Patent Publication Number: US-2023139434-A1

Title: Suture release constructs and methods of tissue fixation

Description:
BACKGROUND 
     The disclosure relates to surgical devices and, more specifically, to sutures and associated methods of tissue repairs. 
     SUMMARY 
     Surgical constructs with releasable junctions and methods of tissue repairs are disclosed. A surgical construct can offer both repair and reinforcement capability. A surgical construct can include one or more repair strands provided with one or more releasable junctions (one or more releasable stitches), to allow the repair strands to be joined and subsequently released. At least one of the one or more releasable junctions (releasable stitches) can be formed by passing back and forth another flexible strand (releasing suture) through the one or more repair strands to form a plurality of passes. When the another flexible strand is pulled, it pulls out the one or more releasable junctions (releasable stitches) from the repair strands, releasing the repair strands. The surgical construct may be part of a knotless or knotted construct. 
     Methods of forming a releasable, stitched junction capable of being released to allow repair strands to be disengaged/disjoined are also provided. One or more repair strands are provided with at least one or more releasable junctions (one or more releasable stitches) formed by another independent strand (releasing suture) which is passed/shuttled through the one or more repair strands, to form a releasable junction. The another independent strand (releasing suture) may be similar to or different from the one or more repair strands, and may have similar or different characteristics and properties as those of the repair strands. The one or more releasable junctions (releasable stitches) can be removed to allow release of the repair strands by pulling on the releasing suture. 
     Methods of tissue repair are also disclosed. A first tissue is approximated to a second tissue with a repair strand provided with at least one or more releasable junctions (one or more releasable stitches) formed by a releasing suture that is passed or weaved back and forth through at least a portion of the repair strand. When the releasing suture is pulled, it pulls out the releasable stitch from the repair suture, freeing up the repair suture. The releasable junction provides additional support, strength, and reinforcement of the tissue repair. In an embodiment, a repair strand with at least one releasable junction (releasable stitch) is attached to a first tissue and to a second tissue, to provide a reinforced tissue repair and assist in surgical procedures requiring repair sutures to be joined to each other, as well as released from each other at a certain time during the surgery. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG.  1    illustrates a surgical construct according to an exemplary embodiment. 
         FIG.  2    illustrates a surgical construct according to another exemplary embodiment. 
         FIGS.  3  and  4    illustrate subsequent steps of removing the releasable stitch of the construct of  FIG.  1   . 
         FIG.  5    illustrates a surgical construct according to another exemplary embodiment. 
         FIG.  6    illustrates a surgical construct according to another exemplary embodiment. 
     
    
    
     DETAILED DESCRIPTION 
     The disclosure provides surgical constructs formed of flexible strands that are joined together and subsequently disengaged. The surgical constructs are suturing constructs. 
     The surgical constructs include a repair strand (flexible strand such as suture) provided with at least one releasable stitch formed by a releasing suture (another flexible strand such as suture) that is passed or weaved back and forth through at least a portion of the body of the repair strand to form a releasable stitch. When the releasing suture is pulled, the releasable stitch is removed (pulled out) from the repair strand. 
     The surgical constructs can be employed for passing or shuttling at least one length of flexible material, for example suture such as high strength suture, tape, wire, cable, or fabric. After the passing or shuttling of various lengths of flexible materials with the surgical constructs in a first configuration (having the releasable stitch), the surgical constructs can attain a second configuration different from the first configuration (without the releasable stitch). The surgical constructs may be knotless or knotted. The surgical constructs may be part of additional knotless or knotted construct(s) and/or may be employed in conjunction with knotless or knotted construct(s). 
     The surgical constructs permit passing and secure attachment of additional flexible strands through and with the repair strand, with increased strength and reinforcement capabilities. The ability to pass additional sutures through and with the repair strand would permit multiple suture strands to be loaded at a tissue repair site without the requirement of individually passing the suture through the tissue more than once. Surgical repairs with improved strands having reinforced junctions/suture releasable stitches such as the improved strands of the present disclosure (and as detailed below) provide multiple strands joined at a releasable junction point which provides increased strength and supporting capabilities at a repair site, with the benefit of releasing the repair strands as desired during the surgical procedure. 
     The surgical constructs include a repair strand that is joined into a predetermined configuration or bounded with other repair strands together by a releasing suture. The releasing suture forms a releasable stitch. The surgical constructs provide for improved methods of tissue repair and multiple suture strand loading techniques with a single suture needle passage. 
