WO2018075615A1

WO2018075615A1 - Meniscal root repair methods and devices

Info

Publication number: WO2018075615A1
Application number: PCT/US2017/057138
Authority: WO
Inventors: Jennifer Ng; Kangqiao LI; Jared HARLOW; Jeffrey Wyman
Original assignee: Smith & Nephew, Inc.
Priority date: 2016-10-18
Filing date: 2017-10-18
Publication date: 2018-04-26

Abstract

Embodiments of the invention include implants (600, 610, 700, 1600), instruments (400, 500), and methods for coupling meniscal tissue to a tibia. Some embodiments provide instruments (400, 500) and methods that enable coupling of meniscal tissue (200) by approaching the meniscal tissue (200) through a tunnel (105) in a tibial plateau (101), where the net surgical approach is substantially perpendicular to a plane of the tibial plateau (101).

Description

MENISCAL ROOT REPAIR METHODS AND DEVICES

CROSS-REFERENCE TO RELATED APPLICATIONS

[001] This application claims priority to U.S. Provisional Patent Application No. 62/409,465, filed October 18, 2016, the disclosure of which is incorporated by reference herein in its entirety.

FIELD OF THE INVENTION

[002] The present invention relates generally to the field of surgical methods and medical devices, and more particularly relates to methods and devices for coupling soft tissue to bone. Some embodiments include specific methods and devices for attaching a meniscus to a tibia through a tibial tunnel.

BACKGROUND

[003] Meniscus root attachment is essential in providing evenly distributed hoop stresses in meniscal cartilage and thereby enabling healthy load-sharing across a knee. Detachment of a meniscus at, for example, its posterior root may damage

circumferential integrity of a meniscus and lead to rapid progression of arthritis. Anatomic root re-approximation and sufficient fixation is required for a repaired meniscus to function properly. Typical meniscal root repair surgery requires the meniscal root to be secured with sutures for sufficient fixation. Sutures are typically passed through a trans-tibial tunnel drilled at an angle ranging from 45 to 55 degrees from a tibial plateau. Drilling at such an angle results in an exit hole from a tibia that guides a suture needle from a face of a tibial plateau at an angle that is not close to perpendicular to the face of the tibial plateau. Lack of perpendicularity increases the difficulty of aligning a suture needle with a desired connection point at a meniscal root. In order to deploy a fixation device such as a suture optimally into the meniscus, perpendicularity of the suture needle at the face of the tibial plateau is an important consideration. Otherwise, the suture needle may skive posteriorly, potentially causing damage to the patient's meniscal tissues.

[004] Anatomic root re-approximation may be difficult with prior art devices. Non-perpendicular connection and/or misalignment also has the potential to create additional and unwarranted stresses in the meniscus when sutures coupled to the meniscus in a non-perpendicular manner are tightened and pull the meniscus at least in part along the plane of the face of the tibial plateau. It would be advantageous to provide methods and devices that allow for accurate and repeatable approaches into a meniscal repair site that result in substantially perpendicular entry through a tibial plateau into a meniscus to be repaired.

SUMMARY

[005] An embodiment of the invention is a method of coupling meniscal tissue to a tibia. Method embodiments may include creating a tunnel with a diameter through the tibia wherein the tunnel has an inferior end and a superior end and wherein an angle of a straight line that intersects a center of the inferior end and a center of the superior end is between about 60 and 70 degrees from a face of a tibial plateau of the tibia such that the superior end of the tunnel is located on the tibia near a portion of the meniscal tissue to be coupled to the tibia. The method may also include inserting a curved needle through the tunnel with at least one curved section having a curvature between about 15 and 25 degrees wherein the curved section fits within the diameter of the tunnel and between the inferior end and the superior end of the tunnel; and puncturing the meniscal tissue at one or more fixation locations with the curved needle and passing a fixation element through the meniscal tissue at one or more of the fixation locations to couple meniscal tissue to the tibia.

