in a tensioned state. With the first and second tissues in the desired relationship, the tensioning strands  42 ,  44 ,  42 ′,  44 ′ can be drawn under tension and attached to a selected area of the second tissue  14  in any suitable manner. For example, the tensioning strands  42 ,  44 ,  42 ′,  44 ′ can be attached in a manner substantially similar to that described above for the TFD  10 . 
     With particular reference to  FIG. 16 , another TFD  400  and surgical method for using the TFD  400  for affixing the first tissue  12  to the second tissue  14  will now be described. The TFD  400  and the method illustrate alternate features according to the present teachings that can be employed to engage loop engaging members of an adjustable locking member with two or more loops of a suture construct. For purposes of the example shown in  FIG. 16 , the locking member  180  shown in  FIG. 11  can be employed in the TFD  400 . The TFD  400  can include the suture constructs  20 ,  20 ′ and the suture anchoring members  22 ,  22 ′. 
     With reference to  FIG. 11  and  FIG. 16 , an exemplary method of using the TFD  400  can include coupling the suture constructs  20 ,  20 ′ to the second tissue  14  and passing the loops  30 ,  32 ,  30 ′,  32 ′ through the first tissue  12  in substantially the same manner as described above for the TFD  10 . Next, with the TFD  400  in an untensioned state, the locking member  180  can be passed through and positioned within the loops  30 ,  32 ,  30 ′,  32 ′ such that ends of the locking member  180  extend past the end loops  30 ,  30 ′. More particularly, the locking member  180  can be positioned such that the sleeves  184 ,  186  are disposed outboard of the end loops  30 ,  30 ′. 
     Once the locking member  180  is routed through the loops  30 ,  32 ,  30 ′,  32 ′ in the foregoing manner, the tensioning strands  42 ,  44 ,  42 ′,  44 ′ can be selectively pulled to cinch the loops  30 ,  32 ,  30 ′,  32 ′ around the locking member  180  and to draw the locking member  180  into engagement with the first tissue  12 . With the locking member  180  engaged, the sleeves  184 ,  186  can be brought into engagement with the loops  30 ,  30 ′, respectively, by pulling on one or both the ends  188 ,  190 . The sleeves  184 ,  186  can deform from a first configuration having a first shape (see  FIG. 11 ) to a second configuration having a cinched shape as shown in  FIG. 16  that resists pull through. Once the sleeves  184 ,  186  are engaged, a distance between the loops  30 ,  30 ′ can be reduced by further pulling on one or both of the ends  188 ,  190 . Next, the first and second ends  188 ,  190  can be tied together to create the knot  326  that engages the sleeve  184  and thereby fixes the length of the locking member  180  and the distance between the loops  30 ,  30 ′. 
     Next, the tensioning strands  42 ,  44 ,  42 ′,  44 ′ can be further selectively pulled to draw the locking member  180  towards the suture anchoring members  22 ,  22 ′. Further drawing the loops  30 ,  32 ,  30 ′,  32 ′ can draw the first tissue  12  in close proximity with the second tissue  14  in a desired relationship and subsequently compress the first tissue  12 , thereby creating tension in the suture constructs  20 ,  20 ′.  FIG. 16  illustrates the suture constructs  20 ,  20 ′ in a tensioned state. With the first and second tissues  12 ,  14  in the desired relationship, the tensioning strands  42 ,  44 ,  42 ′,  44 ′ can be drawn under tension and attached to a selected area of the second tissue  14  in any suitable manner. For example, the tensioning strands  42 ,  44 ,  42 ′,  44 ′ can be attached in a manner substantially similar to that described above for the TFD  10 . 
     With particular reference to  FIG. 17 , another TFD  500  and surgical method of using the TFD  500  for affixing two tissues according to the present teachings will now be described. The TFD  500  can be used, for example, to affix the rotator cuff  70  to the humerus  72 . The TFD  500  and the method illustrate alternate features according to the present teachings including coupling ends of a locking member with a tensioning member of a suture construct. In this way, the locking member can assist the suture construct to resist tension generated in one or both the tissues due to muscle contraction. 
