Universal anterior cruciate ligament repair and reconstruction system

Abstract

A system is disclosed for repairing and reconstructing an injured anterior cruciate ligament (ACL); This system may be used irrespective of the type of patient or the ACL graft selected. Means for performing single or multiple bundle reconstruction, primary ACL repair and physeal-sparing ACL reconstruction are disclosed. A guide for inside-out creation of a femoral tunnel independent of the tibial tunnel is also disclosed, as well as a series of implant options for tibial and femoral fixation of any bone-soft-tissue composite or soft-tissue-only graft.

Description

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a perspective view of a novel femoral guide in accordance with the present invention.

FIG. 2 is a top plan view of the guide in FIG. 1.

FIG. 3 is a perspective view of an alternative embodiment of the novel femoral guide of FIG. 1 with a semi-circular flexible guide loop.

FIG. 4 is a schematic view of the disposition of a guide pin in the femur of a knee utilizing the femoral guide of claim 1 in accordance with the present invention.

FIG. 5 is a schematic view of an alternative manner of disposing a guide pin in the femur of a knee utilizing the femoral guide of claim 1 in accordance with the present invention.

FIG. 6 is an exploded view of the disposition of a guide pin in the femur of a knee utilizing the femoral guide of claim 1 in accordance with the present invention.

FIG. 7 is a perspective view of a cannulated scalpel in accordance with the present invention.

FIG. 8 is a schematic view of a manner of incising the skin and soft-tissue over a guide wire utilizing the cannulated scalpel of FIG. 7 in accordance with the present invention.

FIG. 9 is a schematic view of a manner of creating a tunnel in a bone over a guide wire utilizing a cannulated reamer or drill in accordance with the present invention.

FIG. 10 is a schematic view of an alternative manner of creating a tunnel in a bone over a guide wire utilizing a cannulated reamer or drill in accordance with the present invention.

FIG. 11 is a schematic view of a second alternative manner of creating a tunnel in a bone over a guide wire utilizing a cannulated reamer or drill in accordance with the present invention.

FIG. 12 is a perspective view of a surgical ring fixation tool with its ring engaged in its ring capture button in accordance with the present invention.

FIG. 13 is a perspective view of the ring of FIG. 12.

FIG. 14 is a perspective view of a ring capture button in the surgical ring fixation tool of FIG. 12.

FIG. 15 is a side elevational view of the ring capture button of FIG. 14.

FIG. 16 is a schematic view of a manner of passing the ring of FIG. 13 along with a looped end of soft-tissue graft in accordance with the present invention.

FIG, 17 is a schematic view of a manner of assembling the ring of FIG. 13 and the ring capture button of FIG. 14 in accordance with the present invention.

FIG. 18 is a schematic view of a manner of femoral placement of the surgical ring fixation tool of FIG. 12 in a knee in accordance with the present invention.

FIG. 19 is a schematic view of a manner of tibial placement of the surgical ring fixation tool of FIG. 12 in a knee in accordance with the present invention.

FIG. 20A is a perspective view of a suspension pin in accordance with the present invention.

FIG. 20B is a perspective view of an alternative embodiment of a suspension pin in accordance with the present invention.

FIG. 20C is a perspective view of a suspension pin insertion tool in accordance with the present invention.

FIG. 20D is a perspective view of a guide wire cutting tool for removing the wire ends of a surgical pin guide wire element in accordance with the present invention.

FIG. 21 is a perspective view of a surgical pin guide in accordance with the present invention.

FIG. 22 is a perspective view of a surgical guide pin in accordance with the present invention.

FIG. 23A is a schematic view of a manner of inserting the surgical guide pin shown in FIG. 22 across a bone tunnel in accordance with the present invention.

FIG. 23B is a schematic view of a manner of inserting the surgical guide pin shown in FIG. 22 across a bone tunnel in accordance with the present invention.