[006] Another embodiment of the invention is a method that includes at least introducing a needle through a tibial plateau from a position inferior to the tibial plateau at an angle that is substantially perpendicular to a face of the tibial plateau at a location where the needle passes through the tibial plateau. The method may also include drilling a tunnel with a diameter through the tibial plateau through a drill guide, the drill guide having an angle of between about 60 and 70 degrees between a drilling tube of the drill guide and a reference plane of the drill guide, such drilling occurring when the reference plane of the drill guide is aligned relative to the tibial plateau; and inserting generally inferiorly to superiorly a curved needle through the tunnel with at least one curved section having a curvature between about 15 and 25 degrees, wherein the curved section fully fits within the diameter of the tunnel and the curved section fully fits along a length of the tunnel not substantially longer than a distance from a) an inferior point where the tunnel is drilled in the tibia and b) the tibial plateau.

[007] Yet another embodiment of the invention is a kit configured for use in coupling meniscal tissue to a tibia. The kit may include a drill guide and a curved needle. The drill guide may include at least a guide tube with a length through which creation of a tunnel with a tunnel diameter in the tibia may be controlled in a direction extending from the guide tube, and a reference member coupled to the guide tube at an angle, the reference member including a reference alignment plane along a length of the reference member at the angle with the length of the guide tube. The angle between the length of the guide tube and the reference member reference alignment plane may be between about 60 and 70 degrees during creation of the tunnel. The curved needle may include at least one curved section having a curvature between about 15 and 25 degrees along the curved section, wherein the curvature between about 15 and 25 degrees along the at least one curved section fully fits within the tunnel diameter configured to be created through the drill guide.

BRIEF DESCRIPTION OF THE DRAWINGS

[008] FIG. 1 is a superior plan view of a tibia and fibula that shows meniscal tissue, including damaged medial meniscal tissue.

[009] FIG. 2 is a side perspective view of the medial meniscus and the tibia shown in FIG. 1.

[0010] FIG. 3 is a side elevation view of a drill guide embodiment.

[0011] FIG. 4 is a side elevation view of a needle embodiment.

[0012] FIG. 5 is a partial cross-sectional side view of a needle embodiment placed through a tibia.

[0013] FIG. 6 is a side elevation view of a drill guide embodiment in use on a tibia. [0014] FIG. 7 is a side elevation view of a needle embodiment placed through a tibia, where the tibia is drawn as a transparent component to better illustrate the needle's orientation relative to the tibia.

[0015] FIG. 8 is an expanded side elevation view of a distal end of an embodiment of the needle.

[0016] FIG. 9 is a superior plan view of a tibia that shows meniscal tissue returned to an anatomically correct location for coupling to the tibia. [0017] FIG. 10 is a side elevation view of the tibia and medial meniscal tissue (drawn as a transparent component) as configured in FIG. 9 with a needle embodiment penetrating the meniscal tissue.

[0018] FIG. 11 is a superior plan view of the tibia, meniscal tissue, and needle of FIG. 10.

[0019] FIG. 12 is a superior plan view of the tibia and meniscal tissue as arranged in FIG. 11 with a suture and suture head in place to couple the meniscal tissue to the tibia.

[0020] FIG. 13 is a side elevation view of the tibia and medial meniscal tissue (drawn as a transparent component) as configured in FIG. 12. [0021] FIG. 14 is a side elevation view of a button coupled to an inferior end of a fixation element to secure the fixation element relative to the tibia.

DETAILED DESCRIPTION

[0022] A tibia 100 with a tibial plateau 101 is shown with a medial meniscus 200 and a lateral meniscus 300 in FIGS. 1 and 2. A posterior root 201 of the medial meniscus 200 is shown separated from the tibial plateau 101 by a distance illustrated in FIG. 2 by arrow 199, and consequently is in need of repair by coupling to the tibia 100. A plateau line 111 along an average plane of the tibial plateau 101 is shown in FIGS. 1, 3, and 5. The plateau line 111 and the tibial plateau 101 as used herein will refer to a substantial average plane, or predominant plane, of the superior portion of the tibia 100 boney surfaces of the tibial plateau 101. Because the superior portion of the tibia 100 boney surfaces are irregular, such a substantial average plane, or predominant plane, is understood by those skilled in the art to serve as an angular reference for a tibia. The illustrated plateau line 111 is drawn along the tibial plateau 101 in a substantially anterior-posterior direction at an approximate medial-lateral midline of the tibia 100. Methods and devices described herein are illustrated in association with coupling of a posterior root of a medial meniscus to a tibia; however, the methods and devices described may be equally applicable to other repairs involving coupling of soft tissue to bone. Reattachment or repair may be

