Technique Overview

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Flexor Tendon repair – The PONTiS Solution

PONTiS has investigated every aspect of tendon repair and developed a step-by-step procedure solution for each of the problems that surgeons encounter.

The PONTiS patent estate encompasses the core PONTiS system which uses a multifilament stainless steel suture. This material consists of 49 stainless steel filaments. This suture is attached to the tendon or ligament on each side of a laceration by an innovative strong suture attachment method. All current repair methods use knot attachment to connect the two sides of a laceration. Our design attaches the device to each side of the repair separately and is then connected to the opposite side using a specially designed crimp instead of a knot.

This repair is unique in that it uses this new suture-crimp system, providing a faster and simpler connection that is knotless. The repair gives immediate strength. It also provides the option of repair through mini incisions without wide finger and hand exposure. This system is particularly suited to repair of severely damaged tendons in major trauma because of the stiffness of both the stainless steel suture and the crimp attachment. It is also ideally suited for use in replantation surgery because it allows attachment of each side of the laceration separately. In replantation, the tendon attachment to the amputated part can be done before the replantation. This allows the tendon attachment to be done in only a few minutes.

Related Science

Mini Incision Article

Cable Crimp Article

Crimp Article

Suture Article

Related Information

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Technical Tips

Passage of the tendon

  • When passing the funnel and catheter, clamp the suture at the far cut end of the catheter which should hold the tip of the funnel securely inside the lumen of the catheter – then pull on the suture and catheter to pass the tendon.
  • As the tendon enters the pulley, go slowly and watch the tendon enter the tunnel.

Suturing

  • Make sure the first pass is 1-1.2 cm from the cut end – helps to use a 1cm segment cut from a ruler to make sure. If not, the cross-lock will not hold at optimum strength.
  • Second pass halfway, i.e. 0.6mm to cut end.
  • The gliding stitch should come out the MIDDLE of the tendon end – otherwise the crimp will end up too volar.
  • After making the cross-lock, pull each cable VERY TIGHT so the cross lock sits flush and firm on the surface of the tendon – and NOT loose.

Passing cables through the crimp

  • Pass the shrink wrapped portion of the cable through the crimp so that only the metal part is within the crimp. To thread the final or fourth cable, hold the cable very near the end and an assistant may help by pulling the cables that are already in the crimp to one side. As the last cable goes through the crimp, the assistant may pull the other strands in the same direction, which pulls the final cable through, allowing it to pass.
  • To pass the last cable through the crimp, hold the cable very close to the end. Holding with a needle holder may be helpful.
  • Once again, pull EACH STRAND INDEPENDENTLY tight so the cross-lock is tight before approximating the tendon ends.
  • Place one 6-0 epitendinous stitch to get the exact tendon rotation for the repair.

Crimping

  • When placing the crimp tool, be careful not to have the posterior jaw include any tendon – try to include only the crimp —- make sure the tool is on straight and rotated exactly correct before crimping.
  • Be careful to not to crush any cable – only the crimp.
  • Leave the crimp tool on for 5-10 seconds.
  • Cut the cable very short on the crimp.

Testing

  • Take the tendon through 5-10 excursions after the repair.

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PONTiS Tendon Repair Technique
Using the PONTiS stainless steel suture, make the first pass through the tendon, 1.2cm from the cut end. This passes perpendicular to the long axis of the tendon.
Using the PONTiS stainless steel suture, make the first pass through the tendon, 1.2cm from the cut end. This passes perpendicular to the long axis of the tendon.
Pull the PONTiS suture through the tendon so the suture lengths are equal.
Pull the PONTiS suture through the tendon so the suture lengths are equal.
Cross one needle over the tendon and pass it through the tendon perpendicular to the long axis of the tendon, 0.6 cm from the cut end.
Cross one needle over the tendon and pass it through the tendon perpendicular to the long axis of the tendon, 0.6 cm from the cut end.
Starting close to the exit point, pass the needle out the cut end of the tendon so the exit point is close to the center of the tendon. Cut off the needles close to the end of the sutures.
Starting close to the exit point, pass the needle out the cut end of the tendon so the exit point is close to the center of the tendon. Cut off the needles close to the end of the sutures.
With the crimp in the crimp holder, pass the two proximal sutures through the proximal opening, and pass the two distal sutures through the distal opening. The sutures are color coded.
With the crimp in the crimp holder, pass the two proximal sutures through the proximal opening, and pass the two distal sutures through the distal opening. The sutures are color coded.
Pull the PONTiS sutures to exactly approximate the tendon ends. Place and tie an epitendonous stitch at the lateral corner of the repair. Place this suture on the side opposite from where you expect to crimp. This stitch will control rotation of the tendon.
Pull the PONTiS sutures to exactly approximate the tendon ends. Place and tie an epitendonous stitch at the lateral corner of the repair. Place this suture on the side opposite from where you expect to crimp. This stitch will control rotation of the tendon.
Firmly tighten each PONTiS suture strand individually prior to using the crimp tool. Insert the crimp tool transverse to the tendon. The crimp tool must be completely closed until the cam-action (bottoming) is felt. The assistant should gently maintain tension on the sutures as the crimp tool is closed.
Firmly tighten each PONTiS suture strand individually prior to using the crimp tool. Insert the crimp tool transverse to the tendon. The crimp tool must be completely closed until the cam-action (bottoming) is felt. The assistant should gently maintain tension on the sutures as the crimp tool is closed.
Cut the PONTiS sutures as close to the crimp as possible.
Cut the PONTiS sutures as close to the crimp as possible.
Place one or two more interrupted epitendonous stitches across the palmar surface of the repair, in order to bury the crimp. Two or three stitches are usually needed. No sutures are needed posteriorly. Take the repaired tendon through 5 or 6 excursions to ensure good motion through the pulleys.
Place one or two more interrupted epitendonous stitches across the palmar surface of the repair, in order to bury the crimp. Two or three stitches are usually needed. No sutures are needed posteriorly. Take the repaired tendon through 5 or 6 excursions to ensure good motion through the pulleys.