     The surgical construct in the predetermined configuration can be employed as a passing/shuttling loop, through which the same suture strand and/or another independent strands (sutures) may be passed in a single pass step, for improved tissue repair constructs. The surgical construct provides a site where additional sutures or strands or flexible materials may be passed/threaded through loops formed by the releasable stitch. The repair strands can be disengaged by pulling on the releasing suture to remove the releasable stitch and release the repair strands. 
     Referring now to the drawings, where like elements are designated by like reference numerals,  FIGS.  1 - 6    illustrate various views of surgical constructs  100 ,  200 ,  300 , 400  (suture releasable stitch constructs  100 ,  200 ,  300 ,  400 ; suturing constructs  100 ,  200 ,  300 ,  400 ; constructs  100 ,  200 ,  300 ,  400 ; assemblies  100 ,  200 ,  300 ,  400 ) of the present disclosure. 
       FIG.  1    depicts construct  100  with repair suture  10  (repair strand  10 ; first flexible strand  10 ; strand  10 ; flexible member  10 ) which may be formed of suture or any similar material and releasing suture  20  (releasing strand  20 ; second flexible strand  20 ; strand  20 ; flexible member  20 ), connected by releasable stitch  50  (stitch  50 ; interconnection  50 ; junction  50 ; releasable junction  50 ; suture releasable stitch  50 ; release stitch  50 ; connecting region  50 ). 
     Repair suture  10  of  FIG.  1    can include a middle region  12  with two tail regions  11 ,  13  (tails  11 ,  13 ; ends  11 ,  13 ) and one exemplary releasing suture  20  being provided extending through the middle region  12  and along a longitudinal axis  12   a  of the middle region  12  and out of tail  13 . The middle region  12  can be a suture or tape, for example a round suture or flat suture tape. The middle region can have a constant diameter/dimensions or a gradual taper. The two tail regions  11 ,  13  can be formed of round suture, with same or different diameter. 
     Middle region  12  can have cross-sections of various forms and geometries, including round, elliptical, rectangular or flat, among others, or combination of such forms and geometries. In an exemplary embodiment only, middle region  12  can be provided as a braided round suture that can be coreless. The diameter of middle region  12  may be constant or may vary. The middle region  12  can be any suture strand or suture tape, for example, Arthrex FiberWire® suture (disclosed in U.S. Pat. No. 6,716,234, the entire disclosure of which is incorporated herein by reference). However, the surgical constructs  100 ,  200 ,  300 ,  400  can be used with any type of flexible material or suture known in the art. The tail regions  11 ,  13  may have similar or different diameters and/or widths. As illustrated in  FIG.  1   , each of the widths/diameters of the tail regions  11 ,  13  is about similar to the width/diameter of the middle region  12 . Tail regions  11 ,  13  may have similar or different lengths. One or both of the tail regions  11 ,  13  may have a very fine end that is coated, impregnated, or stiffened with a material such as plastic, for example. One or both of the tail regions  11 ,  13  may include a tapered end that terminated in a very fine end. 
     For simplicity,  FIGS.  1 - 6    illustrate repair suture  10  with only one exemplary releasable stitch  50 ; however, the disclosure contemplates strands and flexible materials with any number of releasable stitches  50 , depending on the desired number of working strands and the particulars of each surgical repair. In addition, any number of repair sutures  10  may be employed with any number of releasing sutures  20  and releasable stitches  50 . 
     Releasable stitch  50  may be formed by passing releasing suture  20  at least once, preferably multiple times, through at least two separate regions/portions of the repair suture  10 , as shown in  FIG.  1   , for example. Releasing suture  20  is provided inside the repair suture  10 , by for example, being fed inside the repair suture  10 . Releasable stitch  50  can be formed by passing back and forth the releasing suture  20  at different, spaced location and through bodies of portions/lengths/regions a, b of the repair suture  10 . Releasable stitch  50  can include a plurality of passes  51  (for example, five passes  51 , as illustrated in  FIG.  1   ) but it must be understood that the disclosure contemplates releasable stitch  50  with any number of passes  51  formed through the repair suture  10 . Additional passes through the repair suture  10  would typically provide a stronger overall stitch  50 . 
       FIG.  1    shows an “inside releasing suture” embodiment, i.e., releasing suture  20  is being fed inside of the repair suture  10  with the releasing suture  20  exiting an open end of the repair suture  20 , for example, a most distal end  20   b . The releasable stitch is provided adjacent tail  11  to form continuous, uninterrupted, flexible, knotless loop  55 . The “inside releasing suture” embodiment confers a clean appearance to the overall construct  100  and it is easier to manage. The repair suture  10  is in a first configuration (a “loop configuration”). 
