Patent Description:
This invention relates to surgical methods and apparatus in general, and more particularly to surgical methods and apparatus for treating a hip joint.

The hip joint is a ball-and-socket joint which movably connects the leg to the torso. The hip joint is capable of a wide range of different motions, e.g., flexion and extension, abduction and adduction, medial and lateral rotation, etc. See <FIG>. With the possible exception of the shoulder joint, the hip joint is perhaps the most mobile joint in the body. Significantly, and unlike the shoulder joint, the hip joint carries substantial weight loads during most of the day, in both static (e.g., standing and sitting) and dynamic (e.g., walking and running) conditions.

The hip joint is susceptible to a number of different pathologies. These pathologies can have both congenital and injury-related origins. In some cases, the pathology can be substantial at the outset. In other cases, the pathology may be minor at the outset but, if left untreated, may worsen over time. More particularly, in many cases, an existing pathology may be exacerbated by the dynamic nature of the hip joint and the substantial weight loads imposed on the hip joint.

The pathology may, either initially or thereafter, significantly interfere with patient comfort and lifestyle. In some cases, the pathology can be so severe as to require partial or total hip replacement. A number of procedures have been developed for treating hip pathologies short of partial or total hip replacement, but these procedures are generally limited in scope due to the significant difficulties associated with treating the hip joint.

A better understanding of various hip joint pathologies, and also the current limitations associated with their treatment, can be gained from a more thorough understanding of the anatomy of the hip joint.

The hip joint is formed at the junction of the leg and the torso. More particularly, and looking now at <FIG>, the head of the femur is received in the acetabular cup of the hip, with a plurality of ligaments and other soft tissue serving to hold the bones in articulating condition.

More particularly, and looking now at <FIG>, the femur is generally characterized by an elongated body terminating, at its top end, in an angled neck which supports a hemispherical head (also sometimes referred to as "the ball"). As seen in <FIG> and <FIG>, a large projection known as the greater trochanter protrudes laterally and posteriorly from the elongated body adjacent to the neck of the femur. A second, somewhat smaller projection known as the lesser trochanter protrudes medially and posteriorly from the elongated body adjacent to the neck. An intertrochanteric crest (<FIG> and <FIG>) extends along the periphery of the femur, between the greater trochanter and the lesser trochanter.

Looking next at <FIG>, the hip socket is made up of three constituent bones: the ilium, the ischium and the pubis. These three bones cooperate with one another (they typically ossify into a single "hip bone" structure by the age of <NUM> or so) in order to collectively form the acetabular cup. The acetabular cup receives the head of the femur.

Both the head of the femur and the acetabular cup are covered with a layer of articular cartilage which protects the underlying bone and facilitates motion.

Various ligaments and soft tissue serve to hold the ball of the femur in place within the acetabular cup. More particularly, and looking now at <FIG> and <FIG>, the ligamentum teres extends between the ball of the femur and the base of the acetabular cup. As seen in <FIG> and <FIG>, a labrum is disposed about the perimeter of the acetabular cup. The labrum serves to increase the depth of the acetabular cup and effectively establishes a suction seal between the ball of the femur and the rim of the acetabular cup, thereby helping to hold the head of the femur in the acetabular cup. In addition to the foregoing, and looking now at <FIG>, a fibrous capsule extends between the neck of the femur and the rim of the acetabular cup, effectively sealing off the ball-and-socket members of the hip joint from the remainder of the body. The foregoing structures (i.e., the ligamentum teres, the labrum and the fibrous capsule) are encompassed and reinforced by a set of three main ligaments (i.e., the iliofemoral ligament, the ischiofemoral ligament and the pubofemoral ligament) which extend between the femur and the perimeter of the hip socket. See, for example, <FIG> and <FIG>, which show the iliofemoral ligament, with <FIG> being an anterior view and <FIG> being a posterior view.

As noted above, the hip joint is susceptible to a number of different pathologies. These pathologies can have both congenital and injury-related origins.

By way of example but not limitation, one important type of congenital pathology of the hip joint involves impingement between the neck of the femur and the rim of the acetabular cup. In some cases, and looking now at <FIG>, this impingement can occur due to irregularities in the geometry of the femur. This type of impingement is sometimes referred to as cam-type femoroacetabular impingement (i.e., cam-type FAI). In other cases, and looking now at <FIG>, the impingement can occur due to irregularities in the geometry of the acetabular cup. This latter type of impingement is sometimes referred to as pincer-type femoroacetabular impingement (i.e., pincer-type FAI). Impingement can result in a reduced range of motion, substantial pain and, in some cases, significant deterioration of the hip joint.

By way of further example but not limitation, another important type of congenital pathology of the hip joint involves defects in the articular surface of the ball and/or the articular surface of the acetabular cup. Defects of this type sometimes start out fairly small but often increase in size over time, generally due to the dynamic nature of the hip joint and also due to the weight-bearing nature of the hip joint. Articular defects can result in substantial pain, induce and/or exacerbate arthritic conditions and, in some cases, cause significant deterioration of the hip joint.

By way of further example but not limitation, one important type of injury-related pathology of the hip joint involves trauma to the labrum. More particularly, in many cases, an accident or sports-related injury can result in the labrum being torn away from the rim of the acetabular cup, typically with a tear running through the body of the labrum. These types of injuries can be very painful for the patient and, if left untreated, can lead to substantial deterioration of the hip joint.

The current trend in orthopedic surgery is to treat joint pathologies using minimally-invasive techniques. Such minimally-invasive, "keyhole" surgeries generally offer numerous advantages over traditional, "open" surgeries, including reduced trauma to tissue, less pain for the patient, faster recuperation times, etc..

By way of example but not limitation, it is common to re-attach ligaments in the shoulder joint using minimally-invasive, "keyhole" techniques which do not require large incisions into the interior of the shoulder joint. By way of further example but not limitation, it is common to repair torn meniscal cartilage in the knee joint, and/or to replace ruptured ACL ligaments in the knee joint, using minimally-invasive techniques.

While such minimally-invasive approaches can require additional training on the part of the surgeon, such procedures generally offer substantial advantages for the patient and have now become the standard of care for many shoulder joint and knee joint pathologies.

In addition to the foregoing, in view of the inherent advantages and widespread availability of minimally-invasive approaches for treating pathologies of the shoulder joint and knee joint, the current trend is to provide such treatment much earlier in the lifecycle of the pathology, so as to address patient pain as soon as possible and so as to minimize any exacerbation of the pathology itself. This is in marked contrast to traditional surgical practices, which have generally dictated postponing surgical procedures as long as possible so as to spare the patient from the substantial trauma generally associated with invasive surgery.

Unfortunately, minimally-invasive treatments for pathologies of the hip joint have lagged far behind minimally-invasive treatments for pathologies of the shoulder joint and the knee joint. This is generally due to (i) the constrained geometry of the hip joint itself, and (ii) the nature and location of the pathologies which must typically be addressed in the hip joint.

More particularly, the hip joint is generally considered to be a "tight" joint, in the sense that there is relatively little room to maneuver within the confines of the joint itself. This is in marked contrast to the shoulder joint and the knee joint, which are generally considered to be relatively "spacious" joints (at least when compared to the hip joint). As a result, it is relatively difficult for surgeons to perform minimally-invasive procedures on the hip joint.

Furthermore, the pathways for entering the interior of the hip joint (i.e., the natural pathways which exist between adjacent bones and/or delicate neurovascular structures) are generally much more constraining for the hip joint than for the shoulder joint or the knee joint. This limited access further complicates effectively performing minimally-invasive procedures on the hip joint.

In addition to the foregoing, the nature and location of the pathologies of the hip joint also complicate performing minimally-invasive procedures on the hip joint. By way of example but not limitation, consider a typical detachment of the labrum in the hip joint. In this situation, instruments must generally be introduced into the joint space using an angle of approach which is offset from the angle at which the instrument addresses the tissue. This makes drilling into bone, for example, significantly more complicated than where the angle of approach is effectively aligned with the angle at which the instrument addresses the tissue, such as is frequently the case in the shoulder joint. Furthermore, the working space within the hip joint is typically extremely limited, further complicating repairs where the angle of approach is not aligned with the angle at which the instrument addresses the tissue.

As a result of the foregoing, minimally-invasive hip joint procedures are still relatively difficult to perform and relatively uncommon in practice. Consequently, patients are typically forced to manage their hip pain for as long as possible, until a resurfacing procedure or a partial or total hip replacement procedure can no longer be avoided. These procedures are generally then performed as a highly-invasive, open procedure, with all of the disadvantages associated with highly-invasive, open procedures.

As a result, there is, in general, a pressing need for improved methods and apparatus for treating pathologies of the hip joint.

As noted above, hip arthroscopy is becoming increasingly more common in the diagnosis and treatment of various hip pathologies. However, due to the anatomy of the hip joint and the pathologies associated with the same, hip arthroscopy is currently practical for only selected pathologies and, even then, hip arthroscopy has generally met with limited success.

