U.S. patent number 3,805,300 [Application Number 05/275,932] was granted by the patent office on 1974-04-23 for tendon prosthesis.
This patent grant is currently assigned to Cutter Laboratories, Inc.. Invention is credited to James R. Doyle, James A. Stubstad, Manuel Tascon-Alonso.
United States Patent |
3,805,300 |
Tascon-Alonso , et
al. |
April 23, 1974 |
**Please see images for:
( Certificate of Correction ) ** |
TENDON PROSTHESIS
Abstract
A tendon prosthesis for repair or replacement of a damaged or
diseased natural tendon which comprises an elongated member made of
biocompatible material having a central portion and two end
sections at least one of which has a plurality of longitudinally
arranged fenestrations for interweaving with a resected tendon to
provide a strong, functional anastomosis. In one embodiment, the
second end section of the prosthesis is formed of a pair of
flexible cord-like members adapted to anchor the prosthesis to bone
structure. In a second embodiment, both end sections include
fenestrations allowing each end section to be secured to interwoven
segments of a resected tendon.
Inventors: |
Tascon-Alonso; Manuel (Oakland,
CA), Stubstad; James A. (Lafayette, CA), Doyle; James
R. (Woodside, CA) |
Assignee: |
Cutter Laboratories, Inc.
(Berkeley, CA)
|
Family
ID: |
23054417 |
Appl.
No.: |
05/275,932 |
Filed: |
July 28, 1972 |
Current U.S.
Class: |
623/13.14;
128/DIG.14; 128/DIG.21 |
Current CPC
Class: |
A61F
2/08 (20130101); Y10S 128/21 (20130101); Y10S
128/14 (20130101) |
Current International
Class: |
A61F
2/08 (20060101); A61f 001/24 () |
Field of
Search: |
;3/1
;128/334R,DIG.14,DIG.21 |
References Cited
[Referenced By]
U.S. Patent Documents
Primary Examiner: Gaudet; Richard A.
Assistant Examiner: Frinks; Ronald L.
Attorney, Agent or Firm: Gardiner, Sixbey, Bradford &
Carlson
Claims
We claim:
1. A tendon prosthesis for repair of a resected tendon within a
living organism wherein the tendon is characterized by an elongated
segment having a free end, comprising
a. an elongated central portion formed of flexible, biocompatible
material;
b. a first end portion connected with one end of said elongated
central portion, said first end portion including first connective
means for securing said first end portion within the living
organism; and
c. a second end portion connected with the other end of said
elongated central portion, said second end portion including second
connective means for connecting the second end portion with the
resected tendon by permitting the elongated segment of the resected
tendon to be interwoven through said second end portion, said
second connective means including a plurality of longitudinally
spaced fenestrations formed in said second end portion, each said
fenestration passing completely through said second end portion
from one side to the other, each said fenestration further being of
sufficient size to permit the elongated segment of the resected
tendon to pass therethrough, whereby the free end of the elongated
segment may be interwoven with said second connective means by
being passed back and forth through said longitudinally spaced
fenestrations of said second end portion.
2. A tendon prosthesis as defined in claim 1 wherein the surface of
said elongated central portion includes means resistant to living
tissue ingrowth.
3. A tendon prosthesis as defined in claim 1 including
reinforcement means for reinforcing said elongated central portion
and said first and second end portions.
4. A tendon prosthesis as defined in claim 3, wherein said
reinforcement means includes fibers within said central portion and
said first and second end portions.
5. A tendon prosthesis as defined in claim 4, wherein said fibers
are formed of polyethylene terephthalate cord extending
substantially the entire longitudinal length of said central
portion and said first and second end portions.
6. A tendon prosthesis for repair or replacement of a natural
tendon comprising an elongated central portion formed of flexible,
biocompatible material, a first end portion integral with a first
end of said central portion, said first end portion including first
connective means for securing said first end portion, and a second
end portion integral with a second end of said central portion,
said second end portion including second connective means for
securing said second end to a segment of a natural tendon, said
second connective means including a plurality of longitudinally
spaced fenestrations formed in said second end portion for
receiving the tendon segment, wherein the surface of said second
end portion extending longitudinally between said fenestrations
includes means receptive to tissue ingrowth.
7. A tendon prosthesis as defined in claim 4, wherein said first
connective means is formed by an extension of said fibers beyond
said first end portion.