FIG. 24A is a schematic view of an alternative manner of inserting the surgical guide pin shown in FIG. 22 across a bone tunnel in accordance with the present invention.

FIG. 24B is a schematic view of a flexible wire attached to the surgical guide pin of FIG. 22 traversing a bone tunnel in accordance with the present invention.

FIG. 24C is a schematic view of a manner of exchanging the surgical guide pin shown in FIG. 22 with the flexible wire of the suspension pin of the present invention.

FIG. 24D is a schematic view of an alternative manner of attaching a flexible wire of the suspension pin to the surgical guide pin traversing a bone tunnel in accordance with the present invention.

FIG. 24E is a schematic view of an alternative manner of exchanging the surgical guide pin of this invention with the flexible wire of the suspension pin of this invention.

FIG. 25A is a perspective view of a wire passing tool in accordance with the present invention.

FIG. 25B is an exploded view of the wire passing tool shown in FIG. 25A opening its functional tip.

FIG. 25C is a schematic view of a manner of utilizing the wire passing tool shown in FIG. 25A to pass a central loop of flexible wire from a tunnel in a bone out through a tunnel in another bone in accordance with the present invention.

FIG. 26 is a sectional view of FIG. 25C showing the wire passing tool of FIG. 25A passing the central loop of flexible wire in the manner illustrated in FIG. 25C.

FIG. 27 is a schematic view of a manner of loading a free soft-tissue graft into a central loop of a flexible wire in accordance with the present invention.

FIG. 28 is a schematic view of a manner of straightening and advancing a flexible wire to draw the loop end of a free soft-tissue graft through a tunnel in a bone into a tunnel of another bone in accordance with the present invention.

FIG. 29 is a schematic view of a manner of making an additional pass of a central loop of flexible wire from a tunnel in a bone out through an additional tunnel in another bone in accordance with the present invention.

FIG. 30 is a schematic view of a manner of loading a free soft-tissue graft into a central loop in a flexible wire in accordance with the present invention.

FIG. 31 is a schematic view of a manner of straightening and advancing a flexible wire to draw a loop end of a second free soft-tissue graft through a second tunnel in a bone into a tunnel of another bone in accordance with the present invention.

FIG. 32A is a schematic view of a manner of inserting the suspension pin shown in FIGS. 20A and 20B using the suspension pin insertion tool shown in FIG. 20C in accordance with the present invention.

FIG. 32B is a schematic view of a manner of cutting a flexible wire from the end of a suspension pin of this invention utilizing the wire cutting tool shown in FIG. 20D in accordance with the present invention.

FIG. 32C is a schematic view of a manner of inserting the suspension pin shown in FIGS. 20A and 20B to secure a loop end of a free soft-tissue graft in a bone tunnel in accordance with the present invention.

FIG. 33 is a schematic view of an alternative manner of passing a central loop of flexible wire from a tunnel in a bone out through a tunnel in another bone in accordance with the present invention.

FIG. 34 is a sectional view of FIG. 33 showing the passage of the central loop of flexible wire illustrated in FIG. 33.

FIG. 35 is a schematic view of a manner of loading a free soft-tissue graft into a central loop of flexible wire in accordance with the present invention.

FIG. 36 is a schematic view of a manner of straightening and advancing a flexible wire to draw the loop end of a free soft-tissue graft through a tunnel in a bone into a tunnel of another bone in accordance with the present invention.

FIG. 37A is a schematic view of a manner of inserting the suspension pin shown in FIGS. 20A and 20B utilizing the suspension pin insertion tool shown in FIG. 20C to secure a loop end of a free soft-tissue graft in a bone tunnel in accordance with the present invention.

FIG. 37B is a schematic view of a manner of cutting a flexible wire from a suspension pin of this invention utilizing the wire cutting tool shown in FIG. 20D in accordance with the present invention.

FIG. 38 is a perspective view of a modular interference screw-ligament washer in accordance with the present invention.

