Toggle suture anchor system

Abstract

A system of toggle-type suture anchors is disclosed. A plurality of suture anchors are connected in series by a single working suture, with each of the suture anchors allowing tensioning of the working suture between itself and the previous anchor embedded in the successive thread. Additionally, each anchor includes a loop-type locking mechanism for locking the working suture in place after tensioning. This creates an independently tensioned suture stitch between each embedded suture anchor and the immediately preceding embedded anchor. Overall, the embedded system creates a continuous array of single anchor-to-anchor stitches that can be placed close together in high density to form stitch lines or areas for stronger fixation of soft tissue to bone.

Description

[Background technology]

[0001] Throughout the human body, there are numerous soft tissue attachments, such as tendons and ligaments, to bones as an integral part of movement in functional joints such as the shoulder. The shoulder joint includes the humeral head of the humerus, which contacts the glenoid cavity, which functions with the rotator cuff, a combination of muscles and tendons that form a capsule to stabilize the joint and effect desired movement. Injury to the connection between the rotator cuff tendons and the humeral head, usually a rupture of the tendon, is common. These tears are not self-healing. In the United States, it is estimated that over 4 million people are referred to surgeons annually for shoulder pain, and of these referrals, over 500,000 undergo shoulder surgery to repair the rotator cuff.

[0002] A great deal of effort has been expended over the past 30 years to develop bone and tissue anchoring devices and methods that address the need for effective rotator cuff repair. Early methods and devices utilized open surgical techniques requiring a large 4-6 cm incision and sectioning of the deltoid muscle followed by reattachment after rotator cuff repair. This method is still used today by some surgeons for large tears due to its high success rate, but the procedure is associated with deltoid dysfunction, significant pain during recovery, and extended rehabilitation time. Due to the invasiveness of open surgery and the resulting rehabilitation time, "mini-open" procedures and associated devices were developed in the early 1990s. In this case, the surgeon uses a partial arthroscopic technique followed by dissection and division of the deltoid muscle fibers to access the rotator cuff tendon for repair. By the late 1990s, further development of devices and instruments to complete the repair of the rotator cuff tendon attachment to bone using fully arthroscopic surgery resulted in further reduction of trauma and recovery time.

[0003] Arthroscopic repair of the rotator cuff tendon attachment to the humeral head is the most common technique used today. However, these fully arthroscopic procedures are recognized to be very difficult to perform and achieve a variety of results. The skill of the surgeon with the available techniques is a known factor related to the success of the procedure. Even with all the advances and experience in arthroscopic techniques over the past 20 years, defects persist as evidenced by studies showing that the overall average rotator cuff repair failure rate is 20% to 40%, with a highly variable range of 4% to 90% in individual studies. Study results show that failure rates are much higher for large or massive tendon tears, with a large variability in failure rates from surgeon to surgeon, as well as various patient factors, instruments used, and type of repair completed.

[0004] There is great controversy among experts as to the reasons for the high incidence of arthroscopic rotator cuff repair failure (i.e., "rotator cuff re-tears"). However, studies clearly indicate that there is a need to decrease the failure rate of arthroscopic rotator cuff repair to avoid the effects of patient loss of mobility, impaired function, increased pain, and / or the need for subsequent more invasive surgery with its attendant pain and rehabilitation. In particular, there is great concern for patients who have some degree of native or repaired tendon failure, but choose to "live with it" rather than undergo initial or additional surgery or rehabilitation, thus affecting their quality of life and promoting continued joint deterioration through disuse.

[0005] The basic device or devices used for repair of tendons torn from bone are one or more suture anchors, where a mechanical structure provides an anchor to the bone, and one or more sutures extend from the suture anchor for attachment to the soft tissue or tendon. Many types of anchoring techniques have been proposed and are used in surgery. A review of the prior art patent literature shows over 1000 designs for suture anchors, bone anchors, tendon repair systems, delivery devices and methods with improved features over the past 25 years, but repair failure rates remain unacceptable, indicating a need for further improvements in the field of arthroscopic reattachment of tendons to bone, especially in rotator cuff repair.

[0006] overview The inventors have recognized that, among other things, the problem to be solved is a need for new and / or alternative devices and methods for arthroscopic fixation of tendon or other soft tissue to bone, such as in rotator cuff repair, with low failure rates, preferably less than 10% on average, with little variation in failure rates between surgeons, patient characteristics, and systems / methods used in the repair. The disclosed devices, systems, and methods are included in the form of a summary followed by a description of the particular structures or methods claimed in the disclosure along with a description of the problem solved by each element.

[0007] The present disclosure includes an overall system for reattaching tendons that have been at least partially avulsed from their bone attachment or footprint. The system is useful for repairing rotator cuff tendons that have been avulsed from bone, but can be used in other soft tissue and tendon repair procedures. The system is particularly useful for repairing rotator cuff tendons by reattaching ruptured tendons, such as the most common ruptured supraspinatus tendon, to the humeral head of the arm. In larger tears, the infraspinatus tendon may also rupture, making repair with the system amenable. The repair is an anatomical repair, meaning that the system, device, and method result in a repaired tendon and bone combination that closely resembles the previous natural anatomical relationship between the tendon and bone to promote healing and provide full function without pain in the healed repair. Anatomical repair using the currently described system can also utilize local synovial fluid to aid healing and improve function after surgery to seal the tendon in place. The system may also be used to reinforce partial tears and provide area beyond the area of ​​a full thickness tear, if necessary. Additionally, the implanted system can dramatically reduce recovery and rehabilitation time due to the robustness of the repair immediately following surgery, shortening the time spent restricting mobility using a sling and allowing early physical therapy to maintain pre-operative mobility and strength during healing. It is believed that the presently disclosed system can reduce sling time and full recovery time by at least 50%, while reducing the average failure rate to less than 10%.

[0008] As mentioned above, in a preferred embodiment, the exemplary rotator cuff repair is an anatomical repair in that the repaired tendon nearly replicates or approximates the relationship of the natural tendon to the bone in a fully functional joint. For example, the tendon / tendons substantially and completely reattach to the original footprint on the bone where it was ruptured. The original footprint area provides the greatest chance of healing the tendon reattachment to the bone while restoring the anatomical structure. Substantially reattaching to the original footprint means that a substantial portion of the remaining ruptured tendon surface that was originally attached to the footprint reattaches to the footprint. Current systems allow each anchor to be placed transtendinous or transtendinous, allowing approximation of the original tendon attachment. Thus, the tendon is held in the desired position when the anchor is placed, unlike current systems that insert anchors into the bone exposed from the rupture and then use a suture threader (to thread the suture when the tendon is not in place) to approximate the position where the surgeon thinks the tendon will be pulled to the footprint. Additionally, the anatomic repair reduces micromotion at the bone-tendon interface so that healing is promoted even during joint movement. Finally, blood access for healing is improved by utilizing substantially more of the proximal humerus foramina that are not occluded by implant sutures for close or dense arrangement of multiple anchors.

[0009] In fresh cadaveric studies with the currently disclosed system, repaired tendon and bone combinations exhibited tensile strengths of over 400 Newtons (N) upon reattachment, with less than 2 millimeters (mm) of early cycle creep or gap formation when cycled with a peak load of 180 N per cycle on the repaired tendon. Early cycle creep measures how much the tendon slides or moves against the bone attachment, and therefore measures the stiffness or robustness of the tendon's attachment to the bone. Lower early cycle creep may result in faster healing and less need for sling immobilization. Thus, creep of less than 2 mm, or even less than 1 mm, is a favorable outcome in some instances. In other words, if the tendon remains fixed in place in compression against the bone (i.e., micromotion reduced), the healing process occurs more quickly and predictably compared to situations involving the tendon sliding back and forth against the bone.

[0010] In selected embodiments, the anatomical repair requires a dense array of small knotless anchors (requiring a bone hole size for insertion of less than 3 mm) with close spacing between anchors (less than 7 mm edge to edge or less than 10 mm hole center to hole center) to create an anchor to a subsequent anchor or series of anchor suture stitches that apply many points of constant independent force on the tendon against the bone. Independent means that the inability of one suture stitch to apply adequate force does not affect other suture stitches, as would occur if a suture stitch broke. Of course, the number of anchors utilized in the repair depends on the size of the tear.

[0011] It is recognized in the art that rotator cuff tears are divided into four categories based on the size of the tear and whether a single-row or double-row repair is completed. Small tears are less than 1 centimeter (cm) in length, medium tears are 1-3 cm in length, large tears are 3-5 cm in length, and large tears are greater than 5 cm in length. With current devices, the size of the tear limits the surgeon to the large anchors available because the medial anchor must fit into the tear area exposing the bone. For example, the surgeon may use about one medial anchor for small tears, one or two medial anchors for medium tears, and two or three medial anchors for large and large tears. With the anatomical repair using the high anchor density of the present application, the surgeon is not limited by the size of the tear because the anchors are implanted through the tendon, and may use more than three medial anchors for small tears, more than five medial anchors for medium tears, and more than six medial anchors for large and large tears. This may include placing an implant outside the area of ​​a full thickness tear to reinforce areas of partial thickness tears or weaker unruptured tendons. Additionally, the suture anchors of the present invention are designed for knotless tensioning and locking to facilitate implantation, maximize surgeon-to-surgeon reproducibility, and not impede shoulder mobility with a protruding knot, while eliminating tension variations found in knotted suture anchors due to the difficulty of tying knots arthroscopically.

[0012] The suture anchors of the present disclosure are bar or toggle type anchors, and the basic structure for bone attachment is a thin elongated and / or cylindrical body with a cross-sectional diameter of less than about 3 mm and a length of about 6 mm to about 10 mm. Alternative sizes can be used in other applications within the body as desired. Although generally described as cylindrical, it is recognized that certain surfaces can be machined or molded to be flat or grooved to allow the suture strands to extend along the implant when placed in a circular delivery tube. That is, the anchors of the present invention can be polygonal, such as hexagonal or octagonal, or other cross-sectional shapes rather than cylindrical. The anchors are transtendinous or transtendinous implants, as described with respect to the delivery devices and methods below. Being transtendinous, there is no need to place the anchor only where there is no tendon, such as in a hole created by a tear or outside the tendon footprint. Additionally, and importantly, there is no need for sutures to pass through the tendon.

[0013] Transtendon implantation with currently used anchors entails technical challenges including passing 3-6 mm diameter anchors through holes drilled in the tendon with a drill while damaging the tendon. Additionally, the threaded and flanged anchor retainers of known larger anchors would damage the tendon during passage.

[0014] In toggle anchors, the anchor is inserted through a bone hole that is slightly larger than the outer axial diameter of the anchor. Once in the bone, the anchor is toggled (also referred to as flipped or rotated) approximately 90 degrees but at least 60 degrees such that a force applied to the suture extending from the toggle body pulls the length of the toggle body against the inner or underside of the cortical shell of the humeral head. The degree to which the toggle body rotates or moves toward the cortical shell is influenced by the quality of the bone as well as individual patient characteristics such as age, sex, location of the bone hole, and the degree of bone deterioration due to lacerations. The toggle body of the present invention is designed to toggle and seat with appropriate pull-out strength over the range of bone qualities of interest.

[0015] The toggle body works in conjunction with a single suture line, referred to herein as a working suture, that passes through at least one passageway formed through the toggle body. The number of passageways can be varied in the design of the toggle body, as can the manner in which the working suture is passed through the passageways to provide the desired tensioning and locking functions. In some embodiments, the toggle body includes three holes that run through the toggle body generally perpendicular to the longitudinal axis. In this embodiment, the working suture passes through the top of the proximal hole and exits at the bottom, then returns upward through the bottom of the distal hole and exits at the top. The working suture is flossable or slidable to be positioned through the two holes by pulling with sufficient force on either of the working suture legs that extend out from the top of the toggle body. On the bottom surface of the toggle body, a length of working suture runs longitudinally through the middle hole. The suture lock, which includes a separate piece of suture or thread or other flexible cord and extends through the central hole, has an adjustable or collapsible loop or slidable knot that allows the loop to contract and extend around a portion of the working suture as it passes through the middle hole. The other end of the suture lock cord extends from the top of the central hole. When the top or proximal end of the suture lock is pulled, the adjustable loop can be knotted tight against the working suture and collapse, drawing at least a portion of the working suture into the central hole and forming a lock on the working suture so that the working suture cannot slide and will not slide under a full load when implanted.