8. A tendon prosthesis as defined in claim 7, wherein the portions
of said fibers forming said extension are formed into at least one
cord-like member.
9. A tendon prosthesis as defined in claim 8, wherein at least a
portion of the surface of said cord-like member is receptive to
tissue ingrowth.
10. A tendon prosthesis as defined in claim 7, wherein said fibers
are separated into groups, said groups being combined to form a
pair of cord-like extensions extending from said first end portion,
a single reinforcing strand extending through said central portion
and a pair of reinforcing strands extending through said second end
portion.
11. A tendon prosthesis as defined in claim 1, wherein said first
connective means includes a plurality of longitudinally spaced
fenestrations formed in said first end portion for receiving a
segment of natural tendon.
12. A tendon prosthesis as defined in claim 1, wherein said first
connective means includes at least one cord-like extension secured
at one end to said first end portion.
13. A tendon prosthesis as defined in claim 12, wherein said
cord-like extension includes a plurality of strands and a woven
cloth tube surrounding at least a portion of said strands, said
woven cloth tube being receptive to tissue ingrowth.
14. A tendon prosthesis as defined in claim 13, including at least
one pad secured to said first end portion adjacent the terminal end
thereof, said pad being formed of material receptive to tissue
ingrowth.
15. A tendon prosthesis for repair or replacement of a natural
tendon comprising an elongated central portion formed of flexible
biocompatible material, a first end portion integral with a first
end of said central portion, said first end portion including first
connective means for securing said first end portion; a second end
portion integral with a second end of said central portion, said
second end portion including second connective means for securing
said second end to a segment of a natural tendon, said second
connective means including a plurality of longitudinally spaced
fenestrations formed in said second end portion for receiving the
tendon segment; and a cuff member surrounding the adjacent outer
surfaces of said central portion and said second end portion, said
cuff member being secured to said central portion and extending a
sufficient distance over said second end portion to cover at least
a substantial portion of the innermost fenestration formed therein,
said cuff member having an outer surface which includes means
resistant to tissue ingrowth.
16. A tendon prosthesis as defined in claim 2 wherein said first
and second end portions include surfaces which includes means
receptive to the ingrowth of tissue.
17. A tendon prosthesis as defined in claim 16 wherein said
fenestrations are centrally located with respect to the side edges
of said second end portion, said fenestrations being oval in
shape.
18. A tendon prosthesis as defined in claim 17 wherein said central
and first and second end portions form a unitary molded body of
plastic material and fiber reinforcing means are provided which
extend essentially longitudinally within said molded body.
19. A tendon prosthesis as defined in claim 18 wherein said first
connective means is formed by an extension of said fiber
reinforcing means beyond said first end portion.
20. A tendon prosthesis as defined in claim 18 wherein said first
connective means is formed by oval shaped fenestrations formed in
said first end portion and centrally located with respect to the
side edges thereof, said means receptive to tissue ingrowth being
positioned to extend between said fenestrations.
21. A tendon prosthesis as defined in claim 19 which includes a
cuff member surrounding the adjacent outer surfaces of said central
portion and said second end portion, said cuff member being secured
at one end to said central portion and extending a sufficient
distance over said second end portion to cover at least a
substantial portion of the innermost fenestration formed therein,
said cuff member having an outer surface which includes means
resistant to tissue ingrowth.
22. A tendon prosthesis as defined in claim 18 wherein said second
end section has a dumbell cross sectional configuration with edge
sections extending on either side of a center section, said edge
sections being of greater thickness than said center section.
23. A method for repairing a natural tendon within a living
organism comprising the steps of
1. forming an elongated tendon prosthesis of biocompatible
material;
2. forming a plurality of longitudinally spaced fenestrations
within one end portion of the prosthesis;
3. anchoring the other end portion of the prosthesis within the
living organism;
4. preparing the remaining portion of natural tendon by forming at
least one elongated end segment of natural tendon having a free end
with a cross section sufficiently small to pass through each
fenestration; and
5. interweaving the elongated end segment with the one end portion
of the prosthesis by passing the free end of the elongated end
segment back and forth through the fenestrations.
24. The method as claimed in claim 23 wherein step 4 further
includes the step of forming at least one additional elongated
segment of natural tendon having a free end with a cross section
sufficiently small to pass through each fenestration and wherein
step 5 includes the step of interweaving the additional elongated
segment of natural tendon with the one end portion of the
prosthesis by passing the free end of the additional elongated end
segment back and forth through the fenestrations.