FIG. 39 is a perspective view of a cannulated interference screw component of the modular interference screw-ligament washer shown in FIG. 38.

FIG. 40 is a perspective view of a separate cannulated screw component and mobile ligament washer component of the interference screw-ligament washer shown in FIG. 38.

FIG. 41 is a perspective view of a non-modular interference screw-ligament washer in accordance with the present invention.

FIG. 42 is a perspective view of an insertion-tensioner tool in accordance with the present invention.

FIG. 43 is a top plan view of the insertion-tensioner tool shown in FIG. 42.

FIG. 44 is a perspective view of a trocar component of the insertion-tensioner tool shown in FIG. 42.

FIG. 45 is a perspective view of a graft loader component of the insertion-tensioner shown in FIG. 42.

FIG. 46 is a perspective view of a cannulated screw driver component of the insertion-tensioner tool shown in FIG. 42.

FIG. 47 is a perspective view of a cutter component of the insertion-tensioner shown in FIG. 42.

FIG. 48 is a schematic view of a manner of loading the free end of a soft-tissue graft into the insertion-tensioner shown in FIG. 42 utilizing the graft loader component shown in FIG. 45 in accordance with the present invention.

FIG. 49 is a schematic view of a manner of positioning the insertion-tensioner shown in FIG. 42 loaded with a soft-tissue graft over an opening of a bone tunnel utilizing the trocar component shown in FIG. 44 and a guide wire in accordance with the present invention.

FIG. 50 is a schematic view of a manner of inserting the interference screw component of the modular interference screw-ligament washer shown in FIG. 38 utilizing the insertion-tensioner shown in FIG. 42 and the cannulated screwdriver component shown in FIG. 46 in accordance with the present invention.

FIG. 51 is a schematic view of a manner of inserting the interference screw component of the modular interference screw-ligament washer shown in FIG. 38 utilizing the insertion-tensioner shown in FIG. 42 and the cannulated screwdriver component shown in FIG. 46 in accordance with the present invention.

FIG. 52 is a schematic view of a manner of inserting the separate cannulated screw and mobile ligament washer components of the modular interference screw-ligament washer shown in FIG. 40 utilizing the insertion-tensioner tool shown in FIG. 42 and the cannulated screw driver shown in FIG. 46 in accordance with the present invention.

FIG. 53 is a schematic view of a manner of cutting free ends of soft-tissue graft utilizing the cutter component shown in FIG. 47 of the insertion-tensioner tool shown in FIG. 42 after the graft has been secured by the modular or non-modular interference screw-ligament washer shown in FIGS. 38 and 41 in accordance with the present invention.

FIG. 54 is a schematic view of a manner of inserting the non-modular interference screw-ligament washer shown in FIG. 41 utilizing the insertion-tensioner tool shown in FIG. 42 and the cannulated screw driver shown in FIG. 46 in accordance with the present invention.

FIG. 55 is a schematic view of a manner of repairing an ACL tear utilizing the femoral guide tool shown in FIG. 1, the surgical guide pin shown in FIG. 22, and the cannulated scalpel shown in FIG. 7 in accordance with the present invention.

FIG. 56 is an enlarged schematic view of a portion of FIG. 55 illustrating a manner of positioning the surgical guide pin shown in FIG. 22 to pass a suture placed in the torn end of the ACL in accordance with the present invention.

FIG. 57 is an enlarged schematic view of a portion of FIG. 55 illustrating a manner of positioning the surgical guide pin shown in FIG. 22 to pass an additional suture placed in the torn end of the ACL in accordance with the present invention.

FIG. 58 is a schematic view of a manner of securing the sutures used to repair the ACL tear after using the femoral guide tool shown in FIG. 1, the surgical guide pin shown in FIG. 22 and the cannulated scalpel shown in FIG. 7 in accordance with the present invention.