[0016] In some embodiments, tightening of the suture lock draws a small portion of the working suture into a slot or channel at the bottom of the mid-hole in the anchor. The working suture is pinched in a tortuous path that provides a sound lock and prevents sliding of the working suture relative to the anchor when the suture is properly tensioned. The strength of the lock is enhanced by the overall tortuous path that the working suture follows as it passes through several approximately 90 degree turns that increase friction against the toggle body and the friction exerted by the suture lock as the anchor is tensioned against the cortical shell.

[0017] Each of the individual anchors includes features that ensure proper embedding through the tendon in a hole drilled through the cortical shell of the humeral head. The anchor is inserted lengthwise through this hole into the spongy or cancellous bone. The implant is pushed by the tip of a bone punch that mates with a recess formed in the proximal end of the implant. The recess in the mating surface is formed to help maintain contact between the anchor and the punch while also allowing the anchor to pivot, rotate, or toggle from an insertion configuration in which the anchor's central axis is aligned with the central axis of the punch to an implant configuration in which the anchor's central axis is not aligned with the central axis of the punch. The rotation or toggling can have two parts: a first change in axial direction as the anchor passes past the cortical shell into the cancellous bone during advancement when the punch is used to push the anchor, and a second change in axial direction under tension applied using a working suture as described below. Cancellous bone varies greatly in characteristics by location and patient, ranging from a very soft and porous cellular structure to a hard cellular structure, depending on many patient-specific factors. The features included in the anchors of the present invention ensure adequate toggle retention within bone across a range of cortical shell and cancellous bone variations.

[0018] In selected embodiments, the implant preferably includes an acute angle on the distal face with the top side projecting further longitudinally than the bottom side. When inserted in this manner, the longer portion engages the cancellous bone and initiates rotation during anchor insertion. With both the distal and proximal portions of the working suture extending up through the bone hole, the distal working suture can be selectively pulled, thereby further rotating the implant body. In some instances, the rotation may be at an angle of up to about 90 degrees relative to the central axis of the bone hole, although the degree of rotation is not necessary to the concept of the present invention. It has been found that in hard cancellous bone, pulling on the distal suture may not result in rotation as the proximal portion is held rigid by a hard layer of cancellous bone, causing the toggle body to retract out of the hole and sit under the tendon. To prevent this, the implant includes fins on the proximal portion that project proximally and radially with a cross-sectional dimension larger than the cross-sectional dimension of the bone hole upon delivery. The size of the fins not only prevents backing out of the anchor, but the fins are positioned to project and hook into the cancellous bone and aid in rotation. In some instances, the fins alone cannot handle the full pull-out force; rather, the force pulling on the anchor is carried by the rotating sidewalls of the toggle body, as the toggle anchor must rotate as well.

[0019] A single working suture is pre-tensioned through multiple anchors used as a set to form an embedded array with tensioned suture stitches extending from one anchor to subsequent anchors in the pre-tensioned chain. As previously described, each anchor is slidable or flossable under sufficient applied force to move along the working suture. Each anchor includes a suture lock as described above, except for the first anchor in the chain, which may have a standard suture lock or a fixed, non-slidable suture connection. A chain of anchors may have between about 8 and 12 anchors in some preferred embodiments.

[0020] A dense array of anchors is formed by implantation of anchors in a chain or row that may be relatively straight or curved depending on the rupture to be repaired at the surgeon's discretion. Also disclosed herein is a delivery device system designed for sequential transtendinous implantation of each anchor in the array. The delivery system includes a delivery tool distal portion used at the surgical site for implantation of the array, and a proximal portion having a handle and features for managing the anchors and associated sutures and suture locks. The distal portion of the delivery tool includes an anchor delivery tube that is sized to allow passage of the anchors and associated working sutures and suture locks. The delivery tool is used with a bone punch that is sized to pass through the anchor delivery tube. The proximal portion of the delivery tool is configured to allow the physician to introduce the anchors pre-strung on the working sutures into the anchor delivery tube. The proximal portion of the delivery tool may include a platform for receiving a magazine that supports several cartridges that individually house the pre-strung anchors. The magazine may include a cartridge ejector that allows one cartridge at a time to be removed from the magazine and placed into a slot on the delivery tool. A plunger is used to transfer individual anchors from the cartridge into a lumen at the proximal end of the anchor delivery tube.

[0021] In use, the physician positions the distal end of the delivery tool at the desired location for introduction of the anchor. Such positioning may be performed with a bone punch that extends beyond the distal end of the delivery tool to allow the physician to probe the desired location using the bone punch. The physician then applies force, such as by pressing the distal end of the delivery tool against the tendon and tapping against the proximal end of the bone punch, to form a pathway through the tendon and then a bone hole. The distal end of the anchor delivery tube (called a nub) may advance at least partially through the tendon and into the bone hole as the bone punch is tapped.

[0022] The bone punch is then retracted while holding the nub in place to maintain alignment through the tendon into the bone hole. With the bone punch retracted, the cartridge is removed from the magazine using a cartridge ejector and transferred to a slot on the proximal portion of the delivery tool, and the plunger is depressed to move the anchor from the cartridge into position for advancement into the anchor delivery lumen. The bone punch is advanced again, this time compressing the proximal end of the anchor, ultimately ejecting the anchor from the anchor delivery tube into the bone hole. As the bone punch pushes the anchor down into the anchor delivery tube, the tip of the bone punch engages the recess. The anchor delivery tube may be sized to the anchor to compress the fins to reduce the outer dimension as the anchor passes through the anchor delivery tube.

[0023] As the anchor exits the anchor delivery tube, the fins expand to a fully relaxed diameter, reducing the likelihood of the anchor backing out of the bone hole. In some embodiments, the relaxed diameter of the fins is greater than the size of the bone hole. The bone punch is advanced such that the tip of the bone punch extends beyond the nub, driving the anchor into the bone. As the anchor advances into the bone, the angled distal surface enters the bone first and begins to turn or toggle the anchor. The dimples allow the anchor to rotate without torqueing the distal tip of the bone punch, toggling as the anchor advances. The bone punch is then retracted into the anchor delivery tube, and the working suture is manipulated to keep the anchor toggling in a position parallel to the bone surface, although a less than full toggle may provide a usable anchor position, especially in hard bones. To prevent interference between the anchor and the anchor delivery tube and / or damage to the working suture during toggling of the anchor, the anchor delivery tube may be retracted such that the nub is located within the delivery tool. Additionally, by retracting the anchor delivery tube and / or nub, the flossing tension can be reduced, allowing flossing of the working suture until tensioned, further assisting in toggling as tension is applied against the previous anchor.

[0024] In this first anchor only, the working suture may be locked in place using a locking suture prior to using the working suture to toggle the anchor. Or, if desired, the working suture may be locked in place using a locking suture even before starting implantation of the first anchor, since the inter-anchor stitch cannot be formed until the second anchor is implanted. In some embodiments, the first anchor may be secured to the working suture and the locking suture may be omitted for the first anchor. Once the first anchor is placed in a material of sufficient strength within the bone (which may be the harder cancellous bone or may be abutting the underside of the cortical shell), the delivery device may be placed with the punch pin partially extended as at the beginning of the procedure and moved for implantation of the next anchor.

[0025] At the second and subsequent anchors, both the proximal and distal suture portions of the working suture extend upward through the delivery device. It is the distal portion of the working suture that is pulled to cause rotation of the anchor, while also allowing the working suture to slide through both holes of that anchor, shortening the slack extending to the distal hole of the immediately preceding anchor. It is also recognized that in some embodiments, the proximal portion of the working suture can be tensioned to assist in rotating and locking the anchor into place in the bone hole. During tensioning of the suture after toggling the anchor, the distal end of the outer tube of the delivery tool may be pressed against the tendon to provide a counter force against pull-out. This continues until a properly tensioned suture stitch is formed, at which point the suture lock on the second or subsequent anchor is activated to maintain tension in the individual suture stitches. The locking suture proximal extension may be cut off after cinching, or a selectively frangible suture may be used, with such frangible portion positioned adjacent and proximal to the slidable knot.

[0026] This is repeated for the desired number of anchors of the pre-threaded strand to be embedded to form a high density array, as described above. As can be appreciated, the number of suture stitches formed is equal to the number of anchors in the embedded strand minus one. Furthermore, the threads of the stitches are sequentially continuous with each stitch being independently tensioned and locked to form the required robust tendon attachment. The continuous threads of stitches can form a row or chain of stitches in a desired shape, such as a straight row, a zigzag shape, an arc, etc. Row or chain means that the suture stitches extend from one anchor to the next in a series of embedded anchors. It is appreciated that, especially for large tears, two or more continuous series of stitches can be formed by embedding multiple anchor arrays that together form the entire repair array.

[0027] As previously mentioned, the distance between the ends of the suture stitches (distance between anchors) is preferably less than about 7 mm (less than about 10 mm from hole center to hole center) to provide a consistent force of the tendon against the bone to reduce creep. One particularly robust array of embedded anchors includes a first array embedded in the medial portion of the original tendon footprint to form a row or line of stitches approximately perpendicular to the length or direction of the force of the tendon. A second array can then be embedded laterally near the edge of the tear, with at least one anchor penetrating the tendon, and at least one other anchor embedded laterally of the edge of the tendon to properly reapproximate the tendon against the bone. The horizontal rows can be embedded in a zigzag pattern or other suitable pattern based on the shape of the tear. Multiple patterns can be utilized depending on the size and location of the tear.

[0028] As the above description makes clear, the pre-tensioned array of anchors combined with a working suture and multiple locking sutures creates a strong need for a delivery system having components that manage the anchors and their associated sutures or suture sections to maintain orderly implantation, use, and sterility during the procedure. Furthermore, the small size of the anchors requires some sort of holder or cartridge for the individual anchors. Applicants disclose herein an attachable magazine and multi-cartridge assembly that integrates with the delivery device described above. The assembly includes a cartridge for each anchor in a given array, the individual cartridges being stored and managed in a cartridge magazine in a manner that maintains the integrity of the array and allows the surgeon to sequentially access and use each anchor in the array.

[0029] The overall design of the anchor may include the following features: The anchor may include a distal end with a beveled leading surface to encourage the anchor to begin toggling as it exits the anchor delivery tube and nub. The anchor has a bottom surface and a top surface, the bottom surface being shorter than the top surface due to the beveled leading surface. The anchor may include a proximal end with a pair of fins on either side of a recess or dimple for receiving the distal tip of a bone punch during insertion, the dimple loosely receiving the distal tip of the bone punch to allow the anchor to begin toggling as it exits the anchor delivery tube and nub. The fins are adapted to be compressed while in the anchor delivery tube and then open after exiting the anchor delivery tube to prevent backout of the anchor as it toggles to its final position. The anchor also includes proximal and distal holes for passing a working suture and an intermediate hole through which a locking loop or cord may be passed. The intermediate hole may include a platform that provides a surface against which the locking loop may be compressed when the free end of the locking loop is pulled, allowing the locking loop to clamp down and secure the working suture.

[0030] The pre-threaded anchor can then be configured such that the working suture enters the top of the anchor into the proximal hole, exits the bottom side, and then passes along the bottom side of the anchor to the distal hole. The working suture may extend upward through the distal hole and exit at the top surface. The locking loop extends from the middle hole and surrounds the working suture. The pre-threaded array of anchors can include multiple anchors arranged along a single working suture, each anchor having its own locking loop. Alternatively, the pre-threaded array of anchors can include a first anchor permanently secured to a single working suture and multiple additional anchors each arranged along a single working suture, each having its own locking loop. Each locking loop may include a free end that, once implanted and tensioned, can be tensioned to lock the working suture of the anchor to the anchor.