25. The method of claim 24 wherein elongated segments of natural
tendon are formed by splitting the natural tendon
longitudinally.
26. The method of claim 25 further including the step of forming
surfaces receptive to tissue ingrowth between the fenestrations and
wherein the step of interweaving the elongated segments of natural
tendon with the one end portion of the prosthesis includes the step
of placing the split surfaces of the elongated segments in contact
with the surfaces receptive to tissue ingrowth.
Description
BACKGROUND OF THE INVENTION
This invention relates to an improvement in an artificial tendon
for replacement of natural tendon damaged or destroyed by such
events as injury, infection, burns, disease and surgical
resection.
Numerous techniques designed to restore the function of a damaged
or diseased tendon by reconstruction or replacement of the affected
member are known to the prior art. One of the most frequently
affected and yet often the most difficult to repair successfully
are the flexor tendons of the hand. Approaches toward surgical
repair by suturing severed ends of tendon or replacement of a
damaged segment with an autologous tendon graft often result in
failure to establish motion of the tendon since post-operative
adhesions in the area of the sutured ends with surrounding tissue
almost always occur with concommitant immobilization of the tendon.
A recent advance in graft repair involves an initial surgery in
which a silicone rod is implanted in the area where the graft is to
be installed. After a natural non-adherent sheath has developed
around the rod for several weeks or months, the rod is removed and
an autologous tendon graft is made within the tunnel of the sheath.
Although reasonably good tendon function is restored in some few
cases, the problem of subsequent adhesion still remains in many
instances. This approach leaves much to be desired since two
surgical procedures are required and the hand must be immobilized
for a good portion of time following both surgeries.
A great many artificial tendons have been devised in an attempt to
improve tendon restoration. Generally, they all have an elongated
flexible central section for bridging the gap between resected
tendon ends. This central position is made of biocompatible
material which inhibits or resists tissue ingrowth. The means for
attachment of the ends of the artificial tendons to the ends of
tendon or bone have been the principal area of investigation. Some
prostheses have a loop at one (or both ends) around which the end
of the natural tendon is looped and sutured. Other prostheses have
a tubular cloth end into which the end of the resected tendon is
placed and sutured. Still another prosthesis has two flaps at each
end with tissue ingrowth material on the inside of the flaps.
Tendon ends are layered between the flaps and are retained by
sutures running through the flaps. Both the tubular and flap ended
types are designed to permit tendon tissue ingrowth to occur into
the receptive surface of the prosthesis encasing the tendon and
provide strength to the attachment.
An artificial tendon should have the capability for being connected
to natural tendon so as to create a strong attachment which will
withstand both normal stress over a prolonged period and intense
stress for shorter periods without breaking the attachment or
causing injury to the natural tendon. Preferably, the means for
attachment should be such that immediate mobility of the repaired
tendon is possible following surgery so as to minimize or avoid the
formation of restricting adhesions. There should also be means for
attachment such that the blood supply to the natural tendon may be
maintained and means for positioning the ends of the natural tendon
so as to minimize the possibility for formation of adhesions to
surrounding tissue. Each of the prior artificial tendons fails to
provide means to accomplish one or more of the above requirements.
Those with looped ends cannot prevent the formation of adhesions
and the high concentration of stresses on the small portion of
tendon in contact with the loop produces trauma to that portion of
the tendon. Those prosthetic tendons with tubular ends or flaps on
the ends cannot envelop the resected end of the tendon for much
more than one centimeter without interferring seriously with the
blood supply to the tendon. Such limited area for subsequent firmer
attachment by tissue ingrowth would be inadequately strong both to
achieve the desired goals of immediate mobility and to withstand
intense stress imposed on the area of attachment. Furthermore, the
flap and the loop designs in particular create bulkiness at the
attachment site tending to comprise motion within the sheath.
SUMMARY OF THE INVENTION
This invention relates to improvements of artificial tendons having
as a primary object a tendon prosthesis which provides an immediate
and long lasting strong functional union between the prosthesis and
tendon. A further object is a tendon prosthesis which permits
immediate mobility following surgery and essentially eliminates
adhesions. Another object is a tendon prosthesis which permits
extensive anastomotic union without compromising the nutrient
supply to the tendon. Another object is a tendon prosthesis which
provides minimal bulk at the anastomotic site.
