Method and apparatus for coupling soft tissue to bone

Abstract

A method and apparatus for coupling a soft tissue implant into a locking cavity formed within a bone is disclosed. A bone engaging fastener is coupled to bone. A second fastener is coupled to a suture construction. The second fastener is coupled to the first fastener. Soft tissue is coupled to the suture construction.

Description

FIELD

The present disclosure relates to method of coupling soft tissue to bone and, more particularly, to a method and apparatus using a plurality of fasteners and suture cinch loop construction to couple soft tissue to a bone.

BACKGROUND

The statements in this section merely provide background information related to the present disclosure and may not constitute prior art.

It is commonplace in arthroscopic procedures to employ sutures and anchors to secure soft tissues to bone. Despite their widespread use, several improvements in the use of sutures and suture anchors may be made. For example, the procedure of tying knots may be very time consuming, thereby increasing the cost of the procedure and limiting the capacity of the surgeon. Furthermore, the strength of the repair may be limited by the strength of the knot. This latter drawback may be of particular significance if the knot is tied improperly as the strength of the knot in such situations may be significantly lower than the tensile strength of the suture material.

To improve on these uses, sutures having a single preformed loop have been provided. FIG. 1 represents a prior art suture construction. As shown, one end of the suture is passed through a passage defined in the suture itself. The application of tension to the ends of the suture pulls a portion of the suture through the passage, causing a loop formed in the suture to close. Relaxation of the system, however may allow a portion of the suture to translate back through the passage, thus relieving the desired tension.

It is an object of the present teachings to provide an alternative device for anchoring sutures to bone and soft tissue. The device, which is relatively simple in design and structure, is highly effective for its intended purpose.

SUMMARY

To overcome the aforementioned deficiencies, a method for configuring a braided tubular suture and a suture configuration are disclosed. The method includes passing a first end of the suture through a first aperture into a passage defined by the suture and out a second aperture defined by the suture so as to place the first end outside of the passage. A second end of the suture is passed through the second aperture into the passage and out the first aperture so as to place the second end outside of the passage.

A method of surgically implanting a suture construction in a bone is disclosed. A suture construction is formed by passing the suture through a bore defined by a locking member. A first end of the suture is passed through a first aperture within the suture into a passage defined by the suture and out a second aperture defined by the suture so as to place the first end outside of the passage and define a first loop. A second end of the suture is then passed through the second aperture into the passage and out the first aperture so as to place the second end outside of the passage, and define a second loop. A fastener is coupled to bone. Soft tissue is then passed through the first and second loops. The locking member is coupled to the fastener. Tension is applied onto the first and second ends to constrict the first and second loops about the soft tissue.

In another embodiment, a method of surgically implanting a suture is disclosed. The suture is passed through a bore defined by a first fastener. A suture construction is formed by passing the suture through a bore defined by a locking member. A first end of the suture is passed through a first aperture within the suture into a passage defined by the suture and out a second aperture defined by the suture so as to place the first end outside of the passage and define a first loop. A second end of the suture is then passed through the second aperture into the passage and out the first aperture so as to place the second end outside of the passage, and define a second loop. A second fastener is coupled between the first and second loops. After the fastener is coupled to the patient, tension is applied onto the first and second ends to constrict at least one of the first and second loops about the soft tissue.

Further areas of applicability will become apparent from the description provided herein. It should be understood that the description and specific examples are intended for purposes of illustration only and are not intended to limit the scope of the present disclosure.

DRAWINGS

The drawings described herein are for illustration purposes only and are not intended to limit the scope of the present disclosure in any way.

FIG. 1 represents a prior art suture configuration;

FIGS. 2A and 2B represent suture constructions according to the teachings;

FIG. 3 represents the formation of the suture configuration shown in FIG. 4A;

FIGS. 4A and 4B represent alternate suture configurations;

FIGS. 5-7 represent further alternate suture configurations;

FIG. 8 represents the suture construction according to FIG. 5 coupled to a bone engaging fastener;

FIGS. 9-11B represent the coupling of the suture construction according to FIG. 5 to a bone screw;

FIGS. 12A-12E represent the coupling of a soft tissue to an ACL replacement in a femoral/tibial reconstruction;

FIGS. 13A-13D represent a close-up view of the suture shown in FIGS. 1-11C;

FIGS. 14A and 14B represent side and top views of a suture construction used to couple soft tissue to bone;

FIGS. 15A-15D represent an alternate method of coupling soft tissue to bone;

FIGS. 16A-16D represent yet another method for coupling soft tissue to bone;

FIG. 17 is an alternate method of coupling soft tissue to bone;

FIGS. 18A-18B represent an alternate mechanism for coupling soft tissue to bone; and

FIGS. 19A-19C represent another method of coupling soft tissue to bone.