[0031] Below are some illustrative and non-limiting examples, the particular features identified in these examples may be studied in conjunction with the overall system and may be further understood by reference to the following detailed description and the accompanying drawings.

[0032] An illustrative, non-limiting example takes the form of a system of pre-threaded, serially connected suture anchors to form an embedded array having tensioned and independent locked suture stitches from successive anchors, said system comprising at least four elongate toggle bodies, each toggle body having at least first and second holes therethrough, each hole being spaced apart along said toggle body, and a single continuous suture connecting said at least four toggle bodies in series, said single continuous suture passing from said first longitudinal surface into said first hole, from said second longitudinal surface out said first hole, then returning up from said second longitudinal surface through said second hole and exiting from said first longitudinal surface out said second hole before going to the next toggle body, each toggle body having at least first and second holes therethrough, each hole being spaced apart along said toggle body, and a toggle body having a length of the single continuous suture extending adjacent the second longitudinal surface of the toggle body between the first and second holes, the single continuous suture configured to slide through the first and second holes of the toggle body when a force is applied; and an individual locking loop for each toggle body encircling a portion of the length of the single continuous suture extending adjacent the second longitudinal surface of the toggle body between the first and second holes, each locking loop being adjustable between a first position that allows the single continuous suture to slide through it and a second position that engages the single continuous suture to prevent sliding within it to lock the single continuous suture in a respective toggle body after tensioning.

[0033] Additionally or alternatively, each toggle body further comprises a third hole extending through the toggle body from the first longitudinal surface to the second longitudinal surface, the third hole being located between the first hole and the second hole, and each of the locking loops extending from the third hole at the second longitudinal surface after passing through the toggle body. Additionally or alternatively, each of the locking loops includes a cord having at least a knot slidably tied thereto that allows for collapse of the locking loop when a free end of the cord passing through the third hole of each of the toggle bodies is tensioned. Additionally or alternatively, the third hole of each toggle body has an upper portion for receiving the slidable knot therein at least partially from the first longitudinal surface and terminates in a platform within the toggle body that does not allow passage of the slidable knot. Additionally or alternatively, each locking loop has first and second legs, and the third hole of each toggle body includes a lower portion having an oval shape to allow both legs of each of the locking loops to pass side-by-side and exit the second longitudinal surface of each toggle body. Additionally or alternatively, the slidable knot is at least a four-way simple knot.

[0034] Another illustrative, non-limiting example takes the form of a system of toggle-type suture anchors connected in series by a single working suture, said system comprising a plurality of toggle bodies, each toggle body having an elongate body with a proximal passage, an intermediate passage, and a distal passage extending from a top surface to a bottom surface, each passage being spaced apart along said elongate body with said intermediate passage located between said proximal and distal passages, and a single working suture connecting said plurality of toggle bodies in series, said single working suture entering said proximal passage from said top surface and exiting said bottom surface and then extending to said bottom surface. a single working suture that passes from the top surface of each toggle body back through the distal hole and exits at the top surface of each toggle body with a predetermined length of the suture extending past the intermediate passage adjacent the bottom surface; and a separate locking loop for each toggle body extending from the intermediate passage at the bottom surface, each locking loop encircling a portion of the length of the working suture of each toggle body that extends past the intermediate passage adjacent the bottom surface and having a first open position that allows the suture to slide through the locking loop and a second closed position that engages the suture to prevent sliding within the locking loop.

[0035] Additionally or alternatively, the elongate body of each toggle body may have a pair of fins extending proximally and radially outward from the elongate body proximal to the proximal passage, with at least a portion of each fin extending radially further beyond a maximum lateral dimension of the elongate body. Additionally or alternatively, the locking loop of each toggle body includes a clamping leg extending from a bottom surface of the intermediate passage and extending through the intermediate passage and out of the intermediate passage at the top surface. Additionally or alternatively, the locking loop of each toggle body includes a cord having at least a slidably tied knot to permit collapse of the locking loop when the clamping leg through the intermediate passage is tensioned. Additionally or alternatively, the intermediate passage of each toggle body has an upper portion for receiving the slidable knot therein at least partially from the top surface, and terminates in a platform within the intermediate passage that does not permit passage of the slidable knot. Additionally or alternatively, each locking loop has first and second legs, and the intermediate passage of each toggle body includes a lower portion having an oval shape to allow both legs of the locking loop to pass side-by-side and exit the bottom surface. Additionally or alternatively, the slidable knot is at least a four-way simple knot.

[0036] Another illustrative, non-limiting example takes the form of a toggle-type suture anchor system with a single continuous working suture connecting a plurality of suture anchors, said toggle-type suture anchor comprising at least six toggle bodies, each toggle body having an elongated body having a generally flat face and a generally flat bottom face and rounded sides, said rounded sides defining a maximum diameter of said elongated body, each elongated body having a proximal hole, an intermediate hole, and a distal hole extending from said top face to said bottom face, each hole being spaced apart along said elongated body with said intermediate hole disposed between said proximal hole and said distal hole; and a single working suture, a length of suture extending from said bottom face of each elongated body past said intermediate hole. a single working suture passing through each of the at least six toggle bodies by extending continuously from the top surface into the proximal hole and then from the bottom surface back through the distal hole to exit the top surface of each toggle body, while retaining a length of time therebetween; and a locking suture for the at least six toggle bodies, each locking suture having a collapsible loop formed therein, the collapsible loop extending from the middle hole at the bottom surface and encircling the portion of the working suture extending along the bottom surface and past the middle hole, the collapsible loop closing in response to tension on a leg of the locking suture that extends upward through the middle hole and exits the top surface.

[0037] Additionally or alternatively, each of the locking sutures is a flexible cord having a length sufficient to extend outside the toggle body during use. Additionally or alternatively, the locking suture of each anchor includes a cord having at least a slidably tied knot to allow collapse of the loop when the clamping legs passing through the intermediate hole are tensioned. Additionally or alternatively, the intermediate hole of each anchor has an upper portion for receiving the slidable knot therein at least partially from the top surface and terminates in a platform within the intermediate hole that does not allow passage of the slidable knot. Additionally or alternatively, each collapsible loop has first and second legs, and the intermediate hole of each anchor includes a lower portion having an oval shape for allowing both legs of the collapsible loop to pass side by side and exit the bottom surface. Additionally or alternatively, the slidable knot is at least a four-way simple knot. Additionally or alternatively, the oval portion of the intermediate hole of each anchor is sized to allow at least a portion of the working suture, which is tensioned in response to tension on the locking suture, to move within the oval portion of the intermediate hole.

[0038] This Summary is intended to introduce the subject matter of the present patent application. It is not intended to provide an exclusive or exhaustive description. The Detailed Description is included to provide further information about the present patent application.

[0039] In the drawings, which are not necessarily drawn to scale, like numerals may describe like components in different figures. Like numerals with different subscripts may represent different instances of the like components. The drawings illustrate generally by way of example, but not by way of limitation, various embodiments discussed in the present document. [Brief description of the drawings]

[0040] [Figure 1A] FIG. 13 is a diagram of a pre-threaded array of toggle-type anchors. [Figure 1B]FIG. 1B is another view of FIG. 1A showing the toggle anchor in cross section to show the suture threading path. [Figure 2A] 1A-1D are various views of a representative toggle body. [Figure 2B] 1A-1D are various views of a representative toggle body. [Figure 2C] 1A-1D are various views of a representative toggle body. [Figure 2D] 1A-1D are various views of a representative toggle body. [Figure 2E] 1A-1D are various views of a representative toggle body. [Figure 2F] 1A-1D are various views of a representative toggle body. [Figure 2G] 1A-1D are various views of a representative toggle body. [Figure 2H] FIG. 13 is a partial cutaway view of a toggle body with the working and locking sutures in the open position shown. [Figure 2I] FIG. 2C is a partial cutaway view of the toggle body of FIG. 2H with the working suture and the locking suture shown in the closed position. [Figure 2J] 1A-1C are schematic diagrams showing the interaction between a locking suture and a working suture. [Figure 2K] 13A-13C are schematic diagrams illustrating alternative interactions between locking sutures and working sutures. [Figure 3A] 1A-1D are perspective views of an exemplary anchor delivery device in several configurations. [Figure 3B] 1A-1D are perspective views of an exemplary anchor delivery device in several configurations. [Figure 3C] 1A-1D are perspective views of an exemplary anchor delivery device in several configurations. [Figure 3D] FIG. 4 is an enlarged view of the distal end of the anchor delivery device corresponding to FIGS. 3A-3C. [Figure 3E] FIG. 4 is an enlarged view of the distal end of the anchor delivery device corresponding to FIGS. 3A-3C. [Figure 3G] 1A-1D are partial cutaway views of an anchor delivery device in several configurations. [Figure 3H]1A-1D are partial cutaway views of an anchor delivery device in several configurations. [Figure 3I] 1A-1D are partial cutaway views of an anchor delivery device in several configurations. [Figure 3J] 1A-1D are partial cutaway views of an anchor delivery device in several configurations. [Figure 3K] 1A-1D are partial cutaway views of an anchor delivery device in several configurations. [Figure 3L] 1A-1D are partial cutaway views of an anchor delivery device in several configurations. [Figure 3M] 1A-1D are partial cutaway views of an anchor delivery device in several configurations. [Figure 3N] 1A-1D are partial cutaway views of an anchor delivery device in several configurations. [Figure 3O] 1A-1D are partial cutaway views of an anchor delivery device in several configurations. [Figure 3P] 1 illustrates features of an exemplary anchor delivery tube. [Figure 3Q] 1 illustrates features of an exemplary anchor delivery tube. [Figure 3R] 1 shows the connection of the bone punch assembly. [Figure 4A] 13 illustrates a plunger feature for securing the cartridge to the anchor delivery device. [Figure 4B] 13 illustrates a plunger feature for securing the cartridge to the anchor delivery device. [Figure 4C] 13 illustrates a plunger feature for securing the cartridge to the anchor delivery device. [Figure 4D] 13 illustrates a plunger feature for securing the cartridge to the anchor delivery device. [Figure 5A] 1 shows a cartridge for holding a toggle anchor. [Figure 5B] 1 shows a cartridge for holding a toggle anchor. [Figure 5C] 1 shows a cartridge for holding a toggle anchor. [Figure 5D]1 shows a cartridge for holding a toggle anchor. [Figure 5E] 5A-5D and a plunger as in FIGS. 4A-4D. [Figure 6A] 1 illustrates steps for implanting an exemplary anchor of the present invention and a continuously tensioned and locked anchor-to-anchor single suture stitch pattern. [Figure 6B] 1 illustrates steps for implanting an exemplary anchor of the present invention and a continuously tensioned and locked anchor-to-anchor single suture stitch pattern. [Figure 6C] 1 illustrates steps for implanting an exemplary anchor of the present invention and a continuously tensioned and locked anchor-to-anchor single suture stitch pattern. [Figure 6D] 1 illustrates steps for implanting an exemplary anchor of the present invention and a continuously tensioned and locked anchor-to-anchor single suture stitch pattern. [Figure 6E] 1 illustrates steps for implanting an exemplary anchor of the present invention and a continuously tensioned and locked anchor-to-anchor single suture stitch pattern. [Figure 6F] 1 illustrates steps for implanting an exemplary anchor of the present invention and a continuously tensioned and locked anchor-to-anchor single suture stitch pattern. [Figure 6G] 1 illustrates steps for implanting an exemplary anchor of the present invention and a continuously tensioned and locked anchor-to-anchor single suture stitch pattern. [Figure 6H] 1 illustrates steps for implanting an exemplary anchor of the present invention and a continuously tensioned and locked anchor-to-anchor single suture stitch pattern. [Figure 6I]1 illustrates steps for implanting an exemplary anchor of the present invention and a continuously tensioned and locked anchor-to-anchor single suture stitch pattern. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0041] The present invention includes multiple components, devices, and methods for creating and using an overall system for reattaching soft tissue to bone. It is particularly useful in arthroscopic rotator cuff repair to create a robust repair of a ruptured tendon, such as the supraspinatus tendon. The implantation and delivery device allows for a faster, easier, and lower failure rate anatomical repair. The tendon is securely attached and held in its original footprint with adequate force with little creep during joint motion. This reduces the time the patient spends in a sling, increases the healing rate of tendon reattachment to bone, and allows early physical therapy to maintain range of motion and strength.