The present invention which accomplishes these objects comprises a
somewhat narrow, rather flat, tape-like structure made of
bicompatible material capable of withstanding functionally
physiological forces exerted at each end without breaking or
stretching significantly. The internal strength-imparting framework
of the prosthesis may be made of non-stretching material such as
braided, woven or standard fabric cords, metal wire, or other
strong flexible filaments. The framework is coated with a
biocompatible material, such as Teflon, silicone, polyurethane or
other suitable flexible polymer, over the entire central portion
and a part of the end sections so as to prevent ingrowth of tissue
into the prosthesis except at certain desired areas at the end
portions. At least in one end section there are a series of holes
or fenestrations centrally located and running longitudinally on
the flatter side of the end section. The surfaces lying centrally
between the holes are of such material and/or structure that they
allow ingrowth of tissue to occur. The other end section may also
be similarly constructed or it may have means, such as cords or
small tapes extending beyond that end for tying or otherwise
securing that end to bone. A resected end of a tendon, preferably
one which is first split down the middle, is interwoven through the
fenestrations at the end section of the prosthetic tendon and
secured by several sutures. The other end of the prosthesis may be
similarly anastomosed to a resected tendon when a tendon prosthesis
is used which has both end sections fenestrated. The attachment of
the natural tendon to the prosthetic tendon by this means gives
immediate strength and security to the attachment somewhat in the
manner of a spliced rope. This means of attachment also permits the
natural tendon in the area of attachment to externally envelop the
prosthesis so that the tendon can continue to be nourished by the
surrounding tissues and necrosis of the tendon is avoided. The
resected end (or ends of the split tendon as the case may be) may
be readily contained within the prosthesis and thus the problem of
adhesion to surrounding tissue is essentially avoided.
The advantages of the prosthetic tendon of this invention will be
more readily understood from a consideration of the following
specification and claims in light of a detailed description of an
embodiment and of the accompanying drawings in which:
FIG. 1 is a top plan view of a tendon prosthesis in accordance with
a first embodiment of this invention, partly broken away;
FIG. 2 is an enlarged cross-sectional view of the prosthesis of
FIG. 1, taken on line 2--2;
FIG. 3 is an enlarged cross-sectonal view of the prosthesis of FIG.
1, taken on line 3--3;
FIG. 4 is a view of a modified portion of the prosthesis of FIG. 1,
showing an integrally attached sleeve at position A of the
prosthesis;
FIG. 5 is top elevational view of a second embodiment of the
invention; and
FIG. 6 is a perspective view showing the interweaving of a tendon
into the end portion of a prosthesis formed in accordance with this
invention.
DETAILED DESCRIPTION OF THE INVENTION
In an embodiment of this invention, a tendon prosthesis 10 as shown
in FIGS. 1 through 4 comprises a central portion 12 and two end
portions 14 and 16. The entire prosthesis 10 is made of
biocompatible material and may be constructed by the same material
or a combination of materials. The central portion 12 is a somewhat
flat or tape-like structure as shown in this embodiment or it may
be ovoid in cross-section or it may be more circular. A variety of
shapes may be manufactured to conform more or less to the
cross-sectional shape of the natural tendon to which the artificial
tendon is to be attached. The length of the central portion 12 may
vary, depending upon the length of damaged or diseased tendon to be
replaced.
The end section 14 is integral with the central portion 12 and has
essentially the same cross-sectional dimensions as the central
portion 12. Located centrally and arranged longitudinally in end 14
are a series of openings or fenestrations 18, at least two and
preferably three or four in number. These openings 18 may take a
variety of shapes, preferably somewhat oval, and are more or less
uniformly spaced apart to provide surfaces 20 in between each
opening 18. These surfaces 20 have structure which is receptive to
ingrowth of tissue. For example, when the body of the prosthesis is
made of silicone, tissue ingrowth surfaces 20 may comprise a favric
such as Dacron velour or woven mesh which may fabric secured to the
desired areas by applying an adhesive such as silicone adhesive
between the body of the prosthesis and the fabric and by
vulcanizing the resulting structure to achieve a firm bond.
Alternatively, the velour or mesh with an unvulcanized silicone
backing may be compressed onto the silicone body and vulcanized.
