Method for using a tendon stripper and leader set

A tendon stripper and leader set for stripping a tendon to a select diameter and engaging the stripped end with a tendon leader sized to the stripped tendon for positioning the tendon during bone attachment or other procedures. The tendon stripper is formed as an elongated tool with a handle, a long slender neck and a tip having a coiled eyelet with a stripping edge and a side entry slot, the tendon leader comprising an elongated semirigid leader with a woven expandable end sized to enlarge over the end of a stripped tendon on installation and contract around the tendon during tension for relocating the tendon.

BACKGROUND OF THE INVENTION 
This invention relates to a cooperative tool and implement for sizing and 
relocating a tendon for arthrotomic or arthroscopic procedures, 
particularly repair procedures for torn or separated tendons, muscles and 
ligaments. The stripper tool isolates, sizes and strips a tendon 
preparatory to repair anchoring or relocation to a new site. The leader 
implement engages the end of a severed tendon, muscle or ligament and aids 
in locating the anatomical tissue structure to a desired site or position. 
Prior tendon stripper have been constructed with a split eyelet presenting 
an incomplete circular eye with an entry slot generally aligned with the 
axis of the elongated neck of the instrument. The slot allows the tendon 
to be engaged with the eyelet by entry through the side slot. In stripping 
a tendon with the prior art device, the portion of the tendon aligned with 
the slot is unaffected on initial strokes, requiring the instrument to be 
periodically rotated to thoroughly strip the complete circumference of the 
tendon. While angling the slot improves the thoroughness of the stripping 
action, it makes the tendon more difficult to engage, necessitating an 
enlarged access incision for angularly orienting the instrument to align 
the slot with the tendon during engagement. Furthermore, the opportunity 
of the tendon to become disengaged from the stripper is substantially 
greater in prior art devices, particularly when the tendon is aligned with 
the slot or becomes aligned with the slot during stripping procedures. 
Customarily, a tendon leader is used in conjunction with a tendon stripper. 
Prior tendon leaders have been constructed when the tendon end is sutured 
to a semi rigid leader. Because a smooth transition between the tendon and 
the leader is difficult to construct, the end of the tendon may snag 
causing the separation of the tendon from the leader. 
The tendon leader and tendon stripper of this invention provide a tool and 
implement for a new method of stripping and locating a tendon. The devices 
are usable in different sizes for a variety of arthrotomic and arthoscopic 
procedures, particularly repair or reconstruction procedures for damaged 
or torn ligaments, muscles or tendons, where tendons are prepared for 
reseating or relocation. The tools, particularly the tendon leader, may be 
used in other unrelated medical procedures for positioning vessels and 
other tubular or tendenous anatomical tissue structure. 
SUMMARY OF THE INVENTION 
This invention relates to a cooperative tendon stripping tool and tendon 
positioning device for arthroscopic or arthrotomic procedures. The tendon 
stripping tool is an elongated instrument with a handle, a long neck and a 
tip having a helical configured eyelet with a side entry for engaging and 
isolating a tendon, and, stripping he outer surface tissue to form a 
relatively uniform strand for relocation and attachment. Once the tendon 
is stripped and one portion of it is severed, the tendon positioning 
device is employed to position the tendon, generally for anchoring to a 
bone. 
The positioning device is a tendon leader that in its preferred form is a 
slender, nonelastic, but bendable instrument with an end having grasping 
means for engaging and gripping the end of the tendon for pulling and 
stretching the tendon to locate the tendon in the desired position with 
the desired tension. The tendon leader and stripping tool are compatibly 
sized for a particular tendon being prepared ranging from the larger 
tendons of the knee to the smaller tendons of the fingers. 
The tendon stripper and tendon leader may have use in other procedures and 
on other anatomic components than as described with reference to a 
particular method for repair of a torn anterior cruciate ligament as 
described herein. 
The cooperative use of the tendon stripper and tendon leader are described 
in detail in the detailed description of the preferred embodiment and 
method. 
