Abstract:
A method of securing a tissue graft within a bone passage includes providing a graft fixation member comprising a closed double-loop having a pair of differently sized loop sections and capturing both sections of the closed-loop within the fixation member. The longer loop section is passed through an opening in the tissue graft then is passed through the smaller loop and thrown

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
       [0001]    This Application is a Continuation of application Ser. No. 10/895,266 filed on Jul. 20, 2004. Ser. No. 10/895,266 is a Continuation-in-part of application Ser. No. 09/859,096 filed on May 16, 2001. 
     
    
     BACKGROUND OF THE INVENTION 
       [0002]    This patent application is a divisional and claims the benefit of the priority of U.S. patent application Ser. No. 10/895,266, which is a continuation-in-part and claims the benefit of the priority of U.S. patent application Ser. No. 09/859,096, filed May 16, 2001, which is now U.S. Pat. No. 6,533,802, published Mar. 18, 2003, all of which are hereby incorporated by reference. 
         [0003]    An increasing number of surgical techniques are now performed arthroscopically. One type of arthroscopic procedure reconstructs the anterior cruciate ligament (ACL) in the knee. Several ACL reconstruction techniques are described in U.S. Pat. No. 5,139,520 (issued Aug. 18, 1992, known herein as “the &#39;520 patent”) and incorporated by reference. 
         [0004]    A substitute graft harvested from the patient or from a donor usually replaces an ACL that has ruptured and is non-repairable. The substitute ACL graft may be a portion of a patellar tendon having so called “bone blocks” at each end. A method and an apparatus for harvesting such a patellar tendon graft is described in U.S. Pat. No. 5,733,289 (issued Mar. 31, 1998, known herein as “the &#39;289 patent”) and incorporated by reference. Alternatively, an artificial graft formed from synthetic materials or from a combination of artificial and natural materials may be used and is sometimes referred to as a ligament augmentation device (LAD). The term “tissue graft” is used herein to encompass all of these tissue replacement items. 
         [0005]    In general, the replacement tissue graft is implanted by securing one end of the tissue graft in a socket formed in a passage formed within the femur (i.e. femoral channel) and passing the other end of the graft through a passage formed in the tibia (i.e. tibial channel). The graft is then secured to the tibia adjacent to the tibial channel. Generally, sutures are used to affix each end of the tissue graft to a fastener (e. g. an interference screw or a post), which is then secured to the bone. Descriptions of these fasteners and methods of forming the passages through the tibia and femur are described in greater detail in the &#39;520 patent. 
         [0006]    Another approach for affixing a tissue graft is described in U.S. Pat. No. 5,306,301 (issued Apr. 26, 1994, known herein as “the &#39;301 patent”) and incorporated by reference. The &#39;301 patent discloses using a fixation button to secure a tissue graft at the femoral cortex. The fixation button has an elongated shape and at least one pair of openings through which a suture may be passed and then tied off. 
         [0007]    In this approach, the femoral channel has a portion having a first diameter sized to accommodate a bone block and a second portion having a smaller diameter through which the bone block cannot pass. By measuring the total length of the femoral channel and the length of the larger portion, the surgeon determines a “suture span” for attaching the fixation button to the tissue graft. 
         [0008]    The surgeon forms an opening in the bone block to be positioned in the femoral channel and threads an end of suture through it. The surgeon then ties the suture to the fixation button, providing the suture span between the button and the bone block. The fixation button and the tissue graft are then passed through the tibial and femoral channels until the graft is properly seated within the socket portion of the femoral passage and the fixation button is firmly seated against the femoral cortex. The tissue graft is then tensioned and anchored at its opposite end using a fixation screw secured within the tibia. 
         [0009]    Still another approach for affixing a tissue graft is described in U.S. Pat. No. 5,769,894 (issued Jun. 23, 1998, known herein as “the &#39;894 patent”) and incorporated by reference. The &#39;894 patent describes a graft fixation member configured to allow the length of the suture between the fixation member and the graft to be adjusted and to maintain the adjusted length when the suture is secured to the graft fixation member. 