[0042] The implanted array of anchors with a continuous set of anchor-to-anchor single suture stitches forms a stitch-like attachment similar to a sewing machine construct. Furthermore, because the anchors have a small cross-sectional size (less than 3 mm in diameter), it is possible to place the anchors close together (less than about 7 mm between adjacent anchors). This creates an anchor-to-anchor suture stitch. Combining this concept with the disclosed anchor design allows the suture stitches to be individually tightened and locked when adjacent suture anchors are implanted. This can be repeated many times to implant rows of anchors with successive independently tensioned and fixed stitches between adjacent anchors. Also, the tension component of the tensioned suture is applied more perpendicular to the top surface of the tendon (or other connective tissue), thus holding the tendon against the bone footprint without creep or slip during articulation.

[0043] In some preferred embodiments, the individual anchors do not function alone, as described in detail below. Instead, each is part of a pre-threaded array having a common continuously disposed working suture passing therethrough. FIG. 1A shows a pre-threaded array 201. Each anchor 200 may be embedded in series within the array, and then the working suture section extending from the just-embedded anchor to the just-embedded anchor may be tensioned and then locked with the just-embedded anchor such that the suture stitch between the two anchors provides a force against the tendon to hold it in place like a single sewn stitch. With the array, multiple continuous stitches may be formed similar to a sewn seam.

[0044] FIG. 1A shows a pre-threaded array 201 of individual anchors 200. The anchors 200 may be similar in form and function to the anchors 100 described herein. The array shown has four anchors 200 as a representative chain. A chain of four to twelve anchors is believed to be useful in tendon repair procedures such as rotator cuff repair. One particular embodiment includes eight anchors in the array. As shown in FIG. 1A, the manner in which the working suture 115 is pre-threaded through the series of anchors 200 is important to ensure that when the suture is tightened, they toggle and tension as desired to form a stitch. The figure shows a first anchor 202 to be implanted, followed by a second anchor 204, then a third anchor 206, and finally a fourth anchor 208. With this implantation sequence understood, the working suture 115 is pre-threaded down through the top of the proximal hole 210 and back up through the distal hole 211 of the first anchor 202. The working suture 115 then continues to the second anchor 204 where it is threaded downward through proximal hole 212 and back up through distal hole 213 of the second anchor 204. The working suture 115 then continues to the third anchor 206 where it enters the top of proximal hole 214 and returns to distal hole 215 of the third anchor 206. The working suture then continues to the fourth anchor 208 where it enters the top of proximal hole 216 and passes up through the bottom of distal hole 217 of the fourth anchor 208. If the array is four or more anchors, pre-threading continues as described for each subsequent anchor.

[0045] FIG. 1B is a cross-sectional view of the array of FIG. 1A, more clearly showing the threading of the working suture 115 into the anchors 200 of the array 201. Also shown is the manner in which the locking suture 116 is positioned within the mid-passage for each anchor 200 as described above, with each locking loop 118 being independent for each anchor. The locking suture 116 can have a preferred break point so that it can be tightened and then broken above the slidable knot. This can be accomplished by tying or cutting a break knot at the free end of the locking loop just above the slidable knot, as further shown in FIGS. 2H-2K below. In some preferred embodiments, the slidable knots are four simple knots, with the break knot at the free end just above the simple knot. The suture lock may be designed to break at a desired tension with the slidable knot in place sufficient to lock the working suture.

[0046] To form an embedded continuous array of tensioned, independently locked anchor-to-anchor suture stitches for attaching tendon to bone, the surgeon begins with the pre-strung array 201 described in Figures 1A and 1B. A first anchor 202 is embedded in a bone hole created through the tendon and the working suture is locked. A second anchor 204 is then embedded proximal to the first anchor 202, preferably less than 7 mm away. The working suture is tensioned by toggling the second anchor and simultaneously pulling the working suture 115 exiting the distal hole 213 of the second anchor 204. The tension in this position not only toggles the second anchor 204 but also tightens the working suture 115 back to the first anchor 202 to form a tension stitch that holds the tendon against the footprint. The second anchor 204 is then locked such that the stitch remains tensioned and is separate or independent from the other stitches. This process is repeated for the third anchor 206 and fourth anchor 208, etc. In one preferred array, eight anchors are implanted with seven in successive rows of tensioned, fixed stitches formed. Additionally, in a rotator cuff repair, multiple arrays can be implanted with one array extending across the tendon on the medial portion of the footprint and a second array extending more lateral to the medial location.

[0047] 2A-2K are a series of views of an exemplary toggle body or toggle-type anchor that may be used in a procedure for attaching a tendon to bone. The views also show a single working suture slidably disposed within a passage through the anchor and a locking loop. The locking loop is configured to have an open position that allows movement of the single working suture and a closed or locked position that prevents movement of the single working suture.

[0048] Referring to FIG. 2A, a perspective view of a representative anchor in the form of a toggle body 100 is shown. The toggle body 100 can be an elongated body 101 having a length defined by a proximal end 102 and a distal end 104. The elongated body 101 can be a generally cylindrical body, although other shapes are possible. For example, as shown in FIG. 2A, the toggle body 100 is generally cylindrical, but the top surface 105 and bottom surface 107 have flat axially extending surfaces that allow space for the suture when the toggle body 100 is in a rounded delivery tube. The length of the toggle body 100 is substantially longer than its diameter, allowing the toggle body 100 to be inserted lengthwise or axially into a small bone hole. Once inserted, unlike most anchors used today, the entire body is pivoted or toggled so that it remains in the bone and substantially its entire length is compressed against the material inside the bone. That is, the longitudinal axis of the toggle body 100 is rotated or pivoted away from the orientation used for insertion through a bone hole, thereby preventing removal. This approach means that removal requires the anchor to break itself rather than simply being released from the surrounding tissue, providing high pull-out strength from the anchor (greater than 600 N before anchor breakage when embedded in the arrays disclosed herein) necessitating very small insertion holes (less than about 3 mm). As previously mentioned and described in more detail below, small insertion holes allow for closer spacing of the anchors in a high density array.

[0049] The toggle body 100 can have a length of about 6 mm to about 10 mm in some embodiments. This length provides adequate strength while leaving enough space inside the bone for multiple anchors to be implanted. The toggle body is preferably molded or machined from a polymeric material, preferably a high tensile strength material such as polyetheretherketone (PEEK), which is highly biocompatible. In applications where MRI imaging is not an issue, metal can be utilized for part or all of the toggle body.

[0050] 2B (top view) and 2C (bottom view), it can be seen that the toggle body 100 can include several holes or passages through a cross section of the toggle body 100. As shown, the toggle body 100 has a proximal hole or passage 110, an intermediate passage 108, and a distal passage 106. The passages 106, 108, 110 extend from the top surface 105 to the bottom surface 107 such that the passages 106, 108, 110 extend through a cross section of the elongate body 101. In other embodiments, the toggle body may have fewer or more holes or passages, such as having a single hole, two holes, or more than three holes. In the illustrated embodiment, the proximal passage 110 and the distal passage 106 receive a portion of a common working suture that is slidable relative to the toggle body 100 during use. The intermediate passage 108 receives a locking suture that is independent for each anchor used in the array of anchors.

[0051] The distal end 104 of the toggle body 100 has a beveled surface. As shown, the beveled surface forms an upper longitudinal surface 105 that is longer than a lower longitudinal surface 107. In other words, the upper surface protrudes a greater distance distally than the lower surface. This is useful during insertion of the toggle body 100, as the protruding distal surface will penetrate into the cancellous bone when implanted to initiate at least partial rotation of the toggle body during insertion. Note that the toggle body 100 of the present invention is preferably implanted through a tendon, and it is important that the toggle body 100 is not visible as it may toggle or be pulled out of the bone hole under tension every time.

[0052] The proximal end 102 of the toggle body 100 can include one or more protruding fins 112. The illustrated embodiment includes two fins 112. Each fin 112 projects outwardly and proximally. Additionally, in some embodiments, as shown, the fins 112 project downward as they extend proximally. The function of the fins 112 is best understood with reference to FIGS. 2D and 2E, which are distal and proximal end views, respectively, of the toggle body 100. A reference circle 113 is included to indicate the general maximum cross-section or diameter of the elongated body 101. The bone hole in which the implant is placed is sized to closely match this dimension, as is the inner diameter of the delivery tube used to deliver the implant. In contrast, as shown, each of the fins 112 projects laterally beyond the outer cross-section or diameter of the elongated body. During insertion, the fins 112 flex inwardly under compressive forces from contact with the inner diameter of the delivery tube to fit the bone hole.

[0053] Once delivered and released from the compressive force of the delivery tube, the fins 112 relax to a size larger than the bone hole. In some preferred embodiments, each fin tip extends approximately 0.5 mm beyond the size of the bone hole into which the feature is inserted. Such fin tips may also be described as extending approximately 0.5 mm beyond the maximum outer diameter of the remainder of the anchor body, such as in the range of 0.4 mm to 0.7 mm. This feature provides an additional safeguard to prevent the toggle body 100 from backing out of the bone hole under tension if the toggle body 100 is not properly toggled. Additionally, the fins 112 are positioned such that tension on the toggle body 100 causes the partially toggled anchor to grip cancellous bone and further rotate the anchor.

[0054] Alternative designs of fins 112 are also shown in Figures 2F and 2G. The fins 112 in these figures have alternative locations on the elongated body 101 and orientation of the proximal extension. The fins 112 in Figure 2F are widest in a central location to keep the anchor centered within the delivery tube, as their largest dimension is horizontal with the diameter of the delivery tube. In some instances, the fins do not provide the pull-out strength required for the implanted anchor to reattach the tendon. As previously mentioned, in preferred instances, each anchor toggles so that the entire length of the anchor is pressed against the internal bone structure to provide adequate pull-out strength.

[0055] The top and bottom views of Figures 2B and 2C show details of the proximal passageway 110, the middle passageway 108, and the distal passageway 106. In particular, the middle passageway has a platform 114 formed partway through the cross section within the elongate body 101. That is, in this example, the middle passageway 108 has a change in size or shape partway along its length to define the platform 114. From the bottom view, it can be seen that the middle passageway 108 continues from the platform 114 with a slotted or elliptical shape or portion 111, but from the top view, it has a circular profile. The functionality of these passageways is shown in detail in the cross-sectional perspective views of Figures 2H and 2I, in which representative cords or sutures 115, 116 are pre-tensioned on the toggle body 100.

[0056] First, there is a single suture, referred to herein as working suture 115, which extends from the top surface into the proximal passage 110 and out at the bottom surface. Then, working suture 115 extends up from the bottom surface through the distal passage 106 and out through the top surface. This causes a portion 117 of working suture 115 to extend along the bottom surface past or adjacent to the middle passage 108. Working suture 115 may be flossed or slidable through the distal passage 106 and the proximal passage 110, meaning that toggle body 100 can slide over working suture 115 when tension is applied. Next, there is a locking loop 118 that encircles a portion of portion 117 of working suture 115 that extends adjacent the outer surface of toggle body 100 between the proximal passage 110 and the distal passage 106. Locking loop 118 has a first, open position, as shown in FIG. 2H, in which working suture 115 slides freely through locking loop 118, and a second, closed position, as shown in FIG. 2I, in which locking loop 118 engages portion 117, preventing it from sliding within locking loop 118.

[0057] Some examples refer to sutures, cords, or threads that can be used as working sutures 115 or within locking loops 118. These elements can be formed, for example, from natural materials (e.g., silk) and / or synthetic materials (e.g., polyglycolic acid, polylactic acid, and polydioxanone, each of which are known for use as absorbable sutures), and / or nylon and polypropylene (which are typically non-absorbable). Various coatings can be applied as well, including antibacterial, anti-wicking, or lubricious coatings. More broadly, these elements 115, 118 may include any item that can be used to bind objects together in a surgical environment, such as any sufficiently biocompatible metals, natural materials, plastics, or other man-made materials adapted for use in surgical procedures. Monofilaments or more complex structures (including braids, wovens, wound wires, twisted threads, coated or multi-layered members, etc.) can be used.

