Patent Application
20170367692
The following patent and other documents (along with their subject matter) are incorporated by reference herein, as if fully set forth hereinafter:
This invention relates to tenorrhaphy: the repair, recession, and revision of tendon ruptures, and especially hand and wrist tendon ruptures, to simulate the original orthopedic structure or to accomplish a remodeling of such structure. Practice of the invention will increase repaired tendon strength, increase favorable patient outcome, reduce surgical procedure time, or allow earlier tendon flexion after surgery.
Rupture of tendons, especially in the hand and wrist, is a common acute injury. Approximately 100,000 corrective procedures are performed in the United States annually to repair ruptured or partially ruptured tendons in the hand and wrist (Tang et at, 2012). This corrective procedure is known as tenorrhaphy. Flexor digitorum tendons have a typical cross-sectional dimension of 3-8 mm (Walbeehm and McGrouther, 1995; Shrewsbury and Kuczynzki, 1974). When a significant amount of tendon has been lost in the acute injury, graft tendon material is used to reform the ruptured tendon, in what is termed a recession surgical procedure. By far the most common surgical expedient for joining tendons is a suture, and among the many suture techniques are the modified Kessler, Stevens, and cruciate procedures. In 2-4% of repairs, there is total failure of the suture (Tang et al., 2012). In another 20-30% of cases, there is poor to fair outcome of the repair procedure, as measured by the Strickland scale (Tang et al., 2012; Strickland, 1995). A second, revision surgical procedure can be used in the rupture cases and in some of the failed or poor to fair outcome cases to improve the result. Sheep's forelimb digital flexor tendons are described as a good model of human flexor digitorum tendons (Tan et al., 2010).
There are a number of reasons for the limitations of current surgical procedures. Among the causes of poor outcome are weakness in proximity of the repaired tendon rupture and excessive scarring and adhesion of the tendon to sheathing, tunnels, or pulleys. The repair is often very weak before the tendon heals, and what would otherwise be normal movement in a healthy tendon may cause another rupture tendon repaired via suture. The body part in question is often immobilized for a significant amount of time; for instance, the hand or wrist of the patient is typically immobilized for 6-8 weeks following the surgery. This immobilization, while protecting the joined tendon from rupture, inhibits recruitment of new blood flow and tissue to the wound. The immobilization also leads to the formation of scar and other tissue that can adhere the tendon to the surrounding matrix, leading to joint, stiffness and poor long term prognosis. Indeed, early active mobilization remains the only long-term, proven strategy to improve outcomes (Khor et al. 2016). Such early mobilization requires a strong repair.
Absorbable suture has been proven suitable for some types of tendon repair. Caulfield et al. (2008) reported the outcome of flexor tendon injuries in a series of 272 consecutive patients treated over 45 months with a mean follow-up of 4 (range 3-12) months. Using the original Strickland criteria, there were 72 excellent/good and 28% fair/poor results in the absorbable core suture group, and 73% and 27%, respectively, in the nonabsorbable core suture group. This study suggested that appropriate absorbable core sutures can be used safely for flexor tendon repair. Kang et al. (2012) likewise showed in a study of flexor tendon repairs with absorbable suture that all the patients were assessed to be excellent or good using the original Strickland criteria. Also, fibrosis and long-term foreign body tissue reactions such as stitch granuloma were less likely to occur in their study. Compared to the Cullen's report as a reference for data on performance of nonabsorbable sutures, there was no significant difference in the rupture or adhesion rates. Therefore, this study, suggests that appropriate absorbable core sutures can be used safely for flexor tendon repairs.
Parikh et al. (2009) reported, on an ex vivo model of flexor tenorrhaphy. A three-strand barbed suture technique achieved tensile strength comparable to that of four-strand cruciate repairs and demonstrated significantly less repair-site bunching. A six-strand barbed suture technique demonstrated increased tensile strength compared with four-strand cruciate controls and significantly less repair-site bunching. They concluded that barbed suture repair may offer several advantages in flexor tenorrhaphy.