         [0010]    An alternative to tying a suture to a fixation button is disclosed in PCT Application WO 99/47079 (published Sep. 23, 1999, known herein as “the &#39;079 application”) and incorporated by reference. The &#39;079 application discloses an apparatus and method for attaching a continuous loop of suture to a fixation button. Using a series of rollers, the continuous loop is formed from a strand of suture repeatedly coiling the suture through openings in a fixation button. In other examples, a continuous loop of suture may be formed without a fixation member. Continuous loops, both with and without fixation buttons attached, are available from Xiros Limited, Leeds, England, in several sizes. A surgeon selects the closest matching size for a given ACL reconstruction procedure. In other examples, a continuous loop of suture may be formed without a fixation member. 
       SUMMARY OF THE INVENTION 
       [0011]    In one aspect of the invention, a method for securing a tissue graft within a bone passage includes providing a graft fixation member comprising a closed double-loop having a pair of loop sections. The first one of the pair of loop sections is passed through an opening in the tissue graft and is secured to the fixation member through a knotting technique with the second one of the pair of loop sections and the graft fixation member. The knotting technique is achieved by passing the first of the pair through the second of the pair and positioned over the fixation member. The fixation member is pulled from the bone block to form the knot. 
         [0012]    One or more of the following features may also be included. The opening is formed in the tissue graft. The opening is formed in a bone block of the tissue graft. The opening is formed in a tendon of the tissue graft. The fixation member is passed through the bone passage. The fixation member is passed through a bone passage in a tibia and then through a bone passage in a femur. The fixation member is first passed through a bone passage in a femur and then through a bone passage in a tibia. The fixation member is positioned to pass through the bone passage using a suture. The fixation member is positioned to pass through the bone passage using closure tape. 
         [0013]    One or more openings pass through the intermediate portion of the member. The openings are cylindrical. The opening in each arm is cylindrical. The openings in each pair of arms occupy different positions on a common axis. The axis is transverse to the member. The pair of arms defines a cylindrical portion of the channel having a diameter equal to the width of the channel. Each pair of arms defines a cylindrical portion of the channel having a diameter greater than the width of the channel. The arms are shaped to pass through bone passage. The member is sized to pass through a bone passage. The member comprises a biocompatible material. The member comprises titanium. The member comprises a bioabsorbable material. 
         [0014]    Embodiments may have one or more of the following advantages. The closed double-loop evenly distributes the load when the loop is passed through a graft. The closed double-loop may be manufactured and purchased separate from the fixation member. This allows the surgeon the flexibility to choose the correctly sized closed double-loop from several sizes available in the operating room without a fixation member on each size loop. In turn, the patient benefits from the reliability of the closed double-loop without the added cost of multiple fixation members. The closed double-loop is positively captured within the fixation member during implantation. The closed double-loop provides superior strength over single loops of tied suture or tape and does not extend a patient&#39;s time under anesthesia while a surgeon forms multiple loops of suture or tape by hand. The closed double-loop may be pre-stressed during the manufacturing process to reduce its elasticity and increase its strength without accommodation for a fixation member. 
         [0015]    The details of one or more embodiments of the invention are set forth in the accompanying drawings and the description below. Other features, objects, and advantages of the invention will be apparent from the description and drawings. 
     
    
     
       BRIEF DESCRIPTION OF DRAWINGS 
         [0016]      FIG. 1  shows an example of a tissue graft being implanted during an ACL reconstruction procedure using the closed-loop suture and a graft fixation member. 
           [0017]      FIG. 2  is an example of the graft fixation member. 
           [0018]      FIG. 3  shows an exploded partial view of how a closed-loop suture could be inserted into tissue graft. 
           [0019]      FIG. 4  is an example of a graft-loop assembly before being attached to the graft fixation member. 
           [0020]      FIG. 5  shows an exploded partial view of a graft-loop assembly partially captured by the graft fixation member. 
           [0021]      FIG. 6  shows an exploded partial view of a graft-loop assembly fully captured by the graft fixation member. 
           [0022]      FIG. 7  shows the graft fixation member positioned for implantation. 
           [0023]      FIG. 8  shows the tissue graft implanted in a knee and secured at one end by the graft fixation member. 
           [0024]      FIG. 9  shows an alternative example of a graft fixation member. 
           [0025]      FIG. 10  shows a second alternative example of a graft fixation member. 
           [0026]      FIG. 11  shows a third alternative example of a graft fixation member. 
           [0027]      FIG. 12  shows a fourth alternative example of a graft fixation member and a method for capturing first and second portions of a closed-loop suture. 