FIG. 59 is a schematic view of a manner of securing an ACL graft in a femoral and tibial epiphysis of a skeletally immature knee without crossing either the femoral or tibial physis utilizing the femoral interference screw-ligament washer shown in FIGS. 38 and 41 and the suspension pin shown in FIGS. 20A and 20B in accordance with the present invention.

FIG. 60 is a perspective view of a protective sleeve in accordance with the present invention.

FIG. 61 is a top plan view of the protective sleeve shown in FIG. 60.

FIG. 62 is a perspective view of a bullet guide in accordance with the present invention.

FIG. 63 is a perspective view of a cannulated drill bit in accordance with the present invention.

FIG. 64 is a schematic view of a manner of placing a guide pin into the ACL footprint of the tibial epiphysis of a skeletally immature knee without crossing the tibial physis utilizing the protective sleeve of FIG. 60, the bullet guide of FIG. 62 and a guide pin in accordance with the present invention.

FIG. 65 is a schematic view of a manner of drilling a bone tunnel into the ACL footprint of the tibial epiphysis of a skeletally immature knee without crossing the tibial physis utilizing the protective sleeve of FIG. 60, a guide pin, and the cannulated drill bit of FIG. 63 in accordance with the present invention.

FIG. 66 is a schematic view of a manner of inserting a surgical guide pin of FIG. 22 across a bone tunnel in the tibial epiphysis of a skeletally immature knee without crossing the tibial physis utilizing the surgical pin guide of FIG. 21 in accordance with the present invention.

FIG. 67 is a schematic view of a manner of passing a central loop of flexible wire from an epiphyseal tibial bone tunnel out through a femoral tunnel in accordance with the present invention.

FIG. 68 is a schematic view of a manner of loading a free soft-tissue graft into a central loop of flexible wire in accordance with the present invention.

FIG. 69 is a schematic view of a manner of securing an ACL graft in the femoral and tibial epiphysis of a skeletally immature knee without crossing either the femoral or tibial physis utilizing a femoral interference screw-ligament washer of FIG. 38 and 41 and a tibial suspension pin of FIG. 20A and 20B in accordance with the present invention.

Claims

1. A femoral guide comprising a body portion,a handle adjacent a first end of the body portion,a functional tip adjacent a second end of the body portion, anda guide ring assembly in the functional tip including a mobile arm forming a first jaw portion of a guide ring, anda segment of the tip forming a second jaw portion of the guide ring.

2. The femoral guide of claim 1, which includes a pivotal mounting at one end of the mobile arm, andthe mobile arm is moveable toward the second jaw portion and captures an object between the first jaw and the second jaw portions.

3. The femoral guide of claim 2 in which the handle is operatively connected to the mobile arm and controls the movement of the arm toward the second jaw portion.

4. The femoral guide of claim 1 in which the functional tip includes a distal end and a hook spaced apart from the guide ring assembly.

5. The femoral guide of claim 4 in which the distal end of the functional tip is disposed a fixed distance from the guide ring assembly.

6. The femoral guide of claim 4 in which the distal end of the functional tip is disposed at an adjustable and measurable distance from the guide ring assembly.

7. The femoral guide of claim 1 in which the functional tip includes a flexible semi-circular guide loop adjacent the guide ring assembly.

8. The femoral guide of claim 7 in which the radius of the flexible semicircular guide loop is adjustable.

9. A method of using a femoral guide comprising the steps of inserting an end portion of the femoral guide into a jointinserting a guide pin into the jointgrasping the guide pin with the femoral guide, andmoving the guide pin with the femoral guide to a desired target site on a bone.

10. The method of claim 9 which includes advancing the guide pin through the target site into the bone, and forming a tunnel in the bone at the target site around the guide pin.