[0058] In the illustrated embodiment, the locking loop 118 extends from the bottom surface of the toggle body 100 through the intermediate passage 108. The locking loop 118 comprises a cord or suture with at least a slidable knot 120 tied therein to allow collapse of the locking loop 118 when the free or proximal end 121 of the suture lock 116 extending through the intermediate passage 108 is tensioned. As illustrated, the top of the intermediate passage 108 is sized to receive at least a portion of the slidable knot 120 therein. The slidable knot 120 then contacts the surface of the platform 114, which does not allow the knot to pass toward the bottom opening. The lower elliptical portion 113 of the intermediate passage 108 is a slot or ellipse that allows both legs of the locking loop 118 to pass through, preferably side-by-side in the slot direction. The interaction of these components locks the working suture 115 to the toggle body 100.

[0059] As shown, and particularly as seen in FIGS. 2C and 2I, the bottom of toggle body 100 includes a channel 125 formed in bottom surface 107 between proximal passage 110 and distal passage 106. When tension is applied to working suture 115, it is drawn up into this channel 125. This channel is sized to more inhibit the suture from flossing or moving therethrough by increasing frictional resistance to such movement, but does not lock the suture. Additionally, the working suture has two approximately 90 degree angle bends at the bottom openings of distal passage 106 and proximal passage 110, which also make it more difficult to floss, but do not lock the working suture 115. Locking loop 118, which closes around working suture 115 and draws it towards slot or oval portion 113, is a structure that locks the working suture such that cumulative friction prevents slippage of working suture 115.

[0060] In the illustrative example shown in Figures 2H-2K, the free end 121 of the suture lock 116 is configured to be spaced from the locking loop 118 proximal to the sliding knot 120. A break knot is shown at 122, which is one example of a method of introducing weakness into the suture lock. The break knot 122 is located above the sliding knot 120 a sufficient distance such that the sliding knot 120 remains intact and secured when the suture lock 116 breaks, for example, around 3-10 mm proximal to the sliding knot. Rather than a break knot 122, a slit or other point of weakness may be provided at the desired or preferred point of failure of the suture lock 116.

[0061] 2J and 2K show how, in two different embodiments, locking loop 118 draws portion 117 of working suture 115 into oval portion 113. The extent to which portion 117 of working suture 115 enters slot 113 depends on how tightly the loop is closed, the size of the locking suture, and the size of the slot opening. In a preferred embodiment, at least a portion of the cross section of working suture 115 is drawn into the slot such that the edge surfaces of the slot walls provide significant friction to aid in locking. In another example, the preferential failure point is designed to allow locking loop 118 to be drawn into the slot before failure occurs.

[0062] The locking loop 118, in combination with the design of the middle passage 108, is an assembly for locking the slidable working suture 115 when pulled within the suture toggle body 100 during tissue fixation to bone. The locking loop 118 encircles a portion of the working suture 115 and compresses the cross section of the working suture 115 by collapsing the locking loop 118 to lock the working suture 115 when under tension. The suture lock 116 is preferably formed from a suture having at least one slidable knot 120 tied therein to form the loop 118, allowing the loop 118 to collapse when the clamping leg 121 through the second passage 108 is pulled. The second passage 108 has an upper portion for at least partially receiving the slidable knot 120 therein and terminates in a platform 114 within the toggle body 100 that does not allow the passage of the slidable knot. The second passage includes a lower portion having an oval shape to allow both legs of the locking loop to pass side by side and exit the passage. A particularly preferred knot is a four-way simple knot. However, other slidable knots 120 may be used as desired. Additionally, the second passage oval portion is sized to allow movement of at least a portion of the working suture 115 being pulled therein in response to tension on the locking cord. The working suture 115 is preferably a braided multi-strand suture having a compressible cross-sectional area that is reduced by at least about 25% when the locking loop is tightened in use. The working suture 115 may be a round and / or braided No. 2 suture in some embodiments. Other sizes and types of sutures may be used.

[0063] 2I and 2K, after the sliding knot 120 is tightened and the working suture is at least partially drawn into the slot, a preferential break point (such as the break knot or slit described above) in the locking loop 116 can break, leaving a free end at 123 on the locking loop a distance above the sliding knot, while discarding the remainder of the proximal portion of the suture lock 124. In some instances, the more proximal portion of the suture lock is secured to the cartridge, allowing the physician to break the suture lock as shown by pulling on the cartridge itself, as described further below. In one instance, the preferential break point is designed to allow tightening of the locking loop 118 onto the working suture 115 before breakage occurs. For example, the locking loop and preferential failure point may be configured to break under a tensile strength ranging from 13.3 to 44.5 Newtons (3 to 10 pounds) of force, more preferably 22.2 to 31.1 Newtons (5 to 7 pounds), or more or less as desired. The tensile strength required to clamp the locking loop 118 onto the working suture may be less than the tensile strength required to break the preferential failure point by an amount within the range of, for example, 2.2 to 13.3 Newtons (0.5 to 3 pounds), or 3.3 to 8.9 Newtons (0.75 to 2 pounds), or 4.4 Newtons (about 1 pound).

[0064] One preferred anchor delivery device 300 for transtendinous implantation of individual anchors in an array is shown in Figure 3 A. Delivery device 300 is particularly useful for implanting the anchors disclosed herein and described in detail below with respect to Figures 2A-2K, and the arrays disclosed in Figures 1A-1B.

[0065] 3A-3C are perspective views of an exemplary anchor delivery device in several configurations, and FIGS. 3D-3F are close-up views of the distal end of the anchor delivery device corresponding to FIGS. 3A-3C. Beginning with FIG. 3A, delivery device 300 may be a gun-like piece having a proximal housing 310 including a pistol-grip style handle 311 and a trigger 312 that moves from a spring-loaded released position to an engaged position when the trigger is held in a squeezed position (as described further below). Trigger 312 is coupled to a movable internal feature within proximal housing 310 to provide desired functionality during implantation, described below. Delivery device 300 includes an elongated tube 306 extending distally from proximal housing 310. As shown in the close-up view of FIG. 3D, elongated tube 306 includes a longitudinal slot 307 spanning the length of tube 306 for receiving a suture as the anchor passes through the central lumen of the tube.

[0066] FIG. 3A also shows that the proximal housing 310 is associated with a bone punch having a distal punch head 322 and a proximal punch head 323. The proximal punch head 323 has a tapping surface 324 on its proximal side. The combined elements 322 and 323 form a punch head assembly. As shown in FIG. 3D (corresponding to the configuration of FIG. 3A), the bone punch includes a punch pin 320 having a tapered tip 321 adapted to explore through the tendon and / or to grasp the tendon to aid in positioning. Positioning may include, for a separated tendon, positioning the tendon in its original footprint. In some instances, positioning as a separate step may be omitted or limited, such as when repairing partial tears, such as a split-thickness articular side tear or a combination of a full-thickness tear and an articular partial-thickness tear. The tendon may be considered to be placed in position for fixation to bone by placing a completely torn or separated tendon in a position such as in its original footprint where it can be reattached, or with a partial tear when the tendon is located where the physician would like to have it when applying an anchor to repair or otherwise address the partial tear.

[0067] The punch pin 320 and tip are configured to be driven into bone to form a bone hole, and the tapered tip 321 is used to engage and press against the proximal end of the anchor in some methods disclosed herein. The punch pin 320 extends through the proximal housing 310 and the elongate tube 306. The punch pin 320 is fixed to a proximal punch head 323 and is slidable within a distal punch head 322. The distal punch head 322 snap-latches to the proximal housing 310 of the delivery device. The proximal punch head 323 and the distal punch head 322 are connected by a spring-loaded mechanism that holds the punch pin 320 in a fully extended position when the proximal punch head 323 is pressed against and latched against the distal punch head 322. When the proximal punch head 323 is released from its intimate connection with the distal punch head 322, a spring load causes the punch pin 320 to retract proximally to a partially retracted position, with only a short distal portion of the punch pin 320 extending beyond the elongated tube 306 for use in probing a potential implantation site. Such a configuration of the implantation tool is shown in Figures 3A and 3D, where the punch pin 320 is the only part extending from the distal tip of the elongated tube 306, the distal punch head 322 is latched to the proximal housing 310, and the proximal punch head 323 is not latched to the distal punch head 322. Also included on the proximal housing 310 is a receptacle 398 for receiving a magazine carrying cartridges that hold the individual anchors of the array to be implanted, as shown in Figure 4A below.

[0068] FIG. 3B and corresponding FIG. 3E show another configuration of the delivery device 300. Starting with FIG. 3B, it can be seen that (similar to FIG. 3A) the trigger 312 remains in a relaxed position and is not depressed. Now, the proximal punch head 323 is latched to the distal punch head 322. Latching the punch heads together causes the distal end of the punch pin 320 to extend further from the distal end of the elongated tube 306, as shown in FIG. 3E. Now, an additional element is shown in that the elongated tube 306 has an anchor delivery tube 330 disposed therein. The action of latching the proximal punch head 323 with the distal punch head 322 advances the anchor delivery tube 330 distally, causing a distal portion of the anchor delivery tube 330 to pass the distal end of the elongated tube 306. The anchor delivery tube 330 also has a longitudinal slot 331 that aligns with the longitudinal slot 307 of the elongated tube for threading the suture. With anchor delivery device 300 configured as shown in Figures 3B and 3E, the device is ready for the surgeon to strike tapping surface 324 with a surgical mallet or the like to drive punch pin 320 and its tip 321 into the bone to form a bone hole.

[0069] 3C and 3F show the next configuration of the delivery device, where the distal punch head 322 is no longer engaged with the proximal housing 310 and the proximal punch head 323 and distal punch head 322 are not latched to one another. Disengagement of the distal punch head 322 and housing 310, and disengagement of the proximal punch head 323 and distal punch head 322 are triggered by actuation of trigger 311, as described further below. As described in the method diagrams of FIGS. 6A-6G below, this configuration occurs after the bone hole has been created and is used to introduce the anchor / suture into the anchor delivery tube for implantation. To facilitate such a step in the procedure, a portion of the anchor delivery tube 330, referred to as nub 332, remains extending from the distal end of the elongate tube 306, as shown by FIG. 3F. Once the bone punch is retracted or removed, anchor delivery tube 330 defines an open lumen 333 allowing the anchor to be introduced and passed through open lumen 333 with the aid of a reinserted bone punch, as described in more detail below. Optionally, as also highlighted in FIG. 3F , the distal end of extension tube 306 may be tapered, as shown at 308. Taper 308, in some embodiments, provides elongated tube 306 with a blunt distal tip that can be used to maintain force against the outside of the tendon during manipulation of the anchor and / or tensioning of the suture between the two anchors.

[0070] At a high level, the procedure may be understood as follows. With anchor delivery device 300 in the configuration shown in FIG. 3A / 3D, the physician may explore the surgical site to identify where the anchor is to be implanted. Once the desired location is identified, the physician applies force to the tapping surface 324 of the bone punch to force the bone punch through the tendon and create a bone hole using the distal tip 321 of punch pin 320. As the physician advances the bone punch in this manner, the proximal punch head 323 and the distal punch head 322 latch together to form the configuration shown in FIG. 3B / 3E. The same action of advancing the bone punch relative to the elongated tube also advances anchor delivery tube 330 and nub 332 over the distal end of elongated tube 306. Trigger 311 is then actuated to release the bone punch and push it proximally to form the configuration shown in FIG. 3C / 3F. The implantation tool 300 is held in place using nub 332 to maintain alignment with the created bone hole. In some embodiments, the nub is partially inserted into the bone hole. An anchor is then introduced into the anchor delivery tube 330 and threaded through the lumen 333 of the anchor delivery tube to the distal end while a force is applied to advance the anchor using the bone punch assembly. Full insertion of the anchor can be confirmed by maintaining pressure on the tendon to hold the nub 332 in the desired alignment with the bone hole and pushing the proximal punch head 323 distally until the distal punch head 323 latches with the proximal housing 310 and the proximal punch head 322 latches with the distal punch head 322. The trigger 311 is now actuated again, but by a mechanism described below, this second actuation of the trigger after insertion of the anchor applies a positive retraction force in conjunction with the spring force to retract the anchor delivery tube 330 and nub 332 into the distal end of the elongate tube 306 and retract the bone punch. With the nubs retracted, the physician can use the working suture to manipulate the toggle of the anchor without the possibility of the nubs 332 damaging the working suture, while maintaining force against the tendon and bone by pressing the distal tip of the elongated tube 306 against the tendon.After toggling the anchor, the delivery tool 300 is pulled back from the implanted position and the suture lock is secured by pulling the suture locking cord. If the anchor is the second or subsequent anchor in a series of anchors, the physician may tighten the working suture to form a stitch while maintaining pressure on the tendon with the elongate tube 306 before moving the delivery device to the next location. The delivery device is then reset and the configuration of Figures 3A / 3D is again assumed.