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Passage of the Tendon with PONTiS Funnel and Catheter
Pass the narrow end of the catheter (pulley dilation tube) from the finger wound into the palm through the pulley system.
Pass the narrow end of the catheter (pulley dilation tube) from the finger wound into the palm through the pulley system.
Dilate the pulley system gently by pulling the catheter back and forth.
Dilate the pulley system gently by pulling the catheter back and forth.
Cut the tube at the proximal and distal ends of the pulley system 1 -2 cm from the skin.
Cut the tube at the proximal and distal ends of the pulley system 1 -2 cm from the skin.
Place the cross-lock in the proximal tendon using the PONTiS stainless steel suture. Cut off the needles. Thread the suture through the large diameter end of the funnel and then directly through the small diameter end. Slide the funnel over the end of the tendon to completely cover the tendon end.
Place the cross-lock in the proximal tendon using the PONTiS stainless steel suture. Cut off the needles. Thread the suture through the large diameter end of the funnel and then directly through the small diameter end. Slide the funnel over the end of the tendon to completely cover the tendon end.
TIPS

  • When passing the funnel and catheter, clamp the suture at the far cut end of the catheter. This will securely hold the tip of the funnel inside the lumen of the catheter – then pull on the suture and catheter to pass the tendon.
  • As the tendon enters the pulley, pull slowly and watch the tendon enter the pulley system.
Thread the PONTiS suture through the lumen of the catheter. Place the tip of the funnel, with the tendon inside the funnel, in the proximal lumen of the catheter.
Thread the PONTiS suture through the lumen of the catheter. Place the tip of the funnel, with the tendon inside the funnel, in the proximal lumen of the catheter.
Clamp the PONTiS suture at the distal end of the catheter at the point that the suture exits the catheter. This holds the funnel tip inside the proximal end of the catheter. Pull the suture and catheter as one, to deliver the tendon. Carefully observe the funnel as it enters the pulley system.
Clamp the PONTiS suture at the distal end of the catheter at the point that the suture exits the catheter. This holds the funnel tip inside the proximal end of the catheter. Pull the suture and catheter as one, to deliver the tendon. Carefully observe the funnel as it enters the pulley system.
Remove the catheter and funnel.
Remove the catheter and funnel.

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Tendon to Bone with PONTiS Anchor
Place a cross-lock stitch in the proximal tendon using the PONTiS stainless steel suture, as described for the standard PONTiS tendon repair.
Place a cross-lock stitch in the proximal tendon using the PONTiS stainless steel suture, as described for the standard PONTiS tendon repair.
At the distal insertion of the tendon drill a hole with the pre-drill and tap to the laser line.
At the distal insertion of the tendon drill a hole with the pre-drill and tap to the laser line.
Insert the PONTiS anchor to the laser line.
Insert the PONTiS anchor to the laser line.
Grip the wings of the protective sleeve and pull outward and away from the driver. Remove the cap of the driver to deliver the needles.
Grip the wings of the protective sleeve and pull outward and away from the driver. Remove the cap of the driver to deliver the needles.
Place a gliding stitch through the distal tendon stump. (Skip this step if no distal tendon is present.) Pass the sutures through the crimp. The two proximal suture strands enter the proximal opening of the crimp and the two distal suture strands enter the distal opening. The sutures are color coded.
Place a gliding stitch through the distal tendon stump. (Skip this step if no distal tendon is present.) Pass the sutures through the crimp. The two proximal suture strands enter the proximal opening of the crimp and the two distal suture strands enter the distal opening. The sutures are color coded.
Release the crimp by squeezing the crimp holder.
Release the crimp by squeezing the crimp holder.
Approximate the tendon ends or attach the tendon to bone by pulling the two PONTiS suture strands.
Approximate the tendon ends or attach the tendon to bone by pulling the two PONTiS suture strands.
If there is a distal tendon stump, then place and tie the first epitendonous stitch at the lateral corner of the repair farthest from the surgeon. This will control rotation of the tendon.
If there is a distal tendon stump, then place and tie the first epitendonous stitch at the lateral corner of the repair farthest from the surgeon. This will control rotation of the tendon.
Tighten each implant strand individually prior to using the crimp tool. The Assistant should gently maintain tension on the sutures as the crimp tool is used to lock the implant. Insert the crimp tool transverse to the tendon. The crimp tool should be completely squeezed until the cam-action (bottoming) is felt.
Tighten each implant strand individually prior to using the crimp tool. The Assistant should gently maintain tension on the sutures as the crimp tool is used to lock the implant. Insert the crimp tool transverse to the tendon. The crimp tool should be completely squeezed until the cam-action (bottoming) is felt.
Cut the PONTiS suture as close to the crimp as possible.
Cut the PONTiS suture as close to the crimp as possible.
Complete interrupted epitendonous stitch(es) across the palmar surface of the repair to cover the crimp. Two or three stitches are usually needed. Take the repaired tendon through 5 or 6 excursions to ensure good motion through the pulleys.
Complete interrupted epitendonous stitch(es) across the palmar surface of the repair to cover the crimp. Two or three stitches are usually needed. Take the repaired tendon through 5 or 6 excursions to ensure good motion through the pulleys.

Download Tendon to Bone Repair with PONTiS Anchor

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