One procedure which is sometimes attempted arthroscopically relates to the repair of a torn and/or detached labrum. This procedure may be attempted (i) when the labrum has been damaged but is still sufficiently healthy and intact as to be capable of repair and/or re-attachment, and (ii) when the labrum has been deliberately detached (e.g., so as to allow for acetabular rim trimming to treat a pathology such as a pincer-type FAI) and needs to be subsequently re-attached. See, for example, <FIG>, which shows a normal labrum which has its base securely attached to the acetabulum, and <FIG>, which shows a portion of the labrum (in this case the tip) detached from the acetabulum. In this respect it should also be appreciated that repairing the labrum rather than removing the labrum is generally desirable, inasmuch as studies have shown that patients whose labrum has been repaired tend to have better long-term outcomes than patients whose labrum has been removed.

Unfortunately, current methods and apparatus for arthroscopically repairing (e.g., re-attaching) the labrum are somewhat problematic. The present invention is intended to improve upon the current approaches for labrum repair.

More particularly, current approaches for arthroscopically repairing the labrum typically use apparatus originally designed for use in re-attaching ligaments to bone. For example, one such approach utilizes a screw-type bone anchor, with two sutures extending therefrom, and involves deploying the bone anchor in the acetabulum above the labrum re-attachment site. A first one of the sutures is passed either through the detached labrum or, alternatively, around the detached labrum. Then the first suture is tied to the second suture so as to support the labrum against the acetabular rim.

Unfortunately, bone anchors of the sort described above are traditionally used for re-attaching ligaments to bone and, as a result, tend to be relatively large, since they must carry the substantial pull-out forces normally associated with ligament reconstruction. However, this large anchor size is generally unnecessary for labrum re-attachment, since the labrum is not subjected to substantial pull-out forces, and the large anchor size typically causes unnecessary trauma to the patient.

Furthermore, the large size of traditional bone anchors can be problematic when the anchors are used for labrum re-attachment, since the bone anchors generally require a substantial bone mass for secure anchoring, and such a large bone mass is generally available only a substantial distance up the acetabular shelf. In addition, the large size of the bone anchors generally makes it necessary to set the bone anchor a substantial distance up the acetabular shelf, in order to ensure that the distal tip of the bone anchor does not inadvertently break through the acetabular shelf and contact the articulating surfaces of the joint. However, labral re-attachment utilizing a bone anchor set high up into the acetabular shelf creates a suture path, and hence a labral draw force, which is not directly aligned with the portion of the acetabular rim where the labrum is to be re-attached. As a result, an "indirect" draw force (also known as eversion) is typically applied to the labrum, i.e., the labrum is drawn around the rim of the acetabulum rather than directly into the acetabulum. This can sometimes result in a problematic labral re-attachment and, ultimately, can lead to a loss of the suction seal between the labrum and femoral head, which is a desired outcome of the labral re-attachment procedure.

Alternatively, the suture path can also surround the labrum, thus placing a suture on both sides of the labrum, including the articular side of the labrum, and thus exposing the articular surface of the femur to a foreign body, which could in turn cause damage to the articular surface (i.e., the articular cartilage) of the femur.

Prior art documents <CIT> and <CIT> disclose apparatus comprising a bone anchor.

<CIT> discloses methods and devices for treating a tear, rent, incision, defect, aperture or delamination of the annulus fibrosus of an intervertebral disc. The methods and devices can employ fixation delivery apparatuses, fixation apparatuses, patch delivery tools and patches positioned, at least in part, in or on aspects of an intervertebral disc for treatment of the intervertebral disc or its components. In some aspects, these techniques include the use of this includes a fixation apparatus that includes at least one bone anchor connected to at least one disc anchor by a shortenable elongate member.

<CIT> discloses a system for suture anchor placement including an apparatus having a handle portion and an operating portion. The handle portion includes a spring, a needle park, and a member for releasably holding a length of the suture. The operating portion includes a sheath tube and a plunger rod slidably disposed within the bore of the sheath tube. The plunger rod is fixedly mounted at its proximal end to the handle. The suture anchor is releasably engaged to the distal end portion of the plunger rod. The sheath tube is mounted to the handle and movable with respect to the handle between a distal position and a proximal position, the sheath tube being resiliently biased to the distal position by the spring and movable to the proximal position in response to proximally directed force of sufficient magnitude applied to the distal end of the sheath tube. The sheath tube has a portion with an outer diameter greater than the diameter of the hole in the bone such that when the installation tool is pressed toward the bone, the sheath tube retracts into the handle and the suture anchor is advanced into a hole previously made in the bone. The suture, initially held in a taut configuration, is released in response to movement of the sheath tube to its proximal position.

Accordingly, a new approach is needed for arthroscopically re-attaching the labrum to the acetabulum.

The present invention provides a novel apparatus for re-attaching the labrum to the acetabulum. Among other things, the present invention comprises the provision and use of a novel suture anchor system.

According to the invention is provided an apparatus for securing an object to bone according to claim <NUM>. Further aspects are set out in the dependent claims. In particular, the apparatus comprises an expandable bone anchor for receipt in a hole formed in a bone, wherein the anchor comprises a passageway extending therethrough. The anchor further comprises an enlargement for expanding the anchor when the enlargement is moved through the passageway. The apparatus further comprises a solid shaft or a suture connected to the enlargement of the bone anchor for moving the enlargement through the passageway. The apparatus further comprises a force delivery mechanism constructed so as to receive an input force from an external source and to selectively apply an output force to the enlargement of the expandable bone anchor by tensioning the solid shaft or suture in order to expand the anchor.

In one form of the invention, there is provided an inserter for deploying an anchor assembly in bone, wherein the anchor assembly comprises an anchor and an actuation element extending from the anchor, and further wherein deploying the anchor assembly in bone comprises positioning the anchor assembly in a hole formed in the bone and applying a force to the actuation element so as to secure the anchor to the bone, the inserter comprising:.

The aforementioned inserter according to the invention may be further improved in that the force delivery mechanism is constructed so that the magnitude of the output force becomes substantially zero when the magnitude of the input force reaches a threshold level.

The aforementioned inserter according to the invention may be further improved in that the force delivery mechanism comprises an input element for receiving the input force from an external source, an output element for selectively applying the output force to the actuation element, and a connection element for transferring force from the input element to the output element as long as the magnitude of the input force is less than the threshold level.

The aforementioned inserter according to the invention may be further improved in that the input element comprises one from the group consisting of a finger pull, a rotary knob, a lever, a trigger and a pull tab.

The inserter according to the invention may be further improved in that the connection element comprises a releasable grip between the input element and the output element.

The aforementioned inserter according to the invention may be further improved in that the releasable grip comprises an outwardly biased element releasably retained in a recess.

The aforementioned inserter according to the invention may be further improved in that the connection element comprises a wishbone connection.

The aforementioned inserter according to the invention may be further improved in that the actuation element comprises a suture, the input element comprises a user interface element movably mounted to the shaft, and the output element comprises a suture cleat, wherein the wishbone connection comprises a recess formed in the user interface element and a wishbone releasably retained in the recess, the suture being mounted to the suture cleat so that movement of the user interface element applies an output force to the suture so long as the wishbone is releasably retained in the recess, and wherein the wishbone is releasably retained in the recess when the magnitude of the input force is less than the threshold level and wherein the wishbone is released from the recess when the magnitude of the input force reaches the threshold level.

The aforementioned inserter according to the invention may be further improved in that the wishbone comprises a pair of bifurcated arms which are biased apart.

The aforementioned inserter according to the invention may be further improved in that a spring is disposed between the pair of bifurcated arms so as to bias the arms apart.

The inserter according to the invention may be further improved in that the pair of bifurcated arms are formed out of resilient material.

The inserter according to the invention may be further improved in that the pair of bifurcated arms comprise outboard projections, the recess comprises inward narrowings, and further wherein the outboard projections engage the inward narrowings when the wishbone is engaged in the recess.

The inserter according to the invention may be further improved in that the suture cleat is secured to the wishbone.

The inserter according to the invention may be further improved in that the suture cleat is secured to the shaft, and further wherein a portion of the wishbone slidingly engages the suture so as to apply tension to the suture when an input force is applied to the input element and the magnitude of the input force is less than the threshold level.

The inserter according to the invention may be further improved in that the actuation element comprises a suture, the input element comprises a user interface element movably mounted to the shaft, and the output element comprises an axle selectively rotatable relative to the user interface element, the suture being secured to the axle and wound thereon, and further wherein the axle is rotatably fixed to the user interface element when the magnitude of the input force is less than the threshold level, and the axle is rotatable relative to the user interface element when the magnitude of the input force reaches the threshold level.

The aforementioned inserter according to the invention may be further improved in that the output element further comprises a keyed collar secured to the axle, wherein lateral movement of the keyed collar enables rotation of the axle, and further wherein lateral movement of the keyed collar occurs when the magnitude of the input force reaches the threshold level.

The inserter according to the invention may be further improved in that the releasable grip comprises at least one inwardly biased element for releasably engaging a recess.