     For purposes of the example shown in  FIG. 17 , the TFD  500  can include the self-locking suture constructs  20 ,  20 ′, the suture anchoring members  22 ,  22 ′, and a locking member  502 . The locking member  502  can be similar to the locking member  24 , except that the locking member  502  can have a length sufficient to enable ends  504 ,  506  to be coupled to the humerus  72  at one or more remote locations. For example, the ends  504 ,  506  can be coupled at the locations separate from the locations where the locking member  502  is coupled via the suture anchoring members  22 ,  22 ′. According to the example shown in  FIG. 17 , the ends  504 ,  506  can be coupled to the humerus  72  along with the tensioning strands  42 ,  44 ,  42 ′,  44 ′ via a suture anchoring member  508 . The ends  504 ,  506  can be coupled to the suture anchoring member  508  via a knot or other suitable locking device. 
     With continued reference to  FIG. 17 , an exemplary method of using the TFD  500  can include coupling the suture constructs  20 ,  20 ′ to the humerus  72  and passing the loops  30 ,  32 ,  30 ′.  32 ′ through the rotator cuff  70  in substantially the same manner as described above for the TFD  10 . Next, with the TFD  500  in an untensioned state, the locking member  502  can be passed through and positioned within the loops  30 ,  32 ,  30 ′,  32 ′ such that the ends  504 ,  506  extend past the end loops  30 ,  30 ′. 
     Once the locking member  502  is routed through the loops  30 ,  32 ,  30 ′,  32 ′ in the foregoing manner, the tensioning strands  42 ,  44 ,  42 ′,  44 ′ can be selectively pulled to cinch the loops  30 ,  32 ,  30 ′,  32 ′ around the locking member  502  and to draw the locking member  502  into engagement with the rotator cuff  70 . Next, the tensioning strands  42 ,  44 ,  42 ′,  44 ′ can be further selectively pulled to draw the locking member  180  towards the suture anchoring members  22 ,  22 ′. Further drawing the loops  30 ,  32 ,  30 ′,  32 ′ can draw the first tissue  12  in close proximity with the second tissue  14  in a desired relationship and subsequently compress the first tissue  12 , thereby creating tension in the suture constructs  20 ,  20 ′.  FIG. 17  illustrates the suture constructs  20 ,  20 ′ in a tensioned state. With tension in the suture constructs  20 ,  20 ′, one or more of the tensioning strands  42 ,  44 ,  42 ′,  44 ′ can be cut to remove excess length where the ends of the one or more strands are not to be attached to the humerus  72 . Alternately, the tensioning strands  42 ,  44 ,  42 ′,  44 ′ can be drawn past an end of the rotator cuff  70  and attached to the humerus  72  as shown. While drawing and/or attaching one or more of the tensioning strands  42 ,  44 ,  42 ′,  44 ′, the ends  504 ,  506  can be drawn past the end of the rotator cuff  70  and attached to the humerus  72 . 
     With particular reference to  FIG. 18 , another TFD  600  and surgical method of using the TFD  600  for affixing two tissues according to the present teachings will now be described. The TFD  600  can be used, for example, to affix the rotator cuff  70  to the humerus  72 . The TFD  600  and the method illustrate alternate features according to the present teachings including overlapping tensioning members of suture constructs in a criss-cross fashion and securing the tensioning members of each suture construct to the humerus  72  at at least two separate locations. An overlapping structure of the tensioning members can engage and thereby further affix the rotator cuff  70  to the humerus  72 . The overlapping structure can further reduce localized stress in one or both the rotator cuff  70  and the humerus  72  by distributing the loads transmitted between the TFD  600  and the rotator cuff  70  and humerus over a larger area and creating a larger area of compression. 