Marrero-Amadeo et al. (2011) tested whether a flexor tendon repair with only a knotless barbed suture technique provides a repair with a greater maximal load to failure and 2-mm gapping resistance than a traditional technique using a 4-strand core plus a running-locking epitendinous suture. The average maximal load to failure was not significantly different between the traditional repair (48+/−12 N) and the barbed suture repair (50+/−14 N). The average 2-mm gapping load was also insignificantly different between the traditional repair (42+/−12 N) and the barbed suture repair (32+/−9 N). The barbed suture repair did not demonstrate a significant difference in maximal load to failure and 2-mm gapping resistance compared with the traditional method of repair. A porcine model showed no difference between barbed and barbless repairs in a porcine flexor tendon model (Sull et al, 2015).
There exist a number of prior approaches to tendon repair. Lubbers et al. U.S. Pat. No. 6,083,244 describes an elongate tensile member to which anchor bodies are attached. The anchor bodies are inserted into the tendon via a wound in the tendon. The anchor bodies are slid long the tensile member to adjust the length of repair. Lubbers et al. U.S. Pat. No. 8,114,120 describes an apparatus and methods for repairing damaged tendons or ligaments. Various repair apparatus include an elongate tensile member and a pair of anchor assemblies connected for movement along the tensile member on either side of a repair site, such as a tear or laceration. A soft tissue anchor is coupled to the tensile member outside of the tendon. Alternatively, the assembly of the soft tissue anchor connected to the tensile member is simultaneously driven into the tendon, in which case the soft tissue anchor includes a helical anchor member and a retaining member. Ostrovsky at al. U.S. Pat. No. 8,968,334 describes apparatus that includes an elongate member having a distal end portion and a proximal end portion The elongate member is used to drive suture'into the tendon. Tissue anchors are attached to the suture during the insertion process.
Dant U.S. Pat. No. 7,637,918 describes an apparatus for repairing, a tear in an annulus fibrosus of a spinal disc that includes a hollow, helically-shaped suturing needle and a retriever. The helical suture pattern spans both sides of the tear, such that the loops of the helix bridge the tear. Similarly, Crainich U.S. Pat. No. 8,906,039 describes a suturing device that includes a housing, a helical needle rotatably mounted relative to the housing, and a drive assembly for rotating the needle relative to the housing whereby the helical needle carries a suture through tissue to be sutured. The helical suture pattern spans both sides of the torn tissue, such that the loops of the helix bridge the tear. Similarly, Craig U.S. Pat. No. 7,776,059 describes an apparatus used with a helical suture device that has a first end and a second end. The helical suture pattern spans both sides of the torn tissue, such that the loops of the helix bridge the tear. And, Craig U.S. Pat. No. 6,626,917 describes a helical, suturing instrument that either pushes or pulls a suture along a helical needle tract. The instrument has one or more helical needle portions, each with a suture retaining component.
Gordon et al. U.S. Pat. No. 8,795,333 describes a method and apparatus for reattaching the opposed ends of a member, such as a tendon, ligament or bone, during preparing and healing of the member using a surgical repair device that can be securely attached to the member and then safely guided through tortuous anatomy for reattachment and repair. All require retrieving through an anatomical passage a first stump of a longitudinal anatomical feature for reattachment to another anatomical feature, and a single type of suture pattern is used to attach the repair to the end of the ruptured tendon, with breach of epitenon.
Miraki et al. U.S. Pat. No. 8,500,757 describes a suture applicator having a proximal handle, a length of suture wound on a spool, and a hollow suture needle extending from a distal end of the handle. The hollow needle can be guided by a mechanism such as a deflection wire.
Kuester, Ill et al. U.S. Pat. No. 8,313,013 describes an assembly for anastomosis having a clamp being arranged to support a fastener. This device is for coupling veins rather than tendons and does not employ suture.
Muller et al. U.S. Pat. No. 6,537,248 describes a surgical apparatus for delivering a helical pattern of conductive fluid to a target site for subsequent formation of a virtual electrode to ablate bodily tissue at the target site by applying a current to the delivered conductive fluid.