DETAILED DESCRIPTION

The following description is merely exemplary in nature and is not intended to limit the present disclosure, application, or uses. It should be understood that throughout the drawings, corresponding reference numerals indicate like or corresponding parts and features.

FIG. 2A represents a suture construction 20 according to the present teachings. Shown is a suture 22 having a first end 24 and a second end 26. The suture 22 is formed of a braided body 28 that defines a longitudinally formed hollow passage 30 therein. First and second apertures 32 and 34 are defined in the braided body 28 at first and second locations of the longitudinally formed passage 30.

Briefly referring to FIG. 3, a first end 24 of the suture 22 is passed through the first aperture 32 and through longitudinal passage 30 formed by a passage portion and out the second aperture 34. The second end 26 is passed through the second aperture 34, through the passage 30 and out the first aperture 32. This forms two structures or loops 46 and 46′. Structures defined herein can be loops, knots or tangles, each having unique properties. As seen in FIG. 2B, the relationship of the first and second apertures 32 and 34 with respect to the first and second ends 24 and 26 can be modified so as to allow a bow-tie suture construction 36. As described below, the longitudinal and parallel placement of first and second suture portions 38 and 40 of the suture 22 within the longitudinal passage 30 resists the reverse relative movement of the first and second portions 38 and 40 of the suture once it is tightened.

The first and second apertures are formed during the braiding process as loose portions between pairs of fibers defining the suture. As further described below, the first and second ends 24 and 26 can be passed through the longitudinal passage 30 multiple times. It is envisioned that either a single or multiple apertures can be formed at the ends of the longitudinally formed passage.

As best seen in FIGS. 4A and 4B, a portion of the braided body 28 of the suture defining the longitudinal passage 30 can be braided so as to have a diameter larger than the diameter of the first and second ends 24 and 26. Additionally shown are first through fourth apertures 32, 34, 42, and 44. These apertures can be formed in the braiding process or can be formed during the construction process. In this regard, the apertures 32, 34, 42, and 44 are defined between adjacent fibers in the braided body 28. As shown in FIG. 4B, and described below, it is envisioned the sutures can be passed through other biomedically compatible structures.

FIGS. 5-7 represent alternate constructions wherein a plurality of loops 46a-d are formed by passing the first and second ends 24 and 26 through the longitudinal passage 30 multiple times. The first and second ends 24 and 26 can be passed through multiple or single apertures defined at the ends of the longitudinal passage 30. The tensioning of the ends 24 and 26 cause relative translation of the sides of the suture with respect to each other.

Upon applying tension to the first and second ends 24 and 26 of the suture 22, the size of the loops 46a-d is reduced to a desired size or load. At this point, additional tension causes the body of the suture defining the longitudinal passage 30 to constrict about the parallel portions of the suture within the longitudinal passage 30. This constriction reduces the diameter of the longitudinal passage 30, thus forming a mechanical interface between the exterior surfaces of the first and second parallel portions as well as the interior surface of the longitudinal passage 30.

As seen in FIGS. 8-11B, the suture construction can be coupled to various biocompatible hardware. In this regard, the suture construction 20 can be coupled to an aperture 52 of the bone engaging fastener 54. Additionally, it is envisioned that soft tissue or bone engaging members 56 can be fastened to one or two loops 46. After fixing the bone engaging fastener 54, the members 56 can be used to repair, for instance, a meniscal tear. The first and second ends 24, 26 are then pulled, setting the tension on the loops 46, thus pulling the meniscus into place. Additionally, upon application of tension, the longitudinal passage 30 is constricted, thus preventing the relaxation of the tension caused by relative movement of the first and second parallel portions 38, 40, within the longitudinal passage 30.

As seen in FIGS. 9-11B, the loops 46 can be used to fasten the suture construction 20 to multiple types of prosthetic devices. As described further below, the suture 22 can further be used to repair and couple soft tissues in an anatomically desired position. Further, retraction of the first and second ends allows a physician to adjust the tension on the loops between the prosthetic devices.

