Abstract:
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. The repair device further includes structural means so as to secure opposed ends of the member against separation during healing. Devices for aiding in the positioning of the surgical repair device are provided.

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
       [0001]    This application claims priority to provisional patent Application No. 61/304,003, filed Feb. 12, 2010, the disclosure of which is hereby incorporated herein by reference. 
     
    
     FIELD OF THE INVENTION 
       [0002]    The invention pertains to methods and apparatus for repairing tendons, ligaments, and the like. More particularly, the invention pertains to surgical implants and techniques for repairing severed or injured tendons and ligaments. It is particularly well-suited for repairing tendons and ligaments of the extremities with minimal disruption of the surrounding tissues. 
       BACKGROUND OF THE INVENTION 
       [0003]    The current standard of care for repairing severed tendons in the hand is to re-attach the two separated ends of the tendon with nothing but sutures. The two ends of the tendon are held together by the suture while the tendon heals. Surgical repair of tendons and ligaments, particularly flexor tendons, has been accurately described as a technique-intensive surgical undertaking. 
         [0004]    The repair must be of sufficient strength to prevent gapping at the apposed end faces of the repaired member to allow the member to reattach and heal as well as to permit post-repair application of rehabilitating manipulation of the repaired member. Considerable effort has been directed toward the development of various suturing techniques for this purpose. Two strand, four strand, and six strand suturing techniques, primarily using locking stitches, have been widely used. There are a wide variety of suturing patterns which have been developed in an effort to attempt to increase the tensile strength across the surgical repair during the healing process. A common suturing technique in recent times is known as the Kessler repair, which involves the use of sutures that span, in a particular configuration or pattern, across the opposed severed ends of the tendon (or ligament). Evans and Thompson, “The Application of Force to the Healing Tendon” The Journal of Hand Therapy, October-December, 1993, pages 266-282, surveys the various suturing techniques that have been employed in surgical tendon repair. Further, two articles by Strickland in the Journal of American Academy of Orthopaedic Surgeons entitled “Flexor Tendon Injuries: I. Foundations of Treatment” and “Flexor Tendon Injuries: II. Operative Technique”, Volume 3, No. 1, January/February, 1995, pages 44-62, describe and illustrate various suturing techniques. 
         [0005]    Generally, the tensile strength of a tendon repair increases with increased complexity of the suturing scheme. As set forth in the Evans and Thompson article, the loads at which failure occur across a sutured joint can vary between about 1,000 grams force to as much as about 8,000 grams force (or about 10 to 80 Newtons). There are at least two modes of potential failure, including breakage of the sutures or the sutures tearing out of the tendon. The Kessler and modified Kessler repair techniques tend to exhibit failure toward the low end of the range, for example, between about 1,500 to 4,000 grams force (or about 15 to 40 Newtons), which is much weaker than the original tendon and requires the patient to exercise extreme care during the healing process so as not to disrupt the tendon repair. 
         [0006]    For instance, normal flexing of the fingers of the hand without any load generates forces of about 40 Newtons (N) on the tendon. Flexing with force to grasp something with the hand typically will place a force of about 60N-100N on the tendon. Finally, strong grasping of an object, such as might be involved in an athletic activity or in lifting of a heavy object can place forces on the tendons of the hand on the order of 140N or more. 
         [0007]    The various suturing techniques also are rather complex and, therefore, difficult to reproduce and perfect as a technique, let alone perform it on the small tendons in the hand. Further, because they employ locking stitches, the two tendon ends must be brought to and maintained in the correct position relative to each other (i.e., with the ends in contact) throughout the entire procedure because the locking stitches do not permit future adjustment of the repair (as did some of the earlier techniques that do not use locking stitches). 
         [0008]    Another significant difficulty with repairing lacerated and avulsed tendons in the hand, and, particularly, in the fingers is the need to re-route the severed tendon (usually the proximal tendon stump) through the pulley system of the finger joint. Specifically, when a tendon is severed or avulsed, the proximal tendon stump tends to recoil away from the laceration site toward the wrist. Accordingly, it often is necessary to make a longitudinal incision proximal to the laceration site in order to retrieve the proximal portion of the severed tendon and guide it through the pulley system of the finger back to the laceration site for reattachment to the distal tendon stump. 
         [0009]    As reported in Evans and Thompson, at least one researcher has employed a Mersilene mesh sleeve having a diameter slightly larger than the tendon that is subsequently sutured to the two apposed tendon ends. Experimental failure loading as high as 10,000 grams force (100N) was reported using the sleeve. However, Mersilene, which is a non-degradable polyester, a common material used for manufacturing sutures used in orthopedics, has the disadvantage that human tissue will experience a local tissue response leading to adhesion of the polyester to tissue surrounding the repair site. This is undesirable in tendons and ligaments since the tendon must be able to glide freely relative to the surrounding tissue, such as the pulleys in the fingers. While a sleeve may be well suited for use with tendons and ligaments which are substantially cylindrical, it is less easily employed with tendons having a flat or ovaloid cross section. Moreover, any added bulk, in this case to the outside of the tendon, could be problematic as this repair would have to traverse the pulley system of the fingers. 
         [0010]    U.S. Pat. No. 6,102,947 discloses another method and apparatus for repairing tendons that involves an implant that can be sutured to the tendon and which provides a splint running between the two tendon ends. The implant essentially comprises a wire bearing a first pair of wedges on one side of the midpoint of the wire with their pointed ends facing away from the midpoint and a second pair of wedges on the other side of the midpoint of the wire with their pointed ends also facing away from the midpoint (i.e., facing oppositely to the first pair of wedges). The first pair of wedges is pushed (or pulled) into one of the severed ends of the tendon and the other pair is pushed (or pulled) into the other severed end of the tendon. The wedges are sutured to the tendon and are retained within the tendon. This system provides high tensile strength to the repair. 
         [0011]    Further, Ortheon Medical of Winter Park, Fla., USA developed and commercialized an implant for flexor tendon repair called the Teno Fix. The Teno Fix implant is substantially described in Su, B. et al, “A Device for Zone-II Flexor Tendon Repair: Surgical Technique”, The Journal of Bone and Joint Surgery, March 2006, Volume 88-A-Supplement 1, Part 1. The assembled implant comprises two intratendonous, stainless-steel anchors (in the form of a coil wrapped around a core) joined by a single multi-filament stainless steel cable. The implant is delivered to the surgeon unassembled, comprising a stainless steel cable with a stop-bead affixed to one end of the cable, two separate anchors with through bores for passing the cable therethrough, and another stop-bead with a through bore for passing the cable therethrough. 
         [0012]    In practice, one of the anchors is advanced into a longitudinal intratendonous split (tenotomy) made in the proximal tendon stump so that the anchor sits within the longitudinal tenotomy and engages the tendon substance by capturing tendonous fibers between the core and the anchor. The other anchor is placed in the distal tendon stump in the same manner. Next, a straight needle with the stainless-steel cable attached thereto is threaded into the through-bore of the distal anchor from the small end of the anchor and is pulled through the center of the cut surface of the distal tendon stump until the stop-bead at the end of the cable opposite the needle contacts the distal anchor. The stainless-steel cable with the needle attached is then guided into the cut end of the proximal stump and through the through-bore of the anchor in the proximal stump from the large end of the anchor to the small end. The proximal stump of the tendon is then brought into contact with the distal stump by tensioning the cable, and the second stop-bead is placed over the stainless-steel cable at the proximal end of the proximal anchor. The second stop-bead is then crimped to lock it to the cable and the excess cable is cut so that the cable end is flush with the second stop-bead. 
         [0013]    A disadvantage of the Teno Fix is the size of the tendon anchor, which is large and, thus, may add resistance to the tendon as it passes through the pulley system. Another disadvantage of the Teno Fix is the invasive nature of implanting the device wherein the entire track of skin over the tendon path must be incised in order to effect the implantation of the device. A third disadvantage is that the attachment of the anchor to the tendon is rather weak, reporting only about  46  Newtons of pull strength. These disadvantages are overcome by the subject and method described in this invention. 
         [0014]    A disadvantage of most, if not all, of the prior art techniques discussed above is a high infection rate. 
       SUMMARY OF THE INVENTION 
       [0015]    The invention comprises methods and apparatus for reattaching the opposed ends of an anatomical 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. The repair device further includes structural means to secure opposed ends of the member against separation during healing. Devices for aiding in the positioning of the surgical repair device also are provided. 
     
    
     
       DESCRIPTION OF THE DRAWINGS 
         [0016]      FIG. 1  shows the various components that may be used for repairing a severed member, such as a tendon or ligament, in accordance with a first embodiment of the apparatus of the invention. 
           [0017]      FIGS. 2A-2L  illustrate various stages of a surgical procedure in accordance with a first embodiment of the method in accordance with the invention. 
           [0018]      FIG. 3  is a photograph of a completed tendon repair in accordance with the first embodiment. 
           [0019]      FIGS. 4A-4D  illustrate various stages of a surgical procedure in accordance with another embodiment of the method in accordance with the invention. 
           [0020]      FIG. 5  shows apparatus for reattaching a member in accordance with another embodiment of the invention. 
           [0021]      FIG. 6A  illustrates an alternative connector for interconnecting two tendon repair devices in accordance with the principles of the present invention. 
           [0022]      FIG. 6B  illustrates a procedure for locking the cables of two tendon repair devices in the connector of  FIG. 7A . 
           [0023]      FIG. 7  illustrates the pulley system of the finger. 
           [0024]      FIG. 8A  illustrates an alternate embodiment of a tendon repair device in accordance with the principles of the present invention. 
           [0025]      FIG. 8B  illustrates the tendon repair device of  FIG. 9A  as it is preferably delivered to the surgical site. 
           [0026]      FIGS. 9A through 9C  illustrate another embodiment of a tendon repair device and technique in accordance with the principles of the preset invention. 
           [0027]      FIG. 10A  illustrates another alternate embodiment of a tendon repair device in accordance with the principles of the present invention. 
           [0028]      FIG. 10B  illustrates two of the devices of  FIG. 10A  used to repair a tendon. 
           [0029]      FIG. 11A  illustrates an alternative apparatus in accordance with the invention. 
           [0030]      FIGS. 11B-11E  illustrate another alternate technique using the apparatus of  FIG. 11A . 
           [0031]      FIG. 12A  illustrates an alternative apparatus in accordance with the invention. 
           [0032]      FIGS. 12B-12C  illustrate another alternate technique using the apparatus of  FIG. 12A . 
           [0033]      FIG. 13A  is a perspective view of one embodiment of a unitary dilation catheter in accordance with another embodiment. 
           [0034]      FIG. 13B  is a perspective view of one embodiment of a multi-piece dilation catheter in accordance with another embodiment. 
           [0035]      FIG. 13C  is a perspective view of one embodiment of a guide member for the dilation catheters of  FIGS. 13A and 3B . 
           [0036]      FIGS. 14A-14G  illustrate another alternate technique using the apparatus of  FIG. 13A  or  FIG. 13B . 
           [0037]      FIG. 15  illustrates a tendon bearing a modified cruciate repair stitch. 
           [0038]      FIG. 16  is a perspective view of a tendon holder in accordance with another embodiment of the invention. 
       
    
    
     DETAILED DESCRIPTION 
       [0039]    In accordance with the present invention, a surgical implant and associated technique is disclosed for repairing tendons, ligaments, and the like following laceration, avulsion from the bone, or the like. The invention is particularly adapted for repairing a lacerated or avulsed flexor tendon, e.g., flexor digitorum profundus from the distal phalanx and/or the flexor digitorum superficialis from the middle phalanx. 
       First Set of Exemplary Embodiments 
       [0040]      FIG. 1  illustrates the components in accordance with a first embodiment of the invention. As will be described in detail below, not all of the components necessarily will be used in each surgical procedure. The components include a pulley catheter  101  which will be used, if needed, to guide the tendon repair device of the present invention along with a severed tendon stump, ligament stump, or similar anatomical feature through one or more anatomical restrictions to the repair site, e.g., through the pulley system of the finger. The components further include a flanged catheter  103 , which will be used to guide a severed tendon stump through anatomical restrictions to the repair site, if necessary. A catheter connector  105  may be used to connect the pulley catheter  101  and the flanged catheter  103  together end to end, as will be described in detail below. The catheter connector  105  may be a metal dowel. A tendon holder tool  107  may be used, as necessary, to hold the tendon during the surgical repair procedure. 
         [0041]    One or more of the tendon repair devices  109  are the actual devices that will effect the repair by reattaching two tendon stumps. Each tendon anchor  109  comprises a multi-filament stainless-steel cable  110 . From one end  141  of the cable to an intermediate point  143  of the cable, the individual filaments of the cable are wound in the normal fashion to form a single cable portion  144 . A straight needle  111  is attached to the first end  141  of the cable. From the intermediate point  143  in the direction opposite from end  141 , the individual filaments of the cable are unwound so as to form a plurality of (in this particular embodiment, seven) separate sutures  147   a - 147   g.  A needle, preferably a curved needle  114   a - 114   g,  is attached to the end of each of the seven separate cable portions  147   a - 147   g.  A fitting attached at the intermediate point  143  keeps the cable portion  144  from unwinding. The fitting, for instance, may be a sleeve  149 . In one preferred embodiment of the invention, the stainless-steel cable is formed of 343 individual strands wound in groups of seven. Thus, from the sleeve  149  to the first end  141 , the cable  144  comprises 343 individual strands making up seven intermediate strands, and each of the intermediate strands comprised of seven smaller wound strands of 49 filaments each, and each of those smaller strands comprised of seven individual strands of seven filaments each. In the other direction from the sleeve  149 , each of the seven individual strands  147   a - 147   g  comprises seven of those smaller strands wound together (wherein each of those smaller strands comprises seven individual strands wound together). 