     According to the example shown in  FIG. 18 , the TFD  600  can include a first suture construct  602 , a second suture construct  604 , and a locking member  606 . The first and second suture constructs  602 ,  604  each can include at least two adjustable loops tensioned by corresponding tensioning members. For example, the first suture construct  602  can include four adjustable loops  610  tensioned by four corresponding tensioning strands  612  as shown. Similarly, the second suture construct  604  can include four adjustable loops  614  tensioned by four corresponding tensioning strands  616 . The adjustable loops  610 ,  614  can be created using various suturing techniques and devices. According to the example shown in  FIG. 18 , the adjustable loops  610 ,  614  can be created by passing a suture through the rotator cuff  70  using a whip and/or a mattress stitching technique. In various implementations, the adjustable loops  610 ,  614  can be created from separate sutures attached to the humerus  72  in a manner similar to that discussed below with reference to  FIG. 21 . The adjustable loops  610 ,  614  can create a series of loops spaced apart in a substantially linear arrangement along a line or axis  618  as shown. The linear arrangement or axis  618  can extend in a direction substantially transverse to a direction in which the rotator cuff  70  tensions due to muscle contraction. 
     The tensioning strands  612 ,  616  can exit the same proximal side of the rotator cuff  70  that the adjustable loops  610 ,  614  are disposed, and in a substantially linear arrangement in the direction in which the rotator cuff  70  tensions due to muscle contraction. The tensioning strands  612 ,  614  can exit on either side of the adjustable loops  610 ,  614 . For example, the tensioning strands  610 ,  614  can each exit in close proximity to the corresponding adjustable loops  610 ,  614  on a side closest to an end of the rotator cuff  70  as shown. The tensioning strands  612 ,  616  can be attached to the humerus  72  in at least two selected areas separated in the same direction in which the adjustable loops  610 ,  614  are arranged. 
     According to the example shown in  FIG. 18 , the tensioning strands  612 ,  616  can be secured at two locations indicated by reference numerals  620 ,  622 . More specifically, at least one of each of the tensioning strands  612  and the tensioning strands  616  can be attached at the first location  620  and at least another one of each of the tensioning strands  612  and the tensioning strands  616  can be attached at the second location  622 . For exemplary purposes, the tensioning strands  612 ,  614  can be attached to the first and second locations  620 ,  622  in an alternating arrangement as shown. When secured, the tensioning strands  612 ,  616  secured at the first location  620  can overlap the tensioning strands  612 ,  616  secured at the second location  622  in a criss-cross fashion. The locking member  606  can extend through each of the loops  610 ,  614  and can include a first end  630  and a second end  632  that are attached at the first location  620  and the second location  622 , respectively. 
     With continued reference to  FIG. 18 , an exemplary method of using the TFD  600  will now be described. The method can include creating the loops  610 ,  614  and tensioning strands  612  and  616  to pass through and exit the rotator cuff  70  and attaching the loops  610 ,  614  to the humerus  72 . The adjustable loops  610  can be attached to the humerus  72  using a first suture anchoring member such as, for example, the suture anchoring member  22  discussed above. Similarly, the adjustable loops  614  can be attached to the humerus  72  using a separate, second suture anchoring member in a similar manner. 
     Next, with the adjustable loops  610 ,  614  in an untensioned state, the locking member  606  can be passed through and positioned within the loops  610 ,  614  such that the ends  630 ,  632  extend past end loops of the adjustable loops  610 ,  614 . Once the locking member  606  is routed through the loops  610 ,  614 , the tensioning strands  612 ,  616  can be selectively pulled to cinch the loops  610 ,  614  around the locking member  606  and to draw the locking member  606  into engagement with the rotator cuff  70 . Next, the tensioning strands  612 ,  616  can be further selectively pulled to draw the locking member  606  towards the humerus  72 . Further drawing the loops  30 ,  32 ,  30 ′,  32 ′ can draw the rotator cuff  70  in close proximity with the humerus  72  in a desired relationship and subsequently compress the rotator cuff  70  against the humerus  72 , thereby creating tension in the loops  610 ,  614 .  FIG. 18  illustrates the loops  610 ,  614  in a tensioned state. 