[0071] Referring now to the detailed features of the exemplary embodiment shown in the drawings, Figures 3G-3I are partial cutaway views of the anchor delivery device in several configurations. Figure 3G corresponds generally to the configuration of Figures 3A / 3D, and can be seen in the drawing by noting that the distal punch head 322 is latched to the proximal housing 310, the proximal punch head 323 is not latched to the distal punch head, and the punch head spring 325 is in an extended position. A nub coupler 355 is shown, which is pushed forward by the proximal punch head via a proximal punch head pin 356 having a ridge that interacts with the nub coupler 355. The device includes a slide stop 350 and an ejector 352. The ejector 352 is in turn secured to a trigger coupler 313, which is pivotally attached at one end to the trigger 312 and at the other end to the ejector 352. Ejector 352, in the configuration shown, abuts at its proximal end against distal punch head 322. The anchor delivery tube is connected at its proximal end to nub sub coupler 340, which is itself spring-loaded against proximal housing 310 by nub spring 343. As noted with respect to FIGURE 3D, in this configuration the anchor delivery tube nub is retracted into the elongate tube, meaning that nub spring 343 is in a relaxed state as shown.

[0072] FIG 3H generally corresponds to the configuration of FIG 3B / FIG 3E, which can be seen in the drawing by noting that distal punch head 322 is latched to proximal housing 310, proximal punch head 323 is latched against distal punch head 322, and punch head spring 325 is in a compressed position. The same action of pushing proximal punch head 323 to latch with distal punch head 322 also pushes nub coupler 355 distally, which in turn pushes nub sub coupler 340 and anchor delivery tube distally, compressing nub spring 343 and advancing the anchor delivery tube so that the nub extends from the distal end of the elongate shaft, as shown by FIG 3E. This movement also changes the apposition of slide stop 350 and nub sub coupler 340, which can be seen now to be positioned distal to the top of slide stop 350 with the proximal edge of nub sub coupler 340.

[0073] FIG. 3I illustrates the use of trigger 312 to force a change in configuration from the configuration of FIG. 3B / E to the configuration of FIG. 3C / F. Here, trigger 312 is retracted relative to grip 311. Trigger coupler 313 moves ejector 352 proximally, overcoming the latching force of proximal and distal punch heads 323, 322 against housing 310, disengaging the latches coupling proximal and distal punch heads 323, 322 together (see FIG. 3R below), and retracting the bone punch. However, nub 332 does not retract into elongate tube 306 because slide stop 350 engages nub subcoupler 340, preventing it from moving proximally. Nub spring 343 remains compressed.

[0074] FIG. 3J shows a close-up view from the rear as a partial cutaway of the proximal housing. Here, it can be seen that the nub sub coupler 340 abuts the slide stop 350 at position 345. The slide stop 350 is supported on a pin 357, which allows for lateral movement, as described further below. The pin 357 carries a slide stop spring 359 that urges the slide stop 350 laterally toward the position shown in FIG. 3J. Additional features of the slide stop 350 are shown in FIG. 3K, which provides another angle from which to view the partial cutaway (with the slide stop spring 359 omitted). Here, the slide stop 350 includes an extension 351, which is the portion that abuts the nub sub coupler 340 at the step shown in FIG. 3I / FIG. 3J. Also visible is a ramp 353 on the ejector 352 which presses against the extension 351 to push down on the ejector 352 and thereby prevent the ejector hook 354 from engaging the corresponding nub sub coupler hook 346. As can be seen, the slide stop 350 in this configuration limits the proximal travel of the nub sub coupler 340, thereby preventing the nub from retracting and preventing the ejector hook 354 from engaging the nub sub coupler hook 346.

[0075] 3L-3N are partial cutaway views further illustrating the interaction of the internal components of the anchor delivery device. FIG. 3L shows the separation of slide stop 350 from nub sub coupler 340 and ejector 352. A plunger control arm 385, inserted as shown below in FIGS. 4A-4D, pushes the slide stop laterally so that nub sub coupler 340 cannot engage extension 351, and moves the slide stop along pin 357 so that it no longer presses against extension 351 as ejector 352 is moved proximally. Thus, slide stop spring 359 is compressed and remains compressed until nub sub coupler 340 is advanced again when driven to form the next bone hole. In an alternative configuration, separation of slide stop 350 from nub sub coupler 340 can be accomplished by coupling item 385 to a switch or lever on the housing, if desired, rather than using a plunger action. The location of the slide stop spring 359 is exemplary and other configurations and locations may be used.

[0076] The movement of the slide stop 350 allows a different interaction to occur when the trigger is subsequently pulled, as highlighted in FIG. 3M. Here, the slide stop is omitted from the view of FIG. 3M because it no longer blocks the movement of the other parts when the trigger is squeezed. The assembly remains extended until trigger actuation, even as the slide stop moves laterally, with the proximal and distal punch heads latching to each other and the distal punch head latching to the proximal housing. Here, it can be seen that the proximal end of the nub sub coupler 340 is free to move proximally. Additionally, the ejector hook 354 can engage with the corresponding nub sub coupler hook 346, so that a positive retraction force can be applied by the ejector 352 when it is pushed proximally by the trigger. To ensure that the hooks 346 and 354 interact, the lower slope 358 of the ejector 352 presses against the plunger control arm 385. The resulting action is illustrated by the diagram in FIG. 3N, which shows how the nub subcoupler 340 moves past slide stop 350 while allowing retraction of the nub when desired, using force applied via trigger actuation and force applied by nub spring 343.

[0077] FIG. 3O is a partial cutaway view of the anchor delivery device during a second actuation of the trigger. Here, trigger 312 is squeezed against grip 311, causing trigger bar 313 to push ejector 352 proximally, unlatching distal punch head 322 from proximal housing 310. Once the slide stop is moved laterally out of the way, nub subcoupler 340 is similarly pushed proximally under a positive force exerted by trigger 311 via trigger bar 313, ejector 352, and hooks 354, 346 (FIG. 3M). By positive force, we mean that a force greater than the spring force is being exerted, such as by the mechanical interlocking of trigger 311, trigger bar 313, ejector 352, and hooks 354, 346. Additionally, nub spring 343 provides the force to move nub proximally and holds nub in a retracted position inside elongate tube 306 until nub is to be used again for placement of another anchor.

[0078] 3P and 3Q show features of an exemplary anchor delivery tube. The anchor delivery tube 330, in this example, has a slot 331 through which the suture and suture locking cord can pass during use. An inner lumen is defined as shown at 333 through which the anchor and bone punch can pass. If desired, the underside of the anchor delivery tube 330 can be stamped or otherwise formed with indentations or internal grooves or channels as shown at 335 to accommodate the suture 336 passing through the underside of the anchor delivery tube 330. Such stamping may not be necessary in some examples depending on the size of the suture used and how closely the features of the anchor and anchor delivery tube lumen 333 align. The proximal end of the anchor delivery tube may be formed with or added to additional material as shown at 337 for securing within the proximal housing 310.

[0079] In an alternative configuration, the anchor delivery tube may be replaced by a push wire coupled to a relatively short nub section having a slotted cylindrical shape. The nub section may have a length of, for example, 3-5 centimeters, so that it can extend from within the lumen of the elongate tube 306 without a portion of the nub section exiting completely from the elongate tube. The push wire may then extend up the elongate tube to the proximal housing, where it is then physically coupled to the nub sub coupler 340. Thus, the full length anchor delivery tube may be replaced with a shorter nub section, if desired. The push wire (and anchor delivery tube) may be pushed distally when the bone punch is advanced at its proximal end (e.g., by including a pusher or linkage attached to the push wire or nub sub coupler), if desired, or at its distal end (e.g., by providing a shoulder toward the distal end of the bone punch to interact with the nub and / or the short anchor delivery tube).

[0080] FIG. 3R shows the joint of the bone punch assembly. In FIG. 3R, an ejector 352 is shown including its proximal end with a beveled surface at 347. The beveled surface at 347 is aligned with a latch arm 348, which is itself part of the proximal punch head. The latch arm 348 is shown engaged with a spring base 349, which is part of the distal punch head and carries the punch head spring 325. As can be seen, when the trigger is depressed, the ejector 352 moves proximally, engages the latch arm 348, and pushes the latch arm 348 outward, disengaging the latch arm 348 from the spring base 349 and releasing the proximal punch head from the distal punch head. In some embodiments, the physician may perform this operation without disengaging the distal punch head from the housing, such as by pulling lightly on the trigger, releasing the proximal punch head from the distal punch head, thereby retracting the punch pin and pointed distal tip. As a result, this feature allows the physician to easily control how far the distal tip of the punch pin extends beyond the nub and / or distal end of the outer tube of the anchor delivery device.

[0081] 4A-4D illustrate features of a plunger for delivering anchors from individual cartridges to a delivery device and a magazine for holding the cartridges on the anchor delivery device. Beginning with FIG. 4A, the delivery device is generally indicated at 300, along with a proximal housing at 310. On one side of the proximal housing is a receiver 370 in which a plunger 380 can be slidably positioned and held. The top of the receiver includes a slot 372 for receiving a cartridge 392 carrying the anchors to be implanted. The cartridge 392 can be seen to have at least first and second ends of a working suture 393 extending therefrom.

[0082] The delivery device is shown for a patient 400 having a patient portal 402, which may be, for example, a shoulder portal formed for performing arthroscopic surgery. In the illustrated example, a removed cartridge 392 is shown with a working suture 393 extending on either side of it. The physician may pull the cartridge away from the magazine and delivery device, as well as the portal 402, to floss the working suture 393 so that a certain amount of slack is available on either side of the anchor housed within the cartridge 392. The purpose of this maneuver is to ensure that as the anchor is advanced through the delivery device and into the patient, there is sufficient slack to facilitate this passage. That is, while it is possible to floss the suture through the anchor during delivery and implantation, it may be preferable to create slack prior to implantation to make it relatively easy to advance the anchor into position. Once the anchor is positioned, the surgeon may apply tension to the working suture to remove excess slack as they form a stitch between the toggled anchor and the previously positioned anchor.

[0083] Opposite the plunger 380 is a magazine 390 that can be releasably secured to the proximal housing 310 and carries a number of cartridges 391. A cartridge ejector is shown at 394 for ejecting cartridges 391 / 392 at a time. The magazine is shown with seven cartridges 391 therein, with an eighth cartridge 392 already ejected. In the illustrated example, at least one additional cartridge has already been ejected and used, as working suture 393 can be seen extending within elongate tube 306 and into patient portal 402. It will also be understood that the magazine is carried on a receiver 398 (FIG. 3A). Further details regarding the magazine and its use can be found in U.S. Patent Application Serial No. 17 / 551,811, entitled "Delivery Device for Implanting Knotless Microsuture Anchors and Anchor Arrays for Attaching Soft Tissue to Bone," the disclosure of which is incorporated herein by reference.