           [0028]      FIG. 13  shows a fifth alternative example of a graft fixation member and a method of attaching it to a tissue graft using a closed-loop suture. 
           [0029]      FIG. 14  shows a sixth alternative example of a graft fixation member and method of attaching it to a tissue graft using a closed-loop suture. 
           [0030]      FIGS. 15-17  show an alternative method for attaching a graft fixation member to a tissue graft using a closed-loop suture. 
           [0031]      FIGS. 18A-18D  show a second alternative method for attaching a graft fixation member to a tissue graft using a closed-loop suture. 
           [0032]      FIG. 19  shows an alternative example of a closed-loop suture. 
           [0033]      FIG. 20  shows a third alternative method for attaching a graft fixation member to a tissue graft using a closed-loop suture. 
           [0034]      FIG. 21A  is an example of the closed double-loop captured in the graft fixation member having a pair of closed-loop sections. 
           [0035]      FIG. 21B  shows an exploded partial view of how the longer end of the closed double-loop suture could be inserted into the tissue graft. 
           [0036]      FIGS. 21C-21F  show a method of tying the knot to secure the graft fixation member and closed double-loop to the tissue graft. 
           [0037]      FIG. 21G  shows the graft fixation member positioned for implantation. 
           [0038]      FIG. 22  is an example of the closed double-loop captured in the graft fixation member having a pair of closed-loop sections. 
           [0039]      FIG. 23  is a second example of the closed double-loop captured in the graft fixation member having a pair of closed-loop sections. 
       
    
    
     DETAILED DESCRIPTION  
       [0040]    Referring to  FIG. 1 , a tissue graft  20  is shown being implanted within a knee  10  during an anterior cruciate ligament (ACL) repair and reconstruction procedure. In one example, tissue graft  20  has bone blocks on both ends sized and shaped to fit within femoral and tibial channels, respectively. More specifically, one end of tissue graft  20  includes a bone block  22  shaped and sized in substantial conformity with a femoral channel  14  of femur  12  while the other end of tissue graft  20  includes a bone block  24  shaped and sized in substantial conformity with tibial channel  16  of tibia  13 . In one example, a closed-loop suture  30  is inserted into bone block  24  and captured within graft fixation member  100 . Closed-loop suture  30  could be, but is not limited to, a Smith &amp; Nephew continuous loop made from polyester, a strand of suture tied in a loop, or a piece of polyester closure tape (e.g. Marselene™ from Ethicon Inc., Cincinnati, Ohio) tied in a loop. As will be described below, graft fixation member  100  is configured to facilitate positioning and securing the tissue graft  20 . 
         [0041]    Sutures  42  and  44  extend through fixation member  100  and are removably attached to passing pin  50  which is used to draw the sutures  42 ,  44  through the tibial channel  16 , femoral channel  14 , and passing channel  18 . As described below, sutures  42 ,  44  are used to pull graft fixation member  100  through passing channel  18  and position tissue graft  20  within femoral channel  14  and tibial channel  16 . 
         [0042]    In one example, shown in  FIG. 2 , graft fixation member  100  has an elongated body  102  formed of biocompatible material (e.g. titanium or acetal) or a bioabsorbable material (e.g. polylactic acid, polyglycolic acid) with a length of about 0.45 inches, a width of about 0.16 inches, and a thickness of about 0.1 inches. Body  102  has a width allowing fixation member  100  to be pulled through tibial channel  16 , femoral channel  14 , and passing channel  18 . 
         [0043]    Body  102  includes an intermediate portion  104  having a length (L), which defines the distance between a pair of channels  108 A,  108 B at opposing ends body  102 , described below. In one example, length (L) of intermediate portion  104  is about 0.05 inches. Intermediate portion  104  supports closed-loop suture  30  during implantation and bears the tension of closed-loop suture  30  after tissue graft  20  has been implanted. 
         [0044]    Pairs of arms  106 A and  106 B extend from intermediate portion  104 . Arms  106  have rounded edges  105  along their length and rounded ends  107 . In one example, rounded edges  105  have a radius of about 0.015 inches and rounded ends  107  have a radius of about 0.067 inches. Rounded edges  105  allow fixation member  100  to be more easily pulled through tibial channel  16 , femoral channel  14 , and passing channel  18 . 