         [0042]    The afore-described embodiment of the tendon repair device  109  is advantageous because it is particularly easy to fabricate from widely available materials. (e.g., 343 strand stainless steel suture cable and a crimp). The materials can be chosen from the implantable family of metals and alloys including the stainless steels, cobalt chrome alloys, titanium and its alloys and nickel-titanium alloy (NiTinol). However, the tendon repair device  109  can be formed of other materials, such as a polymer fiber, and assembled in other manners, such as braiding, welding, or molding. For instance, it may be formed of individual filaments, fibers or yarns welded together. 
         [0043]    In the following discussion, in order to more clearly differentiate them, the single ended portion  144  of the tendon repair device  109  will be referred to as cable portion  144 , whereas the strands  147   a - 147   g  will be referred to as sutures. However, it is to be understood that the use of these terms is not intended to indicate that they are formed of different materials, since, for instance, in the exemplary embodiment described herein, all of the strands are formed of stainless steel wire. 
         [0044]    A connector  112  is used to affix two tendon repair devices  109  to each other as will be described in detail below. The connector  112  in this illustrated embodiment comprises a block of material, preferably a deformable metal such as stainless steel, having two side-by-side through bores  151 ,  152  having inner diameters slightly larger than cable portion  144 . As will be described in greater detail below, near the end of the tendon re-attachment procedure, each cable portion  144  will be inserted in opposing directions through each through bore  151  and  152  of the connector  112  and the connector will be deformed (i.e., crimped) to lock the cable portions  144  therein. 
         [0045]    Finally, a bone anchor  400  or  450  can be used in procedures where the tendon has avulsed from the bone or has been severed too close to the bone to provide sufficient tendon length to retain a tendon repair device  109 . In a first embodiment, the bone anchor  400  has a threaded distal end  401  for screwing securely into bone. The proximal end  403  includes an eyelet  402  through which sutures can be passed. As will be described in more detail hereinbelow, the sutures can be tied in the eyelet. Alternately, the proximal end  403  can be formed of a deformable material, such as a thin-walled metal, so that the eyelet can be crushed by a crimping tool to capture the sutures therein. In a second embodiment, the bone anchor  450  may be manufactured with one or more sutures  451  extending from the proximal end  455 , such as four sutures  451   a,    451   b,    451   c,    451   d.  The ends of the sutures are provided with needles  452   a,    452   b,    452   c,    452   d.    
         [0046]    The tendon repair devices, surgical tools, and methods will be described herein below in connection with the repair of a lacerated flexor digitorum profundus at the level of the middle phalanx. However, it should be understood that this is exemplary only. Various stages of the procedure are illustrated by  FIGS. 2A-2L . 
         [0047]    First, if the proximal end of the divided tendon can be reached from the wound site, then it is gently retrieved through the wound to be held by the tendon holder  107 . 
         [0048]    The tendon holder  107  comprises a handle  201 , a cross bar  203  at the distal end of the handle  201 , and first and second needles  205  and  207 , respectively, extending distally from the cross bar  203 . The needles  205  and  207  are slidable laterally within slots  209  and  211 , respectively, in the cross bar  203 . Particularly, the proximal ends of the needles comprise a stop shoulder  213 , and an internally threaded bore running from the stop shoulder  213  to the proximal end of the needle. A screw  217  can be threaded into the proximal end of each needle  205 ,  207  to trap the cross bar  203  between the head of the screw  217  and the stop shoulder  213  of the needle  205 ,  207  to affix each needle in any given position along its slot  209 ,  211 . 
         [0049]    Depending on the length of tendon extending outside of the wound opening, the surgeon may pierce the tendon with one or both of the needles  205 ,  207  of the tendon holder  107  to hold the tendon outside of the wound. See  FIG. 2C , for example, which illustrates the tendon holder  107  holding a tendon stump  153   a.  The surgeon preferably pierces the tendon about 1 cm from the severed end. 
         [0050]    However, if the tendon is not readily retrievable from the wound and must be accessed through another incision and brought back to the wound site, the tendon holder  107  still may be used, but first the tendon must be retrieved to the wound site. In such a case, the pulley catheter  101  and flanged catheter  103  will be used to retrieve the tendon. Specifically, the pulley catheter  101  is a hollow plastic tube formed of a biocompatible polymer of such composition and/or wall thickness so that it is relatively rigid, but bendable. It might, for instance, have the approximate flexibility of a typical surgical vascular catheter. The relative rigidity of the pulley catheter will permit it to be pushed through narrow anatomical passages, such as the pulleys of the fingers. However, its flexibility will permit some bending to accommodate an overall curved path. Preferably, the pulley catheter is formed of a material having a low friction coefficient to allow the pulley catheter to readily pass through and around bodily tissues such as the tendon pulley system. Suitable biocompatible polymers include homopolymers, copolymers and blends of silicone, polyurethane, polyethylene, polypropylene, polyamide, polyaryl, flouropolymer, or any other biocompatible polymer system that meets the mechanical characteristics above. Various cross sections of the pulley catheter other than a simple tubular structure can also be used, such as a solid structure, multi-lumen, or complex geometry that would provide the mechanical characteristics above. The coefficient of friction of the surfaces of the pulley catheter may be inherent to the materials used to construct the device or may be enhanced through a surface preparation such as a lubricious coating or mechanical modification of the surface such as longitudinal recesses. 
         [0051]    The particular length, material, wall thickness, inner diameter, outer diameter, and stiffness of the pulley catheter  101  may vary greatly depending on the particular tendon or ligament with which is it to be used. The length, of course, would be dictated by the longest length that it might be required to traverse. The inner diameter must be large enough to easily accommodate the cable portion  144  of the tendon repair device  109 . The outer diameter must be small enough to pass through the anatomy that it may be called upon to pass through. The particular material and cross sectional geometry (e.g., wall thickness) of the pulley catheter will largely dictate the stiffness of the catheter and, as noted above, should be selected to provide enough rigidity to allow it to be pushed through a narrow path, but flexible enough to bend to accommodate bends in the path. In the exemplary case of the flexor digitorum profundus at the level of the middle phalanx, the pulley catheter may be formed of silicone and be 120 millimeters in length with a wall thickness of 0.5 mm, and an outer diameter of 2 mm. A silicone having a durometer of 50-80 (Shore A) may be used for the pulley catheter. 
         [0052]    The flanged catheter  103  also is a hollow tube formed of a biocompatible material, preferably a polymer. However, the flanged catheter preferably is softer than the pulley catheter. The flanged catheter has a first end  157  having a diameter that is approximately equal to the diameter of the pulley catheter  103  so that it can be connected end-to-end with the pulley catheter, as described in more detail further below. It also has a flanged end  159  that is tapered so as to essentially form a funnel for accepting the end of a tendon stump, also as will be described in more detail further below. As will become clear in the ensuing discussion, while the flanged catheter will traverse essentially the same path as the pulley catheter, the pulley catheter will guide or pull the flanged catheter into the anatomical path along with the tendon repair device attached to the tendon stump inside the flanged portion  159  of the flanged catheter. Accordingly, the flanged catheter need not be rigid. Actually, the flanged catheter should be relatively flexible because it may need to be bent into a tortuous shape to accommodate passage of the cable portion  144  of the tendon repair device  109 . Furthermore, the flange portion  159  of the flanged catheter  103  particularly should be readily collapsible in order to collapse around the tendon stump and pass through narrow anatomical passages, such as the pulleys of the fingers, with the tendon stump and tendon repair device enclosed therein as will be described in more detail below. 
         [0053]    The flanged catheter  103  should have a length, wall thickness, inner diameter, outer diameter, and material composition suited to its purpose. Its purpose is to allow the single-ended portion  144  of the tendon repair device  109  to pass through it and to follow the pulley catheter through an anatomical path, as will be described more fully below. Accordingly, the flanged catheter has a narrow end  157  and a wide end  158 . The wide end terminates in a cone or flange  159  in order to make it easier to insert the straight needle  111  at the end of cable portion  144  of the tendon repair device  109  into it as well as contain the tendon stump. The narrow end  157  of the flanged catheter  109  is narrow in order to be mated to the end of the pulley catheter. 
         [0054]    The flanged catheter  103  also is preferably formed of a material having a low friction coefficient to allow the flanged catheter to readily pass through and around bodily tissues such as the tendon pulley system. Such biocompatible polymers can be chosen from homopolymers, copolymers, and blends of silicone, polyurethane, polyethylene, polypropylene, polyamide, polyaryl, flouropolymer, or any other biocompatible polymer system that meets the mechanical characteristics above. Various cross sections of the flanged catheter other than a simple tubular structure can also be used such as a solid structure, multi-lumen, or complex geometry that would provide the mechanical characteristics above. The coefficient of friction of the surfaces of the flanged catheter may be inherent to the materials used to construct the device or may be enhanced through a surface preparation such as a lubricious coating or mechanical modification of the surface such as longitudinal recesses. 
         [0055]    In the exemplary case of the flexor digitorum profundus at the level of the middle phalanx, the flanged catheter may be formed of silicone and be 120 millimeters in length with a wall thickness of 0.5 mm, and an outer diameter of 2 mm. However, it is preferred that the flange portion  159  of the catheter be fabricated of a thinner cross section material, for example, 0.25 mm or less, that will allow the flange portion  159  of the flanged catheter to envaginate the tendon stump and collapse as it tracks through the anatomical pathway for repositioning of the tendon stump, e.g., pulley system of the finger. A softer silicone, for instance, of 20 to 40 durometer (Shore A) is preferred for the flanged catheter. 
         [0056]    Referring now to  FIG. 2A , in use, if the tendon has retracted and must be retrieved from a first incision  161  into a second incision (or the wound)  160 , as is typical of tendon lacerations in the hand, an incision  161  is made, typically in the palm of the hand, where the tendon  153  can be retrieved. If, on the other hand, the proximal tendon stump is distal to the A2 pulley, then the tendon would be exposed through an incision just distal to the A2 pulley. The pulley system of the pinky finger is shown in  FIG. 7  disembodied from the surrounding tissue for sake of clarity. It comprises five annular pulleys, termed A1 through A5, and three cruciate pulleys, termed C1, C2, and C3 as shown. The pulley system is not shown in most other Figures in order not to obfuscate the invention. 
         [0057]    The pulley catheter  101  is passed into the wound or incision  160  at the laceration site and slowly pushed proximally toward the new incision  161  beneath the A3 pulley through the pulley system of the finger. If resistance is encountered such that the pulley catheter  101  cannot be pushed through proximally, then a ½ cm to 1 cm incision (not shown) may be made midway between the skin creases of the proximal interphalangeal joint of the finger and the crease at the base of the finger. This is at a level between the A2 pulley and the A3 pulley of the finger. The dissection is carried down gently to the flexor sheath where the pulley catheter will be found. The pulley catheter can then be pulled past the obstruction or resistance through this incision. Then the pulley catheter can continue to be advanced proximally through the pulley system of the finger by pushing gently on it until it reaches the tendon retrieval incision  161  and is exposed proximally. 
         [0058]    Next, as shown in  FIG. 2B , the narrow end  157  of the flanged catheter  103  is connected to the proximal end of the pulley catheter  101 . If the components are sufficiently large and/or the surgeon is sufficiently dexterous, the narrow end of the flanged catheter may be inserted directly into the proximal end of the pulley catheter. Otherwise, a metal dowel  105  or other form of catheter connector (e.g., a hook) may be used to make the connection. Particularly, the catheter connector  105  is rigid and the narrow end  157  of the flanged catheter  103  can be inserted over one end of the catheter connector. Then, the other end of the catheter connector  105  can be inserted into a tight friction fit in the proximal end of the pulley catheter  101  to interconnect the pulley catheter  101  and the flanged catheter  103 . 
         [0059]    Next, with reference to  FIG. 2C , the proximal stump  153   a  of the tendon is delivered through the incision  161  in the palm so that approximately 2 cm of the tendon is exposed outside of the incision  161 . (If the proximal tendon stump has retracted only a short distance and is present at the level of the proximal phalanx, then the tendon can be delivered through an incision distal to the A2 pulley or between the A1 and A2 pulleys, as the case may be). Preferably, a flexible barrier  165  is placed under the tendon holder  107  and the proximal tendon stump  153   a  to create a working ‘table’ for practicing this technique. With the pulley catheter  101  and the flanged catheter  103  attached, the pulley is pulled distally from incision  160  to draw the flanged catheter  103  into and through the pulley system between incisions  160  and  161 . When the leading end  157  of the flanged catheter  103  exits through incision  160  so that the flanged catheter  103  is running between the two incisions  160 ,  161 , the pulley catheter  101  and connector  105  are removed, as shown in  FIG. 2C . 
         [0060]    Turning now to  FIG. 2D , the straight needle  111  at the end of cable portion  144  of the tendon repair device  109  is then placed in the tendon stump  153   a  approximately 1 cm from the end  168   a  of the stump  153   a  and the needle  111  is directed out through cut end  168   a  of the tendon stump  153   a.  The needle  111  is pulled through until the sleeve  149  is approximately ½ cm from the cut end  168   a.  If the tendon exposure is too little, then the sleeve  149  may be positioned somewhat closer to the cut end  168   a.    