The aforementioned inserter according to the invention may be further improved in that the actuation element comprises a suture, the input element comprises a user interface element movably mounted to the shaft, and the output element comprises a suture cleat and pair of grippers longitudinally and laterally movable relative to the user interface element, and further wherein the grippers connect the suture cleat to the user interface element when the magnitude of the input force is less than a threshold level, and the grippers do not connect the suture cleat to the user interface element when the magnitude of the input force reaches the threshold level.

The inserter according to the invention may be further improved in that the actuation element comprises a suture, wherein the input element comprises a user interface element movably mounted to the shaft and a cutting element mounted to the user interface element, and the output element comprises a body, the suture being secured to the body, and the body being biased away from the user interface element so as to keep the suture remote from the cutting element when the magnitude of the input force is less than the threshold level, and the body being drawn toward the user interface element when the magnitude of the input force reaches the threshold level, whereby the cutting element is brought into engagement with the suture so as to cut the suture and thereby release tension on the suture.

The aforementioned inserter according to the invention may be further improved in that the body comprises a plate movably mounted to the user interface element and biased away from the user interface element, and further wherein the suture is secured to the plate.

The aforementioned inserter according to the invention may be further improved in that the body comprises an axle rotatably mounted to the plate, and further wherein the suture is wound around the axle prior to being secured to the plate.

The inserter according to the invention may be further improved in that the body further comprises a sleeve mounted to the plate, and further wherein the suture is mounted to the sleeve.

The aforementioned inserter according to the invention may be further improved in that the suture extends across the lumen of the sleeve, and further wherein the cutting element is disposed within the lumen of the sleeve.

The inserter according to the invention may be further improved in that the force delivery mechanism comprises an input element for receiving the input force from an external source, an output element for selectively applying the output force to the actuation element, and further wherein the output element is configured to remain operative so as long as the magnitude of the input force is less than a threshold level.

The aforementioned inserter according to the invention may be further improved in that the output element comprises a suture, and further wherein the suture comprises a weakened section which is designed to fail when the magnitude of the input force is equal to a threshold level.

The inserter according to the invention may be further improved in that the output element comprises a hook, and further wherein the hook is designed to fail when the magnitude of the input force is equal to a threshold level.

The inserter according to the invention may be further improved in that the output element comprises a rod, and further wherein the rod is designed to fail when the magnitude of the input force is equal to a threshold level.

The inserter according to the invention may be further improved in that the force delivery mechanism comprises an input element for receiving the input force from an external source, an output element for selectively applying the output force to the actuation element, and further wherein at least one of the output element and the actuation element is configured to fail when the magnitude of the input force is equal to a threshold level.

In another form of the invention, there is provided apparatus for securing an object to bone, the apparatus comprising:.

The apparatus according to the invention may be further improved in that the anchor comprises a passageway extending therethrough, and further wherein the actuation element comprises an enlargement for expanding the anchor when the enlargement is moved through the passageway.

The apparatus according to the invention may be further improved in that the enlargement expands the anchor when the enlargement is moved proximally through the passageway.

The apparatus according to the invention may be further improved in that the enlargement expands the anchor when the enlargement is moved distally through the passageway.

The apparatus according to the invention may be further improved in that the actuation element further comprises a suture connected to the enlargement for moving the enlargement through the passageway.

There is provided a method for securing an object to bone, the method comprising:.

The method may further comprise using an element attached to the anchor to secure the object to the bone.

The aformentioned method may be further improved in that the element comprises a suture.

The method may be further improved in that the inserter is constructed so that the magnitude of the output force becomes substantially zero when the magnitude of the input force reaches a threshold level.

The aformentioned method may be further improved in that the inserter comprises a force delivery mechanism comprising an input element for receiving the input force from an external source, an output element for selectively applying the output force to the actuation element, and a connection element for transferring force from the input element to the output element as long as the magnitude of the input force is less than the threshold level.

The aformentioned method may be further improved in that the input element comprises one from the group consisting of a finger pull, a rotary knob, a lever, a trigger and a pull tab.

The method may be further improved in that the connection element comprises a releasable grip between the input element and the output element.

The aformentioned method may be further improved in that the releasable grip comprises an outwardly biased element releasably retained in a recess.

In another form there is provided a method for securing an object to bone, the method comprising:.

The aforementionde method may further comprise using an element attached to the anchor to secure the object to the bone.

These and other objects and features of the present invention will be more fully disclosed or rendered obvious by the following detailed description of the preferred embodiments of the invention, which is to be considered together with the accompanying drawings wherein like numbers refer to like parts, and further wherein:.

The present invention provides a novel apparatus for arthroscopically re-attaching the labrum to the acetabulum. Among other things, the present invention comprises the provision of a novel suture anchor system.

More particularly, and looking now at <FIG>, there is shown a novel suture anchor system <NUM> for use in arthroscopically re-attaching a detached labrum to the acetabulum. Suture anchor system <NUM> generally comprises an anchor <NUM>, a suture <NUM> secured to anchor <NUM>, and an inserter <NUM> for delivering anchor <NUM> into the acetabulum, whereby suture <NUM> may be used to secure a detached labrum to the acetabular rim as will hereinafter be discussed in further detail. Suture anchor system <NUM> preferably also comprises a hollow guide <NUM> for delivering components from outside of the body to the acetabulum, and a punch (or drill) <NUM> which may be used to prepare a seat for anchor <NUM> in the acetabulum.

Looking next at <FIG>, anchor <NUM> comprises a generally cylindrical body <NUM> having a distal end <NUM>, a proximal end <NUM>, and a passageway forming a lumen <NUM> extending between distal end <NUM> and proximal end <NUM>. In one preferred form of the present invention, lumen <NUM> comprises a distal end reservoir <NUM>, a short intermediate portion <NUM>, and an elongated proximal portion <NUM>. As seen in <FIG>, distal end reservoir <NUM> has a diameter which is greater than the diameter of short intermediate portion <NUM>, and short intermediate portion <NUM> has a diameter which is greater than the diameter of elongated proximal portion <NUM>. And in one preferred form of the present invention, the outer surface of generally cylindrical body <NUM> comprises a plurality of ribs <NUM> spaced along the length of generally cylindrical body <NUM>, so as to enhance the "holding power" of anchor <NUM> in bone. In one particularly preferred form of the present invention, ribs <NUM> sub-divide the length of generally cylindrical body <NUM> into a plurality of segments, with each segment having a generally frusto-conical configuration (<FIG>).

Near (but spaced from) the distal end <NUM> of generally cylindrical body <NUM>, there is provided a longitudinally-extending slit <NUM> which extends completely through one side wall (but not the other) of generally cylindrical body <NUM>. Thus, longitudinally-extending slit <NUM> communicates with lumen <NUM> of anchor <NUM>. The distal end of longitudinally-extending slit <NUM> terminates in a distal relief hole <NUM>, and the proximal end of longitudinally-extending slit <NUM> terminates in a proximal relief hole <NUM>. It will be appreciated that distal relief hole <NUM> is spaced from distal end <NUM> of generally cylindrical body <NUM>, so that a solid distal ring <NUM> is located at the distal end of generally cylindrical body <NUM>, whereby to provide the distal end of generally cylindrical body <NUM> with a degree of structural integrity.

Looking now at <FIG> and <FIG>, suture <NUM> generally comprises a distal loop <NUM> terminating in an enlargement <NUM> at its distal end and connected to a proximal open loop <NUM> at its proximal end. More particularly, distal loop <NUM> extends through short intermediate portion <NUM> and elongated proximal portion <NUM> of lumen <NUM>. Enlargement <NUM> may comprise a solid member (e.g., cylindrical, conical, etc.) attached to the distal end of distal loop <NUM>, or it may comprise a suture knot formed by knotting off the distal ends of distal loop <NUM> of suture <NUM>, etc. Where enlargement <NUM> comprises a suture knot, this suture knot may or may not be hardened, shaped or stabilized with cement, heat, etc. For purposes of illustration, enlargement <NUM> is shown in the drawings schematically, i.e., as a generally cylindrical structure, but it should be appreciated that this is being done solely for clarity of illustration, and enlargement <NUM> may assume any other shapes and/or configurations (including that of a suture knot) consistent with the present invention. Enlargement <NUM> is sized so that it is small enough to be seated in distal end reservoir <NUM> of generally cylindrical body <NUM> (see, for example, <FIG>), but large enough so that it may not enter short intermediate portion <NUM> of generally cylindrical body <NUM> without causing radial expansion of generally cylindrical body <NUM> (see, for example, <FIG>). Proximal open loop <NUM> extends back through the interior of inserter <NUM> (<FIG>) and provides a pair of free suture ends emanating from the proximal end of inserter <NUM> (<FIG>), as will hereinafter be discussed.