The present invention comprises in various aspects a novel system, method and is apparatus for securing two ends of ruptured or partially ruptured tendon in the hand or wrist during a repair, recession or revision procedure. With the present inventive system and method, a connector, such as suture material, is inserted into or affixed in one of proximal ends of the completely or partially ruptured tendon whereby it is positioned such that another part of said connector can be attached to a further one of said proximal ends across the site of the rupture. This is accomplished by an innovative apparatus comprising multiple needles of at least two different types. In such manner, the connector (e.g., suture material) can be secured across the site of tenorrhaphy for a ruptured tendon as aforesaid.
In one aspect, the invention is in a system for the repair of a ruptured tendon, which comprises a plurality of high surface area anchor, members each such member being operative for implantation in a part of the tendon proximal the rupture, and each such member further being adapted for interconnection with another such member also operative for implantation in a part of the tendon proximal the rupture; and a connector for attaching one of said members to one another of said members.
In another aspect, the invention is in a method for repair of a ruptured tendon, which comprises implanting a plurality of high surface area anchor members in respective different parts of the tendon proximal the rupture; and interconnecting one of said members with another of said members.
In yet another aspect, the invention is in an apparatus for implanting a repair assembly including a plurality of high surface area anchor members into a ruptured portion of a tendon, which comprises a needle assembly for implanting an anchor member as aforesaid in a part of the tendon proximal said rupture, and for attaching one part of a connector to one of said anchor members whereby it is positioned for attaching of another part thereof to another anchor member.
In still another aspect, the invention a method for deploying a connector adapted to secure two ends of a ruptured (completely or partially) tendon, which comprises: introducing multiple needles of at least two different types which are operative to attach a connector, such as suture material, to a proximal cut surface of the tendon; and attaching a part of the connector to said proximal cut surface with said needles.
In further aspects, the invention is in an apparatus, which comprises multiple needles of at least two different types operative to attach a connector, such as suture material, to a proximal cut surface of the tendon.
In a still further aspect, the invention is in a system for the repair of a ruptured tendon, which comprises a first complement of at least two differently patterned sutures implanted by needles of two or more different types in a part of the tendon proximal the rupture, each such patterned suture further being intertwined with another of such differently patterned sutures; a second complement of at least two differently patterned sutures implanted in another part of the tendon proximal to such rupture, each such patterned, suture of the second complement being intertwined with another of such second complement's differently patterned sutures, such first and second suture complements being interconnected with one another.
Moreover, the invention is in a method for repair of a ruptured tendon, which comprises implanting a first complement of at least two differently patterned sutures in the tendon proximal the rupture and a second such suture complement in a different part of the tendon proximal the rupture; and interconnecting said first and second suture complements with one another.
And, in yet other aspects, the invention is in apparatus and method for inserting a repair system including a first suture into a ruptured portion of a tendon, which comprises an assembly for implanting (or the step of implanting) a patterned suture as aforesaid in a part of the tendon proximal said rupture, and an assembly for introducing (or the step of introducing) a separate (optionally differently patterned) suture for connecting said implanted first suture material across the site of tenorrhaphy to a different part of the tendon.
The term “suture” as used herein refers inclusively to the article utilized to join tendon (or other body) tissues to one another (for instance, thread, wire, or other comparable functional form), pieces or other elements of such article, and the constituent material thereof. The meaning intended concerning any particular appearance of the term shall be as appropriate to the context.
An advantage of practicing the invention is greater strength of the joined tendon. The greater strength is achieved by the high surface area to volume ratio of the patterned sutures employed. This greater strength leads to less likelihood of a failed surgical procedure.
Another advantage of the present inventive approach is the earlier, possibly immediate, flexion of the tendon after surgery. Said flexion increases recruitment of tissue and blood flow to the site of the injury, speeding remodeling. Said flexion also reduces inappropriate adhesion of the tendon to the surrounding sheathing, pulleys, and tunnels.
Yet another advantage of the present inventive approach is a smoother tendon repair or revision. A smooth, tubular tendon joint allows for smoother gliding of the tendon through pulleys and tunnels.
Still another advantage of the present inventive approach is a more flexible tendon joint, which allows for smoother gliding of the tendon through pulleys and tunnels. As regards hand tendons specifically, a more flexible tendon joint allows for a wider range of motion of the affected fingers, as flexion can cause high curvature of the tendon over joints and pulleys, which is better accommodated by a flexible joint.