     The releasable stitch  50  is formed of plurality of passes  51  by sewing back-and-forth strand  20  through the repair suture  10 . The more passes through the repair suture the stronger the overall stitch becomes. At least one of the plurality of passes  51  is provided within the body and end tail/region  11  of the repair suture  10  and along the lengths a, b of the repair suture  10  to permit for the passing/shuttling of the same repair suture  10  and/or other additional repair strands (flexible strands or similar elements such as suture, suture tapes, etc.) through the loop  55 . This aspect allows for additional sutures or tapes or any flexible material to pass through the reinforced loop to increase the strength of the repair. 
     One or more stitches  50  may be provided extending through and along the body of regions a and b of repair suture  10 , to attach/join/connect the regions a and b together, in a secured yet non-permanent manner, and to form a suture loop  55  (flexible, closed loop with a fixed perimeter). The suture loop  55  can allow passing of another strand(s) through the loop to aid in various tissue repairs. If multiple releasable stitches  50  are employed, the releasable stitches may have similar or different geometries and shapes and may be formed by similar or different releasing sutures. 
     Releasable stitch  50  can be formed by passing/sewing/weaving the releasing suture  20  through repair strand  10  at different locations and in at least two different directions, a first, longitudinal direction A about parallel to longitudinal axis  12   a  of repair suture  10  and a second direction B about orthogonal to longitudinal axis  12   a  of repair suture  10 . Releasing suture  20  may be any flexible strand, for example, suture strands, suture tapes, nitinol strands, FiberWire® suture, TigerWire® suture, or FiberLink™ among many others. One or more releasing sutures  20  may pass through repair suture  10 . When the releasing suture  20  is pulled, it pulls out the releasable stitch  50  from the repair suture  10  and opens up the loop  55 . 
       FIG.  2    illustrates surgical construct  200  which is similar in part to construct  100  detailed above (the “inside releasing suture” embodiment with a releasable suture loop) but differs in that construct  200  includes releasing suture  20  (a separate, independent strand  20 ) which exits the repair suture  10  at a location “L” situated along the middle region  12  or tail  13 , and not at a most distal end  20   b  of the tail  13 , as in the first embodiment. The embodiment of  FIG.  2    is an “outside releasing suture” construct with a releasable suture loop, wherein the releasing suture  20  is fed outside of the repair suture  10 . Depending on how the stitch  50  is used and upon the complexity of the surgical activity, the releasing suture  20  may provide additional benefits if fed outside the repair suture. 
       FIGS.  3  and  4    illustrate subsequent steps of removing the releasable stitch  50  of exemplary construct  100  of  FIG.  1   . Pulling on the releasing suture  20  in direction “P” along the length of suture  20  and away from the repair suture  10 , allows the releasing suture  20  to remove the releasable stitch  50  and to confer the repair suture  10  a second configuration. The repair suture loop  55  is free to open.  FIG.  4    illustrates repair suture  10  in the second configuration (non-loop configuration), with releasing suture  20  completely removed and loop  55  completely opened (no loop). 
       FIG.  5    illustrates surgical construct  300  which is similar in part to constructs  100 ,  200  detailed above, but differs in that construct  300  includes releasing suture  20  which extends longitudinally through the middle region  12  or one of the tails  11 ,  13  and the other one of the tails  11 ,  13  of the repair suture  10 , i.e., without a loop formation. Releasing suture  20  also passes through a plurality of regions of the repair suture  10  (for example, four or more separate regions, as shown in  FIG.  5   ) to form releasable stitch  150  in the form of a releasable suture bunch/knot. When releasing suture  20  is pulled in direction “P” to pull out of the repair suture  10 , the stitch  150  is removed and the repair suture  10  becomes unbunched/unknotted, i.e., repair suture  10  changes from first to second configuration to become a flexible, free strand without any joined or connected sections. 
       FIG.  6    illustrates surgical construct  400  which is similar in part to constructs  100 ,  200 ,  300  detailed above, but differs in that construct  400  includes releasing suture  20  which forms releasable stitch  250  joining two or more repair sutures  10 ,  110  and extending longitudinally only through one of the repair sutures  10 ,  110 , without a loop formation. When the releasing suture  20  is pulled, it pulls out the releasable stitch  250  from the repair sutures  10 ,  110  and frees the repair sutures  10 ,  110  (a “releasable sutures” embodiment). 