         [0061]    Next, a small tenotomy is made in the tendon so that the crimp can be buried within the tendon. The condition of the tendon and tendon repair device at this point of the procedure is shown in  FIG. 2D . 
         [0062]    With the tendon repair device  109  in this position, the seven free strands  147   a - 147   g  of the tendon repair device are used to stitch the tendon repair device  109  to the tendon stump  153   a.  More particularly, two of the sutures, e.g.,  147   a  and  147   g,  are pushed through the tendon using the curved needles  114   a  and  114   g  and tied to each other in a knot  185 . In a preferred embodiment, the two sutures are stitched to the tendon  153   a  using a locking cross stitch or cruciate pattern. In this instance, the loading will be spread amongst multiple points of fixation along the length of the repair. Also, due to the cruciate method, under tension, the repaired tendon would tend to reduce in diameter which would facilitate traversing through the pulley system. The sutures  147   a,    147   g  are cut at the far side of the knot to remove excess material beyond the knot. In order not to obfuscate the invention, however, the stitches are shown in most of the drawings, including  FIGS. 2E-2J , representatively as Xs. Only in drawings that are of suitable scale, such as  FIG. 2L , or in which some significant discussion of the stitches is given in the corresponding text is the stitching represented more accurately. 
         [0063]    Next, two more sutures, e.g.,  147   b  and  147   f,  are stitched to the tendon using the curved needles and  114   b  and  114   f  and tied together in another knot  187 . Preferably, the knot  187  is a crisscross locking stitch with the two limbs traveling proximally. The sutures are cut after the knot is tied. In a preferred embodiment of the invention, as shown in  FIG. 2E , the first knot  185  and the second knot  187  are tied at different levels along the length of the tendon stump  153   a.  Finally, two more sutures, e.g.,  147   c  and  147   e,  are tied in a similar crisscross knot (not seen) on the other side of the tendon stump  153   a  and cut. 
         [0064]    Finally, the single remaining suture  147   d  may be cut off or may be used to couple with any of the other free ends (prior to trimming) to form yet another knot. It is preferable that there be multiple points of fixation of the tendon repair device to the tendon stump. 
         [0065]    In one embodiment of the invention, the sutures can be of different lengths, organized in pairs, such that each of the two sutures forming a pair are the same length and each pair of sutures is of a different length. When stitching the sutures to the tendon, each pair of sutures of the same length are stitched to the tendon and knotted to each other. This embodiment is advantageous in that it provides an easy visual indication to the surgeon which pairs of sutures are to be tied to each other during the procedure (the sutures of the same length) thus simplifying the procedure. 
         [0066]    Referring to  FIG. 2F , now that the tendon repair device  109  is securely fixed to the proximal tendon stump  153   a,  the tendon is removed from the tendon holder and the straight needle  111  at the end of cable portion  144  is inserted into the flange  159  of the flanged catheter  103 . Tendon repair device  109  is advanced through the flanged catheter until the end of the tendon stump  153   a  (which is stitched to the back end of the tendon repair device  109 ) is in the flange portion  159  of the flanged catheter  103 . Cable portion  144  preferably is rigid enough that the cable can be pushed along with the flanged catheter through the pulley system of the finger and follow the flanged catheter  103  out of the wound  160 . Now the surgeon can grasp the needle  111  through the flanged catheter  103  with a clamp and pull the needle  111 , cable portion  144 , flanged catheter  103  and tendon stump  153   a  (contained inside collapsible flange  159  of flanged catheter  103 ), through the pulley system of the finger and out of the wound  160 . Alternately, if the needle  111  protrudes from the distal end  157  of the flanged catheter, the surgeon can grasp the needle  111  or cable portion  144  directly by hand or with a clamp and pull the needle  111 , cable portion  144 , flanged catheter  103 , and tendon stump  153   a  (contained inside collapsible flange  159  of flanged catheter  103 ), through the pulley system of the finger and out of the wound  160 . If any resistance is encountered, then the path through the pulley system can be inspected through a separate incision. 
         [0067]    The flange  159  of the flanged catheter  103  will collapse around the tendon stump as needed to pass through the pulley system of the fingers. 
         [0068]    Referring to  FIG. 2G , once the tendon stump  153   a  has reached the wound  160 , flanged catheter  103  can be removed from the tendon repair device  109  and tendon stump  153   a,  thereby exposing the tendon repair device  109  and tendon stump  153   a  through the wound  160 . Needle  205  of tendon holder  107  can be placed across the proximal tendon stump  153   a  to hold the tendon stump  153   a  in a stable position. 
         [0069]    In  FIG. 2G  and subsequent drawings, the length of the tendon stump(s) may be exaggerated to help with the illustration of the repair. However, it should be understood that, once the tendon has been retrieved to or near the original wound site (as in  FIG. 2G ), there is little or no excess tendon to expose outside of the skin, especially if the finger is in an open (i.e., unflexed) condition. In actuality, if the finger is unflexed, the surgeon will probably be working on the tendon primarily within the skin. However, in some of the drawing figures, the length(s) of the tendon stump(s) may be exaggerated in order not to obscure the illustration of the methods and apparatus being described in connection therewith. Furthermore, in some of the drawings in which the stitches are not substantially related to the features being discussed in connection therewith, the stitches and/or knots are represented by a simple criss-cross pattern in order not to overly complicate the drawings. In other drawings in which the stitching or knots are more closely related to the features being the discussed, a more accurate representation of an appropriate knot/stitch is presented. 
         [0070]    It also should be noted that other features, such as the diameters or lengths of the sutures, crimps, crimp connectors, and needles, are not necessarily drawn to scale in all of the figures. 
         [0071]    Next, referring to  FIG. 2H , a very similar procedure is performed with respect to the distal tendon stump. Particularly, the distal tendon stump  153   b  is delivered into the wound  160  in a similar fashion as described above in connection with the proximal tendon stump  153   a.  That is, if adequate exposure is not possible to retrieve the distal tendon stump  153   b  directly from the wound  160 , a 1 cm incision  174  may be made just distal to the crease at the distal interphalangeal joint and dissection carried down onto the distal extent of the A5 pulley so that the distal tendon stump  153   b  can be exposed through this new incision. The pullet catheter  101  is guided between the incisions  160 , and  174  and the flanged catheter  103  is inserted into the distal end of the pulley catheter  101 . The pulley catheter  101  is then pulled through the pulley system with the flanged catheter  103  following it until the flanged catheter  103  is positioned through the pulley system and extending at opposite ends from incision  160  and  174 , as shown in  FIG. 2H . Next, another tendon repair device  109  is attached to the distal tendon stump  153   b  in the same manner as described above in connection with the proximal tendon stump.  FIG. 2H  illustrates the procedure at this stage. 
         [0072]    Referring next to  FIG. 2I , the distal tendon stump is next guided to the original wound site  160  using pulley catheter  101  and the flanged catheter  103  as described above in connection with the proximate tendon stump  153   a.  The second needle  207  of the tendon holder  107  may be placed through the distal tendon stump  153   b,  exposing approximately 1 cm of tendon as described above in connection with the proximal tendon stump. This stage of the procedure is illustrated in  FIG. 2I . 
         [0073]    Next, referring to  FIG. 2J , the connector  112  is brought to the site and the straight needles  111  at the ends of the cable portions  144  are inserted through the bores  151 ,  152  in the connector  112 . More particularly, the straight needle  111  of the tendon repair device  109  that is attached to the proximal tendon stump  153   a  is passed through one of the bores  151  traveling in the proximal-to-distal direction and the straight needle  111  of the tendon repair device  109  that is attached to the distal tendon stump  153   b  is passed through the other through bore  152  in the connector traveling in the opposite direction, i.e., from the distal-to-proximal direction. 
         [0074]    Referring now to  FIG. 2K , the proximal and distal tendon stumps  153   a,    153   b  are removed from their respective tendon holder needles (and the tendon holder is put aside) and traction is applied to pull the distal tendon stump  153   b  proximally and pull the proximal tendon stump  153   a  distally until there is overlap of the two tendon stumps of approximately 1 mm, with the connector  112  essentially buried in tendon between the tendon ends  168   a,    168   b .    
         [0075]    A crimping tool  113  is then used to crimp the connector  112 , thereby securely affixing the cable portions  144  of the two tendon repair devices inside of the connector  112 . More particularly, with reference to  FIG. 2K , the tendon stumps  153   a,    153   b  can be folded back slightly to expose the connector  112  so that the crimping tool  113  can be placed over the crimp connector without contacting or damaging the tendon. 
         [0076]    Alternatively, if necessary, the tendon holder  107  can be used to help bring or hold the tendon stumps together by adjusting the positions of the two needles  205 ,  207  in the slots  209 ,  211  of the tendon holder  107  towards the center so that they are very close to each other and piercing each tendon stump with one of the needles. 
         [0077]    The extra lengths of cable portions  144  extending from the connector  112  are then cut as close to the edge of the crimp connector as possible and discarded. The connector  112  will then retract into the substance of the tendon when it is released and the tendon ends are unfolded and there will be excellent cooptation of the tendon ends, as illustrated in  FIG. 2L .  FIG. 2L  represents four cruciate stitches  185 ,  187 ,  185 ′, and  187 ′ made using the tendon repair devices. While cruciate stitches are believed to be particularly efficacious, other types of stitches can be used as well. If desired, one or more 6-0 nylon epitendonous stitches  183  can be placed around the tendon ends to assure good cooptation of the tendon ends in order to ‘tidy up’ the edges of the repair. 
         [0078]      FIG. 3  is a photograph of an actual tendon repair performed in accordance with the first embodiment of the invention. The first and second knots  185  and  187 , respectively, can be seen in the proximal tendon stump  153   a.  Similar knots  185 ′ and  187 ′ are seen in the distal tendon stump  153   b.  Four epitendonous stitches  183  also can be seen. 
         [0079]    The one or more skin wounds can be stitched closed as usual and the procedure is ended. 
         [0080]    While the procedure and apparatus has been described above in connection with one particular procedure relating to the repair of a flexor tendon laceration, flexor digitorum profundus at the level of the middle phalanx, this is merely an exemplary application. The invention can be applied to reattach other types of tendons, ligaments, or other similar load-bearing soft tissues. 
       Second Set of Exemplary Embodiments 
       [0081]      FIGS. 4A-4D  illustrate another apparatus and procedure in accordance with the principles of the present invention that can be used in situations where the tendon (or ligament) has avulsed or otherwise been separated from the bone, rather than severed. The apparatus and procedure described in connection with  FIGS. 4A-4D  also may be used in situations where the tendon or ligament has been severed very close to the bone so that there is not enough tendon length left to effectively attach a tendon repair device  109  to that stump. 
         [0082]    In these types of situations, a tendon repair device such as the afore-described tendon repair device  109  is still used in the manner described above in connection with  FIGS. 2A-2H  in connection with the stump that has sufficient length, e.g., at least 2 cm, (typically the proximal stump). However, with respect to the bone or short tendon stump, one or more cables are attached directly to a bone anchor  400  instead of using a second tendon repair device. 
         [0083]    The bone anchor may be any bone anchor that can be attached to bone at its distal end and to which a suture or cable can be attached to the proximal end thereof. Suitable bone anchors are disclosed, for instance, in PCT International Published Patent Application WO 2008/054814, which is incorporated herein by reference. However, much simpler bone anchors can be used also. 
         [0084]    In a simple embodiment of a suitable bone anchor, such as illustrated in  FIG. 1 , the bone anchor may comprise a threaded distal portion  401  for threading into bone and an eyelet  402  for receiving the cable of the tendon repair device integrally formed in the proximal portion of the bone anchor main body. In other embodiments, the bone anchor may be prefabricated with one or more sutures integrally formed therein and extending from the proximal end thereof. 
         [0085]    A surgical procedure in accordance with this embodiment will now be described in connection with an exemplary injury in which the flexor digitorum profundus has been lacerated very close to the distal phalanx. However, it should be understood that variations of this procedure can generally be used in connection with any tendon or ligament that has avulsed from the bone or been severed close to the bone. 
         [0086]      FIGS. 4A-4D  illustrate various stages of an exemplary procedure for effecting a four strand repair (i.e., the repair will have four suture strands running between the two tendon stumps). This embodiment utilizes a different tendon repair device  1001  than the tendon repair device  109  illustrated in  FIGS. 1-2L . This tendon anchor is illustrated in  FIG. 10A , which is discussed in more detail below in connection with another exemplary surgical procedure. With reference to  FIG. 10A , it comprises two strands or filaments  1047   a,    1047   b,  with each strand having a needle at each end. In the illustrated embodiment, curved needles  1014   a  and  1014   b  are provided at the first ends of the strands  1047   a,    1047   b,  respectively, and straight needles  1011   a,    1011   b  are provided at the second end of the strands  1047   a,    1047   b,  respectively. The two strands comprising the tendon repair  1001  device are joined intermediate their ends, such as by a fixed or slidable crimp  1049 . The crimp  1049  may initially be uncrimped so that it can slide along the device and, if desired, crimped at a suitable stage of the procedure. As shown in  FIG. 10A , the tendon repair device  1001  may be delivered to the surgeon with a portion of the sutures and the straight needles  1011   a,    1011   b  on end  1001   a  enclosed in a sheath  1011  to ease the process of passing that end of the tendon repair device  1001  into the pulley catheter  101  and/or flanged catheter  103 . 