accomplished, for example and without limitation, on a different part of the medial meniscus, on a lateral meniscus, such as the lateral meniscus 300 shown, or on any other soft tissue structure. The soft tissue attached or reattached may be cartilage, ligaments, tendons, or any combination or part of these soft tissues or others. The bone to which soft tissue is reattached may be, for example and without limitation, a tibia, femur, patella, humerus, radius, or any combination or part of these bones or others. Soft tissue coupled, attached, reattached, repaired, or brought into contact with bone in various embodiments may consequently be given the opportunity to grow into the bone.

[0023] An embodiment of the invention is a kit configured for use in coupling meniscal tissue to a tibia. As illustrated in FIG. 3, the kit may include a drill guide 400. The drill guide 400 illustrated includes a guide tube 410 and a reference member 420. The reference member 420 shown includes a guide 422 and an aimer 424 that are adjustable relative to one another. A knob 423 may be loosened to allow for adjustment between the guide 422 and the aimer 424 and then tightened to fix movement between the guide 422 and the aimer 424. Because the guide tube 410 is angularly fixed relative to the guide 422, adjustment between the guide 422 and the aimer 424 effectively adjusts the angular relationship between the guide tube 410 and the aimer 424. The drill guide 400 shown also include a reference alignment plane 425 along the aimer 424. The reference alignment plane 425 provides a visible alignment surface for a user to employ to position the aimer 424 in, for example, a parallel relationship with the tibial plateau 101. For example, as shown in FIG. 3, the reference alignment plane 425 is placed in a parallel relationship with the plateau line 111, which is a line on the surface of the tibial plateau 101 (FIG. 1). Stated another way, alignment of the reference alignment plane 425 may be from parallel alignment with the predominant plane of the tibial plateau 101.

[0024] The guide tube 410 shown has a length through which creation of a tunnel 105 (FIG. 5) in the tibia 100 may be controlled in a direction extending from the guide tube 410. As shown in FIG. 3, the direction extending from the guide tube 410 is generally superior. The reference member 420 is coupled to the guide tube 410 at an angle. Using the reference alignment plane 425 of the reference member 420 as a measuring position, a set angle 430 is established for the drill guide 400. As shown in FIG. 3, the set angle 430 is about 65 degrees between the reference alignment plane 425 and the guide tube 410. This setting is also marked with indicia along an arched portion of the aimer 424. Guide tubes of various embodiments may include a distal end, such as the distal end 412, with drilling, cutting, or punching components.

Alternatively or in addition, guide tubes of some embodiments may serve as a cannula through which other drilling, cutting, or punching tools may be placed to create a tunnel, such as the tunnel 105 (FIG. 5). The set angle 430 between the length of the guide tube 410 and the reference member reference alignment plane 425 may be between about 60 and 70 degrees during creation of the tunnel for some embodiments. As illustrated in FIGS. 3 and 6, the set angle 430 is about 65 degrees.

[0025] A curved needle 500 is depicted in FIGS. 4 and 5. The curved needle 500 includes at least one curved section 510 having a curvature between about 15 and 25 degrees. As used herein, a curvature in degrees of a curved section refers to a change in angle of a tangent line taken at one end of the curved section relative to a tangent line taken at the other end of the curved section. As illustrated in FIG. 4, the curvature is measured from an initial tangent line 511 to a distal tangent line 512 and measured as the curvature angle 530. The initial tangent line 511 is measured from initial tangent point 521 in the illustrated embodiment, and the distal tangent line 512 is measured at the distal tip 522 of the needle 500. As depicted in this embodiment, the distal tip 522 is the piercing end of the needle 500 along the curved section 510. In some embodiments, the curvature of the curved section 510 is about 20 degrees along the curved section 510.