     While maintaining the tension in the loops  610 ,  614 , a first pair of the tensioning strands  612  and a first pair of the tensioning strands  616  can be drawn together and attached at the selected location  620 . Subsequently, a second pair of the tensioning strands  612  and a second pair of the tensioning strands  616  can be drawn together and attached at the selected location  622 . When attached in the foregoing manner, the first and second pairs of the tensioning strands  612 ,  616  can extend at angles with respect to the axis  618  and overlap in a criss-cross fashion to create an overlapping structure that compresses an end portion of the rotator cuff  70  against the humerus  72 . In this way, the overlapping structure can further secure the rotator cuff  70  to the humerus  72 . 
     With particular reference to  FIG. 19 , another TFD  700  and surgical method of using the TFD  700  for affixing two tissues according to the present teachings will now be described. The TFD  700  can be used, for example, to affix the rotator cuff  70  to the humerus  72 . The TFD  700  and the method illustrate alternate features according to the present teachings including using one or more portions of a suture construct to create a locking member for adjustable loops of the suture construct and securing the portions at a remote location. 
     According to the example shown in  FIG. 19 , the TFD  700  can include a first suture construct  702  and a second suture construct  704 . The first and second suture constructs  702 ,  704  can be substantially similar to the suture constructs  20 ,  20 ′ and can be attached to the humerus  72  in substantially the same way as the suture constructs  20 ,  20 ′. The first suture construct  702  can include a first adjustable loop  710  tensioned by a tensioning strand  712  and a second adjustable loop  714  tensioned by a tensioning strand  716 . The first adjustable loop  710  and the tensioning strand  712  can pass through a common first aperture  720  formed through the rotator cuff  70  and exit on the same side. The tensioning strand  712  can pass through the second adjustable loop  714 . The second adjustable loop  714  and tensioning strand  716  can pass through a common second aperture  722 . The tensioning strand  716  can pass through the adjustable loop  710 . 
     The second suture construct  704  can include a third adjustable loop  730  tensioned by a tensioning strand  732  and a fourth adjustable loop  734  tensioned by a tensioning strand  736 . The third adjustable loop  730  can pass through a first aperture  740  and the tensioning strand  732  can pass through a separate, second aperture  742  and through the adjustable loop  730 . The fourth adjustable loop  734  can pass through a third aperture  744  and the tensioning strand  736  can pass through a separate, fourth aperture  746  and through the fourth adjustable loop  734 . The adjustable loops  710 ,  714 ,  730 ,  734  can be spaced apart along a line or axis  750  and the apertures  720 ,  722 ,  740 ,  744  can extend at angles with respect to the axis  750 . For example, the apertures  720 ,  722  can extend at angles of, for example, approximately forty-five degrees ( 45  so that the adjustable loops  710 ,  714  can face each other and to facilitate the passage of the tensioning strands  712 ,  716 . The apertures  740 ,  744  can extend at angles so that the adjustable loops  730 ,  734  face towards the apertures  742 ,  746  and thereby facilitate the passage of the tensioning strands  732 ,  736 . The tensioning strands  712 ,  716 ,  732 ,  736  can be cut to remove excess length and/or attached to a selected area of the humerus  72  at a single, remote location  752  as shown or, alternately, can be secured at two or more remote locations. 
     With continued reference to  FIG. 19 , an exemplary method of using the TFD  700  can include attaching the first and second suture constructs  702 ,  704  to the humerus  72  and passing the adjustable loops  710 ,  714 ,  730  through the respective apertures  720 ,  722  of rotator cuff  70 . The method can further include passing the tensioning strands  712 ,  716 ,  732  through the respective apertures  720 ,  722 ,  734 . In various implementations, the tensioning strands  712 ,  716  can be passed through the apertures  720 ,  722  at the same time as the respective adjustable loops  710 ,  714  are passed. 