         [0087]    The long tendon stump  501  is operated upon essentially as described above in connection with the first embodiment. Particularly, with reference to  FIG. 4A , the tendon stump  501  is retrieved, if necessary, by making a retrieval incision  531  where needed, exposing the tendon stump  501 , and stitching end  1001   b  of the tendon repair device  1001  to the tendon stump using the curved needles. In this exemplary case, where there are only two sutures  1047   a,    1047   b,  one cruciate stitch is preferred. In embodiments using tendon repair devices having more sutures, such as the tendon repair device  109  of  FIGS. 1-2L  having seven sutures, then the tendon repair device can be stitched to the tendon stump using multiple cruciate or other stitches, exactly as described above in connection with the embodiment of  FIGS. 1-2L , for instance. Next, the pulley catheter  101 , flanged catheter  103 , and catheter connector  105  (if needed) can be used as previously described to guide the tendon repair device  1001  and tendon stump  501  back to the injury site  533 . The narrow sheath  1011 , if provided, will facilitate threading of the end  1001   a  of the tendon repair device  1001  into and through the catheters. 
         [0088]    Then, the tendon stump  501  is placed in a tendon holder  107  while the distal tendon stump is prepared.  FIG. 4A  shows the condition of the surgical site after these steps have been performed, i.e., with the tendon  501  in a tendon holder  107  with a tendon repair device  1001  stitched thereto. 
         [0089]    Next, referring to  FIG. 4B , with respect to the bone  503  (and distal stump  505 , if any is present), an incision  532  (which may include original injury  532 ) is made and dissection is carried down to expose the bone  503  of the distal phalanx. A bone anchor, such as bone anchor  450  shown in  FIG. 1 , is then affixed to this bone  503  by screwing it in securely. 
         [0090]    Next, with reference to  FIG. 4C , since this exemplary embodiment is a four strand repair, two of the sutures  451   c,    451   d  of the bone anchor  450  can be cut off at or as close to the bone anchor as possible. The other two sutures  451   a,    451   b  are threaded through the distal stump  505 . Now, referring to  FIG. 4D , the tendon stumps are brought together with a slight amount of overlap and the two sutures  451   a,    451   b  of the bone anchor  450  are stitched and knotted to the proximal stump  501 . Likewise, the tendon repair device  1001  that is already stitched to the proximal tendon stump  501  at one end thereof is then stitched to the distal stump  505  at the other end.  FIG. 4D  shows the completed repair in accordance with this embodiment. 
         [0091]    Of course, the number of strands on the bone anchor  450  and the number of strands on the tendon repair device  1001  can be increased to provide a stronger repair, such as a six eight, ten, or even twelve strand repair, if desired. 
         [0092]    A tendon injury of the type illustrated in  FIGS. 4A-4D , in which there is only a short distal tendon stump remaining (or none at all) also can be repaired using a tendon repair device  109  such as illustrated in  FIGS. 2A-2L  and the other bone anchor  400  shown in  FIG. 1 , the long tendon stump  501  is operated upon exactly as described above in connection with the first embodiment of  FIGS. 2A-2L . Particularly, the proximal tendon stump  501  is retrieved, if necessary, by making a retrieval incision where needed, exposing the tendon stump  501 , attaching a tendon repair device  109  to the tendon stump, and using the pulley catheter  101 , flanged catheter  103 , and catheter connector  105  (if needed) as previously described to guide the tendon stump back to the injury site. 
         [0093]    Next, an incision is made and the bone anchor  400  is affixed to the bone essentially as described above in connection with  FIGS. 4A-4D , expect that it is bone anchor  400 , rather than bone anchor  450 . 
         [0094]    Next, if a distal stump of the flexor is still present, such as stump  505  in  FIGS. 4A-4D , then the needle  111  and cable  144  of tendon repair device  109  is run through this stump  505  and into and through the eyelet  402  of the bone anchor  400 . Particularly, the straight needle  111  at the end of cable portion  144  is brought into the short distal tendon stump  505  through the severed end of the tendon stump  505  and out through the side of the tendon stump near where the stump  505  is still attached to the bone  503  and then through the eyelet  402  in the bone anchor  400 . 
         [0095]    Next, traction is applied to the cable  144  to draw the proximal tendon stump  501  distally until there is a 1 mm overlap of the proximal tendon stump  501  with the distal tendon stump  505 . 
         [0096]    Then, the cable  144  is fixed to the eyelet of the bone anchor  503 . This can be done by tying the suture or cable to the eyelet  402  of the bone anchor. In a more preferred embodiment, however, the proximal end of the bone anchor  503  is crimped to crush the eyelet  402  of the bone anchor  400 , thereby trapping the cable  144  therein. 
         [0097]    Finally, the procedure is completed essentially as described above in connection with the embodiment of  FIGS. 2A-2L  or  4 A- 4 D. 
         [0098]    If, on the other hand, there is no or virtually no distal tendon stump remaining to attach to, the proximal stump would instead be attached directly to the bone using the bone anchor. Preferably, the cable portion  144  of the tendon repair device attached to the tendon stump is directly attached to the bone anchor without the use of a second suture or cable  509  and the proximal tendon stump is pulled distally so that the stump envelopes the bone anchor and contacts the bone around the bone anchor. As is often the case, the surgeon may roughen, counter bore or tunnel the bone in the area around the bone anchor for the tendon to attach to. 
         [0099]    In another alternate embodiment, only the bone anchor  450  with multiple strands (with needles at the ends of the strands) already extending from the bone anchor is used. No separate tendon repair device  109  or  1001  is used. Rather, the sutures extending from the bone anchor  450  are stitched directly to the proximal tendon stump. This type of embodiment is most suited to an injury in which (1) the proximal tendon stump has not retracted significantly and is, therefore, present at the incision near the distal stump without the need to be retrieved through another incision and (2) there is no distal tendon stump to include in the repair. Particularly, with respect to the first point, if the proximal tendon stump needs to be retrieved, then it would likely be more practical to use the technique described in connection with  FIGS. 4A-4D . More specifically, if the proximal tendon stump must be retrieved, then a separate tendon repair device probably will have to be attached to the proximal tendon stump for purposes of retrieving the stump, in any event. In such a situation, it would be simpler to attach the tendon repair device that is already stitched to the proximal tendon stump to the bone anchor than to add another set of sutures. 
         [0100]    With respect to the second point, if there is a distal tendon stump, it would be preferable to include sutures emanating from the proximal stump that exert a force pulling the distal tendon stump toward the proximal tendon stump. In the absence of a proximal tendon repair device, no sutures exerting such a force would be present and, therefore, the distal tendon stump could conceivably slide away from the end to end contact of the two tendon stumps prior to healing of the tendon stumps. 
         [0101]    In repairs in accordance with the bone anchor embodiment, the load on the distal end is borne completely by the bone and bone anchor. 
         [0102]    Preliminary testing has shown failure strengths of tendon reattachments performed in accordance with the principles of the present invention of approximately 70-100 Newtons. Accordingly, a tendon and ligament repair in accordance with the principles of the present invention results in a much stronger repair that the current standard of care. 
         [0103]    In addition, the procedure is greatly simplified as compared to the present standard of care. 
       Third Set of Exemplary Embodiments 
       [0104]      FIG. 5  illustrates another embodiment in accordance with the principles of the present invention.  FIG. 5  is a close up of the proximal tendon stump  153   a  in accordance with this embodiment of the invention at a stage after the tendon repair device  109  has been stitched to the tendon stump. It is essentially similar to the stage shown in  FIG. 2E , but illustrating a different way to finish off the stitches other than tying them in knots in pairs. 
         [0105]    This embodiment involves a simpler procedure than in the aforedescribed embodiment in so far as the surgeon will not be required to tie any knots. Rather, as shown in  FIG. 5 , rather than tying knots in the sutures  147   a - 147   g  after stitching them to the tendon, a crimp  603  can be advanced over each suture against the stitch as far as it will go and then crimped with a crimping tool to lock the crimp to the suture, thus locking the stitch to the tendon. Depending on the particular configuration of the curved needles  114   a - 114   g  and the crimps  603 , the crimps may be slipped over and around the needles onto the sutures  147   a - 147   g.  If this is not possible, then the needles  114   a - 114   g  can be cut off of the sutures  147   a - 147   g  after the corresponding stitch is tied to permit the crimp to be placed on the suture. In this embodiment, the surgeon is not required to tie any knots with the sutures, thus simplifying the procedure. The surgeon is free to use the sutures to create any stitches desired, but they do not need to be knotted at the end. 
       Fourth Set of Exemplary Embodiments 
       [0106]      FIGS. 6A and 6B  illustrate an alternative to the crimp connector  115  for attaching two tendon repair devices  109  (or a tendon repair device  109  and a bone anchor  115 ) to each other. In this embodiment, the connector  701  comprises a connector main body  711  having two parallel, longitudinal through bores  713 ,  715 . The main body  711  may be cylindrical, rectangular, or any other reasonable shape. Another bore  717  is provided in the main body  711  transverse to the direction of longitudinal through bores  713 ,  715 , this bore intersecting the two longitudinal through bores  713 ,  715 . A pin in the form of a block  719  fits in the transverse bore  717 . Accordingly, when the block is inserted in the transverse bore  717  as shown in  FIG. 6   b , it also transversely passes through portions of the longitudinal through bores  713 ,  715 . The dimensions of the block  719 , the transverse bore  717  as shown in  FIG. 6B , the longitudinal through bores  713 ,  715 , and cable portions  144  (that will pass through the longitudinal through bores  713 ,  715 ) are chosen so that the block  719 , when inserted into the transverse bore  717  will compress the cables in the longitudinal bores  713 ,  715  between the side wall of the block  719  and the side walls of the longitudinal bores  713 ,  715 , thereby trapping the cables in the connector  701 . 
         [0107]    Thus, in this embodiment, rather than crushing the crimp connector with a crimping tool, a pliers or clamp type tool acts on the block  719  and the connector  701  and pushes the block  719  into the connector  701  against the resistance of the cable portions  144  in the longitudinal through bores  713 ,  715 , thereby capturing the cables as described above. 
         [0108]    Some of the advantages of this embodiment of the connector include a much lower force requirement for locking since the block  719  does not have to be plastically deformed. Rather, this mechanism relies on the wedging of cables  144  against the inner wall of connector  701  to effect the lock. 
         [0109]    There are many possible alternative stitching techniques to the few described above. The present invention can accommodate and permit the surgeon to use any stitching technique desired. In alternate embodiments, the tendon repair device may have only four sutures or, if it has more than four sutures, the surgeon may decide to cut off those sutures that he or she does not use. For instance, two of the sutures of the tendon repair device  109  of  FIGS. 1-2L , e.g. sutures  147   a  and  147   g,  may be stitched to the tendon using cross stitches and are knotted together as previously described in connection with the embodiment of  FIGS. 2A-2L , except that the remaining distal portions of the sutures  147   a,    148   g  extending from the knots are not cut off at this time. Next, another two sutures, e.g.,  147   b,    147   f,  are stitched to the tendons at a different level than the first two sutures and knotted, also as described in connection with the embodiment of  FIGS. 2A-2L . Then, sutures  147   a  and  147   b  are tied in a knot and sutures  147   g  and  147   f  are tied in another knot. Now, the distal ends of each of sutures  147   a,    147   g,    147   b,  and  147   f  may be cut off. The other  3  sutures  147   c,    147   d,    147   e,  may be cut off and not used or may be used to form other knots. The inter-dependence of the two pairs of sutures in this technique provides greater assurance that the sutures will not tear out of the tendon. 
         [0110]    In yet other embodiments, the third pair of sutures also may be tied together with the first two pairs of sutures. The various permutations of stitching techniques and tying together of the sutures are virtually endless. 
       Sixth Set of Exemplary Embodiments 
       [0111]      FIGS. 8A  illustrates an alternative embodiment of the tendon repair device. This embodiment is particularly suited to, but not limited to, surgical procedures in which either one or none of the tendon stumps needs to be retrieved from a separate incision and be guided back to the wound site. This embodiment also has the advantage of being capable of effecting a repair using only a single tendon repair device, if desired. 
         [0112]    As can be seen in this embodiment, rather than having one side of the anchor comprised of multiple sutures and the other side comprised of one cable as was the case for the embodiments illustrated in  FIGS. 1-2L  and  4 A- 4 E, this tendon repair device has multiple sutures on both sides  901   a,    901   b  of the tendon repair device  901 . More particularly, this tendon repair device may be formed of four sutures  947   a - 947   d  attached together at one or more intermediate points along their lengths. In one embodiment that is particularly convenient to manufacture, the tendon repair device  901  comprises four sutures  947   a - 947   d  with at least one crimp  949  intermediate their lengths holding them together. The crimp may be initially uncrimped so that it can slide along the lengths of the sutures during the procedure. It may be crimped to lock its position relative to the sutures at any point during the procedure. In some procedures, it may not be crimped at all. 