FIG. 11B represents the coupling of the suture construction according to FIG. 2B with a bone fastening member. Coupled to a pair of loops 46 and 46′ are tissue fastening members 56. The application of tension to either the first or second end 24 or 26 will tighten the loops 46 or 46′ separately.

FIGS. 12A-12E represent potential uses of the suture constructions 20 in FIGS. 2A-7 in an ACL repair. As can be seen in FIG. 12A, the longitudinal passage portion 30 of suture construction 20 can be first coupled to a fixation member 60. The member 60 can have a first profile which allows insertion of the member 60 through the tunnel and a second profile which allows engagement with a positive locking surface upon rotation. The longitudinal passage portion 30 of the suture construction 20, member 60, loops 46 and ends 24, 26 can then be passed through a femoral and tibial tunnel 62. The fixation member 60 is positioned or coupled to the femur. At this point, a natural or artificial ACL 64 can be passed through a loop or loops 46 formed in the suture construction 20. Tensioning of the first and second ends 24 and 26 applies tension to the loops 46, thus pulling the ACL 64 into the tunnel. In this regard, the first and second ends are pulled through the femoral and tibial tunnel, thus constricting the loops 46 about the ACL 64 (see FIG. 12B).

As shown, the suture construction 20 allows for the application of force along an axis 61 defining the femoral tunnel. Specifically, the orientation of the suture construction 20 and, more specifically, the orientation of the longitudinal passage portion 30, the loops 46, and ends 24, 26 allow for tension to be applied to the construction 20 without applying non-seating forces to the fixation member 60. As an example, should the loops 24, 26 be positioned at the member 60, application of forces to the ends 24, 26 may reduce the seating force applied by the member 60 onto the bone.

As best seen in FIG. 12C, the body portion 28 and parallel portions 38, 40 of the suture construction 20 remain disposed within to the fixation member 60. Further tension of the first ends draws the ACL 64 up through the tibial component into the femoral component. In this way, suture ends can be used to apply appropriate tension onto the ACL 64 component. The ACL 64 would be fixed to the tibial component using a plug or screw as is known.

After feeding the ACL 64 through the loops 46, tensioning of the ends allows engagement of the ACL with bearing surfaces defined on the loops. The tensioning pulls the ACL 64 through a femoral and tibial tunnel. The ACL 64 could be further coupled to the femur using a transverse pin or plug. As shown in FIG. 12E, once the ACL is fastened to the tibia, further tensioning can be applied to the first and second ends 24, 26 placing a desired predetermined load on the ACL. This tension can be measured using a force gauge. This load is maintained by the suture configuration. It is equally envisioned that the fixation member 60 can be placed on the tibial component 66 and the ACL pulled into the tunnel through the femur. Further, it is envisioned that bone cement or biological materials may be inserted into the tunnel 62.

FIGS. 13A-13D represent a close-up of a portion of the suture 20. As can be seen, the portion of the suture defining the longitudinal passage 30 has a diameter d₁ which is larger than the diameter d₂ of the ends 24 and 26. The first aperture 32 is formed between a pair of fiber members. As can be seen, the apertures 32, 34 can be formed between two adjacent fiber pairs 68, 70. Further, various shapes can be braided onto a surface of the longitudinal passage 30.

The sutures are typically braided of from 8 to 16 fibers. These fibers are made of nylon or other biocompatible material. It is envisioned that the suture 22 can be formed of multiple type of biocompatible fibers having multiple coefficients of friction or size. Further, the braiding can be accomplished so that different portions of the exterior surface of the suture can have different coefficients of friction or mechanical properties. The placement of a carrier fiber having a particular surface property can be modified along the length of the suture so as to place it at varying locations within the braided constructions.

FIGS. 14A and 14B represent the coupling of soft tissue to a bone. Shown is a plurality of bone engaging fasteners 60 coupled to suture constructions 22 shown in FIG. 2A or FIG. 4. Each fastener 60 is coupled to a bone by being pressed into or threaded into an aperture formed within the bone. Adjoining fasteners are coupled together using loops 46 from an adjacent suture construction 22.