     Next, with the first suture construct  702  in an untensioned state, an end of the tensioning strand  712  can be inserted through the second adjustable loop  714  and an end of the tensioning strand  716  can be inserted through the adjustable loop  710 . Next, the tensioning strands  712 ,  714  can be selectively pulled to cinch the adjustable loops  710 ,  714  around the tensioning strands  712 ,  714  and engage intermediate portions of the tensioning strands  712 ,  714  with the rotator cuff  70 . Once the tensioning strands  712 ,  714  are engaged, the tensioning strands  712 ,  714  can be further selectively pulled to draw the rotator cuff  70  in close proximity to the humerus  72 . Once the rotator cuff  70  is positioned against the humerus  72  in a desired relationship, the tensioning strands  712 ,  714  can be attached to the humerus  72  in tension to retain the relationship. 
     With the second suture construct  704  in an untensioned state, an end of the tensioning strand  732  can be inserted through the adjustable loop  730  and pulled to cinch the adjustable loop  730  and engage an intermediate portion of the tensioning strand  732  with the rotator cuff  70 . Once engaged in the foregoing manner, the tensioning strand  732  can be further pulled to draw the rotator cuff  70  into a desired relationship and subsequently attached in tension to the humerus  72 . 
     With particular reference to  FIG. 20 , another TFD  800  and surgical method of using the TFD  800  for affixing two tissues according to the present teachings will now be described. The TFD  800  can be used, for example, to affix the rotator cuff  70  to the humerus  72 . The TFD  800  can include a suture construct  802  having at least two adjustable loops and at least one locking member that engages the adjustable loops. According to the example shown in  FIG. 20 , the suture construct  802  can include four adjustable loops  804 ,  806 ,  808 ,  810  and three locking members  820 ,  822 ,  824 . In various implementations, the adjustable loops  804 ,  806  and the adjustable loops  808 ,  810  can be created using the suture construct  20  and the suture construct  20 ′, respectively. 
     The locking member  820 , locking member  822 , and locking member  824  can have ends  830 ,  832 , ends  834 ,  836 , and ends  838 ,  840 , respectively. The locking member  820  can extend through and engage the loops  804 ,  806 . The locking member  822  can extend through and engage the loops  806 ,  808 . The locking member  824  can extend through and engage the loops  808 ,  810 . The ends  830 ,  832 ,  834  can be attached to a selected area of the humerus  72  at a first location indicated by reference numeral  850 , and the ends  836 ,  838 ,  840  can be attached at a second location indicated by reference numeral  852 . 
     With continued reference to  FIG. 20 , an exemplary method of using the TFC  800  can include attaching the loops  804 ,  806 ,  808 ,  810  to the humerus  72  and passing the loops  804 ,  806 ,  808 ,  810  through the rotator cuff  70 . The loops  804 ,  806 ,  808 ,  810  can be passed so as to extend along a line or axis  854  and face in a second direction substantially perpendicular to the axis  854 . With the loops  804 ,  806 ,  808 ,  810  in an untensioned state, the ends  830 ,  832 , the ends  834 ,  836 , and the ends  838 ,  840  can be passed through the loops  804 ,  806 , the loops  806 ,  808 , and the loops  808 ,  810 , respectively, in the second direction. When passed in the foregoing manner, portions of the locking members  804 ,  806 ,  808 ,  810  can span the corresponding loops  804 ,  806 ,  808 ,  810 . Next, the ends  830 ,  832 ,  834 ,  836 ,  838 ,  840  can be pulled to create tension in the loops  804 ,  806 ,  808 ,  810  and to draw the rotator cuff  70  into close proximity with the humerus  72  in a desired relationship. With the rotator cuff  70  and the humerus  72  in the desired relationship, the ends  830 ,  832 ,  834 ,  836 ,  838 ,  840  can be attached to the humerus  72  at the respective locations  850 ,  852  in a tensioned state. 