         [0113]    In this embodiment, the tendon repair device  901  preferably is delivered to the surgical site in the condition illustrated in  FIG. 8B , i.e., with at least one of the side  901   a  contained in a narrow sheath  911  (e.g., a plastic tube) that can be easily passed through the flanged catheter. However, depending on the diameters of the needles, sutures, flanged catheter, the number of sutures in the device, and the material of the flanged catheter, a sheath may be unnecessary or may cover only part of the end  901   a  (such as just the tips of the needles  913   a - 913   d ). In this embodiment, the needles  913   a - 913   d  attached to the ends of the sutures on side  901   a  of the crimp  949  that will be placed in the sheath  911  should be straight needles in order to more readily fit into the sheath  911  and/or through the catheters  101 ,  103 .The needles attached to the other ends of the sutures  947   a - 947   d  may be curved needles  914   a - 914   d  to facilitate stitching. However, they also may be straight needles. 
         [0114]    The first half of the surgical procedure is essentially identical to the procedure described above in connection with the first embodiment illustrated in  FIGS. 2A through 2L . More particularly, the procedure is essentially identical to that embodiment up to the stage illustrated in  FIG. 2F , the only difference being that, instead of a single cable  144  extending from the far side of the intermediate crimp  949 , there are four individual sutures (or cables) contained in a sheath  911 . 
         [0115]    After the device has been stitched to one tendon stump, the sheath  911 , containing the four straight needles and sutures is traversed through the pulley system to the site of the wound as described previously. Next, the protective sheath  911  is removed; thereby releasing the four sutures  947   a - 947   d  and straight needles  913   a - 914   d.    
         [0116]    In one embodiment, the sheath  911  is cut with a knife or scissor. In another embodiment, the sheath can be torn by hand. In yet another embodiment, and, particularly, the illustrated embodiment, the sheath  911  comprises an integral longitudinal strip  911  a, such as a string embedded within the material of the sheath, having a “tail”  911   b  extending beyond at least one end of the sheath so that it can be grasped by the surgeon and pulled to tear the sheath, thus freeing the needles for attachment to the tendon stump. Alternately, the strip may comprise a weakened radial segment of the sheath running the full longitudinal length of the sheath. The weakened segment may comprise a strip of the sheath that is integrally formed with the rest of the sheath, but having a thinner wall thickness than the rest of the sheath. 
         [0117]    The crimp  949  may be crimped at this stage of the procedure to lock its position on the device  901 . For instance, it may be crimped immediately adjacent the end of the tendon stump  902   a  to which it has been stitched at this point. 
         [0118]    When using this embodiment, the other tendon stump  902   b  preferably is exposed at the wound site without the need to be retrieved. If, however, it must be retrieved through a different incision, it can be retrieved using any reasonable technique, including conventional techniques for tendon retrieval or using the pulley catheter and flanged catheter of the present specification as described above. For instance, a small suture can be stitched to the tendon temporarily and the suture can be advanced through the pulley system of the finger using the pulley catheter  101  and flanged catheter  103  much as described above in connection with the first embodiment. 
         [0119]    In any event, with the other tendon stump  902   b  exposed at the wound, the two stumps  902   a,    902   b  are positioned with their ends opposed to each other and the second end  901   a  of the tendon repair device can be stitched to the distal tendon stump  902   b  much in the same way as described above in connection with the first embodiment. Care should be taken to assure that the two tendon ends  902   a,    902   b  appose each other, since it will be difficult, if not impossible, to adjust the relative positions of the ends of the tendon stumps after the first stitch is completed and locked. The tendon holder  107  can be used as previously described to hold the tendon ends apposed to each other. The sutures may be stitched to the tendon in pairs as previously described. The repair can be completed with an epitendonous stitch between the two stumps as previously noted. 
         [0120]    This embodiment is advantageous in that it requires no crimp connector or crimping tool and has fewer parts. For example, only one tendon repair device is involved in the procedure, that tendon repair device being double headed, as shown in  FIG. 8A . 
       Seventh Set of Exemplary Embodiments 
       [0121]      FIGS. 9A-9C  help illustrate yet another embodiment of a tendon repair device and technique particularly suited, but not limited, to repairs where both tendon stumps must be retrieved to the repair site by being tracked through anatomy between two incisions.  FIG. 9A  shows the tendon repair device  951  in accordance with this embodiment. In this embodiment, two tendon repair devices  951  are used, each comprising two strands or filaments  953   a,    953   b,  with each strand having a needle at each end. In the illustrated embodiment, curved needles  954  are provided at the first end and straight needles  955  are provided at the second end of each strand. The two strands comprising a single tendon repair device are joined intermediate their ends, such as by a slidable crimp  956  as previously described in connection with other embodiments. The crimp  956  may initially be uncrimped so that it can slide along the device and, if desired, crimped at a suitable stage of the procedure. 
         [0122]    As shown in  FIG. 9B , one end  951   a  of each tendon repair device  951 - 1 ,  951 - 2  is stitched to a respective tendon stump  961   a,    961   b  using the two strands of that end. The other end  951   b  of each tendon repair device may be initially encased within a sheath  968  similarly to the embodiment of  FIGS. 8A and 8B  for purposes of being passed through anatomy, such as the pulleys of the finger, using the pulley catheter and flanged catheter described above in connection with other embodiments. However, as noted above in connection with the embodiments of  FIGS. 8A and 8B , the sheath may not be necessary. 
         [0123]    Next, the tendon repair devices and tendon stumps to which they are stitched can be tracked through anatomy to the repair incision using the pulley and flanged catheters as previously described. The condition of the tendon repair procedure at this point is illustrated in  FIG. 9B . Referring now to  FIG. 9C , the two tendon stumps  961   a,    961   b  are brought together. If desired, they can be held in position using the tendon holder  107 , with one needle  205 , 207  in each of the tendon stumps  961   a,    961   b  (not shown). 
         [0124]    Next, the free ends  951   b  of the two strands of the first tendon repair device  951 - 1  (the other ends  951   a  of which are already stitched to the first tendon stump  961   a ) are stitched to the second tendon stump  961   b,  preferably at a different level than the stitches of the second tendon repair device  951 - 2 . Likewise, the free ends  951   b  of the two strands of the second tendon repair device  951 - 2  (the other ends  951   a  of which are already stitched to the second tendon stump  961   b ) are stitched to the first tendon stump  961   b.  The completed repair is shown in  FIG. 9D . The repair can be completed with an epitendonous stitch as previously described, if desired. 
         [0125]    Like the embodiment of  FIGS. 8A-8B , this embodiment provides four strands running between the two tendon stumps, and two stitches at different levels in each tendon stump, thereby providing a very sturdy repair. 
       Eighth Set of Exemplary Embodiments 
       [0126]      FIG. 10A  illustrates a tendon repair device in accordance with yet another embodiment of the invention. This device  1001  is essentially the same device of  FIG. 9A , but with one side in a sheath, as will be described in more detail below. In these embodiments, two tendon repair devices will be used, as in the first embodiment as illustrated in FIGS.  1  and  2 A- 2 L. However, both of these tendon repair devices  1001  have multiple strands at each end, as in the embodiments illustrated in  FIGS. 8A-8B  and  9 A- 9 D. More particularly, each tendon repair device  1001  comprises two sutures  1047   a,    1047   b.  The two sutures may be coupled together intermediate their ends, such as by a crimp  1049  or sliding sleeve. Alternately, the two sutures may be independent of each other. 
         [0127]    Even further, the tendon repair device  1001  may comprise a single cable or suture over much of its length and be broken out into two sutures only near the opposite ends of the anchor. Again, such a tendon repair device may be formed of two sutures twisted together over much of their length and separated near the opposite ends with a crimp, such as crimp  956 , at each end of the twisted portion holding the twisted portion together. As in the embodiment of the tendon repair device illustrated in  FIGS. 8A-8B  and  9 A- 9 D, straight needles  1013   a,    1013   b  preferably are employed on at least one end  1001   a  of the device  1001  and curved needles  1014   a,    1014   b  are employed on the other end  1001   b.  As shown, the tendon repair device may be delivered to the surgeon with the sutures and straight needles  1011   a,    1011   b  on end  1001   a  enclosed in a sheath  1011 . The procedures and apparatus for repairing a tendon using this embodiment of the tendon repair device are rather similar to those described previously in connection with the first and second embodiments. Particularly, one or both of the tendon stumps can be retrieved through the pulley system of the finger, as needed, exactly as described in connection with the first embodiment of the invention illustrated in FIGS.  1  and  2 A- 2 L, except that only two sutures are stitched to each tendon stump at one side  1001   b  of the tendon repair device  1001 . 
         [0128]    In this embodiment two of the tendon repair devices  1001 - 1  and  1001 - 2  are used. One side  1001   a  of each tendon repair device  1001 - 1  and  1001 - 2  is stitched to one of the tendon stumps. 
         [0129]      FIG. 10B  helps illustrate how two of these fixation devices  1001  could be used to effect a repair by looping them around each other in accordance with this embodiment of the invention. Generally, one tendon repair device  1001 - 1  would be folded to form a loop  1091  and stitched to the first tendon stump  1087   a  and the other tendon repair device  1001 - 2  would be folded to form another loop  1092  and embedded in the other tendon stump  1087   b  with the loops joined in the middle as described in detail below. 
         [0130]    Specifically, the two sutures  1047   a,    1047   b  and curved needles  1014   a,    1014   b  on one side  1001   b  of first tendon repair device  1001 - 1  would be stitched to the first tendon stump  1087   a  with the other side  1001   a  of the device sticking out of the end of the respective tendon stump, basically as described in connection with previous embodiments. 
         [0131]    Next, with reference to  FIG. 10B , the other side  1001   a  of the first tendon repair device  1001 - 1  is returned back into the tendon same stump through the end of the stump so that the tendon repair device  1001 - 1  forms a loop  1091  sticking out of the end of the tendon stump  1087   a.  This may be performed by individually threading each of the two sutures and straight needles  1014   a,    1014   b  back through the end of the tendon stump  1087   a  and pulling them out through the side of the tendon stump. The suture(s) should be pulled through so that the loop  1091  protrudes from the end of the tendon stump  1087   a  by 1 millimeter or less. Preferably, the sutures are pulled through so that the loop  1091  does not protrude at all, but is essentially in the substance of the tendon stump  1087   a.  Then, the two sutures  1047   a,    1047   b  are stitched to the tendon essentially as described above in connection with the previously described embodiments. At this point, both ends  1001   a,    1001   b  of the tendon repair device  1001 - 1  are stitched to the tendon stump  1087   a  and a loop  1091  is located at the severed end of the tendon stump  1087   a.    
         [0132]    Next, the second tendon repair device  1001 - 2  is attached to the second tendon stump  1087   b  in essentially the same manner as the first tendon repair device  1001 - 1  was attached to the first tendon stump  1001   a,  except that, after the first two needles  1013   a,    1013   b  at the first end of the  1001   a  anchor  1001 - 2  are stitched to the tendon, the other two needles  1014   a,    1014   b  and sutures  1047   a,    1047   b  are guided through the loop  1091  formed by the first tendon repair device  1001 - 1  to form a second loop  1092  before being stitched to the second tendon stump  1087   b.  If the loop  1091  of the first tendon repair device  1001 - 1  is within the substance of the first tendon stump  1087 , the substance of the first tendon stump may need to be retracted with a suitable retractor tool to expose the loop momentarily for the second tendon repair device needles and sutures to be passed through the loop. Alternately, the surgeon may simply pierce the tendon substance with the second tendon repair device  1001 - 2  to access the loop  1091 . Then the two sutures and needles  1014   a,    1014   b  at the second end  1001   b  of the second tendon repair device  1001 - 2  are stitched to the second tendon stump. This embodiment offers another technique for providing a four strand repair between the two tendon stumps. 
       Ninth Set of Exemplary Embodiments 
       [0133]      FIGS. 11A-11E  illustrate alternate embodiments and associated techniques to be used therewith, which techniques can be used in conjunction with some or all of the features and aspects of many of the other embodiments of both the methods and apparatus disclosed herein.  FIG. 11A  is a perspective view of the apparatus in accordance with this alternate embodiment. Particularly, in this embodiment the flanged catheter is replaced with a guidance member in the form of a funnel  1101 . 
         [0134]    In a preferred embodiment, funnel  1101  is formed of a biocompatible material, such as a biocompatible plastic, that is relatively rigid, so that it is not easily collapsible. The funnel  1101  comprises a small opening  1102  at one end and a large opening at the other end  1103 . Funnel  1101  defines a frustoconical surface when in an unbiased condition, but is split along its entire length, whereby it can be radially spread apart at the split  1104  to resiliently deform the funnel to provide a lateral gap at the split  1104  through which a tendon, ligament or the like can be inserted into the funnel. Alternately, the funnel may overlap somewhat at the split as long as it can be spread apart radially to provide a lateral opening. 
         [0135]    The small opening  1102  should be smaller than the entrance to the anatomical passage in connection with which it will be used for introducing a tendon therethrough and the large opening  1103  is larger than the anatomical passage. For instance, in the various embodiments of the invention discussed above in connection with a repair of a finger tendon, the small opening should be sized to help facilitate entry into the pulleys of a finger. The large opening at the other end  1103  of the funnel  1101  should be sufficiently large to readily accept the end of a tendon stump with a tendon repair device stitched thereto. A handle  1197  can be provided extending from the side of the funnel  1101  to facilitate easy manipulation by the surgeon. 