The fasteners 60 define a locking feature 92 which is used to couple the fastener 60 to the bone. Disposed on a first end of the fastener 60 is an aperture 94 configured to hold the suture construction 22. Additionally, in the fastener 60 is a locking feature 100 configured to engage with one of the first or second loops 46 or 47 of an adjacent suture construction 22. Returning briefly to FIG. 14A, a suture end 26 and first loop 46 can be passed around or through an aperture 84 in soft tissue.

The first loop 46 is then fed around or through a second aperture 84′ formed in the soft tissue 80. After passing through the aperture 84′, the first loop 46 is coupled to the coupling feature 100 in an adjacent bone coupling fastener 60. At this point, the first and second ends 24, 26 of the suture 22 are pulled tight, tightening the suture loop 46 about the soft tissue 80. This pulls the soft tissue 80 against a surface of the bone. This can be used to couple soft tissue in an anatomy such in the repair of a rotator cuff.

It is envisioned that a plurality of fasteners 60 can have associated suture constructions 22 which can similarly be coupled to adjacent fasteners 60. Alternatively, the loops 46, 47 can looped around or passed through the soft tissue 80 and then can be coupled to the coupling feature 100 of its fastener 60.

FIGS. 15A-15D represent an alternate method of coupling soft tissue 80 to a bone. As shown in FIG. 15A, a first bone coupling fastener 60 is coupled to an aperture 63 formed in the bone. The bone coupling fastener 60 defines a fastener accepting bore 96. The bore 96 may be a through bore or may terminate within the fastener 96. The fastener accepting bore 96 is configured to accept a suture bearing fastener 98. The first loop 46 can be coupled to the second loop 47 to fix the soft tissue 80.

The suture bearing fastener 98 defines an aperture 104 configured to accept the suture construction 22 according to any of the present teachings. As described below, the fastener 98 can also have a concave suture locking feature 100. Disposed at a proximal end 102 of the fastener 96 can be soft tissue piercing feature 105 which can be an acute angle. Additionally, the suture bearing fastener 98 can have locking features to facilitate the coupling to the bore 96 of the bone coupling fastener 60.

As seen in FIG. 15B, the suture construction of FIGS. 1-7 can be coupled to the suture bearing fastener 98 through the suture bearing aperture 104 using a knot. After the suture bearing fastener 98 is pressed through or adjacent to the soft tissue 80, the suture construction 22 can be looped over the soft tissue 80 and engaged with the concave locking feature 100. The suture bearing fastener 98 can be pressed into the fastener 60 to lock the suture 22 into place. Tension can then be applied to the suture 22 construction to constrict the loop 46 or loops 46 and 47 about the soft tissue 80.

As seen in FIGS. 15C and 15D, the soft tissue 80 can be threaded through the loops 46 and 47 prior to or after the coupling of the suture bearing fastener 98 to the bone engaging fastener 60. A guide wire 99 can be coupled to the bone through the fastener bore 96. The guide wire 99 is then used to align the suture bearing fastener 98 through the soft tissue 80 and into the bore 96 of fastener 60.

As shown in FIG. 16A-16C, one loop 46 of the suture construction 22 can have a fastening element 112 coupled thereto. This fastener element 112 can take the form of a hook having an aperture which accepts the suture from a loop 47. The loop 46 of the suture construction can be passed through the aperture 84 formed in the soft tissue 80.

FIG. 16D shows the fastener element 112 can be coupled to the first loop 46. After the first and second loops 46 and 47 are coupled together about the soft tissue 80, tension can be applied to the ends of the construction to pull the soft tissue to the bone.

As shown in FIG. 17, bone engaging fastener 60 can have a bore 96 defined therein. The bore 96 can have a defined fastening loop 114 which is used to couple a suture construction 22 to the fastener 60. In this regard, it is envisioned the passage portion 30 of the suture construction can be fixed within the fastening loop. One or both loops 46 and 47 can then be passed though an aperture 84 defined in the soft tissue 80. These loops of material can be hooked to a hook 116 defined within the bore 96. The application of tension to the ends pulls the soft tissue to the bone without the use of knots or additional fasteners.

FIGS. 18A and 18B represent an alternate method of coupling soft tissue 80 to bone. Shown is a bone engaging fastener 60 defining an internal bore 96. The internal bore 96 defines a locking mechanism such a through pin 120. Disposed about the locking mechanism is a suture construction 22 having a single loop 46. Disposed on the loop 46 is a locking hook 122.