Looking now at <FIG>, inserter <NUM> generally comprises a shaft in the form of a hollow push tube <NUM> having a lumen <NUM> extending therethrough. Inserter <NUM> terminates at its distal end in a drive surface <NUM> for engaging the proximal end <NUM> of anchor <NUM>, and terminates at its proximal end in a handle <NUM>. Handle <NUM> may include features to secure the free ends of suture <NUM>, e.g., one or more suture cleats, suture slots, suture clamps, etc. Where such features are provided, and where appropriate, handle <NUM> may also include one or more release mechanisms to release the free ends of suture <NUM>. Handle <NUM> may also have one or more mechanisms to apply tension to the secured free ends of suture <NUM>. Suture <NUM> (i.e., proximal open loop <NUM> of suture <NUM>) extends through lumen <NUM> of hollow push tube <NUM>. By maintaining a slight proximally-directed tension on the proximal end of suture <NUM> (e.g., by maintaining a slight proximally-directed tension on the free suture ends of proximal open loop <NUM>), anchor <NUM> can be held against the drive surface <NUM> of hollow push tube <NUM>, thereby providing a degree of control for maneuvering the anchor.

Preferably anchor <NUM>, suture <NUM> and inserter <NUM> are pre-assembled into a single unit, with suture <NUM> extending back through lumen <NUM> of inserter <NUM> with a slight proximal tension so as to hold anchor <NUM> on the distal end of inserter <NUM>.

Suture anchor system <NUM> preferably also comprises a hollow guide <NUM> for guiding components from outside of the body to the acetabulum. More particularly, hollow guide <NUM> generally comprises a lumen <NUM> for slidably receiving anchor <NUM> and inserter <NUM> therein, as will hereinafter be discussed. The internal diameter of hollow guide <NUM> is preferably approximately equal to the largest external feature of anchor <NUM> (e.g., one or more of the barbs <NUM>), so that anchor <NUM> can make a close sliding fit within the interior of hollow guide <NUM>. Alternatively, the internal diameter of hollow guide <NUM> may be slightly smaller or larger than the largest external feature of anchor <NUM> if desired. Where suture anchor system <NUM> also comprises a punch (or drill) <NUM>, lumen <NUM> of hollow guide <NUM> is preferably sized to slidably receive punch (or drill) <NUM>, as will hereinafter be discussed. The distal end of hollow guide <NUM> preferably includes a sharp tip/edge for penetrating the labrum and engaging the acetabulum, as will hereinafter be discussed.

If desired, and looking now at <FIG> and <FIG>, suture anchor system <NUM> may also comprise a punch (or drill) <NUM> having a sharp distal end <NUM> and a proximal end <NUM> having a handle <NUM> mounted thereto. Where element <NUM> is a drill, handle <NUM> could comprise a mount for the drill so as to facilitate turning the drill with a powered driver, etc. Again, the sharp distal end <NUM> of punch (or drill) <NUM> is adapted to penetrate the acetabulum, as will hereinafter be discussed.

Suture anchor system <NUM> is preferably used as follows to secure a detached labrum to the acetabulum.

First, the sharp distal end <NUM> of hollow guide <NUM> is passed through the labrum and positioned against the acetabulum at the location where anchor <NUM> is to be deployed. Preferably the sharp distal end of hollow guide <NUM> penetrates through the labrum and a short distance into the acetabulum so as to stabilize the hollow guide vis-à-vis the acetabulum. A stylet (e.g., an obturator) may be used to fill the hollow guide <NUM> during such insertion and thus prevent tissue coring of the labrum during insertion. The distal portion of the punch (or drill) <NUM> may also be used to fill the hollow tip of the hollow guide <NUM> during such insertion.

Next, if desired, punch (or drill) <NUM> may be used to prepare a seat in the acetabulum to receive anchor <NUM>. More particularly, if punch (or drill) <NUM> is used, the sharp distal end <NUM> of punch (or drill) <NUM> is passed through hollow guide <NUM> (thereby also passing through the labrum) and advanced into the acetabulum so as to form an opening (i.e., a seat) in the bone to receive anchor <NUM>. Then, while hollow guide <NUM> remains stationary, punch (or drill) <NUM> is removed from hollow guide <NUM>.

Next, inserter <NUM>, carrying anchor <NUM> thereon, is passed through hollow guide <NUM> (thereby also passing through the labrum) and into the seat formed in the acetabulum. As anchor <NUM> is advanced into the bone, the body of anchor <NUM> (e.g., ribs <NUM>) makes an interference fit with the surrounding bone, whereby to initially bind the anchor to the bone. At the same time, the solid distal ring <NUM> located at the distal end of the anchor provides the structural integrity needed to keep the anchor intact while it penetrates into the bone. When anchor <NUM> has been advanced an appropriate distance into the acetabulum, the proximal end of suture <NUM> (i.e., proximal open loop <NUM>) is pulled proximally while the distal end of inserter <NUM> is held in position, thereby causing enlargement <NUM> to move proximally relative to the generally cylindrical body <NUM>, forcing the distal end of generally cylindrical body <NUM> to split and expand, in the manner shown in <FIG>, whereby to further bind anchor <NUM>, and hence suture <NUM>, to the bone. In one preferred form of the present invention, expansion of generally cylindrical body <NUM> occurs along some or all of the circumference of the generally cylindrical body, and there may be variations in the amount of expansion about the circumference of the generally cylindrical body, e.g., with the construction shown in <FIG>, there may be greater expansion in a direction perpendicular to the direction of longitudinally-extending slits <NUM> (for example, in the direction of the arrows shown in <FIG>). It will be appreciated that the location and magnitude of expansion of generally cylindrical body <NUM> can be controlled by the number and location of longitudinally-extending slits <NUM>, the configuration of enlargement <NUM>, the configuration of generally cylindrical body <NUM> (e.g., its lumen <NUM> and the associated side wall of the cylindrical body <NUM> adjacent the lumen), etc. In one preferred form of the present invention, expansion of generally cylindrical body <NUM> occurs at the zone where distal end reservoir <NUM> meets short intermediate portion <NUM>, with expansion occurring as enlargement <NUM> moves out of the comparatively larger diameter distal end reservoir <NUM> and into the comparatively smaller diameter intermediate portion <NUM>.

Significantly, in view of the modest holding power required to secure the labrum in place, anchor <NUM> can have a very small size, much smaller than a typical bone anchor of the sort used to hold a ligament in place. By way of example but not limitation, anchor <NUM> may have a length of <NUM> (<NUM> inches), an outer diameter (unexpanded) of <NUM> (<NUM> inches), and an outer diameter (expanded) of <NUM> (<NUM> inches). This small size enables a minimal puncture to be made in the labrum (and hence a minimal hole to be made in the labrum), thus reducing potential damage to the labral tissue and enabling a more accurate puncture location through the labrum. The small size of anchor <NUM> also allows the anchor to be placed closer to, or directly into, the rim of the acetabular cup, without fear of the anchor penetrating into the articulating surfaces of the joint. See, for example, <FIG>, which shows anchor <NUM> placed close to the rim of the acetabular cup, and <FIG>, which shows anchor <NUM> placed directly into the rim of the acetabular cup. This significantly reduces, or entirely eliminates, the labrum eversion problems discussed above. Furthermore, the small size of the anchor significantly reduces trauma to the tissue of the patient.

Once anchor <NUM> has been set in the acetabulum, guide <NUM> is removed from the surgical site, leaving anchor <NUM> deployed in the acetabulum and suture <NUM> extending out through the labrum.

This process may then be repeated as desired so as to deploy additional anchors through the labrum and into the acetabulum, with each anchor having a pair of associated free suture ends extending out through the labrum.

Finally, the labrum may be secured to the acetabular cup by tying the labrum down to the acetabulum using the free suture ends emanating from the one or more anchors.

If desired, and looking now at <FIG>, a deployment cylinder <NUM> may be disposed on distal loop <NUM> of suture <NUM> just proximal to enlargement <NUM>. Deployment cylinder <NUM> can be advantageous where enlargement <NUM> comprises a suture knot, since the deployment cylinder can ensure the uniform application of a radial expansion force to the wall of the anchor body even where the suture knot has a non-uniform configuration. Deployment cylinder <NUM> may have a beveled proximal end <NUM> to facilitate expansion of anchor <NUM> when suture <NUM> is pulled proximally. <FIG> depicts anchor <NUM> in an unexpanded state, while <FIG> depict the anchor <NUM> in an expanded state.

Furthermore, one or more of the ribs <NUM> may utilize a different construction than that shown in <FIG>. More particularly, in <FIG>, each of the ribs <NUM> comprises a proximal portion which comprises a cylindrical surface <NUM>. Such a cylindrical surface provides increased surface area contact for engaging the adjacent bone when anchor <NUM> is disposed in the acetabulum. However, if desired, one or more of the ribs <NUM> may terminate in a sharp proximal rim <NUM> (<FIG>) for biting into adjacent bone when suture <NUM> is pulled proximally.

Or one or more of the ribs <NUM> may be slotted as shown in <FIG> so as to provide a rib with increased flexibility. Such a construction can be useful since it allows the slotted rib <NUM> to be radially compressed so as to fit within inserter <NUM> and then radially expanded, in a spring-like manner, when deployed in the acetabulum.

If desired, alternative arrangements can be provided for coupling anchor <NUM> to the distal end of inserter <NUM>. More particularly, in <FIG>, a male-female connection is used to couple anchor <NUM> to inserter <NUM>, with anchor <NUM> having a male projection <NUM> and inserter <NUM> having a corresponding female recess <NUM>. In <FIG>, inserter <NUM> includes the male projection <NUM> and anchor <NUM> has the corresponding female recess <NUM>. In <FIG>, inserter <NUM> has a convex surface <NUM> and anchor <NUM> has a corresponding concave surface <NUM>. Still other constructions of this type will be apparent to those skilled in the art in view of the present disclosure.