         [0136]      FIGS. 11B-11D  illustrate a surgical technique using the funnel  1101 . With reference to  FIG. 11B , a pulley catheter  103  is positioned through the pulley system of the finger between two incisions  1112 ,  1113 , as previously described, and a tendon repair device  1114 , which could be any of the tendon repair devices previously discussed herein, is attached to the end of the proximal tendon stump  1116 . Furthermore, the leading end  1114   a  of the tendon repair device  1114  is passed into the pulley catheter  101  also essentially as previously described, except without the use of a flanged catheter  103 , the function of which will essentially be replaced by the funnel  1101 , as described in detail below. 
         [0137]    In this embodiment, the leading end  1114   a  of the tendon repair device  1114  is pushed through the pulley catheter  101  to a point where the end of the tendon stump  1116  is close to, but not touching the trailing end  101   b  of the pulley catheter  101 . Next, the pulley catheter  101  and tendon repair device  1114  are pulled distally through the pulley system of the finger from the distal incision  1113  to a point where the trailing end  101   b  of the pulley catheter  101  passes the entrance of the first pulley  1121  that must be traversed, but the tendon stump  1116  is near the entrance to the pulley  1121 , but has not passed it yet. Specifically, as previously noted, the end of the tendon stump  1116  is deformed and enlarged and is unlikely to pass easily through the pulley  1121  without a structure to compress it and guide it in. In the previously discussed embodiments, that structure was the flanged catheter  103 . In this embodiment, it will be the funnel  1101 . 
         [0138]    Thus, with reference to  FIG. 11C , funnel  1101  is spread apart and slipped over the tendon stump  1116  with the small end  1102  of the funnel facing the entrance to the pulley  1121  and the large end  1103  facing away from the entrance to the pulley. More particularly, the surgeon positions the funnel  1101  in the entrance to the pulley  1121  in order to dilate the pulley  1121  and facilitate the tendon&#39;s entering into and passing through the pulley, as shown in  FIG. 11C . Funnels of different sizes may be provided as part of a kit in order to accommodate different sized parts of the anatomy and/or different sized patients and to facilitate dilation of the pulley (or other anatomical feature). 
         [0139]    With the funnel in the position shown in  FIG. 11C , the surgeon can then pull on the leading end  1114   a  of the tendon repair device  1114  to draw the end of the tendon stump  1116  into and through the funnel  1101  and the pulley  1121 . 
         [0140]    It should be apparent that the primary issue addressed by the funnel  1101  (as well as the flanged portion  159  of the flanged catheter  103  disclosed in connection with previous embodiments) is that often, if not always, the end of the tendon stump with the trailing end of the tendon repair device attached thereto bunches up to become larger than the passageway through the pulley and therefore difficult to insert into and through the pulley. The funnel (as well as the flanged portion  159  of the aforedescribed flanged catheter  103 ) contains the end of the tendon stump gradually to facilitate insertion into and passage through the pulley (or other narrow anatomical passage as the case may be). The funnel  1101  of this embodiment also serves to dilate the entrance to the pulley to even further facilitate passage. 
         [0141]    Unlike the embodiment utilizing the flanged catheter  103 , in this embodiment, the funnel  1101  does not pass through the pulleys. It remains in the position shown in  FIG. 11C  just inside the entrance to the pulley, while the tendon stump  1116  slides through the funnel  1101  and through the pulley  1121 . Once the end of the tendon stump  1116  has passed through the pulley  1121 , the funnel  1101  is removed. Particularly, it can be spread apart and slipped off the tendon. Alternately, the funnel can be cut away.  FIG. 11D  shows the repair at this point of the procedure. 
         [0142]    If the tendon stump  1116  must be guided through a second or subsequent pulley, the same process is essentially repeated with respect to the second pulley. For instance, if the tendon must pass through a second pulley, then another incision can be made above that pulley (in the corresponding crease of the finger) and the aforescribed process can be repeated using the same or a different funnel. However, the surgeon should first attempt to pull the tendon through without using the funnel, as, often, the tendon might track through a second or subsequent pulley without the help of the funnel. 
         [0143]    The tendon stump can then be (1) attached to the distal tendon stump directly, (2) attached to another tendon repair device attached to the distal tendon stump, or (3) be attached to a bone anchor, as the case may be, using any one of the aforedescribed tendon repair devices and/or techniques. 
         [0144]      FIG. 11E  illustrates an alternate embodiment of the guidance member. The guidance member  1140  in this embodiment is of a split hollow frustoconical form having a smaller diameter end  1143  and a larger diameter end  1144 , with a portion of the frustoconical surface removed. The lateral opening  1142  defined by the removed portion of the surface should be sufficiently wide to permit easy insertion of the particular tendon, ligament, or other anatomical feature with which it is intended for use, but sufficiently narrow so as not to permit the tendon to slip out of the member  1140  accidentally. Thus, preferably, the opening is no more than 50% of the conical surface. The opening, for instance, may be about 5%-35% of the conical surface with ⅓ being preferred. In this embodiment, since the guidance member  1140  need not deform to permit the tendon to be inserted therein, it preferably is substantially rigid and not deformable under normal loads. It may be formed of a biocompatible metal, such as stainless steel or titanium. Again, a handle  1198  may be provided to facilitate handling of the guidance member  1140  by the surgeon. 
         [0145]    The guidance member  1140  of this embodiment is used essentially exactly as was described above in connection with the funnel  1101  of the preceding embodiment, except that the member  1140  is not be spread apart in order to insert the tendon therein. Rather, the tendon can simply be laid inside the member  1201  through the lateral opening  1142 . As in the previous embodiment, a handle  1198  may be provided to facilitate manipulation by the surgeon. 
         [0146]    This embodiment is advantageous in that it is easier to insert a tendon in the member. Furthermore, the guidance member is rigid and, therefore, provides more efficient dilation of the anatomy. 
         [0147]      FIG. 11F  illustrates yet another alternate embodiment of the guidance member. Like the embodiment of  FIG. 11A , the guidance member  1150  in this embodiment is a funnel  1151  with a small opening  1152  and a large opening  1153 . It is split along its entire length, whereby it can be radially spread apart at the split  1154  to resiliently deform the funnel to provide a lateral gap at the split  1154  through which a tendon, ligament or the like can be inserted into the funnel. 
         [0148]    A lip  1156  is provided at the large end to prevent the funnel from being inadvertently pulled through a pulley. A small handle  1157  provides a place for the surgeon to grasp the guidance member  1150 . The use of a small handle or merely a lip with no handle at all per se facilitates the ease with which a surgeon may spin the guidance member about its longitudinal axis. Specifically, spinning is sometimes helpful in introducing the small end  1152  of the guidance member into the pulley. A longer handle might interfere with the ability to freely spin the guidance member because a longer handle is more likely to hit an obstruction, such as another part of the patient&#39;s hand or another surgical instrument. 
         [0149]    In still other embodiments, the guidance member could be formed as a split cone with overlap at the split so as to have a spiral-like shape. The overlap should be relatively small, such as on the order of between about 5° and 90° of radial overlap, and preferably about 70° of radial overlap when unstrained. Particularly, too much radial overlap might make it difficult to spread the guidance member apart sufficiently to open the gap through which the tendon must pass. 
         [0150]    Embodiments with overlapping at the split have several advantages. First, the overlap would make it essentially impossible for the tendon to accidentally slip out of the gap in the guidance member once the expansion pressure to open the gap is removed. Second, the overlap will permit some adjustability to the radial size of the guidance member. That is, by applying inward radial force on the outer wall of the guide member, the radius of the guide member can be decreased temporarily to help fit the small opening of the guidance member into a pulley should that be necessary. Conversely, the radius of the guidance member may be temporarily increased should that be necessary to allow a tendon to pass through the opening at the small end of the guidance member, but without opening the gap in the side wall, which might allow the tendon stump to inadvertently escape from the guidance member through the gap). More specifically, if the tendon stump being guided through the pulley system by the guidance member is smaller than the opening at the small end of the guidance member, the pulling force on the tendon repair device and tendon stump will simultaneously also apply a radially outward force on the inner wall of the guidance member. That outward radial force will force the guidance member to radially expand, which will cause the opening at the smaller end to increase in diameter and allow the tendon stump to pass through. 
       Tenth Set of Exemplary Embodiments 
       [0151]    While the invention has been described above in connection with attaching two tendon stumps and/or one tendon stump directly to bone, it should be understood by those of skill in the related arts that it can also be employed in connection with repairs that use a tendon graft. In such situations, one end of the tendon graft is attached to one tendon stump and the other end of the tendon graft is attached to either another tendon stump or directly to bone using the above-described apparatus and techniques. The tendon graft may be taken from another part of the patient&#39;s body, such as the patient&#39;s foot, or may be an allograft. 
         [0152]    In accordance with another aspect of the invention, a thin walled tube that functions as an adhesion barrier may be placed over the tendon at the repair site in order to facilitate the free gliding of the tendon through the pulley system of the finger. More particularly, as an injured tendon, ligament, or other longitudinal anatomical member heals, scar tissue forms around the repair site. During the healing process, the scar tissue can interfere with the free movement of the tendon through the pulley system. Additional surgery may also be needed to remove such scar tissue. 
         [0153]    In order to facilitate the free movement of the tendon through the pulley system, the repair site(s) may be encased in an adhesion barrier in the form of a thin walled tube. The adhesion barrier may comprise a thin walled tube  1201  such as illustrated in  FIG. 12A .  FIG. 12B  illustrates one particular embodiment of the adhesion barrier being used in connection with a tendon repair in which two tendon stumps are being reattached without an intervening graft. As shown, the tube  1201  may be slipped over the end of one of the severed tendon stumps  1203   a  prior to the repair being performed and slid out of the way during the repair process. Then, referring to  FIG. 12C , after the repair is completed, the tube  1201  may be slid along the repaired tendon to the repair site  1204  (including the stitches, the tendon repair device, and both tendon stumps  1203   a,    1203   b ). Preferably, the tube  1201  is stitched to the tendon at this point with at least one stitch  1221  and, preferably, with each at least one stitch  1221  at each end of the tube. 
         [0154]    The tube will provide a barrier to allow healing to take place along the length of the tendon (inside the tube) rather than outwardly where such scar tissue might interfere with the free movement of the tendon through the pulley system. The tube may also provide guidance for growth on the outside of the tube diameter to bolster the structure that will ultimately provide the passageway for the repaired tissue inside the tube. The external and internal surfaces of the tube should be lubricious and have a low friction coefficient so that it (with the tendon inside of it) can slide freely through the pulley system and allow the tube to be removed after healing has occurred. 
         [0155]    The wall thickness of the tube should be as thin as possible so as to add minimal bulk to the tissues being repaired. In the case of flexor tendon repair, wall thicknesses of less than 0.25 mm are contemplated. However, the best wall thickness of the tube depends upon the surgical application of the repair and should proportionally thin compared to the tissue being repaired. The length and diameter of the tube will, of course, be dictated primarily by the particular repair. Furthermore, the tube should be formed of a bio-inert material, such as a material chosen from the family of fluoropolymers of Teflon™, PET, PTFE, and EPTFE or the family of silicone polymers. Preferably, the tube is porous so as to allow fluid exchange therethrough in order to keep the tendon healthy. It may have holes or other openings to facilitate such fluid transfer. Preferably, the holes are small enough so as not to permit tissue ingrowth therethrough. It may also be coated with a lubricant to facilitate sliding through the pulley system (or any other anatomical restrictions). Passive motion of the finger during the healing period of the tendon will also prevent any scar tissue adherence of the tendon to the surrounding tissues through the holes in the tube. 
         [0156]    The tube should be long enough to completely cover the repair site. In the case of a repair utilizing a graft, depending on the length of the graft, accessibility and other factors, a single longer tube may be used to cover both ends of the graft or two separate, smaller tubes may be used. 
         [0157]    The tube will remain in place for the duration of the healing process, from several weeks to several months. At the end of the process, it may be removed by making one or more small incisions in the patient near one end of the tube and then carefully pulling the tube out of the incision as the surgeon cuts the tube. In alternate embodiments, the tube may be formed of a bioabsorbable material that will simply dissolve over time, provided that the bioabsorbable material does not promote adhesions or a local tissue response as it absorbs. An example of a bioabsorbable material would be a crosslinked Hyaluronic Acid or other bioinert polymer. In yet another embodiment, the adhesion barrier may be provided with a longitudinal slit over its entire length so that no cutting would be necessary when it is removed, but rather, it would simply need to be spread apart to be removed from the tendon. Such an embodiment would also facilitate the option of installing the adhesion barrier over the repair site by spreading it apart and slipping it over the tendon after the repair is completed, thereby eliminating the need to slide it longitudinally over the end of a tendon stump before the repair and then sliding it over the repair site after the repair is completed. This may be advantageous where the repair site is long and/or there is insufficient available length of the tendon stump to slide the adhesion barrier out of the way during the repair procedure. 