As shown in FIG. 18B, the locking hook 122 can be used to couple the fastener 60 to a suture loop 124 passed through an aperture 84 formed in soft tissue 80. The application of tension to the ends 22 and 26 of the suture construction 22 pulls the locking hook 122 and suture 124 into the bore 96, thus locking the soft tissue 80 to the bone.

As seen in FIGS. 19A-19C, the fastener 60 can have a pair of suture constructions 22 and 22′. The first suture 22 can have a coupling member 122, while the second suture 22′ can have a loop 46 threaded through the soft tissue 80. After the loop 46 is threaded through or around the soft tissue, the locking member 122 is coupled to the loop 46. The application of tension to the ends 26 of the suture constructions 22 and 22′ pull the locking member 122 into a bore 96 formed by the fastener 60. This locks the loop 46 into position. Tension on the end 26 of suture 22 then pulls the soft tissue to the bone.

It should be noted that while the interior bore of the fasteners 60 is shown as being smooth, it is envisioned that the interior surface can have features such as barbs or locking tabs to facilitate the coupling of the suture engaging fastener 98 with the bone engaging fastener 60. Additionally, the interior bores can define driving surfaces or features such as a hex head.

The description of the invention is merely exemplary in nature and, thus, variations that do not depart from the gist of the invention are intended to be within the scope of the invention. For example, any of the above mentioned surgical procedures is applicable to repair of other body portions. For example, the procedures can be equally applied to the repair of wrists, elbows, ankles, and meniscal repair. The suture loops can be passed through bores formed in soft or hard tissue. It is equally envisioned that the loops can be passed through or formed around an aperture or apertures formed in prosthetic devices, e.g. humeral, femoral or tibial stems. Such variations are not to be regarded as a departure from the spirit and scope of the invention.

Claims

1. A method of coupling a soft tissue to a bone, comprising: determining an area of the bone to couple a first anchor and a second anchor, wherein: (i) the first anchor includes a first bone engaging feature, a first aperture, and a first suture member, the first suture member including a braided body disposed in the first aperture and defining a longitudinally extending passage having a plurality of passage apertures, and a first end extending from the braided body and passing through a passage aperture, through the passage and out another passage aperture, so as to place the first end outside of the passage, and define an adjustable first loop, and a second end extending from the braided body and passing through a passage aperture, through the passage and out another passage aperture, so as to place the second end outside of the passage, and define an adjustable second loop, and (ii) the second anchor includes a second bone engaging feature and a first coupling feature;forming a first hole in the area;forming a second hole in the area adjacent to the first hole;positioning the first anchor in the first hole;positioning the second anchor in the second hole;coupling the first loop to the soft tissue;coupling the first loop to the first coupling feature; andadjusting a size and tensioning the first loop to compress the soft tissue against the bone by pulling on the first end of the first suture member, after the first anchor is positioned in the first hole and after the second anchor is positioned in the second hole.

2. The method according to claim 1, further comprising passing the first loop through the soft tissue.

3. The method according to claim 2, further comprising passing the first loop through the soft tissue prior to coupling the first loop to the first coupling feature.

4. The method according to claim 3, further comprising: passing the first end through the first loop; andpassing the first end through the soft tissue.

5. The method according to claim 1, further comprising looping the first loop around the soft tissue.

6. The method according to claim 5, further comprising looping the first loop around the soft tissue prior to coupling the first loop to the first coupling feature.

7. The method according to claim 1, wherein the first coupling feature includes a hook configured to receive the first loop, and wherein coupling the first loop to the first coupling feature includes coupling the first loop to the hook after the second anchor is positioned in the second hole.

8. The method according to claim 1, the method further comprising: passing the soft tissue through the second loop; andadjusting a size of the second loop to compress the soft tissue against the bone by pulling on the second end after the first anchor is positioned in the first hole and after the second anchor is positioned in the second hole.

9. The method according to claim 1, the method further comprising: coupling the second loop to the soft tissue; andcoupling the second loop to one of the first coupling feature or the second coupling feature.

10. The method according to claim 1, the method further comprising: coupling the second loop to a third anchor in the bone adjacent to the first anchor.