     With particular reference to  FIG. 21 , another exemplary TFD  900  and surgical method of using the TFD  900  for affixing the first and second tissues  12 ,  14  according to the present teachings will now be described. The TFD  900  can be used, for example, to affix the rotator cuff  70  to the humerus  72 . The TFD  900  and the method illustrate alternate features according to the present teachings. The alternate features can include engaging a locking member with at least two adjustable loops disposed on one side of a first tissue and drawing the locking member and the first tissue into engagement with a second tissue using tensioning strands disposed between the first and second tissues. 
     According to the example shown in  FIG. 21 , the TFD  900  can include a flexible suture construct  902  created by suture strands  904 ,  906 . The suture strand  904  can be passed through the first tissue  12  to create loops  910 ,  912  that extend from a first side of the first tissue  12  opposite a second side to be engaged with the second tissue  14 . The suture strand  904  can be further passed through the first tissue  12  such that ends  914  and  916  exit and extend from the first tissue  12  on the second side of the tissue facing the second tissue  14 . The suture strand  906  can be passed through the first tissue  12  to create loops  920 ,  922  that extend from the first side of the first tissue  12  and ends  924 ,  926  that exit and extend from the second side of the first tissue  12 . Each of the loops  910 ,  912 ,  920 ,  922  can be created by passing the respective suture strands  904 ,  906  through a single aperture or, alternately, through separate apertures in the first tissue  12 . Ends of the suture strands  904 ,  906  can be secured to the second tissue  14  in any desired manner such as, for example, using one or more suture anchors. While two suture strands  904 ,  906  forming four loops  910 ,  912 ,  920 ,  922  are shown, fewer or more suture strands can be used where fewer or more loops are desired. 
     With continued reference to  FIG. 21 , an exemplary method of using the TFD  900  can include positioning a locking member (not shown) within the loops  910 ,  912 ,  920 ,  922  and subsequently engaging the loops  910 ,  912 ,  920 ,  922  with the first tissue  12  via the locking member. The loops  910 ,  912 ,  920 ,  922  can be engaged by pulling on the ends  914 ,  916 ,  924 ,  926  to cinch the loops  910 ,  912 ,  920 ,  922  into engagement with the locking member and to draw the locking member into engagement with the first tissue  12 . The locking member can include one or more features of the locking members  24 ,  100 ,  120 ,  140 ,  160 ,  180 ,  200 ,  220 ,  240 . With the loops  910 ,  912 ,  920 ,  922  engaged, the ends  914 ,  916 ,  924 ,  926  can be selectively pulled to draw the first tissue  12  into close proximity with the second tissue  14  in a desired relationship. The desired relationship can be maintained by maintaining tension in the loops  910 ,  912 ,  920 ,  922 . With the first and second tissues  12 ,  14  in the desired relationship, the ends  914 ,  916 ,  924  and  926  can be drawn and attached to the second tissue  14  in tension to retain the relationship. 
     With reference to  FIGS. 22-24 , another TFD  1000  and surgical method of using the TFD  1000  for affixing the rotator cuff  70  to the humerus  72  according to the present teachings will now be described. The TFD  1000  can include two or more flexible anchors  1002 ,  1004 , one or more self-locking, flexible suture constructs  1006 , and a locking member  1010 . For example, the TFD  1000  can include four (4) flexible anchors  1002 , four (4) flexible anchors  1004 , four (4) flexible suture constructs  1006 , and one (1) locking member  1010  as shown. The locking member  1010  can incorporate one or more features of the locking members  24 ,  100 ,  120 ,  140 ,  160 ,  180 ,  200 ,  220 ,  240  discussed above. 