         [0045]    Channels  108 A and  108 B are formed by pairs of arms  106 A and  106 B, respectively. Channels  108 A and  108 B are open at end portions  110 A and  110 B of elongated body  102  and have cylindrical closed portions  112 A and  112 B formed by intermediate portion  104  and pairs of arms  106 A and  106 B, respectively. For example, cylindrical closed portions  112 A and  112 B could have a diameter of about 0.05 inches and channels  108  and  108 B could have a corresponding width of about 0.05 inches. Open end portions  110 A and  110 B of channels  108 A and  108 B allow closed-loop suture  30  to pass into channels  108 A and  108 B as described below. 
         [0046]    In this particular embodiment, each arm  106  has an opening  118  located toward the end of and extending through arm  106 . Openings  118  are cylindrical and have a diameter of about 0.04 inches. Openings  118  in pair of arms  106 A are disposed on a common axis  119 A, which is transverse to the length of elongated member  102 . Openings  118  in pair of arms  106 B are disposed on a common axis  119 B, which is also transverse to the length of elongated member  102 . In other examples, openings  118  could be skewed in relation to each other or disposed at different positions along arms  106 . 
         [0047]    Referring to  FIGS. 3-7 , an example of a procedure for attaching graft fixation member  100  to tissue graft  20  follows. Referring to  FIGS. 3 and 4 , opening  28  is formed, for example, by drilling through bone block  22 . A surgeon chooses a closed-loop suture  30  from closed-loops of several lengths to best position the tissue graft  20  within femoral channel  14  and tibial channel  16  ( FIG. 1 ). The surgeon inserts suture grabber  52  into opening  28  until the end  54  of device  52  extends from bone block  22  and positions closed-loop suture  30  with suture grabber  52  and pulls both back through opening  28  in direction  62 , forming a first bight  32  and a second bight  34  of about the same size on either side of bone block  22 . Alternatively, a length of suture (not shown) could be used to pull closed-loop suture  30  into opening  28 . One end of the suture could be passed through opening  28 , through closed-loop suture  30 , and back through opening  28 . Closed-loop  30  may then be positioned in opening  28  by pulling both ends of the strand of suture. 
         [0048]    Referring to  FIGS. 5 and 6 , bight  32  is positioned around graft fixation member  100  and into channels  108 A,  108 B so that the continuous loop of suture  30  is wrapped around intermediate portion  104  of graft fixation member  100 . Bight  34  of continuous loop suture  30  is then similarly positioned around graft fixation member  100  and into channels  108  so that the continuous loop of suture  30  wraps around intermediate member  104  of graft fixation member  100 . Both bights  32 ,  34  are wrapped around intermediate member  104  so that the closed-loop suture  30  does not interfere with the positioning of strands of suture  42  into openings  118 . 
         [0049]    Lengths of suture  42  and  44 , shown in  FIG. 6 , are chosen to capture closed-loop suture  30  within graft fixation member  100  during the ACL reconstruction described below. In one example, lengths of polyester closure tape could be used instead of sutures  42 ,  44 . End  43  of suture  42  is passed through opening  118  ( FIG. 2 ) in either arm  106  of pair of arms  106 A and over closed-loop suture  30 . End  43  is then passed through opening  118  in the corresponding arm  106  of pair of arms  106 A thereby capturing closed-loop suture  30  within graft fixation member  100 . It is important that suture  42  passes over, and not under, closed-loop suture  30 . Allowing suture  42  to pass under closed-loop  30  would not capture closed-loop  30  within graft fixation member  100 . Similarly, end  45  of suture  44  is passed through opening  118  in either arm  106  of pair of arms  106 B and over closed-loop suture  30 . End  45  is then passed through opening  118  in the capturing closed-loop suture  30 . As was the case with suture  42 , passing suture  44  under closed-loop  30  does not capture closed-loop  30  within graft fixation member  100 . In this manner, closed-loop suture  30  is captured twice within fixation member  100 . 
         [0050]    Referring to  FIG. 7 , pulling to sutures  42  and  44  removes slack from closed-loop suture  30  and positions graft fixation member  100  to pass through tibial channel  16 , femoral channel  14 , and passing channel  18  ( FIG. 2 ). 