Looking next at <FIG>, in another form of present invention, suture <NUM> is intended to exit anchor <NUM> at proximal relief hole <NUM> and extend along the exterior of the generally cylindrical body <NUM>. If desired, slots <NUM> may be provided in ribs so as to accommodate suture <NUM> therein.

In another form of the present invention, and looking now at <FIG>, suture <NUM> can be replaced by a solid shaft <NUM>. More particularly, solid shaft <NUM> extends through lumen <NUM> of anchor <NUM> and lumen <NUM> of inserter <NUM>, and has enlargement <NUM> formed on its distal end. Proximal movement of solid shaft <NUM> causes enlargement <NUM> to expand the distal end of anchor <NUM> so as to cause anchor <NUM> to grip adjacent bone.

If desired, one or both of distal relief hole <NUM> and proximal relief hole <NUM> may be omitted, with longitudinally-extending slit <NUM> terminating in a blind surface at one or both ends.

Furthermore, if desired more than one longitudinally-extending slit <NUM> may be provided in anchor <NUM>, e.g., two diametrically-opposed longitudinally-extending slits <NUM> may be provided. Additionally, if desired, longitudinally-extending slit <NUM> may extend all the way to the distal end of the anchor body, rather than stopping short of the distal end of the anchor body. See, for example, <FIG>, which show two diametrically-opposed, longitudinally-extending slits <NUM>, wherein the slits extend all the way to the distal end of anchor <NUM>, and with the two figures showing examplary rib configurations. See also <FIG>, which shows an anchor <NUM> having a single longitudinally-extending slit <NUM>, wherein the slit extends all the way to the distal end of the anchor.

If desired, and looking now at <FIG>, lumen <NUM> may extend along a longitudinal axis <NUM> which is eccentric to the longitudinal axis <NUM> of generally cylindrical body <NUM>. Such an eccentric construction can provide a thinner side wall on one side of the anchor and a thicker side wall on another side of the anchor, so as to create preferential body expansion.

Or anchor <NUM> may be provided with an angled through-hole to create varying wall thicknesses and non-symmetric effects as shown in <FIG>.

If desired, and looking now at <FIG>, anchor <NUM> can be constructed so that longitudinally-extending slit <NUM> is omitted entirely. In this form of the invention, anchor <NUM> is preferably formed with one or more thin-walled sections <NUM> (<FIG>) which fracture when enlargement <NUM> is forced proximally.

Alternatively, in another form of the invention, anchor <NUM> is constructed so that its generally cylindrical body <NUM> expands radially when enlargement <NUM> moves proximally, but the distal end of the anchor does not split open. Again, the direction and extent of the expansion of cylindrical body <NUM> may be controlled by the number and location of the longitudinally-extending slits <NUM>, the configuration of enlargement <NUM>, the configuration of generally cylindrical body <NUM> (e.g., its lumen <NUM> and the associated side wall of the cylindrical body <NUM> adjacent the lumen), etc..

Anchor <NUM> can be made out of any material consistent with the present invention, e.g., anchor <NUM> can be made out of a biocompatible plastic (such as PEEK), an absorbable polymer (such as poly-L-lactic acid, PLLA), bio-active materials such as hydrogels, or metal (such as stainless steel or titanium).

Suture <NUM> can be made out of any material consistent with the present invention, e.g., common surgical suture materials. One such material is woven polymer such as PE or UHMWPE. Another material is a co-polymer material such as UHMWPE/polyester. Yet another material is an absorbable polymer such as polyglycolic acid, polylactic acid, polydioxanone, or caprolactone. Proximal loop <NUM> is preferably a #<NUM> suture size; alternatively, it is a #<NUM> suture size, a #<NUM> suture size, or a #<NUM>-<NUM> suture size. Distal loop <NUM> is preferably a #<NUM>-<NUM> suture size; alternatively, it is a #<NUM> suture size, a #<NUM> suture size, or a #<NUM> suture size.

As noted above, enlargement <NUM> may comprise a solid member attached to the distal end of distal loop <NUM>, or it may comprise a suture knot formed by knotting off the distal ends of distal loop <NUM> of suture <NUM>. In this latter construction, enlargement <NUM> can be formed out of a single knot or multiple knots. It can be an overhand knot or other knot such as a "<FIG>" knot. Suture <NUM> can also be heat formed so as to create the enlargement <NUM>. This will create a more rigid feature that better enables movement of enlargement <NUM> from its distal position to its more proximal position. Such heat forming could also be done on a knot or to seal the suture ends distal to the knot.

In the preceding sections, there was disclosed a novel suture anchor system <NUM> which may be used for, among other things, arthroscopically re-attaching a detached labrum to the acetabulum. As discussed above, novel suture anchor system <NUM> generally comprises an achor assembly comprising an anchor <NUM> and an actuation element extending from the anchor a suture <NUM> secured to anchor <NUM>, and an inserter <NUM> for delivering anchor <NUM> into the acetabulum. As also discussed above, novel suture anchor system <NUM> is constructed so that after inserter <NUM> has delivered anchor <NUM> into the acetabulum, tensioning of suture <NUM> causes the body of anchor <NUM> to expand laterally so that the anchor is secured to the bone, whereby to secure suture <NUM> to the bone.

In one preferred form of the present invention, suture <NUM> may comprise a pair of sutures, e.g., a thinner distal suture <NUM> extending through anchor <NUM> and a thicker proximal suture <NUM> extending from thinner distal suture <NUM> to the proximal end of inserter <NUM> (e.g., to the handle of inserter <NUM>), such that thicker proximal suture <NUM> can be used to actuate the anchor by pulling proximally on thinner distal suture <NUM> and to secure an object (e.g., the labrum) to the bone in which anchor <NUM> is deployed, e.g., the acetabulum.

And in one preferred form of the present invention, novel suture anchor system <NUM> is intended to be constructed on a very small scale, e.g., so that anchor <NUM> has a diameter on the order of <NUM>, thinner distal suture <NUM> is a "Size <NUM>-<NUM> suture" with a diameter of approximately <NUM>, and thicker proximal suture <NUM> is a "Size <NUM> suture" with a diameter of approximately <NUM>.

In view of this unusually small construction, it can be extremely important to limit the magnitude of the tension applied to the suture, since applying too much tension to the suture can result in unintentional damage to the body of anchor <NUM> and/or in breakage of the suture (particularly the thinner distal suture <NUM>). At the same time, however, it is also important that an adequate amount of force be applied to the anchor in order to ensure proper actuation of the anchor.

In the following sections of this document, there is disclosed force delivery mechanisms which are force-limiting so as to provide for the controlled delivery of an actuation force to anchor <NUM>.

In accordance with the present invention, there is disclosed apparatus that may be used to deliver an anchor into bone and to actuate that anchor (i.e., by pulling proximally on an element) while the anchor is disposed in the bone, so as to set the anchor in the bone. In one preferred form of the present invention, the anchor is an expandable anchor that requires the application of a force at the anchor (preferably by tensioning a suture) in order to expand and/or deform the anchor (either a section of the anchor or the entire body of the anchor). In accordance with the present invention, the apparatus for actuating the anchor (e.g., for tensioning the suture) comprises a force delivery mechanism which is force-limiting in the sense that the mechanism allows the user to manually apply force to the anchor (e.g., by tensioning a suture) up to a specific, desired force limit, whereupon the mechanism automatically disengages and the force thereafter applied to the anchor (e.g., by tensioning the suture) drops to zero (or substantially zero). The disengagement and force-limiting aspect of the force delivery mechanism is automatic and does not require any additional action by the user. In other words, the force delivery mechanism is configured so that when the magnitude of the tension applied to the anchor (e.g., to the suture connected to the anchor) exceeds a certain, pre-determined limit, the force delivery mechanism automatically disengages and no further tension is applied to the anchor.

The alternative to such a force-limiting mechanism is a mechanism that either (i) applies a variable force over a fixed distance of travel, or (ii) a mechanism that requires the user to actively control the delivery of the activation force to the anchor. Neither approach is preferable to a force-limiting mechanism of the sort provided by the present invention. Significantly, a force-limiting mechanism is independent of device variables such as suture stretch, anchor material properties and required actuation travel, and anatomical variables such as bone type and bone quality. For example, in equivalent bone quality, a device that has greater suture stretch may only see partial actuation at the anchor; however, a force-limiting mechanism is independent of suture stretch and hence will actuate the anchor to a consistent, specific force. By way of example but not limitation, the amount of stretch in a suture may significantly exceed the actuation travel required by an anchor, e.g., the suture might stretch <NUM> - <NUM> along the length of an inserter when the suture is tensioned, whereas the anchor may only require an actuation travel of <NUM>. In this situation, suture stretch can make it virtually impossible to reliably apply the desired actuation force to the anchor. Furthermore, dense bone will resist the lateral expansion of an anchor more than soft bone will resist the lateral expansion of the anchor. So where the bone is dense, the force applied to the actuation suture may be taken up (i.e., absorbed) by the suture and hence incomplete anchor expansion may occur. Additionally, a device which requires the user to actively control the delivery of the actuation force to the anchor introduces the possibility of user error and unnecessary complications to the device function.