[0084] Further details of the plunger and receiver are shown in Figures 4B and 4C. Starting with Figure 4B, the plunger itself is shown at 380 in an extended position relative to the receiver 370. The slot 372 can be seen in a top view of the proximal housing 310. Once a cartridge (not shown) is placed in the slot 372, the plunger can be depressed as shown in Figure 4C. Doing so moves the anchor laterally from the cartridge through the length of the delivery device and into the bore. The anchor is then ready to be inserted by advancing a bone punch through the proximal housing and down the anchor delivery lumen. Referring back to Figure 4B, the anchor is carried within the cartridge 392 such that when the cartridge 392 is inserted into the slot 372, the anchor lies generally along line 374, with the midline of the anchor delivery tube generally indicated at 376. The plunger prepares the anchor for delivery by pushing the anchor laterally to the midline of the anchor delivery tube at 376 and holds the anchor in place until a bone punch is advanced to force the anchor down the anchor delivery tube.

[0085] Additionally, as the plunger is depressed, the aforementioned configuration changes occur within the proximal housing. In particular, in the illustrative examples shown herein, depressing the plunger moves the slide stop 350 described above out of the way of the nub subcoupler 340 and laterally out of the way of the ejector 352, allowing retraction of the nub after the anchor is inserted. In some examples, the anchor delivery device does not allow the plunger to be actuated from its extended position to a depressed position while the bone punch extends down the lumen of the anchor delivery tube. That is, in some examples, the plunger cannot be fully depressed until the bone punch is retracted after the physician first activates the trigger.

[0086] FIG. 4D shows the plunger in isolation. Here, it can be seen that the plunger 380 includes an anchor pusher 384, which includes an anchor platform 383 that sits below the anchor and an alignment bar 382 that extends into an alignment slot in the cartridge. Also shown is the plunger control arm 385. The control arm 385 is the previously mentioned element that moves the slide stop 350 laterally to allow retraction of the anchor delivery tube and nub after the anchor is fully implanted. The control arm 385 also functions, when in place, to push the ejector 352 upward to ensure coupling of the ejector (and therefore the trigger) to the nub sub coupler, which is in turn attached to the anchor delivery tube and nub. The guide arm 381 is used to guide the plunger 380 as it slides in and out of the receiver 370.

[0087] Referring back to FIG. 3M, the plunger latch 386 (not visible in FIG. 4D) is carried on the control arm 385. The plunger latch 386 rests against the plunger catch 387 when the plunger is fully inserted, preventing the plunger 380 from disengaging. When the ejector 352 is used to retract the nub sub coupler 340, the bottom of the ejector 352 pushes the control arm 385 proximally, allowing the plunger latch 386 to be released once the nub and bone punch are at least initially retracted, as shown in FIG. 3M. The body of the plunger 380 can be connected to the anchor pusher 384 with a wave spring (not shown, but present within the body of the plunger 380) that, in some instances, allows overtravel to ensure latching of the control arm 385 and plunger latch 386. When the plunger latch 386 is released, the wave spring (or another spring, if provided) pushes the plunger back to its extended position. The slide stop may also move back to its original position under spring pressure.

[0088] In an alternative configuration, the control arm 385 may not be part of the plunger, but instead may be coupled to a switch or lever on the proximal housing, allowing the physician to determine the mode of trigger action without using the plunger. To this end, member 399 in FIG. 4A may be used, for example, as a switch or button to control the position of a slide stop.

[0089] In another alternative, slot 372 may be located directly in line with central axis 376 (FIG. 4B) of the anchor delivery tube, and the anchor may be located in a position for direct downward advancement of the anchor delivery tube, rather than lateral movement from the cartridge. As an example, slot 372 may instead be located at position 372A of FIG. 4B, in which case plunger 380 and receiver 370 may be omitted. For example, a physician may remove a pre-strung anchor from a sterile package and place the anchor directly into the centrally located slot. Alternatively, a physician may place the anchor in a central slot, such as 372A, by inserting a cartridge. Although some examples herein show cartridges configured for lateral removal of anchors, in the alternative where the cartridge is inserted into a centrally located slot (372A), cartridges as shown in Figures 5A / 5B may instead have openings as shown at 527 that allow removal of the anchor in an axial direction (such arrays may omit boss 512 and / or have a working suture positioned on top of boss 512 to allow axial movement). Other alternative configurations may be used as well.

[0090] In summary with respect to the implantation procedure, the physician explores the surgical site using the configuration of FIG. 3A to identify the location where the anchor will be placed. The physician then taps or slams the proximal punch head which advances the bone punch. As the bone punch is advanced, the proximal punch head latches with the distal punch head, assuming the configuration of FIG. 3B, forcing the nub distal to the distal end of the outer elongate tube. As a tapping force is applied, each of the bone punch pins and tips extends through the tendon and into the bone, forcing the nub into alignment with the bone hole, at least partially engaging the nub with the bone hole. While this sequence of operations is useful in one example, the steps can be reordered as desired, such as by latching the punch heads together prior to exploring, if desired.

[0091] The surgeon then pulls the trigger a first time. Because the plunger is not engaged / depressed at this point, trigger actuation causes the bone punch to retract, but does not cause retraction of the nub at the end of the anchor delivery tube. The cartridge is removed from the magazine, extends from the magazine to create slack on both sides of the cartridge in the working suture, and is inserted into a slot on the delivery device housing to receive the cartridge. Before or after cartridge placement, the bone punch is retracted to a position that places the distal tip of the bone punch proximal to the location of the plunger, allowing the plunger to now be depressed. With the cartridge in place and the bone punch retracted, the plunger is used to push the anchor into alignment with the anchor delivery tube. The bone punch is then advanced to move the anchor in and out of the distal tip of the anchor delivery tube. Full extension of the bone punch is demonstrated by latching the proximal punch head to the distal punch head, which is latched to the proximal housing of the delivery tool.

[0092] The surgeon squeezes the trigger again. This second actuation of the trigger is done with the plunger fully inserted, meaning that the actuation of the trigger retracts the bone punch as well as the anchor delivery tube, as the plunger insertion moves the slide stop out of the way of the nub sub coupler, engaging the ejector with it and actively pulling the nub as well as the bone punch of the bone hole. The same trigger action also releases the plunger when the ejector presses the control bar to release the plunger under spring action. As described in Figures 6A-6I, all that remains is to complete the toggle of the anchor, tension the working suture, and subsequently secure the suture lock before moving on to the next anchor. Although not shown, the anchor delivery tool can optionally include a punch stop to prevent the bone punch from being completely removed from the device.

[0093] Figures 5A-5D show a cartridge for holding a toggle anchor. Starting with Figure 5A, a cartridge 500 is shown with a handle 502 adapted to be grasped by a user / physician. An inner holder is indicated at 510 and is surrounded by a cover 520. The inner holder 510 secures the anchor 100 between an upper anchor support 511 and a boss 512. In the configuration shown in Figure 5A, the cartridge is "closed" in that the anchor 100 cannot be removed.

[0094] FIG. 5B shows the cover 520 raised to an "open" position where the anchor 100 is no longer secured by the cover 520. The cover defines two channels at 522, 524. The first channel 522 provides a path for the working suture to exit the cartridge 500, and the second channel 524 provides a path for the suture lock, as described in further detail below. The cover may be spring-biased in the closed position, if desired, to prevent the anchor 100 from inadvertently dislodging during handling. Alternatively, the cover may include a detent to hold the cover in the closed position until pressure is applied during insertion. Additionally, the upper anchor support 511 and boss 512 are spaced apart so that the anchor 100 is held in place to prevent it from falling out.

[0095] As previously mentioned, an alternative design may have the inner holder 510 open in alignment with the slot 527 to allow for removal of the anchor axially rather than laterally. In such an alternative, in one example, the upper anchor support 511 and boss 512 are positioned higher on the inner holder such that the anchor 100 is held in position 516 as shown in FIG.

[0096] 5C shows cartridge 500 in a closed position with the cover down again. Here, working suture 530 is shown passing through first channel 522. The suture lock is also shown with its free end 540 passing through second channel 524 and locking loop shown at 542. As can be seen, boss 512 holds working suture 530 away from the underside of anchor 510, making it easier to floss the working suture before releasing anchor 510 from the cartridge. That is, keeping working suture 530 away from the bottom side of anchor 100 may make flossing easier, as the bottom side of anchor 510 may include channels that make it more difficult to floss the working suture therethrough. Also, as the working suture 530 is pulled near the bottom side of the anchor 100, the path it must be guided through when flossing includes first and second turns of approximately 90 degrees, increasing friction as the working suture 530 is flossed. Thus, the boss 512 can be seen to make flossing easier in some instances. In other instances, the boss 512 may be designed so that the working suture does not wrap around it, and instead a simple support on the bottom side of the anchor 100 may be provided, with the working suture then resting between the support and the bottom side of the anchor. It should also be noted that having the working suture positioned as shown may help hold the anchor in place until released by insertion of a plunger in the illustrated example.

[0097] FIG. 5D shows the back of the cartridge 500. It is noted that the free end 540 of the locking loop 542 enters the channel and then leads to the spool 514. In one example, the free end 540 is attached to the spool 514, such as by a knot, so that the free end can be pulled a selected distance (e.g., 10-20 cm) before it reaches a point where it can no longer unspool. When a physician wishes to use the locking loop, they can grasp the cartridge 500 and pull until the spool breaks. The physician can then pull the cartridge, and thus the free end of the locking loop, until the locking loop breaks at the break knot (or other preferred break point), as described below and above. As a result, the physician can grasp the cartridge by hand and easily lock the locking loop and break the free end of the locking loop, without the need for special tools and / or attempting to grasp the length of cord at the free end of the locking loop. It can be seen that the spool 514 includes an internal mechanism 515 that allows a tool to be inserted and twisted to wrap the free end 540 of the locking loop onto the spool 514. Similar to the toggling and / or tensioning steps, the distal end of the anchor delivery tool can be used to apply external pressure to the tendon as the locking loop is tightened and the free end is removed.

[0098] FIG. 5E illustrates the interaction of the cartridge of FIGS. 5A-5D with a plunger as in FIGS. 4A-4D. Although the remainder of the proximal housing of the anchor delivery tool has been omitted, it can be seen that the insertion of cartridge 500 into the slot for receiving the cartridge has raised cover 520 to an open position. The plunger is then slid into the position shown. As the plunger is depressed, anchor pusher structure 584 passes through the cartridge, and anchor support 383 and alignment rail 382 pass through the cartridge. Rail 382 passes on either side of upper anchor support 511 to ensure that the working suture is released from the cartridge when the plunger is depressed. As can be seen, control bar 385 is inserted and performs the function of moving the slide stop described above.

[0099] Further details regarding the exemplary magazine and its use can be found in U.S. Patent Application No. 17 / 551,811, entitled "Delivery Device for Implanting Knotless Microsuture Anchors and Anchor Arrays for Attaching Soft Tissue to Bone," the disclosure of which is incorporated herein by reference. It should be noted that the illustrated exemplary anchor implantation system is only one example of how the anchor system of the present disclosure may be implanted. For example, the system of fully retracting the distal end of the bone punch into the proximal housing as illustrated may not be necessary. A separate cartridge for each bone anchor is shown in the implantation system, and in other examples, several anchors may be placed together in one cartridge, e.g., longitudinally, for sequential loading. Another anchor delivery tool is disclosed, for example, in U.S. Provisional Patent Application No. 63 / 172,629, filed April 8, 2021, entitled "Delivery Device for Implanting Microsuture Anchors and Anchor Arrays for Attaching Soft Tissue to Bone," the disclosure of which is incorporated herein by reference. Axial release of the anchor from the cartridge may be used rather than lateral release. In some instances, the cartridge may be omitted entirely. Any suitable embedding system may be used as desired.

[0100] Exemplary methods for implanting individual anchors and arrays of anchors are shown in Figures 6A-6G, and Figures 6H and 6I further show exemplary suture stitch arrays implanted on the surface of a rotator cuff tendon with independently tensioned and locked running stitches between anchors that may result from using the present methods.