11. The method of claim 10 in which the bone is a femur.

12. The method of claim 10 in which the tunnel is formed in the femoral epiphysis without violating the physis

13. The method of claim 10 in which one or more tunnels are formed in the bone.

14. The method of claim 13 in which sutures attached to a torn ACL stump can be passed through the tunnels and secured.

15. A cannulated scalpel comprising a blade end,a handle adjacent the blade, anda longitudinal cannulation in the blade.

16. A method of using a scalpel comprising the steps of positioning a guide wire through the skin and soft-tissue of a patient adjacent to a target site on a bone,running the scalpel along the guide wire, andcreating a passageway through the skin and soft-tissue along the guide wire to the target site with the scalpel blade

17. A surgical ring fixation tool disposable within a tunnel in a bone comprising a ring capture button having a base membera movable central bar, anda hinge connected to an end of the central bar on which the central bar may be pivoted, anda ring disposed through the base member engaging the central bar of the ring capture button.

18. A method of securing a graft containing soft-tissue in a tunnel in a bone comprising the steps of loading a loop end of a soft-tissue graft on a ring on one side of the bone,drawing the graft through the tunnel in the bone to a second side of the bone,assembling the ring with the graft to a ring capture button, anddrawing the ring and graft into the tunnel until the ring capture button is seated against the bone at the tunnel.

19. The method of claim 18 in which the tunnel resides in an epiphysis of the bone, and the ring fixation tool secures the graft in the epiphysis of the bone without violating or traversing the physis with the tool.

20. A suspension pin comprising an elongate body portiona tapered tip located on a leading end of the body portiona rear end on the body portion configured for cooperative engagement with a tool arranged to insert or advance the pin into a bone.

21. The suspension pin of claim 20 which includes a flexible wire component extending from the body portion.

22. The suspension pin of claim 21 in which the flexible wire is slideably engaged in the pin longitudinally throughout the length of the body portion.

23. A method of placing and fixing a graft containing soft-tissue in a bone tunnel comprising the steps of placing a surgical guide pin across the tunnel,attaching a flexible wire onto the guide pin outside the tunnel,moving the guide pin and the wire across the tunnel to extend the wire across the tunnel and leaving portions of the wire outside the tunnel,grasping a portion of wire in the tunnel and withdrawing that portion from an opening of the tunnel to form a loop,loading a graft containing soft-tissue in the loop of the wire,drawing the graft into the tunnel by pulling on the portions of the wire outside of the tunnel to straighten the loop in the wire,advancing a suspension pin on the wire into the bone and placing the suspension pin across the tunnel to support the graft in the tunnel, andremoving the wire from the suspension pin.

24. The method of claim 23 in which the tunnel resides in an epiphysis of the bone, and the suspension pin secures the graft in the epiphysis of the bone without violating or traversing the physis with the pin.

25. The method of claim 23 which includes drawing the portion of the wire out of the tunnel and then through a second passage, and forming the loop in the wire outside of the second passage.

26. The method of claim 25 in which the second passage is a second bone tunnel.

27. A surgical guide pin for use with a surgical pin guide in anterior cruciate ligament repair and reconstruction surgery comprising a straight shaft forming a body portion,a leading end portion on the body portion,a trailing end portion on the body portion,a slot formed in and extending transversely through the body portion adjacent the leading end portion, anda slot formed in and extending transversely through the body portion adjacent the trailing end portion.

28. The surgical guide pin of claim 27 which includes a passage enlarging section on the body portion having a bone cutting outer surfacea cross-sectional dimension greater than that of the body portion

29. A surgical pin guide for use in anterior cruciate ligament repair and reconstruction surgery comprising a target arm containing a target point adjacent an outer end,a guide arm which includes an adjustable attachment site connected to an inner end of the target arm movable along the guide arm,an aiming end portion spaced apart from the adjustable attachment site, andan aiming bullet mounted in the aiming end portion of the guide arm containing a longitudinal cannulation with a trajectory continuously intersecting the target point.