[0026] As is evident from the illustration in FIG. 5, the at least one curved section 510 is configured to fully fit within a diameter of the tunnel 105 created through the drill tube 410 of the drill guide 400. This relative sizing allows a penetration angle 130 between the distal tip 522 of the needle 500 and a meniscal tissue to be coupled to the tibia 100 to be substantially perpendicular, as will be more particularly described in association with FIG. 8 herein.

[0027] A kit embodiment of the invention may also include one or more sutures (600, 1600; FIGS. 12-14) used to couple between the medial meniscus 200 and the tibia 100. Such sutures may be sized to fit through a tunnel in the tibia 100, such as the tunnel 105. Such sutures may include one or more of a single strand suture, a multiple strand suture, or a wire. An illustrative suture 600 is shown in FIGS. 12 and 13 attached with a suture head 610. Other embodiments may employ suture alone without a retention device such as the suture head 610 or may use a different type of retention device. An example non-limiting effective multiple strand suture may be an ULTRATAPE brand tape-type suture 1600 that includes multiple strands woven into an advantageous structure, as is shown in FIG. 14. ULTRATAPE is a trademark of Smith & Nephew, Inc., 1450 Brooks Road, Memphis, Tennessee. Other

embodiments may include use of any effective known or later developed suture or similar structure capable of attaching between soft tissue and bone.

[0028] Some kit embodiments may include a button configured to couple to an inferior end of the fixation element to secure the fixation element relative to the tibia. For example and without limitation, an ENDOBUTTON as shown in FIG. 14 may be a button 700 used to couple one or more strands of an ULTRATAPE fixation element (suture 1600) to the tibia 100. ENDOBUTTON is a registered trademark of Smith & Nephew, Inc. Other embodiments may include use of any effective button, anchor or similar device, such as but not limited to, a washer, another type of proprietary suture anchor, an interference screw, a post, a tenodesis screw, or a knotless anchor.

[0029] A method of coupling meniscal tissue to a tibia is specifically illustrated in FIGS. 6-14. The instruments and implants shown in FIGS. 6-14 are substantially the same as the instruments and implants described in association with FIGS. 3-5 herein where common designations are used. The illustrations in FIGS. 6-14 are intended to better depict aspects of method embodiments of the invention. Creation of the tunnel 105 with a diameter through the tibia 100 is illustrated in FIGS. 6 and 7. Method embodiments may also be described as methods of introducing a needle 500 through a tibial plateau from a position inferior to the tibial plateau 101 at an angle that is substantially perpendicular to a face of the tibial plateau 101 at a location where the needle 500 passes through the tibial plateau 101. As used herein, the term

substantially perpendicular may refer to an angle reasonably close to perpendicular, such as for example, about 80 to 100 degrees. In the illustrated embodiment, the posterior portion of the tibial plateau 101 and the position inferior to the tibial plateau 101 is anterior of where the needle 500 passes through the tibial plateau 101.

[0030] The tunnel 105 shown in FIGS. 5, 7, and 9-13 has a round cross-section. However, in other embodiments, a tunnel may have any effective shape. The tunnel 105 has an inferior end 106 and a superior end 107, as shown in FIG. 7. The tunnel 105 or another effective tunnel may be created by drilling, cutting, punching, or in any effective manner of creating a tunnel in bone. Tools such as drill bits, augers, fluid jets, stylets, corkscrews, or any other effective drilling mechanism, may be used in tunnel creation.

[0031] The set angle 430 (FIGS. 3, 6, and 8) of a straight line, for example, a line parallel to the initial tangent line 511, that intersects a center of the inferior end 106 and a center of the superior end 107 may be between about 60 and 70 degrees from a face of the tibial plateau 101 of the tibia 100. In some embodiments, the set angle 430 is more particularly about 65 degrees. In FIG. 8, the plane of the tibial plateau 101 is represented by the plateau line 111. As noted herein, the plateau line 111 and the tibial plateau 101 as used herein refer to a substantial average plane of the superior portion of the tibia 100 boney surfaces. In this embodiment, the face of the tibial plateau 101 is measured substantially between points along the tibial plateau 101 that are substantially parallel to an anterior to posterior axis of the tibia 100, such as the illustrated plateau line 111. Considered from a perspective of the drill guide 400 setting, the drill guide 400 may have an angle of between about 60 and 70 degrees between the drilling tube 410 of the drill guide 400 and the reference or alignment plane 425 of the drill guide 400. Drilling may be accomplished when the reference plane of the drill guide 400 is aligned relative to the tibial plateau 101 as described here.