11. A method of coupling a soft tissue to a bone, comprising: determining an area of the bone to couple a first anchor, a second anchor, and a third anchor, wherein: (i) the first anchor includes a first bone engaging feature and a first suture member coupled to the first anchor and forming an adjustable first loop, where the first suture member includes: (a) a first braided body defining a longitudinally extending first passage, and a first end extending from the first braided body and passing through a first aperture in the braided body and along the first passage and out a second aperture in the braided body so as to place the first end outside of the first passage, and define the first loop; and (b) a second end extending from the braided body and passing through the second aperture in the braided body and along the first passage and out the first aperture in the braided body so as to place the second end outside of the first passage, and define a second loop, (ii) the second anchor includes a second bone engaging feature, a first coupling feature, and a second suture member coupled to the second anchor and forming an adjustable third loop; and (iii) the third anchor includes a third bone engaging feature and a second coupling feature;positioning the first anchor, the second anchor, and the third anchor in the bone adjacent to each other in the area;coupling the first loop to the soft tissue and to the first coupling feature of the second anchor, wherein the first loop is coupled to the second anchor after the first anchor and the second anchor have been positioned in the bone; andcoupling the third loop to the soft tissue and to the second coupling feature of the third anchor, wherein the third loop is coupled to the third anchor after the second anchor and third anchor have been positioned in the bone.

12. The method according to claim 11, further comprising passing the third loop through the first loop.

13. The method according to claim 11, further comprising passing at least one of the first loop or the third loop through the soft tissue.

14. The method according to claim 13, further comprising looping at least one of the first loop or the third loop around the soft tissue.

15. The method according to claim 11, further comprising: adjusting a first size of the first loop to compress the soft tissue against the bone by pulling on a first end of the first suture member after the first anchor and the second anchor are positioned in the bone; andadjusting a second size of the third loop to compress the soft tissue against the bone by pulling on a third end of the second suture member after the second anchor and the third anchor are positioned in the bone.

16. The method according to claim 11, further comprising passing the soft tissue through the first loop and the third loop.

17. The method according to claim 11, wherein: the second suture member includes: a second braided body coupled to the second anchor defining a longitudinally extending second passage, and a third end extending from the second braided body and passing through a first aperture in the second braided body and along the second passage and out a second aperture in the second braided body so as to place the third end outside of the second passage, and define the third loop.

18. The method of claim 11, further comprising: passing the soft tissue through the third loop; andadjusting a size of the third loop to compress the soft tissue against the bone by pulling on a third end.

19. The method of claim 11, wherein the first anchor further includes a third coupling feature, the method further comprising: coupling the second loop to the soft tissue; andcoupling the second loop to the third coupling feature.

20. A method of coupling a soft tissue to a bone, comprising: determining an area of the bone to couple a first anchor, a second anchor, and a third anchor wherein: (i) the first anchor includes a first bone engaging feature, a first aperture, and a first suture member, the first suture member including a first braided body disposed in the first aperture and defining a longitudinally extending first passage, and a first end extending from the first braided body and passing into the first passage and and out the first passage so as to place the first end outside of the first passage, and define a self-locking, adjustable first loop, and a second end extending from the first braided body and passing into the first passage and out the first passage so as to place the second end outside of the first passage, and define a self-locking, adjustable second loop, (ii) the second anchor includes a second bone engaging feature, a second aperture, a first hook feature, and a second suture member, the second suture member including a second braided body disposed in the second aperture and defining a longitudinally extending second passage, and a third end extending from the second braided body and passing into the second passage and out the second passage so as to place the third end outside of the second passage, and define a self-locking, adjustable third loop, and a fourth end extending from the second braided body and passing into the second passage and out the second passage so as to place the fourth end outside of the second passage, and define a self-locking, adjustable fourth loop, and (iii) the third anchor includes a third bone engaging feature and a second hook feature;forming a first hole, a second hole, and a third hole adjacent to each other in the area;positioning the first anchor, the second anchor, and the third anchor in the first hole, the second hole, and the third hole, respectively;coupling the first loop and the third loop to the soft tissue;coupling the first loop to the first hook feature;passing the third loop through the first loop;coupling the third loop to the second hook feature; andtensioning the first loop and the third loop to compress the soft tissue against the bone by pulling on the first end of the first suture member and the third end of the second suture member after the first anchor is positioned in the first hole, after the second anchor is positioned in the second hole, and after the third anchor is positioned in the third hole.

21. The method of claim 20, wherein the bone is a shoulder bone and the soft tissue is a rotator cuff, and wherein coupling the first loop and the third loop to the soft tissue includes coupling the first loop and the third loop to the rotator cuff.