     Typically, sutures can be spliced (fixed spliced sutures) or tied together or joined permanently in different manners but they cannot be disengaged (set free subsequent to the splicing or joining other than being cut to open the joined region). The present disclosure provides a solution to join a suture in a predetermined configuration or to bind multiple sutures together, while also providing a simple method to release these sutures. The formed loop can be released by removing/uncoupling the suture release stitch from the repair suture of the surgical construct. After the stitch has been removed, the suture(s) attains and returns to the initial form/state. 
     A surgical construct  100 ,  200 ,  300 ,  400  includes one or more repair sutures  10 ,  110  provided with one or more junctions  50 ,  150 ,  250  (one or more releasable stitches  50 ,  150 ,  250 ), to allow the repair sutures  10 ,  110  to be joined and subsequently released. At least one of the one or more junctions  50 ,  150 ,  250  (releasable stitches) can be formed by passing or weaving back and forth another flexible strand  20  (releasing suture  20 ) through the one or more repair strands  10 ,  110 . When the releasing suture  20  is pulled, it pulls out the one or more junctions  50 ,  150 ,  250  (one or more releasable stitches  50 ,  150 ,  250 ) from the repair sutures  10 ,  110 , releasing the repair sutures  10 ,  110  and opening up loop  55 . The surgical construct  100 ,  200 ,  300 ,  400  may be a knotless or knotted construct, or may be part of a knotless or knotted construct. 
     Methods of forming a reinforced or stitched junction  50 ,  150 ,  250  (one or more releasable stitches  50 ,  150 ,  250 ) capable of being released to allow repair strands to be disengaged/disjoined are also provided. One or more repair sutures  10 ,  110  are provided with at least one or more junctions  50 ,  150 ,  250  (one or more releasable stitches  50 ,  150 ,  250 ) formed by another independent strand  20  (releasing suture  20 ) which is passed/shuttled through the one or more repair sutures  10 ,  110 , to form a junction. The another independent strand (releasing suture) may be similar to or different from the one or more repair sutures, and may have similar or different characteristics and properties as those of the repair strands. The one or more junctions  50 ,  150 ,  250  (one or more releasable stitches  50 ,  150 ,  250 ) can be removed to allow release of the repair strands by pulling on the releasing suture. 
     Methods of tissue repair are also disclosed. A first tissue is approximated to a second tissue with a repair suture  10 ,  110  provided with at least one or more junctions  50 ,  150 ,  250  (one or more releasable stitches  50 ,  150 ,  250 ) formed by a releasing suture  20  that is passed back and forth through at least two different locations of the repair suture  10 ,  110 . When the releasing suture  20  is pulled, it pulls out the releasable stitch  50 ,  150 ,  250  from the repair suture  10 ,  110 , freeing up the repair suture  10 ,  110 . The junction  50 ,  150 ,  250  (one or more releasable stitches  50 ,  150 ,  250 ) provides additional support, strength, and reinforcement of the tissue repair as well as of the repair suture  10 ,  110 . In an embodiment, a repair suture  10 ,  110  with at least one reinforced junction  50 ,  150 ,  250  (one or more releasable stitches  50 ,  150 ,  250 ) is attached to a first tissue and to a second tissue, to provide a reinforced tissue repair and assist in multiple surgical procedure requiring repair sutures to be joined to each other, as well as released from each other to go back to their initial shape/configuration/state. 
     A repair suture  10 ,  110  includes a releasable stitch  50 ,  150 ,  250 . The releasable stitch  50 ,  150 ,  250  includes a plurality of passes  51  formed by passing at least another strand  20  multiple times through two regions a, b of the repair suture  10 ,  110 . When the another strand  20  is pulled out of the suture  10 ,  110 , the releasable stitch  50 ,  150 ,  250  is removed from the repair suture. 
     A surgical construct  100 ,  200 ,  300 ,  400  comprises a repair suture  10 ,  110  with at least one releasable stitch  50 ,  150 ,  250  formed of a plurality of passes  51  which extend in between two separate regions a, b of the repair suture  10 ,  110  and which are formed by a strand  20  passing back and forth through the two separate regions a, b of the repair suture  10 ,  110  to form the releasable stitch  50 ,  150 ,  250 . The strand  20  is passed at an angle relative to a longitudinal axis  12   a  of the repair suture  10 ,  110  to connect the two separate regions a, b or the two separate repair sutures  10 ,  110  and form a loop  55 . The repair suture  10 ,  110  has a middle region  12  and two tail regions  11 ,  13  adjacent the middle region  12 . The releasable stitch  50 ,  150 ,  250  is removable when the strand  20  is pulled out of the repair suture  10 ,  110 . 