[0032] In some method embodiments, the superior end 107 (FIG. 7) of the tunnel 105 is located on the tibia 100 near a portion of meniscal tissue (medial meniscus 200) to be coupled to the tibia 100. More particularly, as illustrated in FIGS. 9-13, the superior end 107 of the tunnel 105 is located on the tibia 100 near the posterior root 201 that is to be coupled to the tibia 100. Note also that in the illustrated

embodiment, the damaged medial meniscus illustrated in FIGS. 1 and 2 has been repositioned to a more anatomically correct position before being acted on as shown in FIGS. 10-13. [0033] Another act of the illustrated method includes inserting the curved needle 500 through the tunnel 105 with at least one curved section 510 having a curvature between about 15 and 25 degrees. As noted herein, the curvature in degrees of the curved section 510 refers to a change in angle of the initial tangent line 511 from the initial tangent point 521 at one end of the curved section 510 to the distal tangent line 512 at the other end of the curved section 510, which is in this case the distal tip 522. In some embodiments, insertion of a curved needle includes inserting a needle with a curvature along the curved section 510 that is about 20 degrees. As demonstrated in FIGS. 5 and 7, the curved section 510 is sized to fit within the diameter of the tunnel 105 and between the inferior end 106 and the superior end 107 of the tunnel. Stated another way, embodiments of the method include inserting of the curved needle 500 generally inferiorly to superiorly through the tunnel 105 with at least one curved section having a curvature between about 15 and 25 degrees, wherein the curved section fully fits within the diameter of the tunnel 105 and the curved section fully fits along a length of the tunnel 105 not substantially longer than a distance from a) an inferior point where the tunnel is drilled in the tibia (the inferior end 106) and b) the tibial plateau 101. The resulting penetration angle 130 is a sum of the set angle 430 and the curvature angle 530, as particularly illustrated in FIG. 8.

[0034] The illustrated method embodiment also includes puncturing the meniscal tissue, for example, the posterior root 201, at one or more fixation locations with the curved needle 500, as shown in FIG. 10. The method may also include passing a fixation element, such as the suture 600 (FIGS. 12 and 13) or the tape 1600 (FIG. 14), through the meniscal tissue at one or more of the fixation locations to couple the meniscal tissue to the tibia 100. Passing the fixation element through the meniscal tissue may include passing one or more of a single strand suture, a multiple strand suture (such as ULTRATAPE brand tape), a wire, or any effective known or later developed suture or similar structure capable of attaching between soft tissue and bone. Passing the fixation element through the meniscal tissue may include introducing the fixation element through a portal that does not pass through the tunnel 105. For example and without limitation, method acts disclosed herein may be accomplished through a portal, such as an endoscopic portal. In addition, method acts may be observed through a portal. Multiple portals may be used to accomplish or observe acts of the methods disclosed herein. [0035] A further act of some embodiments includes tensioning the fixation elements (600, 1600) and reducing the distance illustrated in FIG. 2 by arrow 199 to bring more of the posterior root 201 into contact with the tibial plateau 101. When a desired tension for the fixation elements (600, 1600) is achieved, the fixation elements may be secured relative to the tibia 100. Fixing one or more of the fixation elements (600, 1600) near the inferior end 106 of the tunnel 105 is shown in FIG. 14. In the illustrated embodiment, fixing near the inferior end 106 of the tunnel 105 is accomplished by tying the tape 1600 to an ENDOBUTTON brand device. Other embodiments may include any effective button or other fixation device, such as but not limited to, a washer, another type of proprietary suture anchor, an interference screw, a post, a tenodesis screw, or a knotless anchor.