The ingrowth surface also extends inwardly on the surfaces within
the openings 18 as shown in FIG. 2. When the body of the prosthesis
is made of polyurethane, for example, the ingrowth surface 20 may
also be of polyurethane having an open pore structure. The
polyurethane may be molded into the desired shape to form the body
with its fenestrations and then an overlayer of polyurethane having
open pore structure may be secured to those areas where tissue
ingrowth is desired. The prosthesis may be made of metal, and if
made from woven or twisted strands of metal wire, such as titanium
wire, the woven or twisted structure has crevices into which tissue
may grow and one needs only to coat the central portion 12 and
outer edges 22 of the end section 14 with a suitable material, for
example, silicone, to provide a surface which prevents tissue
ingrowth as may be required.
Although the surfaces 20 may be more or less flat, it is preferable
that these surfaces be somewhat depressed, resulting in the dumbell
cross sectional configuration illustrated in FIGS. 2 and 3.
Providing depressions in these areas of the end section 14 serves
to decrease further the bulkiness of the anastomotic union between
the natural tendon and the prosthetic tendon as will be discussed
later in greater detail.
A cuff 24 illustrated in FIG. 4 may be included at the junction
between the central portion 12 and the end section 14 as indicated
at position A of FIG. 1. When provided, cuff 24 fits snugly around
the peripheral surface of the prosthesis. Cuff 24 is secured to the
prosthesis, by sutures and/or adhesive applied near edge 26 of the
cuff closest to the central portion, and is capable of being rolled
back prior to the installation of the natural tendon. The cuff 24
is made of cloth, preferably Dacron velour and its exterior surface
is coated with material, such as silicone, which resists ingrowth
of tissue. The length of cuff 24 is usually of sufficient length to
extend over a good portion of the innermost fenestration 18 in the
end section 14.
In the embodiment shown in FIG. 1, end section 16 is different from
end section 14 and is designed to be used to anchor end section 16
of the prosthesis to other more rigid tissue such as bone. End
section 16 in this embodiment comprises a cord-like extension 18,
preferably two in number, although one or more than two may provide
the function for which the extension 28 is intended. The extension
28 may be made of fabric preferably in the shape of a cord. The
extension 28 may be made of metal wire, advantageously several
small strands of wire twisted together, and is particularly useful
when the body of the prosthesis is made of flexible metal. In the
embodiment shown in FIG. 1, the extension 28 comprises several
strands of cord 30, preferably braided, snugly covered by a woven
cloth tube 32. Both cord 30 and tube 32 are made of material
receptive to ingrowth of tissue, such as Dacron. Although it is not
essential for cord 30 to be covered by tube 32, the tube helps to
preserve cord 30 from abrasion on sharp edges which may be present
at the point where extension 28 enters and leaves bone as will be
explained below. For a short distance on the surface of both sides
of the central portion 12 adjacent to extensions 28, pads 40 may be
present. These pads 40 are of such material or structure, such as
Dacron velour, as to permit ingrowth of tissue.
When the prosthesis 10 is made of plastic, for example, silicone,
it is preferable to have internal reinforcement to add strength to
the prosthesis. Reinforcing cords 34, preferably of braided
non-extensible strands of suitable material such as Dacron strands
may be incorporated at the time of molding. The cords 34 are
integral with the extensions 28 of end section 16 and run through
the entire length of the prosthesis. The cords 34 may run through
any part of the central portion 12 and near the outer edges 22 of
end section 14 or they may extend more or less in the middle of
central portion 12 and criss-cross between fenestrations 18 as
shown in FIG. 1.
Prosthesis 10 may be made in various lengths depending on where the
prosthesis is to be used to effect a repair or replacement.
Generally the length can be varied merely by making the central
portion 12 longer or shorter at the time of manufacture to provide
a variety of sizes for a particular use. The width of prosthesis 10
also may vary depending on which particular tendon is to be
replaced. The width selected should generally be slightly smaller
than the width of the natural tendon.
As an example of how the prosthesis is made, the reinforcement in
combination with the end extensions 28 is first formed by braiding
two separate groups of three strands of Dacron for a length of
about 3 inches for the formation of the two extensions 28. The six
strands are then divided into three groups of two and braided into
a single tape-like structure for a length corresponding to the
central portion 12. The six strands are finally divided into two
groups of three as before and braided to form the two reinforcing
cords for end section 14. The fenestrated section 14 is usually
about 2 to 3 inches in length. Woven Dacron tubing is next slipped
over the two extensions 28 and secured at each end by
stitching.