       Eleventh Set of Exemplary Embodiments 
       [0158]      FIGS. 13A-13C , and  14 A- 14 C illustrate further alternate embodiments and associated techniques to be used therewith, which techniques can be used in conjunction with some or all of the features and aspects of many of the other embodiments of both the methods and apparatus disclosed herein.  FIG. 13A  is a perspective view of one embodiment of a unitary dilation catheter in accordance with this set of embodiments.  FIG. 13B  is a perspective view of one embodiment of a multi-piece dilation catheter in accordance with this set of embodiments. The dilation catheter is designed to fit through and dilate the passage or passages (e.g., pulleys) through which the longitudinal anatomical member (e.g., tendon) must be pulled. As will be described in detail below, it will essentially be used like and serve the same functions as the pulley catheter  101  of the first set of embodiments described in connection with FIGS.  1  and  2 A- 2 L above. However it also will serve to dilate the passage.  FIG. 13C  is a perspective view of a guide member that may be used in conjunction with the dilation catheter to dilate the passage. Particularly, as will be described in detail below, it may serve essentially as a guidewire for inserting the dilation catheter through the pulley system. However, it is believed that the guide member will be unnecessary in the majority of applications. 
         [0159]    The dilation catheter  1301  comprises an elongated tube having a lumen therein. The tube comprises a series of consecutive stepped diameter longitudinal segments  1302 ,  1303 ,  1304 ,  1305 , each consecutive segment larger than the previous. The use of four steps in the illustrated embodiment is merely exemplary. Any number of steps is possible. The outer diameters and number of different diameter segments should be determined as a function of the size of the anatomical passage or opening through which the dilation catheter  1301  will pass. We will continue to use the example of a severed tendon in the hand in the following discussion. The smallest diameter segment should be smaller than the diameter of the pulley system of the smallest hand size reasonable through which it must pass so that the smallest diameter segment can pass through any pulley system relatively easily. Each larger diameter segment should be designed to gently and in a gradual, stepped manner dilate the pulley system to a larger size in preparation for passing the tendon stump therethrough. The last, largest diameter segment of the dilation catheter should be at least as large as the largest diameter to which one would reasonably dilate the pulley system of the largest reasonable hand size. 
         [0160]    As will be seen from the discussion below, according to one exemplary technique, any segment having a diameter that is larger than needs to be passed through the pulley system of the particular patient simply will not be passed through the pulley. Therefore, the largest diameter segment of the dilation catheter can be virtually any diameter. In one embodiment adapted for use in passing tendons through the pulleys of the fingers, the various segments of the dilation catheter range from a smallest diameter of about 10 French to a largest diameter of about 18 French. In one embodiment, this is accomplished with nine segments of 10 F, 11 F, 12 F, 13 F, 14 F, 15 F, 16 F, 17 F, and 18 F diameters. Each segment may be about 10 cm in length. 
         [0161]    In one embodiment such as illustrated in  FIG. 13A , the dilation catheter  1301  can be unitary. If, prior to or during the surgical procedure, the surgeon determines that any of the smaller diameter segments are clearly smaller than will be needed and/or any of the larger diameter segments are larger than will be needed, the surgeon may simply cut them off prior to use or during the procedure. Hence a single dilation catheter can be offered that can be used in a large number of different anatomical passages and with a large number of different sized patients, thus reducing the number of different versions of the dilation catheter that need to be manufactured. 
         [0162]    In another embodiment of the dilation catheter  1310  such as illustrated in  FIG. 13B , each diameter segment  1311 ,  1312 ,  1314 , et seq. may be separable from each other. For instance, in one simple embodiment, each catheter segment may have a neck portion  1315  near its proximal longitudinal end sized to mate in an interference fit with the distal end of the next smaller diameter segment. Preferably, the necked down portion is sized to fit within the distal end of the next smaller segment so that the edges of the longitudinal ends of the various segments will not be exposed on the outside of the dilation catheter  1310 . 
         [0163]    Like the pulley catheter  101 , the dilation catheter preferably is formed of a biocompatible, low friction material having a wall thickness sufficient to make the entire catheter sufficiently stiff to be pushed through the pulley system and to serve the purpose of dilating (holding open) the pulleys against their natural size, yet soft and resilient enough to track through curves in the anatomical passage through which it must pass. It might, for instance, have the approximate flexibility of a typical surgical vascular catheter. The inner diameter of all of the segments should be large enough to easily accommodate the tendon repair device that will be used with the dilation catheter. 
         [0164]    In yet other embodiments, the dilation catheter need not have discrete segments of different diameter, but may be continuously tapered over its entire length. As in the segmented embodiments, any portion or portions of the catheter clearly not necessary for the surgery may be cut off before insertion and any portion not necessary after insertion may be curt off after the dilation catheter is in place in the anatomical passage. 
         [0165]      FIG. 13C  illustrates an optional guide member  1320 . As shown, the guide member comprises an elongate member having an outer diameter smaller that the inner diameter of lumen in the smallest diameter segment of the dilation catheter so that the dilation catheter may pass over the guide member easily. In other words, the entirety of the lumen of the dilation catheter is of sufficient size and shape to accept the guide member  1320  therethrough. The guide member  1320  may be cannulated. Alternately, it may be solid (e.g., essentially a guidewire). The guide member should be relatively stiff so that it can be pushed through the pulley system without kinking, yet sufficiently flexible to track through curves in the anatomical passages through which it will be passed in accordance with the techniques disclosed herein. The outer diameter of the guide member should be substantially smaller than the anatomical passage through which it must pass. 
         [0166]    In most practical embodiments, the guide member and dilation catheter will both be cylindrical. However, a cylindrical cross-section is not necessary, and, depending on the particular anatomical passage through which the guide member and dilation catheter will be passed, other shaped cross-sections may be preferable. The term diameter is used in this application in a non-limiting manner and not to imply that the cross-section necessarily is cylindrical. 
         [0167]    Preferably, each of the segments of different diameter of the dilation catheter is long enough to individually traverse the entire length of the anatomical passage through which it will be passed and stick out sufficiently at each end thereof to provide easy access thereto to the surgeon. Particularly, as will be discussed in detail further below, after the dilation catheter is placed through the relevant anatomical passage, all segments other than the largest segment that fit through the passage can be cut off or removed. For a human hand, 10 cm should be sufficient. 
         [0168]    The dilation catheter (and optional guide member) is used to dilate the pulley system so as to best assure that the tendon stump will be able to pass through the pulley system without binding. Both the guide member and the dilation catheter are hollow tubes formed of a biocompatible polymer of such composition and/or wall thickness so that it is bendable, but sufficiently rigid to be pushed through a pulley system. The relative rigidity of the dilation catheter and guide member will permit it to be pushed through narrow anatomical passages, such as the pulleys of the fingers. However, its flexibility will permit some bending to accommodate an overall curved path. Preferably, the dilation catheter is formed of a material having a low friction coefficient to allow the dilation catheter to readily pass through and around bodily tissues such as the tendon pulley system. Suitable biocompatible polymers include homopolymers, copolymers and blends of silicone, polyurethane, polyethylene, polypropylene, polyamide, polyaryl, flouropolymer, or any other biocompatible polymer system that meets the mechanical characteristics above (PELLETHANE™ a DOW thermoplastic polyurethane elastomers (TPU), which is commonly use in other dilating catheters is targeted for this device.) 
         [0169]    The required low coefficient of friction of the surfaces of the dilation catheter may be inherent to the materials used to construct the device or may be enhanced through a surface preparation such as a lubricious coating or mechanical modification of the surface such as longitudinal recesses. 
         [0170]    The particular length, material, wall thickness, inner diameter, outer diameter, and stiffness of the dilation catheter will vary depending on the particular tendon or ligament with which is it to be used. 
         [0171]    The inner diameter should be large enough to easily accommodate the cable portion and straight needle of the tendon repair device. The particular material and cross sectional geometry (e.g., wall thickness) of the dilation catheter will largely dictate the stiffness of the catheter and, as noted above, should be selected to provide enough rigidity to allow it to be pushed through a narrow path, but flexible enough to bend to accommodate bends in the path. In the exemplary case of the flexor digitorum profundus at the level of the middle phalanx, the pulley catheter may be formed of silicone and be 120 millimeters in length with a wall thickness of 0.5 mm, and an outer diameter of 2 mm. A biocompatible elastomer having a durometer of 50-90 (Shore A) may be used for the dilation catheter. 
         [0172]    Similarly to the pulley catheter  101  of  FIG. 1 , the dilation catheter, with or without the guide member, can be used in connection with a tendon or other repair using virtually any of the tendon repair devices and related accoutrement described herein and in conjunction with virtually any of the surgical techniques described herein. 
         [0173]      FIGS. 14A-14G  illustrate various stages in an exemplary surgical procedure to reattach a severed tendon. If the tendon stump has retracted and must be retrieved from a first incision into a second incision (or the wound), as is typical of tendon lacerations in the hand, first, an incision  1361  is made, typically in the palm of the hand, as illustrated, where the proximal tendon stump  1370  can be retrieved. If, on the other hand, the proximal tendon stump is distal to the A2 pulley, then the tendon would be exposed through an incision just distal to the A2 pulley. Referring first to  FIG. 14A , if a guide member is used, the guide member  1320  is passed into the wound or incision  1360  at the laceration site and slowly pushed proximally toward the other incision  1361  beneath the A3 pulley through the pulley system of the finger. If resistance is encountered such that the pulley catheter cannot be pushed through proximally, then a ½ cm to 1 cm incision (not shown) may be made midway between the skin creases of the proximal interphalangeal joint of the finger and the crease at the base of the finger. This is at a level between the A2 pulley and the A3 pulley of the finger. The dissection is carried down gently to the flexor sheath where the pulley will be found. The dilation catheter  1301  can then be pulled past the obstruction or resistance through this incision. The guide member  1320 , if used, should be long enough to pass entirely through the pulley system and stick out at both ends. If the guide member is substantially longer than the desired length, it may be cut to a suitable length either before it is inserted or after. 
         [0174]    With reference to  FIG. 14B , once the guide member  1320  is in place, the dilation catheter  1301  (or  1310 ) is slipped through the pulley system over the guide member  1320  working from distal to proximal. Particularly, the smallest diameter portion  1302  is slipped over the guide member  1320  and pushed over the guide member through the pulley system until it exits the other incision. In embodiments omitting the guide member  1320 , the smallest diameter segment of the dilation catheter  1301  is simply inserted through the pulley system just as described above for the guide member. 
         [0175]    In either event, the smallest diameter segment of the dilation catheter is slid back-and-forth about 10 mm to enlarge the annular rings. Then the next larger catheter segment is pulled through and slid similarly. This continues for each longitudinal segment of the dilation catheter until the surgeon determines that the annular rings in the pulley system are enlarged enough to accept passage of the tendon stump. Generally, this will be at about the 14, 16, or 18 French diameters for most hands. This largest fitting catheter size is centered between the two surgical wounds  1360 ,  1361 . In this example, segment  1304  is the largest segment passed through the pulley system. 
         [0176]    With reference to  FIG. 14C , once the dilation catheter  1301  is in place, the guide member, if used,  1320  may be removed. 
         [0177]    With reference to  FIG. 14D , at this point, all of the segments of the dilation catheter other than the one traversing the pulley system can be removed. As previously mentioned, if the dilation catheter is unitary, then the other diameter segments of the dilation catheter can be cut off. On the other hand, if the dilation catheter comprises multiple separable segments, then the other segments can simply be pulled off. In addition, the surgeon also may cut off part of the remaining segment if it is longer than needed. 
         [0178]    At this point, the surgical procedure to reattach the tendon stump can be performed essentially as described in accordance with any of the embodiments discussed previously in this specification, with the tendon repair device and tendon stumps being passed through the dilation catheter rather than the pulley catheter. 
         [0179]    Thus, for example, with reference to  FIG. 14E , a flexible barrier  1376  is placed under the tendon holder to create a working ‘table’ for suture repair and a tendon holder may be used to pierce the tendon stump to hold the tendon stump for stitching. Next, a tendon repair device, which could be any of the tendon repair devices previously discussed herein, is attached to the end of the tendon stump  1370 .  FIGS. 14A-14G , illustrate an embodiment in which a single suture  1401  with a needle  1402 ,  1403  at each end thereof is used to perform the repair. In this embodiment, one needle may be curved and the other straight or both needles may be straight. In fact, a repair could be performed with a needle on only one end of the suture; however, having a needle at each end is advantageous and will allow the stitching to be performed much faster since the surgeon can stitch from both ends of the suture. In any event, the suture is stitched to the proximal tendon stump using the needle(s). A modified cruciate stitching technique, as will be discussed in more detail below in connection with  FIG. 15 , provides a particularly advantageous stitch because it is a locking stitch. 
         [0180]    Once the tendon repair device  1350  is securely fixed to the proximal tendon stump  1370 , the tendon stump is removed from the tendon holder, if used. Next, the loose end(s)  1350   a,    1350   b  of the suture  1350  are passed all the way through and out of the other end of the dilation catheter  1301  (essentially as previously described in connection with the pulley catheter  101 ). Stainless steel sutures typically have sufficient rigidity to permit them to be pushed through the dilation catheter segment. In fact, multifilament stainless steel sutures such as described above in connection with previous embodiments of the suture repair device are particularly suitable because they are strong, exhibit little, if any, shape memory, and hold knots quite well. One exemplary suture is the multifilament stainless steel 4-0 (MFSS) suture available from Fort Wayne Metals of Fort Wayne, Ind., USA. The MFSS comprises 49 wound filaments of 0.023″ diameter 316L stainless steel wire. There are seven sets of seven wires wound with each other, each set comprising seven wires wound with each other. 