[0036] Various embodiments of the kit, instruments, and implants wholly or their components individually may be made from any biocompatible material. For example and without limitation, biocompatible materials may include in whole or in part: non-reinforced polymers, reinforced polymers, metals, ceramics, adhesives, reinforced adhesives, and combinations of these materials. Reinforcing of polymers may be accomplished with carbon, metal, or glass or any other effective material. Examples of biocompatible polymer materials include poly amide base resins, polyethylene, Ultra High Molecular Weight (UHMW) polyethylene, low density polyethylene, polymethylmethacrylate (PMMA), polyetheretherketone (PEEK), polyetherketoneketone (PEKK), a polymeric hydroxy ethylmethacrylate (PHEMA), and polyurethane, any of which may be reinforced. Polymers used as bearing surfaces in particular may in whole or in part include one or more of cross-linked and highly cross-linked polyethylene. Example biocompatible metals include stainless steel and other steel alloys, cobalt chrome alloys, zirconium, oxidized zirconium, tantalum, titanium, titanium alloys, titanium-nickel alloys such as Nitinol and other superelastic or shape-memory metal alloys.

[0037] Terms such as inferior, superior, distal, medial, lateral, posterior, anterior, near, and the like have been used relatively herein. However, such terms are not limited to specific coordinate orientations, distances, or sizes, but are used to describe relative positions referencing particular embodiments. Such terms are not generally limiting to the scope of the claims made herein. Any embodiment or feature of any section, portion, or any other component shown or particularly described in relation to various embodiments of similar sections, portions, or components herein may be interchangeably applied to any other similar embodiment or feature shown or described herein.

[0038] While embodiments of the invention have been illustrated and described in detail in the disclosure, the disclosure is to be considered as illustrative and not restrictive in character. All changes and modifications that come within the spirit of the invention are to be considered within the scope of the disclosure.

Claims

What is claimed is:

1. A method of coupling meniscal tissue to a tibia comprising:

creating a tunnel with a diameter through the tibia wherein the tunnel has an inferior end and a superior end and wherein an angle of a straight line that intersects a center of the inferior end and a center of the superior end is between about 60 and 70 degrees from a face of a tibial plateau of the tibia such that the superior end of the tunnel is located on the tibia near a portion of the meniscal tissue to be coupled to the tibia;

inserting a curved needle through the tunnel with at least one curved section having a curvature between about 15 and 25 degrees wherein the curved section fits within the diameter of the tunnel and between the inferior end and the superior end of the tunnel; and

puncturing the meniscal tissue at one or more fixation locations with the curved needle and passing a fixation element through the meniscal tissue at one or more of the fixation locations to couple meniscal tissue to the tibia.

2. The method of claim 1 wherein the act of creating a tunnel includes creating a tunnel with a superior end to inferior end straight line angle of about 65 degrees from a face of a tibial plateau of the tibia.

3. The method of claim 1 wherein the act of creating a tunnel with a superior end includes creating the superior end of the tunnel near posterior meniscal tissue.

4. The method of claim 1 wherein the act of creating a tunnel having an angle relative to the orientation of the face of the tibial plateau is measured substantially between points along the tibial plateau that are substantially parallel to an anterior to posterior axis of the tibia.

5. The method of claim 1 wherein the act of inserting a curved needle through the tunnel with at least one curved section includes inserting a needle having a curvature along the at least one curved section of about 20 degrees.

6. The method of claim 1 wherein puncturing the meniscal tissue at one or more fixation locations with the curved needle and passing a fixation element includes passing a fixation element that is a single strand suture.

7. The method of claim 1 wherein puncturing the meniscal tissue at one or more fixation locations with the curved needle and passing a fixation element includes passing a fixation element that is a multiple strand suture.

8. The method of claim 1 wherein passing a fixation element through the meniscal tissue at one or more of the fixation locations includes introducing the fixation element through a portal that does not pass through the tunnel.

9. The method of claim 1 , further comprising fixing one or more of the fixation elements near the inferior end of tunnel.

10. The method of claim 9 wherein fixing one or more of the fixation elements near the inferior end of tunnel includes fixing one or more of the fixation elements to a button.