30. A method of claim 23 which includes using a surgical pin guide to direct insertion of the surgical guide pin

31. The method of claim 23 which includes inserting a target arm of the surgical pin guide into a bone tunnel from any direction, andadvancing the surgical guide pin through a longitudinal cannulation in an aiming bullet of the surgical pin guide across the bone tunnel.

32. The method of claim 23 which includes inserting a surgical guide pin having a cutting portion of larger cross section than the rest of the pin and cutting through both cortices of the bone,advancing the surgical guide pin until the slots in the pin adjacent its leading and trailing ends are exposed outside of skin and soft-tissue adjacent the bone and leaving an intermediate body portion of the pin in the bone,placing a portion of a flexible wire through an exposed slot in one of the ends of the surgical guide pin, anddrawing the surgical guide pin from the bone by the end without the wire and leaving a portion of the wire in the bone.

33. In combination, a tunnel in the bone,a flexible wire disposed in the tunnel,a tool engaging a portion of the wire inside the tunnel arranged to draw the wire through the tunnel, andthe tool including a body portion partly in the tunnel,a handle adjacent a first end of the body portion outside the tunnel,a functional tip adjacent a second end of the body portion inside the tunnel, anda wire grasping assembly in the functional tip having a mobile arm forming a first jaw portion of the wire grasping assembly engaging the portion of the wire in the tunnel, anda segment of the tip forming a second jaw portion of the wire grasping assembly engaging the portion of the wire in the tunnel along with the mobile arm.

34. The method of forming a loop in a flexible wire for receiving a graft containing soft-tissue to repair or reconstruct a ligament of a joint comprising inserting a tool for passing the wire into a first bone tunnel from any direction capturing a portion of the flexible wire in the tunnel to form a loop in the wire drawing the loop of wire into the articular space of the joint withdrawing the loop of wire out of the joint through a second bone tunnel with the tool

35. A interference screw-ligament washer for fixing free ends of a graft containing soft-tissue in a bone tunnel comprising a first screw which includes leading and trailing end portions andan outer diameter and length to engage the free ends of the soft-tissue graft and wall segments of the tunnel inside the tunnel adjacent to an open end of the tunnel,a first cannulation in the first screw at the leading end having a diameter large enough to accept a guide wire leading into the tunnel,a socket axially and longitudinally arranged in the first screw extending from the first cannulation to the trailing end of the first screw,a second screw which includes a head portion at one end,an externally threaded portion adjacent a second end and the externally threaded position having a diameter to engage the socket in the first screw, anda second cannulation axially and longitudinally arranged throughout the length of the second screw having a diameter large enough to accept the guide wire, anda disc which includes a cannulation with a diameter large enough to accept the externally threaded portion of the second screw and permit the disc to be moved along the second screw and engage the head.

36. The interference screw-ligament washer of claim 35 in which the second screw includes a disc pivoting segment adjacent the head portion having a cross section which is sufficiently smaller than the cannulation in the disc and permits the disc to adopt a variety of planes.

37. The interference screw-ligament washer of claim 35 in which the head portion of the second screw includes a geometrical configuration formed to accept engagement with a driving tool used to turn the second screw.

38. The interference screw-ligament washer of claim 35 in which the disc includes a first surface which grips bone and soft-tissue, and a geometrical configuration formed to position the disc over the tunnel.

39. The interference screw-ligament washer of claim 35 in which the first screw includes an adhesive outer surface for engaging bone or soft-tissue

40. The interference screw-ligament washer of claim 35 in which the trailing end portion of the first screw includes a socket which is formed for interlocking engagement with a screw-driving tool.

41. The interference screw-ligament washer of claim 35 in which the second screw includes a portion spaced apart from the head portion and driver formed for interlocking engagement with the socket in the trailing end portion of the first screw.

42. The interference screw-ligament washer of claim 35 in which the disc includes one or more cannulations which are spaced apart from the cannulation around the second screw at suitable places for receiving sutures attached to the graft in the tunnel and tying the sutures to the disc.