On account of the foregoing, the present invention provides a force delivery mechanism which is force-limiting so as to provide for the controlled delivery of an actuation force to an anchor.

For purposes of clarity of description, the novel force-limiting mechanism will hereinafter generally be discussed in the context of applying an actuation force to an anchor <NUM> by pulling proximally on its thicker proximal suture <NUM>, whereby to cause its thinner distal suture <NUM> to move an actuation element in the form of a suture knot (e.g., enlargement <NUM>) or a PEEK cylinder (e.g., deployment cylinder <NUM>) proximally, whereby to expand anchor <NUM> and set it in bone.

Looking now at <FIG>, there is shown a wishbone force delivery mechanism <NUM> which is force-limiting so as to provide for the controlled delivery of an actuation force to an anchor, e.g., to the thicker proximal suture <NUM> of anchor <NUM>. Wishbone mechanism <NUM> is intended to be incorporated into the handle <NUM> of the inserter <NUM> discussed above, which may cause handle <NUM> to take on a modified configuration from that previously shown. In one preferred form of the invention, wishbone mechanism <NUM> generally comprises a handle <NUM>, a cap <NUM>, a cleat <NUM>, a wishbone <NUM> and a finger pull <NUM>. Wishbone apparatus <NUM> also comprises a proximal spring <NUM>, a distal spring <NUM> and a wishbone spring <NUM>.

Wishbone <NUM>, finger pull <NUM> and wishbone spring <NUM> are the critical components that enable the force-limiting aspect of wishbone mechanism <NUM>, and handle <NUM> and cap <NUM> act to contain and guide the actuation. Additionally, proximal spring <NUM> dampens the hard stop at the end of actuation (i.e., when wishbone <NUM> pops out of finger pull <NUM>, as will hereinafter be discussed) and distal spring <NUM> maintains tension on the suture (e.g., thicker proximal suture <NUM>) while the apparatus is in its packaging and/or prior to the delivery of an actuation force to finger pull <NUM>, as will hereinafter be discussed.

Wishbone mechanism <NUM> is integrated into inserter <NUM> by mounting cap <NUM> to the proximal end of hollow push tube <NUM> of inserter <NUM>, with thicker proximal suture <NUM> of anchor <NUM> extending up hollow push tube <NUM> for releasable connection to cleat <NUM>, with handle <NUM> configured to be grasped by the hand of a user, and with finger pull <NUM> configured to be grasped by the index finger and middle finger of the user.

Delivery of the suture anchor (e.g., anchor <NUM>) requires a hole in the bone, created by either a drill bit or a punch; the anchor is then inserted into the hole to a specific depth indicated by markings (not shown) provided on the hollow push tube <NUM>. Once the anchor is located at the proper depth, the anchor requires an actuation step in which a suture knot (e.g., enlargement <NUM>) and/or a PEEK cylinder (e.g., deployment cylinder <NUM>) at the distal end of the suture (e.g., the thinner distal suture <NUM>) are pulled proximally through the anchor, causing the anchor to expand in the manner previously described. The proximal advancement of the suture knot (e.g., enlargement <NUM>) and/or the PEEK cylinder (e.g., deployment cylinder <NUM>) within anchor <NUM>, and thereby expansion of the anchor, is controlled by the force-limiting wishbone mechanism <NUM> which is disposed at, and constitutes, the proximal (i.e., handle) end of the inserter <NUM>, with cap <NUM> being connected to the hollow push tube <NUM> of the inserter <NUM>. The force-limiting wishbone mechanism <NUM> is single-handedly actuated by the user via finger pull <NUM> which is disposed at the proximal (handle) end of the inserter <NUM>.

To ensure optimal expansion of the anchor and maximum resistance to pullout, the expansion of the anchor is effected by the application of a pre-determined actuation force. The force-limiting wishbone mechanism <NUM> allows the user to actuate and expand the anchor up to the pre-determined maximum level of force and, upon reaching that pre-determined maximum level of force, the wishbone mechanism automatically disengages and thereby prevents the user from applying any further force to the anchor, but it does not disengage the force delivery mechanism until after that pre-determined maximum level of force has been applied to the anchor. Thus, wishbone mechanism <NUM> ensures that the correct level of tension is applied to anchor <NUM> every time (provided, of course, that an adequate level of force is supplied to finger pull <NUM> during actuation).

As discussed above, after anchor <NUM> has been positioned in a bone hole, it is set by expanding the anchor body, which is effected by pulling the thinner distal suture <NUM> (and hence suture knot <NUM> and/or PEEK cylinder <NUM>) proximally. As also discussed above, the thinner distal suture <NUM> is pulled proximally by pulling the thicker proximal suture <NUM> (which extends to the handle) proximally. With wishbone mechanism <NUM>, the proximal end of the thicker proximal suture <NUM> is secured to cleat <NUM>, which is itself releasably connected to finger pull <NUM> via wishbone <NUM>, as will hereinafter be discussed. From the user's point of view, anchor actuation is effected by pulling finger pull <NUM> proximally until wishbone apparatus <NUM> has automatically disengaged (<FIG>), whereupon any further proximal movement of finger pull <NUM> is dampened by proximal spring <NUM>. During anchor actuation and prior to finger pull <NUM> engaging proximal hard stop <NUM>, the wishbone apparatus <NUM> will make an audible "snap" and, simultaneously, the resistance at finger pull <NUM> will drop significantly - this signifies that the pre-determined maximum level of force has been reached and that the wishbone apparatus <NUM> has automatically disengaged (i.e., by virtue of wishbone <NUM> popping free of finger pull <NUM>, as will hereinafter be discussed). At this point, the anchor has been expanded in the bone, and the proximal end of the thicker proximal suture <NUM> can be then unwrapped from cleat <NUM> and the inserter <NUM> (which includes wishbone mechanism <NUM>) can be removed from the patient, leaving anchor <NUM> secured to the bone, and suture <NUM> extending out of the bone.

In addition to the foregoing, the force-limiting feature of the wishbone mechanism can be provided via the following design alternatives.

In another form of the invention, and looking now at <FIG>, wishbone mechanism <NUM> may be replaced by a spooling mechanism <NUM> wherein the force-limiting mechanism is completely contained within finger pull <NUM>. More particularly, in this form of the invention, the thicker proximal suture <NUM> is wrapped around a shaft <NUM> which is disposed within finger pull <NUM> and selectively rotatable. In accordance with this form of the invention, shaft <NUM> is prevented from rotating until the pre-determined maximum level of force is reached, whereupon shaft <NUM> is permitted to rotate freely, and thicker proximal suture <NUM> is unwrapped from the shaft, whereupon to terminate the application of force to thicker proximal suture <NUM>.

The following step-by-step description further describes the structure and function of spooling mechanism <NUM>.

In another form of the invention, the force-limiting (force-controlling) mechanism may comprise the double wedge mechanism <NUM> shown in <FIG> and <FIG>. This double wedge mechanism uses two spring-loaded wedges <NUM> to hold cleat <NUM> to finger pull <NUM> as force is applied to finger pull <NUM>, whereby to apply force to the thicker proximal suture <NUM> secured to cleat <NUM>. At the pre-determined maximum level of force, the force applied to spring-loaded wedges <NUM> by cleat <NUM> causes the spring-loaded wedges to slide distally and sideways, away from cleat <NUM>, thereby freeing cleat <NUM> from finger pull <NUM>, and allowing cleat <NUM> to remain stationary as finger pull <NUM> moves proximally, whereby to terminate the application of force to thicker proximal suture <NUM>.

More particularly, and looking now at <FIG> and <FIG>, finger pull <NUM> comprises a plate <NUM> having an opening <NUM> extending therethrough, and a pair of opposing inclined guides <NUM> mounted thereon. Wedges <NUM> ride along guides <NUM> so that, as wedges <NUM> move proximally, the wedges move closer together, and so that, as wedges <NUM> move distally, the wedges move further part. Springs <NUM> bias wedges <NUM> proximally, and hence bias wedges <NUM> together. Wedges <NUM> include projections 440A which clamp cleat <NUM> between the wedges <NUM> when the wedges are close together (e.g., in the position shown in <FIG>) but which fail to clamp cleat <NUM> between the wedges <NUM> when the wedges are spaced apart (e.g., in the position shown in <FIG>).

