Tips & Techniques

Novel Technique for Passing Tendon Grafts Through Bone Tunnels

Jeffrey A. Levy, DO; Gerald L. Farber, MD; Kenneth F. Taylor, MD

  • Orthopedics
  • November 2012 - Volume 35 · Issue 11: 944-946
  • DOI: 10.3928/01477447-20121023-04
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Abstract

Anatomic reconstruction in orthopedic surgery often requires the passage of soft tissue through bone tunnels. Difficulties may arise due to anatomic constraints surrounding the bone tunnels or the graft size. The authors present a novel technique for passing tendon grafts through bone tunnels that is simple, readily available, effective, and comparatively inexpensive.

Drs Levy and Farber are from the Orthopaedic Surgery Service, Tripler Army Medical Center, Honolulu, Hawaii; and Dr Taylor is from the Department of Orthopaedics and Rehabilitation, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania.

Drs Levy, Farber, and Taylor have no relevant financial relationships to disclose.

The views expressed in this manuscript are those of the authors and do not reflect the official policy of the Department of Army, Department of Defense, or US government. All authors are employees of the US government. This work was prepared as part of their official duties, and as such, there is no copyright to be transferred.

Correspondence should be addressed to: COL(Ret) Kenneth F. Taylor, MD, Department of Orthopaedics and Rehabilitation, Penn State Milton S. Hershey Medical Center, 30 Hope Dr, PO Box 859, Hershey, PA 17033 (ktaylor3@hmc.psu.edu).

Many soft tissue reconstruction techniques pass tendons through bone tunnels, which can be challenging for several reasons: the tunnel diameter may be small; the tunnel path may be long and indirect; and the bone may be comparatively small or the overlying bone bridge may be fragile.

Reconstruction of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb represents a common clinical scenario. It requires passing a tendon graft through a tunnel in the proximal phalanx under a thin bone bridge that is at risk for disruption.1,2 Anatomical reconstruction of the distal radiolulnar joint presents another situation in which multiple passes of the tendon through bone tunnels at various tight angles occurs through a limited surgical exposure and overlying soft tissue constraints.3,4

Many commercial devices are available for passing tendon grafts (Figure 1), and each has distinct advantages and disadvantages (Table).

Photograph showing 4 devices used to pass tendon: Frazier Suction Instrument 10Fr (Cardinal Health, Naples, Florida); QuickPass Tendon Shuttle (Arthrex, Naples, Florida); Hewson Suture Passer (Smith & Nephew, Andover, Massachusetts); and Surgical Steel 26-g Wire (Ethicon, Circle Cornelia, Georgia).

Figure 1: Photograph showing 4 devices used to pass tendon: Frazier Suction Instrument 10Fr (Cardinal Health, Naples, Florida); QuickPass Tendon Shuttle (Arthrex, Naples, Florida); Hewson Suture Passer (Smith & Nephew, Andover, Massachusetts); and Surgical Steel 26-g Wire (Ethicon, Circle Cornelia, Georgia).
Comparison of Available Tendon-passing Devices

Table: Comparison of Available Tendon-passing Devices

Most are effective when a straight trajectory is required. However, a long and inflexible loop has the potential to fold back onto itself. Rigidity of the device may also make it an inappropriate choice when encountering acute curvature in the bony or soft tissue tunnel.

Other more flexible devices are limited by size or the ability to retrieve the leading end without direct visualization because of the inability of the rubber device to maintain its curvature after exiting the bony tunnel. Others may be more appropriate for passing sutures but not the tendon graft itself. Another limitation of currently available devices relates to their single use or relatively high cost.

Surgical Technique

The authors use a novel technique that is simple, inexpensive, and effective. A 12- to 18-inch, 22- to 26-gauge flexible steel wire can replace commercially available tendon passers. With the mid-point of the wire looped over a drill bit or held by a needle driver, the 2 free ends are placed into a wire driver (Figure 2A). The wire driver is carefully engaged, resulting in a uniformly tight spiral configuration, which facilitates simple tendon passage (Figure 2B). The graft or suture is placed in the loop and then pulled back through the bone tunnel.

Photographs showing the Surgical Steel 26-g Wire (Ethicon, Circle Cornelia, Georgia) (A) and the technique of making tendon passes (B).

Figure 2: Photographs showing the Surgical Steel 26-g Wire (Ethicon, Circle Cornelia, Georgia) (A) and the technique of making tendon passes (B).

This technique is effective in passing tendon graft through a curved tunnel under a relatively thin bony bridge, such as in the proximal phalanx when reconstructing the thumb ulnar collateral ligament (Figure 3). The device in this application must be sufficiently malleable for the leading edge to assume a tight arc while maintaining its curvature radius. This technique is effective in passing and retrieving tendon grafts without the need for direct observation, such as in the reconstruction of the distal radioulnar joint (Figures 4, 5).

Photograph showing the clinical application of flexible wire tendon passer under a thin bone bridge.

Figure 3: Photograph showing the clinical application of flexible wire tendon passer under a thin bone bridge.
Photograph showing passing tendon graft across distal radius tunnel.

Figure 4: Photograph showing passing tendon graft across distal radius tunnel.
Photograph showing passing tendon tails through the ulnar tunnel and circumferentially around ulnar neck.

Figure 5: Photograph showing passing tendon tails through the ulnar tunnel and circumferentially around ulnar neck.

The authors have used this technique in various surgical applications. The advantages of this device are that it is flexible enough to pass though curved bone tunnels and rigid enough to transport large grafts through long and straight tunnels. Other advantages include its availability, simplicity, and cost effectiveness.

References

  1. Glickel SZ, Malerich M, Pearce SM, Littler JW. Ligament replacement for chronic instability of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb. J Hand Surg Am. 1993; 18(5):930–934. doi:10.1016/0363-5023(93)90068-E [CrossRef]
  2. Smith RJ. Post-traumatic instability of the metacarpophalangeal joint of the thumb. J Bone Joint Surg Am. 1977; 59(1):14–21.
  3. Adams BD. Anatomic reconstruction of the distal radioulnar ligaments for DRUJ instability. Tech Hand Upper Extrem Surg. 2000; 4(3):154–160. doi:10.1097/00130911-200009000-00003 [CrossRef]
  4. Adams BD, Berger RA. An anatomic reconstruction of the distal radioulnar ligaments for posttraumatic distal radioulnar joint instability. J Hand Surg. 2002; 27(2):243–251. doi:10.1053/jhsu.2002.31731 [CrossRef]

Comparison of Available Tendon-passing Devices

Device Manufacturer Cost, $ Advantages Disadvantages
Surgical Steel 26-g Wire Ethicon, Circle Cornelia, Georgia 2.92 Flexible; low cost None recognized
Hewson Suture Passer Smith & Nephew, Andover, Massachusetts 103.04 Easy to use; useful when rigidity needed Lasso folds back onto itself;rigidity; cost
QuickPass Tendon Shuttle Arthrex, Naples, Florida 85.00 Easy to use; useful when rigidity needed Not useful for suture; relative rigidity; cost
Frazier Suction Instrument 10Fr Cardinal Health, Naples, Florida 57.90 Often already on field Cost; rigidity

doi: 10.3928/01477447-20121023-04

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