     With particular reference to  FIG. 22 , the flexible anchors  1002 ,  1004  can be elongate members having a sleeve or tubular construction. The flexible anchors  1002 ,  1004  can be configured to attach to the humerus  72  within respective bores  1012  formed in the humerus  72 . For example, the flexible anchors  1002 ,  1004  can deform between a first shape configured to be received within the bores  1012  and a second shape larger than the first shape configured to engage the bores  1012 . The flexible anchors  1002 ,  1004  can include longitudinal passages  1020 ,  1022  and openings  1024 ,  1026 ,  1028 ,  1030  extending through respective walls. The flexible suture construct  1006  can include a braided body  1040  and tensioning strands  1042 ,  1044  that form a self-locking adjustable loop including loop sections  1050 ,  1052 . The braided body  1040  can define a longitudinal passage  1054  and openings  1056 ,  1058  in communication with the longitudinal passage  1054 . The tensioning strands  1042 ,  1044  can extend from opposite ends of the braided body  1040 . 
     The loop sections  1050 ,  1052  can be formed and coupled to the flexible anchors  1002 ,  1004  by passing the braided body  1040  and the tensioning strand  1042  through the flexible anchors  1002 ,  1004  as shown. More specifically, the tensioning strand  1042  and the braided body  1040  can pass through the openings  1024 ,  1026  and the longitudinal passage  1020  of the flexible anchor  1002 . The tensioning strand  1042  can further pass through the openings  1028 ,  1030  and longitudinal passage  1022  of the flexible anchor  1004  and the openings  1056 ,  1058  and the longitudinal passage  1054  of the braided body  1040 . When coupled, the flexible anchor  1002  and the braided body  1040  can be disposed at a first end  1060  and the flexible anchor  1004  can be disposed at a second end  1062 . Further details of the flexible anchors  1002 ,  1004  and the flexible suture construct  1006  are disclosed in commonly assigned U.S. patent application Ser. No. 12/915,962, the entire disclosure of which is expressly incorporated herein by reference. 
     With continued reference to  FIGS. 22-24 , the method of using the TFD  1000  can include selectively adjusting a size of the loop sections  1050 ,  1052  by pulling on the tensioning strand  1042 . The size of the loop sections  1050 ,  1052  can be adjusted to provide a desired length between the first and second ends  1060 ,  1062 . The first ends  1060  can be passed through apertures  1068  in the rotator cuff  70  along a line or axis  1070  and the flexible suture anchors  1002  can secured within the respective bores  1012  formed in the humerus  72  at proximal locations  1072 . The proximal locations  1072  can be located beneath the rotator cuff  70  when the rotator cuff  70  is secured in a desired position. The locking member  1010  can be positioned on an outer surface  1074  of the rotator cuff  70  to extend between the flexible suture constructs  1006 , and generally parallel to the axis  1070 . The second ends  1062  can be drawn over the locking member  1010 , past an end  1080  of the rotator cuff  70 , and secured within the respective bores  1012  formed in the humerus  72  at distal locations  1076  adjacent the end  1080 . The distal locations  1076  can be spaced apart from the proximal locations  1072  and can be disposed adjacent the end  1080  of the rotator cuff  70  as best seen in  FIG. 24 . When secured, tension in the flexible suture constructs  1006  can compress the locking member  1010 . The tensioning strands  1042 ,  1044  can be cut to a desired length, for example, flush to the outer surface  1074  of the rotator cuff  70 . 
     The foregoing description of the embodiments has been provided for purposes of illustration and description. It is not intended to be exhaustive or to limit the disclosure. Individual elements or features of a particular embodiment are generally not limited to that particular embodiment, but, where applicable, are interchangeable and can be used in a selected embodiment, even if not specifically shown or described. The same may also be varied in many ways. Such variations are not to be regarded as a departure from the disclosure, and all such modifications are intended to be included within the scope of the disclosure.