         [0181]    Whichever type of suture is used, it may be desirable to lodge at least the tips of the needles on the ends of the suture in a small diameter rod that is smaller than the inner diameter of the dilation catheter before passing them through the dilation catheter  1301 . This will help prevent the needles from sticking into the side of the lumen of the dilation catheter  1301  and getting stuck. In one embodiment, the rod may be a small, double lumen tube, and each needle  1351 ,  1352  may be inserted into one of the lumens. The lumens may be sized so that the needles  1351 ,  1352  fit within the respective lumens in a friction fit. Alternately, the rod may be solid (i.e., not a hollow tube with a lumen) and made of a material soft enough to be punctured by the needles so that the needles could be pushed into the end of the rod, like a pin cushion.  FIG. 14E  illustrates yet another embodiment, in which a tube  1368  has a single lumen sized to accept both needles  1351 ,  1352  together in a friction fit. The tube  1368  need be only long enough to accept the tips of the needles and provide a sufficient length over the needles to form a reasonable friction fit so that the tube does not fall of the needles. 
         [0182]    In other embodiments, if one of the needles is a curved needle, the needle can be cut off after stitching and the bare suture end can be inserted into the tube  1368  along with the needle at the other end of the suture. In yet even further embodiments, only one end of the suture may be passed through the dilation catheter  1301 . Thus, the other end of the suture may have a curved needle that is simply cut off after stitching or no needle at all. 
         [0183]    In any event,  FIG. 14F  illustrates yet another possible embodiment. In this embodiment, the tube  1368  of  FIG. 14E  is replaced with a much longer tube or rod  1380 . Tube or rod  1380  is long enough to be passed through the dilation catheter in the distal to proximal direction and extend from both ends of the dilation catheter. After the suture  1350  (or other tendon repair device) has been stitched to the tendon stub  1370 , the needle(s)  1351 ,  1352  can be inserted into the proximally facing end  1380   a  of the tube  1380  and the surgeon can grasp the distally facing end  1380   b  of the tube or rod that is protruding from the distal end of the dilation catheter  1301  and pull the suture(s)/tendon repair device  1350  through the dilation catheter, rather than pushing it through. This embodiment is advantageous in that it allows other types of suture(s), such as nylon sutures, that may not have sufficient stiffness to be pushed through the dilation catheter, to be used in the repair. Alternately, a short tube, rod, block or anything to which the needles can be temporarily affixed (e.g., by sticking, adhesive, tape etc.) may be attached to the end of any longitudinal member (e.g., another suture, a narrow surgical instrument) that is thin enough to fit within the dilation catheter in order to pull the sutures through the dilation catheter. 
         [0184]    In any event, after the tendon repair device/suture  1350  is through the dilation catheter and extending from its distal end  1301   a,  if the stitched end of the tendon stump  1370  is sufficiently small to pass into the dilation catheter itself, it can be pulled just into the proximal end  1301   b  of the dilation catheter  1301  and then the dilation catheter  1301 , tendon repair device/suture(s)  1350 , and tendon stump  1370  can be pulled through the pulley system as a unit as previously described in connection with the pulley catheter  101  of  FIG. 1 . 
         [0185]    However, with reference now to  FIG. 14G , most likely the tendon stump  1370 , because of its deformation and excess bulk due to the stitching, will not readily fit within the dilation catheter  1301 . In such cases, the leading end of the tendon repair device  1350  is pushed or pulled through the dilation catheter  1301  to a point where the end of the tendon stump  1370  is close to, but not touching the trailing end  1301   b  of the dilation catheter  1301 , as seen in  FIG. 14G . 
         [0186]    Next, the dilation catheter  1301 , tendon repair device  1350 , and tendon stump  1370  are pulled as a unit through the pulley system to a point where the trailing end  1301   b  of the dilation catheter  1301  has passes the entrance of the first pulley  1321  that must be traversed with the end tendon stump  1370  is near the entrance to the pulley  1321 , as shown in  FIG. 14G . This may require the making of an additional incision  1333  adjacent an end of the pulley if the existing incisions are not already adjacent the pulley entrance. In fact, as will become clear, such an additional incision may be necessary for each separate pulley that must be traversed. A funnel, such as  1140  of  FIG. 11E , is slipped over the tendon stump  1370  with the small end  1143  of the funnel positioned slightly inside of the entrance to the pulley  1121  and the large end  1144  facing away from the entrance to the pulley. 
         [0187]    With the funnel  1140  in the position shown in  FIG. 14G , the surgeon can then pull on the leading end of the tendon repair device  1350  and dilation catheter  1301  to draw the end of the tendon stump  1370  into and through the funnel  1140  and the pulley  1321 . 
         [0188]    The funnel  1140  contains the end of the tendon stump  1370  gradually to facilitate insertion into and passage through the pulley  1321 . The tendon stump  1370  slides through the funnel  1140  and through the pulley  1321 . Once the end of the tendon stump  1370  has passed through the pulley  1321 , the funnel  1140  is removed, as seen in  FIG. 14G . 
         [0189]    The dilation catheter  1301  may be provided with mm markers on its surface to assist in determining exactly where a hidden blockage is positioned (and a new incision must be made) when pulling the tendon through the pulley system with the dilation catheter. Particularly, the specific mm mark at the skin in the incision is noted prior to pulling the tendon through the finger. If a resistance is encountered, then the mm marking at the same location of the skin is noted. The exact site of the blockage is calculated by determining the difference between the two observed markings and measuring the equivalent distance on the skin surface of the patient. 
         [0190]    If the tendon stump  1370  must be guided through a second or subsequent pulley, the same process using the funnel  1140  is repeated with respect to the second or subsequent pulley. 
         [0191]    If there is a distal tendon stump that has retracted and must be passed through a different portion of the pulley system in the opposite direction, then that can be done using the techniques and apparatus just described, but working in the opposite direction. 
         [0192]    The tendon stump  1370  can then be (1) attached to the other, mating tendon stump directly, (2) attached to another tendon repair device attached to the other, mating tendon stump, or (3) be attached to a bone anchor, as the case may be, using any one of the aforedescribed techniques. Particularly, the two tendon stumps are brought together in an abutting condition and the needle(s) and suture(s) extending from the proximal tendon stump are stitched to the distal tendon stump. A tendon holder may be used to help bring or hold the tendon stumps together by adjusting the positions of the needles of the tendon holder toward the center so that they are very close to each other and piercing each tendon stump with one of the needle pairs. The needle(s) and suture(s), if any, previously attached to and extending from the distal tendon stump can also be stitched to the proximal tendon stump to double the strength of the repair. Again, a modified cruciate stitch may be used. 
         [0193]      FIG. 15  illustrates the aforementioned modified cruciate repair stitch as used in the exemplary repair procedure of  FIGS. 14A-14G . The numbers  1 - 14  in  FIG. 15  provided alongside some of the linear segments of the sutures and near the knots help indicate the chronological order of the stitching steps. The dashed lines indicate that the suture is within the substance of the tendon and the solid lines indicate that the suture is on the surface of the tendon. 
         [0194]    Chronologically, (1) the first suture  1350  is stitched to the proximal tendon stump  1370  using a modified cruciate stitch as shown (steps 1-3), (2) a second suture  1380  is stitched to the distal tendon stump  1390  also using a modified cruciate stitch as shown (steps 4-6), (3) after the two tendon stumps are brought together (a tendon holder may be used to help bring or hold the tendon stumps together by adjusting the positions of the needles of the tendon holder toward the center so that they are very close to each other and piercing each tendon stump with one of the needles or needle sets), the first suture is then stitched to the distal tendon stump using another modified cruciate stitch (steps 7-9), (4) the two ends of the first suture are tied together with a knot (steps 10), (5) the second suture is stitched to the proximal tendon stump with another modified cruciate stitch (steps 11-13), and (6) the two ends of the second suture are tied together with a knot (steps 14). Finally, although not shown in  FIG. 15  in order not to obfuscate the illustration of the modified cruciate stitches, one or more epitendonous stitches (using 6-0 Ethibond™) may be applied circumferentially at the repair junction. 
         [0195]      FIG. 16  is a perspective view of another embodiment of a tendon holder. In this embodiment, the tendon holder  807  still comprises a handle  801 , and a cross bar  803  at the distal end of the handle  801 . In this embodiment, the cross bar holds a turnbuckle  812  (essentially a screw with oppositely directed threads on each half  812   a,    812   b  of its length) between two rotatable mounting points  813 ,  814  on arms  816   a,    816   b.  A knob is attached to at least one end of the turnbuckle to permit the surgeon to rotate the turnbuckle. A needle holder block  815  is threadedly mounted on each half  812   a,    812   b.  Thus, when the turnbuckle  812  is rotated in one direction, the two needle holder blocks  815  approximate each other (i.e., they move medially toward each other on the turnbuckle  812 . When the turnbuckle  812  is rotated in the other direction, the two needle holder blocks  815  move laterally away from each other on the cross bar  803 . An unthreaded larger diameter cylindrical portion  821  of the turnbuckle  812  exactly in the middle of the turnbuckle may be provided to prevent the two needle holder blocks  815  from hitting each other. A support block  822  may hold the unthreaded cylindrical portion  821  rotatably therein to provide support for the turnbuckle  812  intermediate its two ends. 
         [0196]    Each needle block can hold a number of different needles in different configurations. Particularly, each needle block  815  includes a transverse threaded hole  825  for accepting a needle holder  823 . The needle holder  823  comprises a screw shank  826  with mating threads to the transverse threaded holes and a head  827  at its proximal end for manually rotating the screw  826  into the transverse hole  825  of the needle block  815 . One or more needles  828  extend from the distal end of the screw  826  for holding tendons. Different needle holders with different numbers and configurations of needles can be provided for addressing different surgical conditions. 
         [0197]    Each needle block  815  further comprises one or more additional holes  818  through which needles or K-wires may be inserted. The various holes  818  may be oriented at different angles in order to provide a plurality of choices as to the angle(s) at which the needle(s) or K-wire(s) extend from the block. Particularly, when the apparatus and techniques of the present invention are used to reattach a tendon or ligament that has avulsed from the bone, rather than been lacerated, one of the blocks can be used to attach the tendon holder to the bone, rather than one of the tendon stumps. Then, the tendon holder can be to approximate the tendon stump to the bone. For instance, one or more a K-wire may be passed through one or more of holes  818  of one of the blocks  816  and stuck into the bone to which the avulsed tendon stump is to be reattached (such as by any of the techniques described above in connection with  FIGS. 4A-4D ). The needle(s) of the other block  816  are stuck into the tendon stump and the turnbuckle is turned to approximate the tendon stump to the bone. 
         [0198]    In use, the turnbuckle can be turned to position the needles with a desired spacing relative to each other before piercing the tendon stump(s) with the needles. Alternately, two tendon stumps that are to be rejoined can be pierced with one of the needles (or plurality of needles) and then the turnbuckle can be turned to draw the needle blocks medially toward each other to bring the stumps into abutting contact. 
         [0199]    A stabilizer bar  831  may be provided for use with the tendon holder, into which the tips of the needles  828  can be stuck both before and during surgery. The stabilizer bar  831  may be a cylinder formed of a relatively soft cylinder of material  832  that the needles can penetrate relatively easily that is partially wrapped in a second annulus of harder material  833  with a gap  834  through which the soft inner material  832  is accessible for sticking the needles into it. The harder outer material  833  is much more difficult to penetrate with the needles, and thus will prevent the needles from poking all the way through the stabilizer bar  831  and becoming exposed again. Alternately, the stabilizer bar may be formed unitarily of materials with two different hardnesses, such as by a dual extrusion process. 
         [0200]    Both before and during surgery, the stabilizer bar  831  can serve several functions. First, it protects the needle tips, preventing the surgical personnel from inadvertently sticking themselves or anything else with the needles. Second, it braces the needles, creating a rectangular structure that helps prevent the needles from inadvertently being bent out of shape. Finally, during surgery, it can prevent the tendon stumps from becoming inadvertently disengaged from the needles. 
       Conclusion 
       [0201]    Preliminary testing has shown failure strengths of tendon reattachments performed in accordance with the principles of the present invention of approximately 70-100 Newtons. Accordingly, a tendon and ligament repair in accordance with the principles of the present invention results in a much stronger result that the current standard of care. 
         [0202]    In addition, the procedure is greatly simplified as compared to the present standard of care. 
         [0203]    The present invention provides a safe, simple, easy, and strong repair for tendons, ligaments, and the like. In preliminary tests, failure strengths of up to 100 N have been observed. 
         [0204]    It should be understood that the numbers of sutures/cables and needles forming the various parts of the tendon repair devices described in association with the various embodiments herein are merely exemplary and that fewer or more sutures/cables (and needles) may be provided depending on the desired strength of the repair, the particular tissue that is being repaired, the strength of the material from which the tendon repair device is manufactured, and other factors. 
         [0205]    Even though description of the utility of the various embodiments was limited to the flexor tendons of the hand, it must be understood that many soft tissue repairs can be carried out by use of the device as described, either in part of in full. Examples of such anatomical structures include the tendons and ligaments of the body as well as any other structure require fixation in multiple points, subsequently attached to soft tissue or to bone. 
         [0206]    Having thus described particular embodiments of the invention, various alterations, modifications, and improvements will readily occur to those skilled in the art. Such alterations, modifications, and improvements as are made obvious by this disclosure are intended to be part of this description though not expressly stated herein, and are intended to be within the spirit and scope of the invention. Accordingly, the foregoing description is by way of example only, and not limiting. The invention is limited only as defined in the following claims and equivalents thereto.