A further advantage of the present invention is minimal required exposure of the tendon at the site of the acute injury. Unlike sutures wherein at least 1 cm of tendon distal to the site of acute injury must be exposed in the present method only enough tendon for a secure grip during implantation of patterned suture material during surgery is required. Thus the present invention requires a significantly smaller flap of skin, tunnel, and pulley material to be exposed.
Additional advantages of the invention are increased levels of patient care and satisfaction, as well as attainment of a more rapid and reproducible procedure. A faster procedure allows for more efficient utilization of surgical and facility resources. Reproducibility and standardization of the procedure are important factors in achieving a good or excellent outcome. Reproducibility and standardization lead to a more predictable outcome, a desirable feature for the medical profession and insurance market.
These, and other embodiments and advantages that will appear from the invention's description, imply a higher likelihood of good long term performance in the patient. The patient will experience less pain and a more rapid recovery. Moreover, it is more likely that only a single surgery will be required.
The following detailed description is meant to be read not only in its stand-alone form, but also (as helpful) with reference to the figures. The figures, which are not necessarily to scale, depict selected embodiments and are not intended to limit the scope of the invention. Examples of construction, material, dimension, and manufacturing process particulars are provided for selected elements. All other elements employ that which is known to those of skill in the field of the invention. Those skilled in the art will recognize that many of the examples provided have suitable alternatives that can be utilized.
The invention (especially the inventive system, method and apparatus and other embodiments) is, for instance, beneficial for repairing ruptured hand or wrist tendons. As regards hand tendons, we have in mind especially tendons in zone 2 in the hand, such as flexor tendons in zone 2 of the hand.
In respect of the system, method, apparatus and other embodiments of the invention, an anchor assembly can be a simple double-sided high-surface-area unit. Alternatively, the anchor assembly can comprise a plurality of (e.g., two) high-surface-area anchor members and one or more connectors. The high-surface-area anchor member or the connecting member can be delivered via a needle. The high-surface-area anchor member can be coil-shaped. The shape of the high surface area anchor members may be a coil, deformable and autolocking, or barbed. An anchor assembly in accordance with the invention may be unitary or constituted of two or more pieces. If unitary, the anchor assembly may include a tensioning device to allocate more of the joining force to the ends of the anchor embers distal to the rupture.
On the other hand, in accordance,with the system, method, apparatus and other embodiments of the invention, a helical-based anchoring suture is connected (to another part of the ruptured tendon) across the site of tenorrhaphy by loops of other suture. The suture materials are delivered via needles. In such embodiments, a helical needle can be used to deploy the helical based anchoring suture and one or multiple straight needles can be used to deploy the loop-based connecting suture. The loop-based connecting suture can be shortened by multiple steps of length reduction for instance, via a knot.
In yet other good embodiments, the helical-based suture material is barbed. In various preferred embodiments, the suture members (and accordingly the constituent suture material) are absorbable. In various other embodiments, the connecting suture comprises two parts which join together between the cut ends of the tendon. The two parts can join together in a zip-tie fashion, or with a knot.
The various members and elements of the inventive system can comprise materials which are polymers. Preferably, the polymers are synthetic. The polymers can be nylon, polypropylene, polyethylene, polyester, polybutester, or any mixture of two or more thereof and preferably are absorbable. More specifically, the polymers are any of polylactic acid (PLA), polyglycolic acid (PGA), polycaprolactone (PGA), polydioxanone (PDX), or any mixture of two or more thereof. At least one of the monomers comprising the polymer may be enantiomerically pure.
In various additional good embodiments, a tool, grips an end of the ruptured tendon, such that one or more suture patterns can be deployed. The tool may be hand- or motor-driven, so as to effect deployment of the patterned suture. The drive of the needle assembly is achieved by a slider or a gear. The needle assembly drives the suture beyond the tendon surface proximal to the acute injury site. Optionally, the suture can be trimmed at the tendon surface proximal to the acute injury site.