         [0051]    An example of a procedure for placing graft fixation member  100  in the position shown in  FIG. 8  follows with reference to  FIG. 1 . Drilling procedures are performed to provide the appropriately sized tibial channel  16  extending through tibia  13  and femoral passage  14  in the manner described in the &#39;301 patent. Sutures  42  and  44  are removably attached to passing pin  50 . Passing pin  50  ( FIG. 1 ) is then inserted through an incision below the knee and advanced through tibial channel  16 , femoral channel  14 , passing channel  18 , the quadriceps tissue, and skin  11  of the thigh. Ends of sutures  42  and  44  are withdrawn beyond the skin  11  using passing pin  50 . 
         [0052]    The surgeon then pulls graft fixation member  100  by pulling suture  42  through tibial channel  16 , femoral channel  14 , and passing channel  18  to position graft fixation member  100 . It is important that the surgeon keep closed-loop suture  30  captured within channel  108 B by taking up any slack in suture  44  while advancing graft fixation member  100  through passing channel  18  with suture  42 . However, the surgeon must be careful not to apply too much tension on suture  44  in relation to the tension on suture  42  or graft fixation member  100  will wedge within tibial channel  16 , femoral channel  14 , or passing channel  18 . Once fixation member  100  has been pulled through passing channel  18 , the surgeon positions fixation member  100  transversely to passing channel  18  and across opening  19 . Fixation member  100  is secured against femur  12  by attaching tissue graft  20  to tibia  13  and tensioning tissue graft  20  and closed-loop suture  30  according to methods described in the &#39;301 patent. 
         [0053]    Other embodiments are within the scope of the claims. 
         [0054]    For example, referring to  FIG. 9 , cylindrical portions  112 A and  112 B of graft fixation member  130  may have a diameter that is larger than the width of channels  108 A and  108 B, respectively. In one example, portions  112 A,  112 B have a diameter of about 0.078 inches and channels  108 A,  108 B have a width of about 0.05 inches. As the diameter of portions  112 A and  112 B increases, graft fixation member  100  can accommodate a thicker closed-loop suture (i.e. having an increased number of windings). The width of channels  108 A and  108 B do not constrain the use of thicker closed-loop sutures because a closed-loop suture may be flattened to pass through channels  108 A and  108 B. 
         [0055]    Referring to  FIGS. 10 and 11 , intermediate portion  152  of fixation member  150  has a length (L) and defines openings  154 ,  156  extending through intermediate portion  152 . In the example shown in  FIG. 10 , intermediate portion has a length of about 0.268 inches and openings  154 ,  156  are about 0.078 inches in diameter. In the example shown in  FIG. 11 , intermediate portion has a length of about 0.232 inches and openings  154 ,  156  are about 0.06 inches in diameter. A closed-loop suture  30  may be attached to fixation member  150  using the method described in the &#39;079 application. Alternatively a first and second end of a length of suture or closure tape may be threaded through openings  154 ,  156 , respectively, and tied together. Increasing length L adds material to intermediate portion  152  and increases the strength of graft fixation member  150 . 
         [0056]    Referring to  FIG. 12 , fixation member  200  has only one pair of arms  206  extending from intermediate portion  204  and forming a single channel  208  at end  210 . Arms  206  include cylindrical openings for capturing closed-loop suture  30  and positioning fixation member  200 . End  212  is closed and rounded to facilitate passing fixation member  200  through bone passages during the positioning and attachment of tissue graft  20 . End  212  may include opening  222  through which a strand of suture may be threaded to improve a surgeon&#39;s ability to position fixation member  200  during an ACL reconstruction procedure. 
         [0057]    Closed-loop suture  30  is captured in fixation member  200  by positioning arms  206  through bights  32 ,  34  and threading suture  42  (not shown) through a first opening  218 , over bights  32 ,  34 , and through the second opening  218 . In one example, bight  32  is positioned on a first arm  206  and bight  34  is positioned on a second arm  206 . In another example, bights  32 ,  34  could be positioned on the same arm. 
         [0058]    Referring to  FIG. 13 , fixation member  300  includes openings  304 ,  308 , an intermediate portion  302  and a pair of arms  306  with an opening  318  through each arm. Closed-loop suture  30  is formed in openings  304 ,  308  according to the method described in the &#39;079 application. Alternatively, a piece of suture or closure tape could be tied into a loop passing through openings  304 ,  308  as described above. After forming bight  32  by passing closed-loop suture  30  into opening  28  in bone block  22 , closed-loop suture  30  is captured by fixation member  300  by positioning either arm  306  through bight  32  and threading a strand of suture (not shown) through openings  318 , as described above. 