In use, double wedge mechanism <NUM> starts in the position shown in <FIG>. Proximal force is applied to finger pull <NUM>, which causes proximal force to be applied to plate <NUM>. As plate <NUM> begins to move proximally, thicker proximal suture <NUM> initially stretches, allowing springs <NUM> to keep wedges <NUM> proximal and together, but as the finger pull <NUM> and plate <NUM> move further proximally, the tension in thicker proximal suture <NUM> grows. At the pre-determined maximum level of force (e.g., <NUM> ± <NUM> Ibf), the power of springs <NUM> is overcome, so that wedges <NUM> are free to move distally and laterally (<FIG>), whereby to release cleat <NUM> from projections 440A, and hence from plate <NUM> and finger pull <NUM>, and whereby to release the tension on thicker proximal suture <NUM>. Thus it will be seen that with double wedge mechanism <NUM>, force applied to finger pull <NUM> will be transferred to thicker proximal suture <NUM> via double wedge mechanism <NUM> until the level of that force reaches a certain pre-determined level, whereupon the force delivery mechanism is disabled and the application of force to thicker proximal suture <NUM> is completely terminated.

In another form of the invention, the force-limiting mechanism may comprise the suture cutting mechanism <NUM> shown in <FIG> and <FIG>. This suture cutting mechanism <NUM> allows the user to apply a force to the thicker proximal suture <NUM> and then, when the pre-determined maximum level of force is reached, the proximal end of the suture is cut by a blade <NUM> that is positioned on finger pull <NUM>. Cutting of the thicker proximal suture <NUM> disables the force delivery mechanism and terminates tension on the suture.

In essence, with suture cutting mechanism <NUM>, the suture extends up hollow push tube <NUM> of inserter <NUM>, through handle <NUM> and is attached to finger pull <NUM> by wrapping the thicker proximal suture <NUM> around a freely rotating shaft <NUM> mounted to finger pull <NUM> and then securing the end of the suture to a mount <NUM> on finger pull <NUM>. As a result, as long as thicker proximal suture <NUM> is intact, a proximal force applied to finger pull <NUM> applies tension to the suture. When a pre-determined maximum level of force is reached, blade <NUM> cuts the proximal end of thicker proximal suture <NUM>. Once the proximal end of suture <NUM> has been cut, the tension on the suture <NUM> is released, since it has been wrapped around the freely rotating shaft <NUM> mounted to finger pull <NUM> and is no longer secured to mount <NUM> on finger pull <NUM>. With the tension on the suture <NUM> released, the suture <NUM> is free to unwind off rotating shaft <NUM> as the user removes the device from the patient. Thus, cutting thicker proximal suture <NUM> disengages the force delivery mechanism and terminates tension on the suture.

More particularly, in the preferred form of the invention, finger pull <NUM> comprises a pair of axial rods <NUM> upon which is movably mounted a platform <NUM>. Blade <NUM> is fixedly mounted to finger pull <NUM> so as to face the underside of platform <NUM>, and finger pull <NUM> comprises an opening <NUM> for passing thicker proximal suture <NUM> therethrough. A pair of springs <NUM> bias platform <NUM> away from finger pull <NUM>. Platform <NUM> carries a freely rotating shaft <NUM> around which is coiled the thicker proximal suture <NUM>. The proximal end of suture <NUM> comes off freely rotating shaft <NUM>, passes around a post <NUM> and another post <NUM>, and then terminates at mount <NUM>. Thus, a suture segment <NUM> extends between post <NUM> and mount <NUM>. As a result of this construction, a proximal force applied to finger pull <NUM> causes tension to be applied to thicker proximal suture <NUM>, since the end of thicker proximal suture <NUM> is secured to mount <NUM>.

When the pulling force applied to finger pull <NUM> is below the aforementioned pre-determined maximum level of force, springs <NUM> keep platform <NUM> biased proximally, away from finger pull <NUM>, and so as to keep suture segment <NUM> spaced from cutter blade <NUM>. However, when the pulling force applied to finger pull <NUM> exceeds the aforementioned pre-determined level of force, the power of springs <NUM> is overcome and the gap between finger pull <NUM> and platform <NUM> closes so that cutter blade <NUM> engages the suture segment <NUM>, whereby to sever the thicker proximal suture <NUM>. As a result, the thicker proximal suture <NUM> is no longer fixed to mount <NUM>, so that freely rotating shaft <NUM> can spin, allowing thicker proximal suture <NUM> to unwind from freely rotating shaft <NUM> whereby to release the tension on thicker proximal suture <NUM>.

In an alternative embodiment, suture <NUM> mounts directly to platform <NUM> (i.e., there is no freely rotating shaft <NUM>). When the pulling force applied to finger pull <NUM> exceeds the aforementioned pre-determined level of force, the power of springs <NUM> is overcome and the gap between finger pull <NUM> and platform <NUM> closes so that cutter blade <NUM> engages the suture segment <NUM>, whereby to sever the thicker proximal suture <NUM>. As a result, the thicker proximal suture <NUM> is no longer fixed to mount <NUM>, allowing thicker proximal suture <NUM> to be disconnected from platform <NUM>, whereby to release the tension on thicker proximal suture <NUM>.

In another form of the invention, the force-limiting mechanism may comprise the alternative suture cutting mechanism <NUM> shown in <FIG> and <FIG>. In this form of the invention, where anchor <NUM> comprises the deployment cylinder <NUM> which is moved by a thinner distal suture <NUM> having an enlargement <NUM> at its distal end, and where thinner distal suture <NUM> is itself moved by a thicker proximal suture <NUM> extending up into hollow push tube <NUM> of inserter <NUM>, the thicker proximal suture <NUM> is coupled to a movable shaft <NUM> disposed within hollow push tube <NUM> of inserter <NUM> (in this embodiment, suture <NUM> may not serve to secure tissue to bone, rather, another suture, not shown, may be secured to the body of the anchor and used to secure tissue to bone). Thicker proximal suture <NUM> may comprise a loop having a segment <NUM> extending through diametrically opposed openings <NUM> formed in movable shaft <NUM>, with segment <NUM> extending across the central lumen of the movable shaft <NUM>. The inserter <NUM> may have a blade <NUM> which is disposed in the central lumen of the movable shaft <NUM>. In this form of the invention, the blade <NUM> is secured to the finger pull <NUM> (e.g., via a connector <NUM>), and the movable shaft <NUM> is secured to a body <NUM> which is spring biased away from finger pull <NUM> by virtue of springs <NUM>. In this form of the invention, as long as the level of force applied to the finger pull <NUM> is below the aforementioned pre-determined maximum level of force, springs <NUM> will keep body <NUM> biased away from finger pull <NUM>, and hence keep blade <NUM> away from the suture segment <NUM> formed by thicker proximal suture <NUM>, so that proximal movement of finger pull <NUM> will apply a proximal force to thicker proximal suture <NUM>, whereby to actuate the anchor. However, as soon as the level of force applied to finger pull <NUM> reaches the aforementioned pre-determined maximum level of force (e.g., <NUM> ± <NUM> Ibf), the power of springs <NUM> will be overcome and finger pull <NUM> will approach body <NUM>, whereby to bring the cutter blade <NUM> into engagement with the suture segment <NUM> formed by thicker proximal suture <NUM>, and whereby to sever thicker proximal suture <NUM> and terminate the application of an actuation force to the anchor.

In other words, in this form of the invention, as long as the level of force applied to finger pull <NUM> is below the aforementioned maximum level of force, the force applied to finger pull <NUM> is transmitted to body <NUM>, and hence to movable shaft <NUM>, and hence to thicker proximal suture <NUM>, whereby to actuate the anchor, with springs <NUM> keeping body <NUM> sufficiently separated from finger pull <NUM> to keep blade <NUM> separated from segment <NUM> of thicker proximal suture <NUM>, whereby to maintain the integrity of thicker proximal suture <NUM>. However, as soon as the level of force applied to finger pull <NUM> reaches the aforementioned maximum level of force, the power of springs <NUM> is overcome, so that the gap between body <NUM> and finger pull <NUM> decreases, whereby to cause blade <NUM> to engage segment <NUM> of thicker proximal suture <NUM> and sever the suture. This disengages the force delivery mechanism and terminates the tension on the suture <NUM>.

In another form of the present invention, the force-limiting mechanism may comprise the dogbone mechanism <NUM> shown in <FIG>. Dogbone mechanism <NUM> allows the user to apply force to the thicker proximal suture <NUM> which is secured to cleat <NUM> by pulling proximally on finger pull <NUM>, with dogbone <NUM> transmitting force between the two parts (i.e., between finger pull <NUM> and cleat <NUM>). Dogbone <NUM> is constructed so that at force levels below the aforementioned pre-determined maximum level of force, dogbone <NUM> will remain intact and will transmit force between finger pull <NUM> and cleat <NUM>. However, dogbone <NUM> is also constructed so that at force levels above the aforementioned pre-determined maximum level of force, dogbone <NUM> will break and no longer transmit force between finger pull <NUM> and cleat <NUM>. Thus, in this form of the invention, dogbone <NUM> effectively acts as a mechanical fuse, in the sense that it terminates force transmission as soon as the force applied to finger pull <NUM> reaches the aforementioned pre-determined maximum level of force. It will be appreciated that the breaking force of dogbone <NUM> is dictated by material selection and dogbone geometry.