The invention provides an apparatus and method for repair, recession, and revision of hand and wrist tendon ruptures that is completely internal, strong, flexible, and remodeled to simulate or even replicate the original orthopedic structure. This will increase repaired tendon strength, increase favorable patient outcome, reduce surgical procedure time, or allow earlier tendon flexion after surgery. In some embodiments, the apparatus includes a gripper, such as a clamp, holding the end of tendon proximal to the rupture. Such facilitation of alignment allows for the use of optimum sized fasteners without unnecessary or undue size increase. In some embodiments multiple suture patterns are inserted to stabilize the site of tenorrhaphy against twisting forces.
In accordance with certain embodiments of the invention, the apparatus can be used to deliver and implant the suture patterns in a particularly advantageous manner. A motor driven tool may insert the suture patterns into the ruptured surfaces of the tendon proximal to the site of acute injury. The tool may optionally hold the tendon secure proximal to the site of acute injury. The tool may optionally include a removable positioner that facilitates deployment of the suture patterns.
The implanted system or assembly is fabricated from polymeric materials. The polymers may be either natural or synthetic. If synthetic, the polymers may optionally be absorbable, such that high strength across the rupture is maintained for at least 6 weeks.
In a preferred embodiment, two helical patterns of barbed suture and four loop patterns of non-barbed suture are deployed simultaneously into one of the two cut surfaces of tendon proximal to the site of rupture.
The delivery of the suture by the helical needle engages the hops of suture delivered by the straight needles. Precise alignment of the straight;and helical needles facilitates this delivery of the interlocking suture patterns.
To achieve tenorrhaphy, patterns of helical and loop suture are inserted first into one severed end of the tendon proximal to the site of injury and then into the other severed end of the tendon proximal to the site of injury. Delivery of the patterns into both ends of the severed tendon requires two helical needles 703, four straight needles 702, and two types of suture.
The straight needles that deploy the loop pattern of suture insert the suture material and leave the suture material in place as the needles are removed.
The helical needle that deploys the helical pattern of suture must insert the suture material and leave the suture material in place as the needle is removed.
In certain advantageous embodiments of the invention helical and loop patterns of suture have an interlocking configuration. In various embodiments of the invention, the connector element(s), such as sutures, provide a tensioning influence on the system securing the ruptured tendon ends.
There are various methods to insert the coil anchor into the end of the tendon proximal to the site of rupture.
In a preferred embodiment, two helically patterned barbed suture elements and four loop patterned non-barbed suture elements are deployed simultaneously to one of the surfaces of the tendon proximal to the site of rupture. The same patterned suture elements are then deployed to the other surface of the tendon proximal to the site of rupture. The tool employed includes clamps that hold the tendon and facilitate alignment of the needles used to deploy the patterned suture elements. The loop patterned suture elements are then tightened and secured across the site of tenorrhaphy, possibly in multiple steps to firmly interlock the loops with the helices. This system is completely internal to the tendon, is flexible, and maintains a less than 2 mm gap between the tendon surfaces for at least 6 weeks, until the tendon has healed to sufficient tensile strength.
In a second preferred embodiment, innovative apparatus of the invention facilitates firm interlocking of the loop and helical suture patterns as the length of the suture connection across the site of tenorrhaphy is reduced. The tool includes clamps that affix to the two severed ends of the tendon. These clamps provide a resisting force during the process of tightening the suture. This resisting force facilitates settling of the suture material in the tendon and firm interlocking of the loop and helical suture patterns. This system is completely internal to the tendon, has high surface area, and maintains a less than tram gap between the tendon surfaces for at least 6 weeks, until the tendon has healed to sufficient tensile strength.
Numerous characteristics and advantages of the invention covered by this document have been set forth in the foregoing description. It will be understood, however, that this disclosure is, in, many respects, only illustrative. Changes can be made in details, particularly in matters of shape, size, and ordering of steps without exceeding the scope of this invention. The invention's scope is, of course, defined in the language in which the appended claims are expressed.
The benefit of U.S. Provisional Application No. 62/355,674 filed Jun. 28, 2016, and of U.S. Provisional Application No. 62/385,677 filed Sep. 9, 2016, is hereby claimed, each of which along with its subject matter is incorporated by reference herein, as if it had been set forth hereinafter in its entirety.
| Number | Date | Country | |
|---|---|---|---|
| 62355674 | Jun 2016 | US | |
| 62385677 | Sep 2016 | US |