43. The interference screw-ligament washer of claim 35 in which the cannulation in the disc around the second screw is surrounded by a recessed portion in the disc which accepts the head portion of the second screw and provides a low-profile disc surface facing away from the tunnel.

44. A non-modular interference screw-ligament washer for fixing free ends of a graft containing soft-tissue in a bone tunnel comprising a screw having leading and trailing end portions and an outer diameter and length to engage the free ends of the graft and wall segments of the tunnel inside the tunnel adjacent to an open end of the tunnel,a first cannulation in the screw at the leading end having a diameter large enough to accept a guide wire leading into the tunnel,a socket axially and longitudinally arranged in the screw extending from the first cannulation to the trailing end of the screw, anda disc pivotally mounted on the trailing end of the screw having an inner face disposed toward the screw and engageable upon a variety of bone surface planes at the open end of the tunnel.a second cannulation formed in the disc extending through the disc providing a passageway for a driver to be connected to the socket in the screw.

45. The interference screw-ligament washer of claim 44 in which the disc includes a first surface which grips bone and soft-tissue, and a geometrical configuration formed to position the disc over the tunnel.

46. The interference screw-ligament washer of claim 44 in which the leading end portion of the screw includes an adhesive outer surface for engaging bone or soft-tissue.

47. The interference screw-ligament washer of claim 44 in which the disc includes one or more cannulations at suitable places for receiving sutures attached to the graft in the tunnel and tying the sutures to the disc.

48. Securing a graft containing soft-tissue in a bone tunnel comprising the steps of placing a free end of the graft in the tunnel,engaging a socket in a first screw with a driver,positioning a first screw at the tunnel with the graft,advancing the first screw into the tunnel and engaging the graft and wall portions of the tunnel to each other inside the tunnel with the first screw,assembling a disc onto a second screw,engaging the second screw with a driver, andadvancing the second screw into the socket of the first screw until the disc is forcibly compressed against the bone and any graft outside the tunnel.

49. The method of claims 48 in which the tunnel resides in an epiphysis of the bone, and an interference screw-ligament washer secures the graft in the epiphysis of the bone without violating or traversing the physis with the interference screw-ligament washer.

50. Securing a graft containing soft-tissue in a bone tunnel comprising the steps of placing a free end of the graft in the tunnel,assembling an interference screw-ligament washer, having a first screw portion,a socket in the first screw portion,a second screw extending into the socket of the first screw, anda disc slideably maintained on the second screw by a cannulation in the disc and a head on the second screw, andinserting the assembled interference screw-ligament washer into the tunnel while holding the graft under tension, andadvancing the interference screw-ligament washer into the tunnel to engage the graft and wall portions of the tunnel to each other inside the tunnel with the first screw portion and forcibly compress the disc against the bone and against any portions of the graft outside the tunnel with the second screw.

51. The method of claims 50 in which the tunnel resides in an epiphysis of the bone, and an interference screw-ligament washer secures the graft in the epiphysis of the bone without violating or traversing the physis with the interference screw-ligament washer.

52. Securing a graft containing soft-tissue in a bone tunnel comprising the steps of placing a free end of the graft in the tunnel,inserting the non-modular interference screw-ligament washer into the tunnel while holding the graft under tension, andadvancing the interference screw-ligament washer into the tunnel to engage the graft and wall portions of the tunnel to each other inside the tunnel and forcibly compress the disc against the bone and against any portions of the graft outside the tunnel.

53. The method of claims 52 in which the tunnel resides in an epiphysis of the bone, and an interference screw-ligament washer secures the graft in the epiphysis of the bone without violating or traversing the physis with the interference screw-ligament washer.