     A surgical construct  100 ,  200 ,  300 ,  400  comprises a suture  10 ,  110  with a middle region  12  and two end tails  11 ,  13 ; and a strand  20  passed multiple times through the middle region  12  and through one of the end tails  11 ,  13  to form a closed, flexible, continuous end loop  55  with a fixed perimeter and a releasable junction  50 ,  150 ,  250 , and to connect the one end of the tails  11 ,  13  to the middle region  12 . The strand  20  passes through other of the two end tails  11 ,  23 . 
     A method of suturing comprises (i) passing a suture construct  100 ,  200 ,  300 ,  400  through or around tissue, the suture construct comprising a first flexible strand  10 ,  110  with a closed, flexible, continuous end loop  55  with a fixed perimeter and a releasable stitch  50 ,  150 ,  250 , and a second flexible strand  20  passed through and in between at least two separate longitudinal lengths a, b of the first flexible strand  10 ,  110  to form the releasable stitch  50 ,  150 ,  250  and the closed, flexible, continuous end loop  55  with a fixed perimeter; and (ii) pulling on the second flexible strand  20  to remove the releasable stitch  50 ,  150 ,  250  and to open the closed, flexible, continuous end loop  55  with a fixed perimeter. The method further comprises threading at least another flexible strand through the closed, flexible, continuous end loop  55  with a fixed perimeter; and passing the another flexible strand through or around tissue together with the suture construct  100 ,  200 ,  300 ,  400 . The first flexible strand  10 ,  110 , the second flexible strand  20 , and the another flexible strand can be passed simultaneously through the tissue, in a single pass step. The suture construct  100 ,  200 ,  300 ,  400  (with or without any additional strands) can be attached to a fixation device. The fixation device can be knotless or knotted. A knotless fixation device can be a swivel anchor or a pushlock anchor. 
     The surgical construct  100 ,  200 ,  300 ,  400  can be a shuttling/suture passer. The surgical construct  100 ,  200 ,  300 ,  400  can be a repair suture. The surgical construct  100 ,  200 ,  300 ,  400  can be a suturing construct. The suture may be a round suture or a suture tape, or combination thereof. The suture may be high strength suture, tape, suture tape, combination of suture and tape, wire, cable, or fabric, among many others. 
     Methods of tissue repair are also disclosed. In an embodiment, additional flexible strands can be passed simultaneously with a suture construct  100 ,  200 ,  300 ,  400  by conducting a single pass through tissue to be repaired (ligament, tendon, graft, etc.). The suture construct (repair suture  10 ,  110  and releasing suture  20 ) and any additional flexible strands passed and secured through the loop  55  may be passed and/or shuttled simultaneously with or without a surgical instrument such as a suture passer. The suture construct and the additional flexible strands may be passed or shuttled simultaneously without loading a separate shuttling stitch or wire, and without passing each strand independently. One or more additional flexible strands may pass through one or more loops  55  (with a needle or a suture passer). 
     A method of tissue repair (for example, soft tissue to soft tissue, or soft tissue to bone fixation) includes passing a suturing construct  100 ,  200 ,  300 ,  400  through tissue and securing the tissue with the suturing construct. The suturing construct  100 ,  200 ,  300 ,  400  may be passed through or around tissue by loading the construct onto a suture passer and simultaneously passing a repair suture together with the releasing suture and any additional repair strands. Additional repair strands are passed through the closed loop  55  of the suturing construct and passed/shuttled through or around tissue without the need to pass each additional repair strand individually. A single pass loads multiple repair strands at once. The tissue repairs may employ at least one knotless and/or knotted fixation device. The knotless fixation devices may be knotless anchors, for example, swivel and/or screw-in suture anchors and/or push-in anchors (such as an Arthrex SwiveLock® anchor or a PushLock® Anchor). In an exemplary embodiment only, the fixation device is a knotless suture anchor such as the two-piece Arthrex PushLock® anchor, disclosed in U.S. Pat. No. 7,329,272, or an Arthrex SwiveLock® anchor, disclosed in U.S. Pat. No. 8,012,174 issued Sep. 6, 2011, and U.S. Pat. No. 9,005,246 issued Apr. 14, 2015, the disclosures of all of which are fully incorporated by reference in their entirety herein. 