1 1. A method comprising:

introducing a needle through a tibial plateau from a position inferior to the tibial plateau at an angle that is substantially perpendicular to a face of the tibial plateau at a location where the needle passes through the tibial plateau, acts of the method further comprising:

drilling a tunnel with a diameter through the tibial plateau through a drill guide, the drill guide having an angle of between about 60 and 70 degrees between a drilling tube of the drill guide and a reference plane of the drill guide, such drilling occurring when the reference plane of the drill guide is aligned relative to the tibial plateau; and

inserting generally inferiorly to superiorly a curved needle through the tunnel with at least one curved section having a curvature between about 15 and 25 degrees, wherein the curved section fully fits within the diameter of the tunnel and the curved section fully fits along a length of the tunnel not substantially longer than a distance from a) an inferior point where the tunnel is drilled in the tibia and b) the tibial plateau.

12. The method of claim 11 wherein introducing the needle through the tibial plateau includes introducing the needle through a posterior portion of the tibial plateau and the position inferior to the tibial plateau is anterior of where the needle passes through the tibial plateau.

13. The method of claim 11 wherein the act of drilling a tunnel with a diameter through the tibial plateau through a drill guide includes drilling at an angle of about 65 degrees relative to the tibial plateau.

14. The method of claim 11 wherein for the act of drilling, alignment with the tibial plateau is substantially parallel alignment with a predominant plane of the tibial plateau.

15. The method of claim 11 wherein for the act of drilling, alignment with the tibial plateau is substantially parallel alignment with a predominant plane of the tibial plateau and alignment in a direction substantially parallel with an anterior- posterior axis of the tibia.

16. The method of claim 11 wherein for the act of inserting generally inferiorly to superiorly a curved needle through the tunnel includes inserting a curved needle with at least one curved section having a curvature of about 20 degrees.

17. The method of claim 11, further comprising puncturing meniscal tissue at one or more fixation locations with the curved needle and passing a fixation element through the meniscal tissue at one or more of the fixation locations to couple meniscal tissue to the tibia.

18. The method of claim 17 wherein puncturing the meniscal tissue at one or more fixation locations with the curved needle and passing a fixation element includes passing a fixation element that is a single strand suture.

19. The method of claim 17 wherein puncturing the meniscal tissue at one or more fixation locations with the curved needle and passing a fixation element includes passing a fixation element that is a multiple strand suture.

20. The method of claim 17 wherein passing a fixation element through the meniscal tissue at one or more of the fixation locations includes introducing the fixation element through a portal that does not pass through the tunnel.

21. The method of claim 17, further comprising fixing one or more of the fixation elements near the inferior entry point.

22. The method of claim 21 wherein fixing one or more of the fixation elements near the inferior entry point includes fixing one or more of the fixation elements to a button.

23. A kit configured for use in coupling meniscal tissue to a tibia comprising:

a drill guide comprising:

a guide tube with a length through which creation of a tunnel with a tunnel diameter in the tibia may be controlled in a direction extending from the guide tube, and

a reference member coupled to the guide tube at an angle, the reference member including a reference alignment plane along a length of the reference member at the angle with the length of the guide tube,

wherein the angle between the length of the guide tube and the reference member reference alignment plane is between about 60 and 70 degrees during creation of the tunnel; and

a curved needle that includes at least one curved section having a curvature between about 15 and 25 degrees along the curved section, wherein the curvature between about 15 and 25 degrees along the at least one curved section fully fits within the tunnel diameter configured to be created through the drill guide.

24. The kit of claim 23 wherein the drill guide is adjustable such that the angle between the length of the guide tube and the reference member reference alignment plane may be varied and set to a desired angle for use during creation of the tunnel.

25. The kit of claim 23 wherein the angle between the length of the guide tube and the reference member reference alignment plane is about 65 degrees during creation of the tunnel.

26. The kit of claim 23 wherein the at least one curved section has a curvature of about 20 degrees along the curved section.

27. The kit of claim 23, further comprising a fixation element configured to couple the meniscal tissue to the tibia, wherein the fixation element is sized to fit through the tunnel diameter.

28. The kit of claim 27 wherein the fixation element includes at least one of a single strand suture, a multiple strand suture tape, and a wire.

29. The kit of claim 27, further comprising a button configured to couple to an inferior end of the fixation element to secure the fixation element relative to the tibia.