         [0059]    Referring to  FIG. 14 , fixation member  400  is similar in size to fixation member  100 , described above, and has a four opening configuration described in the &#39;301 and &#39;894 patents. Closed-loop suture  30  has been formed in openings  404 ,  408  of fixation member  400  according to the method set forth in the &#39;079 patent, thereby capturing a first portion of closed-loop suture  30 . 
         [0060]    Tissue graft  20  is attached to fixation member  400  by passing closed-loop suture  30  into opening  28 , thereby forming bight  32 , and capturing a second portion of closed-loop suture  30  with fixation member  400 . In the example of  FIG. 14 , bight  32  is inserted into opening  404  at bottom side of member  400  and out of opening  404  at top side  412  until bight  332  can extend past end  414  of fixation member  400 . End  414  is passed through bight  32 . Bight  32  is pulled in direction  62  until bight  32  tightens around fixation member  400 , thereby capturing a second portion of closed-loop suture  30 . In another example, end  416  could be passed through bight  32  instead of end  414 . 
         [0061]    Referring to  FIGS. 15-17 , another method by which tissue graft  20  could be attached to fixation member  400  follows. Closed-loop suture  30  has been formed around intermediate portion  402  of fixation member  400  according to the method described in the &#39;079 application and a portion of closed-loop suture  30  is passed into opening  28 , as described above, to form bights  32 ,  34 . Bight  32  is passed through bight  34  on top side  412  of fixation member  400 ; about 1 inch of closed-loop suture  30  has been pulled through bight  34 . Bight  32  is then opened to form bights  36 ,  38 ; end  414  is then passed through bight  36 , and bight  28  is passed through end  416 . Closed-loop suture  30  is tensioned in direction  57 , removing slack from closed-loop suture  30  and attaching it to fixation member  400 . 
         [0062]    Referring to  FIGS. 18A-D , tissue graft  20  could be attached to fixation member  400  by capturing closed-loop suture  30  only once at fixation member  400 . For example, closed-loop  30  is passed through opening  28  (not shown) in bone block  22  to form bight  32  ( FIG. 18A ). Fixation member  400  is then passed through bight  32  ( FIG. 18B ) and pulled in direction  66 , away from tissue graft  20 , thereby causing bight  32  to tighten around bone block  22 , as best seen in  FIG. 18C . In another embodiment, opening  28  is formed along the length of block  22  ( FIG. 18D ) instead of transversely, as shown in examples above. Fixation member  400  is attached to tissue graft  20  in the same manner as described above despite the longitudinal orientation of opening  28 . 
         [0063]    Referring to  FIG. 19 , closed-loop suture  70  is a suture  72  having opposing ends  73  and  74 . In one example, suture  72  could have a total length of about 1.5 inches. End  73  includes a loop  75 , and end  74  includes a loop  76 . Loops  75 ,  76  have a length of about 0.3 inches or less. 
         [0064]    Referring to  FIG. 20 , a closed-loop suture  230  is formed in more than one fixation member  400 . In one example, closed-loop suture  230  is formed in fixation member  400 A and  400 B. When closed-loop suture  230  is formed by the method disclosed in the &#39;079 application, opening  28  (not shown) in bone block  22  is sized to permit fixation member  400  to pass through opening  28 . When closed-loop suture  230  is formed by tying a length of suture or closure tape, opening  28  need only be sized to accommodate the suture or tape. During implantation, a surgeon could use sutures (e.g. suture  42 ,  44 ) to pass fixation members  400 A,  400 B through passing channel  18  at the same time or pass them individually. 
         [0065]    Tissue graft may also include a closed-double loop formed of the same suture described above. Referring to  FIG. 21A , fixation member  100  has a four opening configuration as described  FIG. 14 . In this embodiment, the closed-loop is a continuous loop  230  passed twice through openings  104 ,  108  forming two differently sized loop ends  32 ,  34 . Loop  230  is captured in fixation member  100 . An advantage of a continuous closed-loop is the even distribution of the load when the loop is passed through the graft. 