     The surgical constructs  100 ,  200 ,  300 ,  400  described above may be formed of strands of a high strength suture material with surgically-useful qualities, including knot tie down characteristics and handling, such as Arthrex fiberWire® suture disclosed in U.S. Pat. No. 6,716,234 the entire disclosure of which is incorporated herein by reference. The surgical constructs may be formed of optional colored strands (preferably black) to assist surgeons in distinguishing between suture lengths with the trace and suture lengths without the trace. 
     Surgical constructs  100 ,  200 ,  300  may be preferably coated (partially or totally) with wax (beeswax, petroleum wax, polyethylene wax, or others), silicone (Dow Corning silicone fluid 202A or others), silicone rubbers (Nusil Med 2245, Nusil Med 2174 with a bonding catalyst, or others) PTFE (Teflon, Hostaflon, or others), PBA (polybutylate acid), ethyl cellulose (Filodel) or other coatings, to improve lubricity of the suture or tape, knot security, pliability, handleability or abrasion resistance, for example. 
     Strands  10 ,  100 ,  20  may be made of any known suture construct, such as multifilament, braided, knitted, woven suture, or including fibers of ultrahigh molecular weight polyethylene (UHMWPE). Flexible strands  10 ,  110 ,  20  can consist of, or consist essentially of, suture. Flexible strands  10 ,  110 ,  20  can be formed of any suture, tape, weave, fabric, ribbon, textile, web, or mesh, or any combinations of these materials. Flexible strands  10 ,  110 ,  20  can be formed of a high strength suture material such as FiberWire® suture, sold by Arthrex, Inc. of Naples, Fla., and described in U.S. Pat. No. 6,716,234, the disclosure of which is incorporated by reference herein. FiberWire® suture is formed of an advanced, high-strength fiber material, namely ultrahigh molecular weight polyethylene (UHMWPE), sold under the tradenames Spectra® (Honeywell International Inc., Colonial Heights, Va.) and Dyneema® (DSM N.V., Heerlen, the Netherlands), braided with at least one other fiber, natural or synthetic, to form lengths of suture material. Flexible strands  10 ,  110 ,  20  can be braided or multi-filament suture such as FiberTape® suture tape (as disclosed in U.S. Pat. No. 7,892,256, the disclosure of which is incorporated in its entirety herewith) or collagen tape, or wide “tape like” material, or combinations thereof. 
     Flexible strands  10 ,  110 ,  20  can consist essentially of suture or suture material, or combination of suture and other materials such as long chain synthetic polymers like polyester and nylon, or materials such as PET, silk nylon or absorbable polymers, or coating materials (such as wax, silk, or silicone products), among many others. Flexible strands  10 ,  110 ,  20  can consist of strands with cross-sections of various forms and geometries, including round, oval, rectangular, or flat, among others, or combinations of such forms and geometries. In an embodiment, at least one of flexible strands  10 ,  110 ,  20  can be provided as a suture which is braided, knitted or woven. 
     Flexible strands  10 ,  110 ,  20  can be also formed of a stiff material, or combination of stiff and flexible materials, depending on the intended application. Flexible strands  10 ,  110 ,  20  can be also coated and/or provided in different colors. In an embodiment, parts (or all) of suturing construct  100 ,  200 ,  300 ,  400  can be coated (partially or totally) with wax (beeswax, petroleum wax, polyethylene wax, or others), silicone (Dow Corning silicone fluid 202A or others), silicone rubbers (Nusil Med 2245, Nusil Med 2174 with a bonding catalyst, or others) PTFE (Teflon, Hostaflon, or others), PBA (polybutylate acid), ethyl cellulose (Filodel) or other coatings, to improve lubricity of the suture and/or tape, pliability, handleability or abrasion resistance, for example. 
     Flexible strands  10 ,  110 ,  20  can be also provided with tinted tracing strands, or otherwise contrast visually with other parts of the construct, which remain a plain, solid color, or displays a different tracing pattern, for example. Various structural elements of surgical construct  100 ,  200 ,  300 ,  400  may be visually coded, making identification and handling of the suture legs simpler. Easy identification of suture in situ is advantageous in surgical procedures. 
     The term “high strength suture” is defined as any elongated flexible member, the choice of material and size being dependent upon the particular application. For the purposes of illustration and without limitation, the term “suture” as used herein may be a cable, filament, thread, wire, fabric, or any other flexible member suitable for tissue fixation in the body.