The tendon stripper and leader are particularly adaptable to the 
reconstruction of a torn anterior crucite ligament. The implements enable 
a reconstruction by arthroscopic techniques minimizing the trauma to the 
knee from more extensive surgical procedures. Both the tendon stripper and 
the leader are of selected size for the tendons utilized for relocation. 
It is understood that reconstruction procedures for other tendons or for 
the tendons of children may require differently sized tools or implements, 
although the leader, being expendable, is suitable for a range of tendon 
diameters.

DETAIL DESCRIPTION OF THE PREFERRED EMBODIMENT AND METHOD. 
The tendon stripper 10 and tendon leader 12 are shown respectively in the 
FIGS. 1 and 2 of the drawings. The drawing figures include a sequence for 
employing the instruments with other auxiliary components in a procedure 
for performing an arthroscopic reconstruction of a torn anterior cruciate 
ligament. 
Referring to FIG. 1 the tendon stripper 10 is shown having a handle 14 with 
an elongated slender shank 16 with a specialty tip 18. The tip 18 is 
uplifted to form an eyelet 20 with a sight that clears the proximal 
tapered end portion 22 of the shank. The eyelet as shown in FIGS. 3 and 4. 
is formed by two, oppositely disposed, counter rotated tines 24, 26 that 
helically wrap around a common axis at a fixed radius from the axis. The 
tines are displaced from each other with terminal ends 28, 30, 
respectively, that circumferentially overlap. The displacement enables the 
lead tine 24, which is most distal from the shank to engage a tendon, and 
by rotating the shank entrain the tendon in the eyelets. The deformable 
tendon easily slips in the narrow slot between the tines. 
The stripper design eliminates the necessity of severing the tendon and 
threading the tendon through an eyelet. Using the devised stripper the 
tendon remains firmly attached at both ends for the stripping procedure. 
The leading edge of the leading tine is prepared to a given sharpness of 
0.03 millimeter radius on 30.degree. edge. The leading edge of the 
counterrotated trailing tine is dulled except proximate its initiation 
wherein it has a similarly prepared edge to cover the circumferential 
sector missed by the lead tine. In this manner the entire circumference of 
the tendon is engaged and stripped by the two prepared edges. The prepared 
edges have a sharpness sufficient to scrape, but not slice or cut the 
tendon during the forward motion of the stripper longitudinal to the 
tendon. Furthermore, the overlapping trailing tine prevents the stripper 
from inadvertently dislodging from the tendon during the stripping 
strokes. 
In many procedures, the tendon leader 12 is used in conjunction with the 
tendon stripper to facilitate relocation of the tendon, particularly 
through a drilled tunnel. The tendon leader 12 is constructed with a 
relatively stiff stem 32 which in the preferred embodiment is deformable 
such that various curved or bent configurations can be devised according 
to the task to be performed or passage to be followed. In the embodiment 
shown the stem is substantially cylindrical in configured with a blunt 
lead end 34. The stem may advantageously be tapered with a rigid pointed 
end where an original passage must be formed. The trailing end 36 has a 
fiber web 38 extending beyond the stem 36. The stem is a vinyl shrink-tube 
that is thermally shrunk-fit over the web. As shown in the enlarged view 
of FIG. 5, the fibers 40 of the web are nylon monofillament, chemically 
inert and arranged are arranged in a cross-weave diagonally oriented to 
the axis of the elongated stem. This construction and arrangement enables 
the tubular web 38 to be expanded in diameter for insertion of a tendon by 
using a hemostat as shown in FIG. 2. The hemostat 40 is used first to 
stretch the opening and then to grasp and insert the end of the tendon 
into the web. The end of the tendon is sutured to the web to prevent 
inadvertent dislodgement. When tension is applied to the tendon leader the 
web contracts around the tendon in the manner of a Chinese finger lock 
enabling the tendon leader to draw the tendon along the path of the 
leader. The tendon leader can be passed through a bored or pierced tunnel 
of minimal dimension without disengaging the attached tendon. Furthermore, 
the construction grip facilitates application of a final tension to the 
tendon during anchoring procedures. A unique procedure for a torn anterior 
crucite ligament is described in FIGS. 6A-6F. 