         [0066]    Referring to  FIG. 21B , continuous loop  230  is attached to bone block  22 , for example, by drilling an opening  28  through bone block  22 . A surgeon chooses an appropriate closed-loop suture  230  (with fixation member  100 ) from closed-loops of several lengths to best position the tissue graft  20  within femoral channel  14  and tibial channel  16  ( FIG. 1 ). The surgeon inserts suture grabber  52  into opening  28  until the end  54  of device  52  extends from bone block  22  and closed-loop suture end  34  is then positioned next to bone block  22 . The surgeon grabs closed-loop suture end  34  with suture grabber  52  and pulls both through opening  28  in direction  55 , leaving loop end  34  on one side of bone block  22 . Graft fixation member  100  and loop end  32  are on the other side of bone block  22  as shown in  FIG. 21C . 
         [0067]    Alternatively, a length of suture (not shown) could be used instead of a suture grabber to pull closed-loop suture end  34  into opening  28 . One end of the suture could be passed through opening  28 , through closed-loop suture  230 , and back through opening  28 . Closed-loop  230  may then be positioned in opening  28  by pulling both ends of the strand of suture. 
         [0068]    In  FIG. 21D , loop end  34  is passed under loop end  32  and pulled above graft fixation member  100 . In  FIG. 21E , loop end  34  is opened sufficiently wide to pass over graft fixation member  100 . In  FIG. 21F , graft fixation member  100  is pulled tight from bone block  22 , causing a knot to form in closed-loop  30 , thereby capturing the bone block  22  with the closed-loop  230  and graft fixation member  100 . The small section of the closed-loop dictates where the knot lies with the knot preferably positioned close to the graft fixation member. 
         [0069]    Lengths of suture  42  and  44  are passed through respective holes  116 ,  112  of fixation member  100 . Sutures  42 ,  44  are used to position graft fixation member  100  during the ACL reconstruction described below. In one example, lengths of polyester closure tape could be used instead of sutures  42 ,  44 . End  43  of suture  42  is passed through opening  116 . End  45  of suture  44  is passed though opening  112 . 
         [0070]    Referring to  FIG. 21G , pulling sutures  42  and  44  removes slack from closed-loop suture  30  and places graft fixation member  100  and loop  230  in a position for passing through tibial channel  16 , femoral channel  14 , and passing channel  18  ( FIG. 1 ). 
         [0071]    As discussed above in conjunction with  FIG. 8 , the surgeon then pulls graft fixation member  100  by pulling suture  42  through tibial channel  16 , femoral channel  14 , and passing channel  18  to position graft fixation member  100 . 
         [0072]    Once fixation member  100  has been pulled through passing channel  18 , the surgeon positions fixation member  100  transversely to passing channel  18  and across opening  19 . Fixation member  100  is secured against femur  12  by attaching tissue graft  20  to tibia  13  and tensioning tissue graft  20  and closed-loop suture  30  according to methods described in the &#39;301 patent. 
         [0073]    Alternative embodiments of the invention include those shown in  FIGS. 22 and 23 . In  FIG. 22 , loop end  72  of closed-loop  230  is passed through opening  104 , then passed though opening  108 . The loop is not captured, but is held to fixation member  100 . In  FIG. 23 , two differently sized closed-loops  230 ,  70  are formed in openings  104 ,  108  of fixation member  100  according to the method set forth in the &#39;079 patent. Both closed-loops are captured in fixation member  100 . Loop ends  34 ,  72  are used in the method of fixation through knotting in the same manner as loop ends  34 ,  32  are for the devices described in  FIG. 21 . 
         [0074]    Other embodiments include an alternative approach for securing a tissue graft within a bone passage using fixation member  100 . Specifically, the fixation member  100  and tissue graft  20  could be pulled first through a femoral channel and then through a tibial channel. 
         [0075]    Although the tissue graft described above has at least one bone block, other types of grafts may be attached to graft fixation member including ligament augmentation devices (LAD) formed of artificial ligament material to which the tissue is sutured. 
         [0076]    In general, the knot tying method using graft fixation member  100  in combination with closed double-loop  30  can be used to secure any suitable kinds of grafts, such as allografts, autografts, and xenografts, and can be used in surgical soft tissue reconstruction procedures other than those related to ACL reconstruction. 
         [0077]    Accordingly, other embodiments are within the scope of the following claims.