It will be appreciated that in the dogbone mechanism <NUM> discussed above, the force-limiting feature of the force delivery mechanism is provided by the "controlled component failure" of the dogbone. In essence, with this design, a component is designed to act as a "mechanical fuse", whereby it will intentionally fail when the applied force exceeds the aforementioned pre-determined maximum level of force, whereby to terminate the application of an actuation force to the anchor assembly. The component which acts as the "mechanical fuse" is selected so that the component failure will not undermine the integrity of the anchor fixation in the bone.

It will be appreciated that numerous other designs can be provided which use the "controlled component failure" scheme of the dogbone mechanism.

Thus, for example, and looking now at <FIG>, in one form of the invention, thicker proximal suture <NUM> can be engineered to break when the applied force exceeds the aforementioned pre-determined maximum level of force (it should be appreciated that in these figures, and the figures which follow, the inserter is omitted from the drawing in order to improve clarity of understanding). Of course, in this form of the invention, inasmuch as thicker proximal suture <NUM> is designed to break when the applied force exceeds the aforementioned pre-determined maximum level of force, an additional suture S is provided for securing tissue to bone. In an alternative form of the invention (not shown), the thinner distal suture <NUM> can be engineered to break when the applied force exceeds the aforementioned pre-determined maximum level of force.

Or, as shown in <FIG>, where a mechanical hook <NUM> is used in place of thicker proximal suture <NUM> to apply a proximal force to thinner distal suture <NUM>, mechanical hook <NUM> can be engineered to fail (e.g., yielding by bending) when the applied force exceeds the aforementioned pre-determined maximum level of force. Of course, in this form of the invention, inasmuch as mechanical hook <NUM> is designed to fail when the applied force exceeds the aforementioned pre-determined maximum level of force, an additional suture S is provided for securing tissue to bone.

Or, as shown in <FIG>, where a rod <NUM> is used in place of thicker proximal suture <NUM> to apply a proximal force to thinner distal suture <NUM>, rod <NUM> can be engineered to fail (e.g., by the thinner distal suture <NUM> tearing through a segment <NUM> of rod <NUM>) when the applied force exceeds the aforementioned pre-determined maximum level of force. It will be appreciated that the force at which thinner distal suture <NUM> tears through segment <NUM> of rod <NUM> is dictated by material selection and geometry of rod <NUM> and thinner distal suture <NUM>. Of course, in this form of the invention, inasmuch as rod <NUM> is designed to fail when the applied force exceeds the aforementioned pre-determined maximum level of force, an additional suture S is provided for securing tissue to bone.

Or, as shown in <FIG>, where a rod <NUM> is used in place of both thinner distal suture <NUM> and thicker proximal suture <NUM> to apply a proximal force to deployment cylinder <NUM>, deployment cylinder <NUM> can be engineered to fail when the applied force exceeds the aforementioned pre-determined maximum level of force. Specifically, in one form of the invention, rod <NUM> comprises an enlargement <NUM> which is positioned distal to a narrowed section <NUM> of deployment cylinder <NUM>. Enlargement <NUM> has a profile in at least one dimension which is larger than at least one dimension of narrowed section <NUM>. Enlargement <NUM> and narrowed section <NUM> are constructed so that at force levels below the aforementioned pre-determined maximum level of force, enlargement <NUM> and narrowed section <NUM> will both remain intact and will transmit force from rod <NUM> to deployment cylinder <NUM>. However, at force levels above the aforementioned pre-determined maximum level of force, one or the other, or both, of enlargement <NUM> and narrowed section <NUM> will deform, so that rod <NUM> can move proximally relative to deployment cylinder <NUM>, and - once free of narrowed section <NUM> - will no longer transmit force between rod <NUM> and deployment cylinder <NUM>. It will be appreciated that the breaking force of enlargement <NUM>, narrowed section <NUM>, or both, is dictated by material selection and geometry of both rod <NUM> and deployment cylinder <NUM>. Of course, in this form of the invention, inasmuch as enlargement <NUM>, narrowed section <NUM>, or both, are designed to fail when the applied force exceeds the aforementioned pre-determined maximum level of force, an additional suture S (threaded through an opening in the anchor) is provided for securing tissue to bone.

Or, as shown in <FIG>, where a suture <NUM> (e.g., a thinner distal suture <NUM> or a thicker proximal suture <NUM>) is used to apply a proximal force to deployment cylinder <NUM>, deployment cylinder <NUM> can be engineered to fail (e.g., by the suture <NUM> tearing through a segment <NUM> of deployment cylinder <NUM>) when the applied force exceeds the aforementioned pre-determined maximum level of force. It will be appreciated that the force at which suture <NUM> tears through segment <NUM> of deployment cylinder <NUM> is dictated by material selection and geometry of deployment cylinder <NUM> and suture <NUM>. Of course, in this form of the invention, inasmuch as deployment cylinder <NUM> is designed to fail when the applied force exceeds the aforementioned pre-determined maximum level of force, an additional suture S (threaded through an opening in the anchor) is provided for securing tissue to bone.

Or, as shown in <FIG>, where a hook <NUM> is used to apply a proximal force to deployment cylinder <NUM>, hook <NUM> can be engineered to fail when the applied force exceeds the aforementioned pre-determined maximum level of force. Again, it will be appreciated that the force at which hook <NUM> fails is dictated by the material selection and geometry of hook <NUM>. Of course, in this form of the invention, inasmuch as hook <NUM> is designed to fail when the applied force exceeds the aforementioned pre-determined maximum level of force, an additional suture S (threaded through an opening in the anchor) is provided for securing tissue to bone.

Or, as shown in <FIG>, where a pull rod <NUM> is used to apply a proximal force to deployment cylinder <NUM>, pull rod <NUM> can be engineered to fail when the applied force exceeds the aforementioned pre-determined maximum level of force. For example, pull rod <NUM> can comprise a break section <NUM>. Break section <NUM> may be a narrowing in the pull rod <NUM> (i.e. creating a weak point in the pull rod <NUM>) or other feature or geometry which forces the pull rod <NUM> to break at that location when the level of force applied to pull rod <NUM> exceeds the aforementioned pre-determined maximum level of force. Of course, in this form of the invention, inasmuch as pull rod <NUM> is designed to fail when the applied force exceeds the aforementioned pre-determined maximum level of force, an additional suture S (threaded through an opening in the anchor) is provided for securing tissue to bone.

Anchor <NUM> of suture anchor system <NUM> may be delivered trans-labrally, i.e., through the labrum and into the acetabular bone, e.g., such as was described above.

In an alternative embodiment, anchor <NUM> may be placed directly into the acetabular bone, without passing through the labrum first, and then suture <NUM> may be passed through the labrum. In this form of the apparatus, the components of suture anchor system <NUM> may remain the same. Alternatively, in this form of the apparatus, the distal end of hollow guide <NUM> need not have a sharp tip/edge <NUM> for penetrating the labrum as described above, and may instead have engagement features for engaging the acetabular bone. One such feature may be a tooth or a plurality of teeth. In this form of the apparatus, the distal end of the hollow guide may also include a window for confirming that the anchor is properly placed into the bone.

Suture anchor system <NUM> may also comprise a curved or angled configuration. More particularly, hollow guide <NUM> may comprise a curve or angle at its distal end. In this form of the invention, the punch (or drill) <NUM>, inserter <NUM> and anchor <NUM> are adapted to pass through the curved or angled hollow guide <NUM> so as to permit a curved or angled delivery of anchor <NUM>.

It should be appreciated that suture anchor system <NUM> may also be used for re-attaching other soft tissue of the hip joint, or for re-attaching tissue of other joints, or for re-attaching tissue elsewhere in the body. In this respect it should be appreciated that suture anchor system <NUM> may be used to attach soft tissue to bone or soft tissue to other soft tissue, or for attaching objects (e.g., prostheses) to bone other tissue.

Claim 1:
Apparatus for securing an object to bone, the apparatus comprising:
- an expandable bone anchor (<NUM>) for receipt in a hole formed in a bone, wherein the anchor (<NUM>) comprises a passageway (<NUM>) extending therethrough, and further wherein the anchor (<NUM>) comprises an enlargement (<NUM>) for expanding the anchor (<NUM>) when the enlargement (<NUM>) is moved through the passageway (<NUM>);
- a solid shaft (<NUM>) or a suture (<NUM>) connected to the enlargement (<NUM>) of the bone anchor for moving the enlargement (<NUM>) through the passageway (<NUM>);
- an inserter (<NUM>) for positioning the anchor (<NUM>) in the hole formed in the bone and for applying a limited force to the anchor (<NUM>), the inserter (<NUM>) comprising:
- a shaft (<NUM>) for releasably engaging the anchor (<NUM>); and
- a force delivery mechanism mounted to the inserter (<NUM>) and connected to the anchor (<NUM>),
wherein the force delivery mechanism
a) is constructed so as to receive an input force from an external source and to selectively apply an output force to the enlargement (<NUM>) of the expandable bone anchor (<NUM>) by tensioning the solid shaft (<NUM>) or suture (<NUM>) in order to expand the anchor (<NUM>), and
b) is constructed so that the magnitude of the output force applied to the enlargement (<NUM>) of the expandable bone anchor (<NUM>) by tensioning the solid shaft (<NUM>) or suture (<NUM>) is limited regardless of the magnitude of the input force.