In the knee reconstruction involving a torn anterior crucite ligament 
(ACL), the procedure begins with an arthrosopic debridement of the torn 
ACL and fat pad to clear the intercondylar notch. A two inch incision is 
made over the pes anserinus and the satorius is split to reveal the 
semitendinosis and gracilis tendons as shown in FIG. 6A. The tendons are 
detached from the muscle using the specialized stripper while the tendons 
remain anchored at each end as shown in FIG. 6B. The tendons should be 
freed of any distal facial expansions by sharp dissection prior to 
stripper use. Tension is placed on the tendon by the index finger of one 
hand while the stripper is carefully directed by the other. Stripping is 
accomplished by engaging each tendon in the tip through the gap by partial 
rotation of the shank. Once engaged, the stripper circumferentially 
debrides the tendon using the leading edge of the eyelet 20 as shown in 
FIG. 6B. In this manner the length of each tendon is maximized before the 
distal end is severed for relocation. 
To relocate, a passage must be formed through the tibia and also through 
the femur that coincide at the former site of the ACL. This is 
accomplished by an arcuate drill guide 40 which includes a pointed 
position pin 42 that is inserted into the joint such that the end is 
located in the intercondylar notch as shown in FIG. 6C. The position pin 
42 is adjustably mounted in a central slot (not visible) in the arcuate 
member 44 of the guide. In this manner, the arcuate member can be tracked 
on the pin to position a drill sight 46 mounted at the end of the arcuate 
member at the position desired. Since the drill sight 46 is radially 
oriented relative to the arcuate member, it sights to a single centerpoint 
regardless how the arcuate member is tracked or pivoted on the position 
pin. 
Using the drill guide as shown in FIG. 6C a k-wire 48 is drilled up through 
the medial tibial plateau from a point just proximal to the pes insertions 
and anterior to the medial collateral ligament. A 2-inch incision is made 
over the lateral condylar flare. The iliotibial band is split and the 
vastus lateralis is retracted. The drill sight 46 is adjusted to position 
the drill 50 for entry at the desired anchoring point on the femoral 
condyle. As shown in FIG. 6D the drill guide 40 sights the femoral 
isometric point in the intercondylar notch and a k-wire 52 is drilled to 
such point, meeting the end of the previously drill wire. 
The k-wire positions are checked and a tunnel is drilled over the inserted 
k-wires in both the tibia and femur using a cannulated drill bit. The 
distal end of each stripped tendon is severed and prepared, removing any 
residual muscle tissue. The tendon ends are sutured together and inserted 
into the end of the tendon leader where further suturing secures the 
tendon to the netting or web of the leader. The end of the leader is fed 
up through the tibial tunnel and guided into the femoral tunnel. Upon 
exiting the femoral tunnel it is pulled to draw the attached tendon up 
through the interconnected tunnels, as shown in FIG. 6E. The gripped 
tendon ends are pulled up through the tunnels and with tension on the 
tendons are secured with a screw 54 and ligament washer 56 to the femoral 
condyle proximate the tunnel end as shown in FIG. 6F. 
The relocated semitendinosis and gracilis tendons provide an anteria 
cruciate ligament graft with minimal trauma to the knee and maximal 
likelihood of successful functioning. 
While the implements described, in particular the tendon stripper and 
tendon leader are particularly adapted to the procedure described, it is 
apparent that with appropriate compatibility in sizing, such implements 
can be adapted for usage in many other surgical procedures. 
While in the foregoing embodiments of the present invention have been set 
forth in considerable detail for the purposes of making a complete 
disclosure of the invention, it may be apparent to those of skill in the 
art that numerous changes may be made in such detail without departing 
from the spirit and principles of the invention.