53. An instrument for tensioning a graft containing soft-tissue in a bone tunnel and maintaining the tension while free end portions of the graft are fixed in place comprising An outer tube and an inner tube telescopically and slideably engaged with each other.the outer tube including a leading end engaging the inner tube,attachment sites on the leading end for connection to the free end portions of the graft andthe inner tube including a trailing end inserted in the outer tubea leading end having a beveled extremity for engaging the surface of the bone around the tunnel andmultiple cannulations adjacent the beveled extremitya passageway formed through the extremity and cannulations of the inner tube for the free end portions of the graft to be passed and engaged upon the attachment sites on the outer tube when the tubes are telescopically collapsed, and for tension on the free end portions of the graft to be increased when the tubes are telescopically extended.

54. The graft tensioning instrument of claim 53 which includes a trocar mounted in the instrument having a tip portion extending beyond the instrument and positioned to precede passage of the instrument through skin and soft-tissue to the opening of the bone tunnel.

55. The trocar of claim 54 which includes a conically shaped tip portion disposed on a leading end of a shaft and a head portion on a trailing end of the shaft with a cross-section greater than the shaft to stop movement of the trocar.

56. The trocar of claim 55 which includes a longitudinal cannulation through the shaft from the tip portion to the head portion.

57. The trocar of claim 55 which includes at least one slot in the tip and shaft portions forming a passageways for the free ends of the graft leading into a distal end of the inner tube of the graft tensioning instrument.

58. A tool for receiving and moving the free ends of a graft containing soft-tissue from a bone tunnel into engagement on a graft tensioning instrument comprising a tool body portion of long stiff bendable wire,a tool handle disposed on a first end of the body portion, anda tool loop sufficiently sized and adapted for receiving and moving the free ends of the graft and sutures attached to the free ends of the graft disposed on a second end of the tool body portion opposite the handle.

59. A screw driver for positioning exteriorly threaded devices in bone tunnels comprising a driver shaft portiona driver handle disposed on a first end of the shaft portion, anda driver bit disposed on a second end of the shaft portion sufficiently sized and adapted for engaging a socket in the exteriorly threaded device and transmitting rotational and linear forces on the device while the device is in the tunnel

60. The screw driver of claim 59 which includes a longitudinal cannulation through the shaft portion and extending through the handle and the bit for moving the driver along a guide wire.

61. The screw driver of claim 60 which includes a driver having angularly disposed exterior surfaces cooperatively engageable in a socket having angularly disposed wall surfaces matching the driver bit surfaces.

62. The graft tensioning instrument of claim 53 which includes a graft and suture end cutting tool having a tip portion with a cutting edge, The tool being slideably positioned inside the inner tube and moveable through the inner tube to engage graft and suture ends with the cutting edge and shear the ends adjacent a wall of the inner tube.

63. The graft tensioning instrument of claim 62 which includes a graft and suture end cutting tool having a longitudinal cannulation in at least a portion of the tool and engaging the tool on a guide wire.

64. Tensioning a graft containing soft-tissue in a bone tunnel and maintaining the tension while free end portions of the graft are fixed in place comprising the steps of assembling an inner tube and an outer tube in a minimally extended telescopic relationship,passing free ends of the graft and connected sutures into a first end of the inner tube and out the inner tube through cannulations in a wall of the tube,inserting a trocar into the inner tube from a second end of the inner tube,inserting the trocar and minimally extended telescopically assembled inner and outer tubes through a passageway in the skin and soft-tissue opened by passage of the trocar and assembled tubes to a bone surface around an opening of the bone tunnel with the first end of the inner tube leading the assembled tubes,removing the trocar,maintaining the first end of the inner tube against the bone surface,securing the free ends of the graft and connected sutures to attachment sites on the outer tubeextending the outer tube of the telescopic assembly to increase the length of the assembly and establish a predetermined amount of tension on the graft,inserting a graft fixation device through the tubes while the graft is under tension,affixing the free end portions of the graft to walls of the bone tunnel inside the tunnel, andshearing and removing portions of graft and connected sutures outside of the tunnel opening.