The assembly is coated with a silicone primer, arranged on an
appropriate mold piece and sandwiched between two layers of
unvulcanized silicone sheets. A mating mold piece is placed on top
and the sandwich is hydraulically compressed. The article, while
still in the clamped mold, is vulcanized above 100.degree. C. then
removed from the mold and trimmed of any flashing. A strip of
Dacron velour with unvulcanized silicone backing and having
fenestrations approximating those of the molded piece is placed on
each side of the fenestrated end section and vulcanized to this
section. The velour pads 40 are likewise incorporated at this
stage. The prosthesis is washed, sterilized and is ready for
use.
As illustrated in FIG. 5, a prosthesis formed in accordance with
this invention may include a pair of fenestrated end sections 114
and 116 attached at one end, respectively, to a central portion
112. This embodiment, identical in all other respects with the
embodiment illustrated in FIGS. 1-4, is adapted to bridge the gap
between two resected ends of a tendon.
In the clinical application of the prosthesis 10, to make the
anastomotic union between a resected tendon and the prosthetic
tendon of this invention, as for example in the repair of a flexor
tendon in the hand, the prosthesis 10 is first anchored to either
the distal or middle phalanx. This may be done by drilling two
small holes into that member, running extensions 28 through the
holes and tying on the dorsal, or medial side of the bone. In
addition, a short stub of the natural tendon where the tendon joins
the phalanx may be retained and sutured to the velour pad 40
portion of the prosthesis. The prosthesis is then led through or
placed within the natural tendon sheath for joining in the palm to
the resected end of the flexor tendon of the appropriate digit. The
primary object is to reconstruct the long flexor or profundus
tendon. (The surgeon may at his option elect to also join the
sublimis tendon with the profundus into a common anastomosis with
the end section 14 of the prosthesis). As illustrated in FIG. 6,
the other end of the prosthesis is attached to a tendon 36 in this
case the profundus tendon which is resected just proximially of the
tendon sheath near the metacarpal head and the end is divided by
scalpel into two tendon segments 38 over a distance of
approximately 2 inches up to the entrance of the carpal tunnel or
sheath. The two tendon segments 38 are then interwoven through the
series of fenestrations 18 provided in end section 14 of the
prosthesis taking care to lay the split surfaces of the tendon
against the ingrowth surfaces 20. The wrist and finger are placed
in full extension and the tendon interweaving is adjusted to
provide light tension. Care is taken to insure that the anastomosed
portion lies in the more open zone of the palm and does not enter
or come too close to the more restricted sheathed areas. The
resected end of the two tendon segments 38 are then abutted and
sutured within the distal fenestration. The tendon may be
additionally sutured at several points along the anastomosis. The
surgeon has the option of choosing an alternative anastomotic site
just proximal of the carpal tunnel at the flexion crease of the
wrist. In this situation the prosthesis 10 has a suitably longer
central portion 12. To make use of the cuff 24 when provided, the
individual tendon segments 38 are abutted and sutured within the
distal fenestration as previously described. The cuff 24 is then
rolled over that portion of the sutured tendon ends and the cuff
optionally secured by sutures. With either procedure, the problem
of adhesion between the resected end of the tendon and the
surrounding tissues is greatly reduced.
Whereas the fenestrated end section 14 is generally intended to be
interwoven with a tendon alone, in certain cases it may be
desirable to incorporate the muscle adjacent the musculotendon
junction along with the tendon into the interweaving with the
prosthesis. In this situation, the outer end of the end section 14
is generally broader and the outermost fenestrations are somewhat
larger so as to accommodate to the larger cross-sectional size of
the muscle.
Immediate mobility of the tendon is thus achieved by the use of the
prosthetic tendon of this invention. In addition, it can be readily
seen that the anastomotic union is not bulky so that motion may be
maintained even within the restricted fibrotic sheath which
develops later around the repaired tendon and prosthesis.
Furthermore, the prosthesis of this invention allows the natural
tendon at the anastomotic site to be exteriorized, i.e., to lie
outside of the prosthetic member so that the nutrient supply to the
tendon in this area is readily available for maintaining the
integrity of the natural tendon.
While preferred embodiments of the invention have been shown and
described, other variations and modifications may be made in the
structures without departing from underlying principles of the
invention.
* * * * *