[0101] Referring first to FIG. 6A, a schematic diagram of selected portions of a rotator cuff 600 is shown to illustrate the implantation method. The diagram includes a portion of a humeral head 602 shown to include an outer cortical shell layer 604 and inner cancellous bone material 606. A tendon, in this case the supraspinatus tendon 608, is shown overlaying a portion of the humeral head attached to the footprint. The method is by transtendinous or tendon repair. The tendon 608 is first positioned at the desired location for reattachment to the bone within the footprint of the original attachment. A toggle suture anchor is then implanted through the tendon 608 utilizing the delivery device of FIGS. 3A-3R or similar. First, the delivery device is set up with an implanted delivery tube 330 and a distal nub 332 extending from the distal end of the elongated tube 306 as in FIG. 3C. The bone punch 320 is inserted fully distally to extend beyond the distal end of the nub 332 and locked in place so that the nub is locked in place. The configured device is placed over the tendon in the desired anchoring configuration as shown in FIG. 6A and hammered until the distal end of the outer tubular member contacts the tendon. At this point, the nub 332 extends through at least a portion of the cortical shell 604 (in thinner bones, the nub 332 may extend into the cancellous bone 606) and the distal end of the bone punch 320 extends deeper into the cancellous bone 606. To achieve the desired embedment depth to ensure toggling, the bone punch extends beyond the distal end of the elongated tube 306 a distance of about 20 mm or more. Additionally, to ensure alignment of the nub with the bone hole, the nub portion 332 extends beyond the distal end of the elongated tube 306 a distance of about 6 to about 10 mm.

[0102] 6B, the bone punch 320 is then retracted while maintaining the elongated tube 306 and nub portion 332 in place, with the nub portion 332 providing alignment with the hole formed in the bone. Without such alignment with the bone hole by the nub portion 332, the position under the tendon would be lost, making it very difficult to feed the anchor through the tendon which would tend to fill the hole the bone punch would travel through. In some embodiments, as described above, this step of the method may be performed by depressing a trigger on an embedding tool, which is configured to maintain the nub portion 332 extended under certain circumstances (e.g., with a slide stop in place) while applying a positive retraction force to the bone punch 320.

[0103] A first toggle anchor is delivered or inserted into the proximal portion of the anchor delivery tube inside the elongate tube 306. Next, the bone punch 320 is reinserted into the lumen of the anchor delivery tube and advanced distally, as shown in FIG. 6C. The toggle body 100 of the anchor is pushed out of the distal end by the bone punch 320, as shown in FIG. 6C. The bone punch 320 continues to advance distally to its original depth to drive the toggle body 100 into the bone. It has been found that driving the proximal end of the anchor deep into the bone with the toggle body 100 having an angled distal end causes or at least initiates rotation of the toggle body 100. This initial rotation ensures continued rotation as tension is pulled on the working suture 115 outside the body.

[0104] As shown in FIG. 6E, the bone punch 320 and nub 332 are then retracted by application of a positive force by the trigger (as shown in the examples above) and with spring action. This ensures that the nub 332 does not cut or fray the working suture. The bone hole remains as shown in the drawing. The distal portion of the working suture extending from the distal passage is then pulled to complete the toggling of the anchor, as assisted by the proximal fin on the toggle body. This is shown in FIG. 6E. While continuing to tension the working suture, the toggle body 100 is pulled towards the inner surface of the bone's cortical shell, as shown in operation 6F. To assist with this step, the distal end of the anchor delivery tool can be pressed against the tendon to provide a counter force against pull-out during toggling and / or suture tensioning, i.e., once the anchor is toggled and the suture is tensioned, the toggle body 100 can reach and press against the cortical shell. Additional reaction forces may be applied at the edges or lateral sides of the fracture footprint and / or in areas where the cortical shell is particularly thin, such as between the greater and lesser canals of the humerus. As the working suture 115 is pulled, the locking suture is pulled to close the locking loop 118 around the working suture 115, securing the working suture against the toggle body 100, as shown in FIG. 6G. In some instances, the locking suture breaks during this step at a knot at or within the central bore of the anchor 100, so FIG. 6G only shows the working suture extending back into the elongate tube 306.

[0105] With implantation of the first anchor, the working suture 115 is simply locked as it cannot be tensioned to form a stitch until the second anchor is implanted. In some instances, the first anchor in the chain of anchors may be pre-locked for this purpose. In other instances, the surgeon locks the first anchor suture lock at the time of implantation. Thus, in a preferred method, the second anchor is implanted by repeating the steps above, except to the extent that the suture lock is engaged differently. As the working suture is tensioned to toggle the anchor, the loose working suture between the first and second anchors is tensioned to form a tensioned stitch. While tensioning the suture, the distal end of the elongated tube 306 can be maintained against the outer surface of the tendon to prevent pull-out or possible fracture in the cortical shell. Once properly tensioned, the second anchor is locked. These steps are repeated for the remaining anchors in the array.

[0106] As shown in Figures 6H and 6I, the above method and device can be used to create rows of closely spaced, individually tensioned and clamped continuous stitches. A preferred pattern includes rows of stitches that are approximately perpendicular to the direction of the tendon, as shown in Figure 6H. In rotator cuff repairs, these are all placed on the medial portion of the original tendon footprint. In some preferred embodiments, especially in rotator cuff repairs, a second row of anchors is also embedded. The second row can include a zigzag pattern embedded laterally of the first row, with some anchors placed on the lateral portion of the original footprint and others on the lateral side of the footprint to hold down the edges of the torn tendon. Other configurations are possible depending on the size and shape of the tear. For example, in small tears, a single zigzag row of stitches can be used, as shown in Figure 6I. Anchors can also be placed to create stitches over the attachment of the tendon to reinforce the periphery / edge of a fully or partially torn tendon.

[0107] A relatively complete description of the anchors themselves, the pre-strung anchor arrays, the suture lock, the cartridge, the magazine, and the anchor delivery tool has been provided above. Thus, the scope of the invention is disclosed and it is not necessary that all components or parts be used together. For example, the delivery tool may be configured for use with other anchors, cartridges, magazines, etc. Similarly, the anchors may be used in different configurations with other working suture and suture lock configurations, other cartridges, magazines, and delivery tools. Thus, the overall combination shown may be modified in a variety of ways.

[0108] Each of these non-limiting examples may exist alone or may be combined in various orders or combinations with one or more of the other examples. The above detailed description includes references to the accompanying drawings, which form a part of the detailed description. The drawings show, by way of example, certain embodiments. These embodiments are also referred to herein as "examples." Such examples may include elements in addition to those shown or described. However, the inventors also contemplate examples in which only the elements shown or described are provided. Furthermore, the inventors also contemplate examples that use any combination or permutation of the elements shown or described (or one or more aspects of those elements) with respect to the specific example (or one or more aspects of that example) shown or described herein, or with respect to other examples (or one or more aspects of those examples) shown or described herein.

[0109] In the event of inconsistent usage between this specification and a document incorporated by reference, the usage in this specification shall prevail. The terms "a" or "one" are used herein, as is common in the patent literature, to include one or more, regardless of other instances or usages of "at least one" or "one or more." Furthermore, in the claims, terms such as "first," "second," and "third" are used merely as labels and are not intended to impose numerical requirements on their objects.

[0110] The above description is intended to be illustrative and not limiting. For example, the above examples (or one or more aspects thereof) may be used in combination with each other. Other embodiments may be used by those of ordinary skill in the art upon review of the above description. The Abstract is provided to comply with Section 1.72(b) of Title 37 of the Code of Federal Regulations to allow the reader to quickly ascertain the nature of the technical disclosure. It is submitted with the understanding that it will not be used to interpret or limit the scope or meaning of the claims.

[0111] Also, in the above detailed description, various features may be grouped together to streamline the disclosure. This should not be construed as intending that an unclaimed disclosed feature is essential to any claim. Rather, innovative subject matter may lie in less than all features of a particular disclosed embodiment. Accordingly, it is contemplated that the following claims will be incorporated into the detailed description as an example or embodiment, with each claim standing on its own as a separate embodiment, and that such embodiments can be combined with each other in various combinations or permutations. The scope of protection should be determined with reference to the appended claims, along with the full scope of equivalents to which such claims are entitled.

Claims

1. 1. A system of toggle-type suture anchors connected in series by a single working suture, comprising: a plurality of toggle bodies, each toggle body having a proximal end, a distal end, a top surface, a bottom surface, a proximal passageway, and a distal passageway, each passageway extending from the top surface to the bottom surface and spaced apart along the toggle body; a single working suture connecting the plurality of toggle bodies in series, the single working suture entering the proximal passage at the top surface, exiting the bottom surface, then returning upwardly from the bottom surface through the distal passage, exiting the top surface of each toggle body with a length of suture extending adjacent the bottom surface of each toggle body; at least one suture lock provided independently of at least one toggle body, the suture lock having a locking loop provided independently of the at least one toggle body and a free end extending from the locking loop, the locking loop encircling a portion of the length of the single working suture adjacent the bottom surface of the at least one toggle body, the locking loop having an open position allowing the working suture to slide through the locking loop and a closed position engaging the working suture to prevent sliding of the working suture within the locking loop, the suture lock configured to transition the locking loop from the open position to the closed position in response to tension applied to the free end; A system comprising:

2. The system of claim 1 , wherein the plurality of toggle bodies includes at least four toggle bodies.

3. 2. The system of claim 1, the at least one toggle body further includes an intermediate passageway extending therethrough from the top surface to the bottom surface, the intermediate passageway being located between the proximal passageway and the distal passageway; the suture lock for the at least one toggle body is positioned relative to the intermediate passage such that the free end extends out of the intermediate passage at the top surface and such that the locking loop extends out of the intermediate passage at the bottom surface.

4. 4. The system of claim 3, the intermediate passage in each toggle body having an upper portion and a lower portion separated by a platform; each suture lock includes a knot at least partially defining said locking loop, said knot being a slidable knot tied to said suture lock to permit collapse of said locking loop from said open position to said closed position when said free end is tensioned; Each suture lock is positioned relative to the intermediate passage such that the platform prevents the slidable knot from exiting the bottom surface.

5. 5. The system of claim 4, wherein the locking loop has first and second legs, and the lower portion of the intermediate passage has an oval shape to allow both legs of the locking loop to pass side by side and exit the bottom surface.

6. The system described in claim 1, wherein the suture lock includes a knot that defines the locking loop and a slidable knot tied to the suture lock, and wherein applying tension to the free end of the suture lock causes the slidable knot to move to position the locking loop in the closed position.

7. 7. The system of claim 6, wherein the slidable knot is at least a four-way simple knot.

8. The system of claim 1 , comprising a suture lock for each of the plurality of toggle bodies.

9. A system according to any one of claims 1 to 7, comprising: the plurality of toggle bodies includes a first toggle body and at least one additional toggle body; the first toggle body is free of a suture lock; the single working suture is secured to the first toggle body; A suture lock is provided for each additional toggle body, the system.

10. 8. The system of claim 1, wherein each toggle body further includes a pair of fins extending both proximally and laterally outward from the toggle body proximal to the proximal passage, at least a portion of each fin extending laterally further beyond a maximum lateral dimension of the toggle body.

11. 8. The system of claim 1, wherein a free end of each suture lock includes a preferential point of weakness to permit breakage of the free end after tension is applied to place the locking loop in the closed position.

12. 8. The system of claim 1, wherein the distal end of each toggle body is such that the top surface of each toggle body is longer than the bottom surface of each toggle body.

13. 8. The system of claim 1, wherein each toggle body has a maximum lateral dimension of less than 3 mm.

14. 8. The system of claim 1, wherein each toggle body has a length in the range of 6 mm to about 10 mm.

15. 8. The system of claim 1, wherein the single working suture is a braided, multi-strand suture having a compressible cross-sectional area that is reduced by at least 25% when the locking loop is tightened in use.

16. 8. The system of claim 1, wherein the top and bottom surfaces of each toggle body are generally flat, and each toggle body further includes rounded sides connecting the top and bottom surfaces.

17. 8. The system of claim 1, wherein the bottom surface of each toggle body further includes a channel through which the single working suture passes when tension is applied to the single working suture, the channel providing friction to prevent movement of the single working suture when tension is applied.

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