The availability of cables, strong synthetic suture materials, interlocking nails, and locking plates has led to a decline in the use of and familiarity with, wiring techniques and tensioning devices (Fig. 1). In this article, a variety of cerclage and tension band wiring configurations are described, and surgical applications are cataloged. Videos of implementation and failure for each configuration are provided. Several previously unreported observations, techniques, and tips are presented, indicated by the symbol (•).
In this article, the word “configuration” is used to refer to the pattern of passage, together with the method of tensioning and fastening the wire.
We classify cerclage wire configurations as:
- Wrapped around once, tensioned, and locked.
- Wrapped around twice (sometimes referred to as a “continuous double loop”), tensioned, and locked.
- Doubled symmetric twist.
- Hairpin loop.
- Mittelmeier’s double loop bend-back with securing twist.
Wrapped Around Once
Cerclage wire may be wrapped around the bone once, then tensioned and locked with one of the 4 methods, listed and described below:
A Symmetric Twist
A symmetric twist is sometimes referred to as a “twist knot” in the literature, not to be confused with the “knot twist” which is described below in the Square Knot or Knot Twist section which follows.
A symmetric twist is formed by twisting a wire while applying equal tension to each of its ends (Video, Supplemental Digital Content 1, http://links.lww.com/INNOV/A195, symmetric twist, finish, and bend). The magnitude of applied tension does not affect the final retained compression, if applied to each end equally.1 An asymmetric twist or wire wrap will form if, during the twisting process, greater tension is applied to one end than to the other. If a symmetric twist is formed and turning continues, secondary twists will develop, and failure will occur at the base of one of the secondary twists. To optimally resist tensile forces, at least 3 full symmetric twists2 with a pitch of about 2.5 twists per centimeter should be retained when using 1-mm wire.3 Symmetrically twisted cerclage wire starting with greater retained compression (sometimes referred to as “pretension” in the literature) maintains compression under tensile loads better than cerclage wire starting with less retained compression,4,5 though wire diameter, pattern, and fastening method are more important determinants of resistance to tension failure.6 To maximize final retained compression, we recommend the following 2-step twisting technique: grip the wire 2 to 3 cm from the bone, pull and rotate around a single axis. Twisting may be interrupted when a secondary twist begins to develop or when an acceptably tight twist pitch has formed, and a small residual space is noted between the first twist and the bone. Trim the twist about 1.5 cm from the bone and regrip close to its base. While pulling away from the bone, apply a finishing twist until the space is eliminated, and for cerclage indications, the wire can neither be slid nor spun on the bone (Fig. 2). This may require as little as fraction of a turn or as much several full turns and will significantly increase wire tension and the compressive force it exerts.
In cerclage wiring experiments using a 2-step technique with 1-mm wire, a variety of twisters were used to form symmetric twists before applying finishing twists with a clamp or pliers. The final mean retained compression was 120 N. The finishing twist tripled the mean tension which had been generated in the first step, increasing it by an average of 90±17 N (mean±SD), without breaking any of the wires (Fig. 3). A description of our methods and tabulated results can be found in the Supplemental Digital Content section (see Research Methods and Results, Supplemental Digital Content 2, http://links.lww.com/INNOV/A196, for additional information).
Some loss of retained compression has been reported to result from trimming the twist stump at a length of 3 twists, as well as from bending the twist down to the bone.1,4,7 To prevent loss of compressive force, leave at least 1.25 cm and >3 twists intact when trimming, and apply the following 2-step twist-bending technique, demonstrated in the video.
Grip the twist near its cut end, bend it about halfway between the first and last twist. Regrip the curl of the twist and supinate (if twisting clockwise), simultaneously twisting and flattening the wire twist down to the bone. This can maintain and even increase wire tension,8 and add resistance to untwisting.5
A Square Knot or Knot Twist
A square knot or knot twist (Fig. 4) may also be used to tension and secure a cerclage wire.
To create a square knot, a half-hitch is formed using wire clamps, tensioned with a crossed-wire tensioning instrument, and provisionally clamped. The second throw is formed, and the clamp is released as the knot is tightened. To avoid the loss of tension which inevitably occurs during clamping and releasing the first throw, the half-hitch may be rotated 180 degrees with tension maintained on the knot. Continued twisting of the wire ends with tension partially relaxed will complete the formation of a knot twist (Video, Supplemental Digital Content 3, http://links.lww.com/INNOV/A197, knot twist).
Wang et al,9 Shaw and Daubert,10 and Bostrom et al11 all found the knot twist superior to the square knot in its compression capability and simplicity of application, and Gaudagni et al3 found the twisting direction irrelevant. These authors all demonstrated significantly greater resistance to tensile loads for the square knot and knot twist than for the symmetric twist. Gripping the base of a knot twist and adding additional twists will cause the wire to break rather than increasing tension. Therefore, if additional twists above the half-hitch are desired to further secure the knot, grip the wire ends, not its base, and turn (•).
An Eyelet Bend-Back
The eyelet bend-back (Fig. 5), sometimes referred to as a “loop knot” or “eyelet loop” can also be used to tension and secure a cerclage wire.
In this method, the straight end of an eyelet-wire is passed around the bone, fed through the eyelet, and tensioned with a peg snapped into an Association for the Study of Internal Fixation (ASIF) handle slot. The handle is bent back with the peg held tight. About 1 cm of wire is released, and the instrument’s tip is used to flatten the bend (Video, Supplemental Digital Content 4, http://links.lww.com/INNOV/A198, eyelet bend-back). If possible, the free wire end is tucked under the wire, trapped under the washer of a capstan screw, or encased in bone cement (•). The eyelet bend-back technique avoids potential irritation from a twist or knot, and accidental wire breakage during tensioning is uncommon. The cerclage wire remains oriented straight around the bone with this method, unlike twisting techniques which tend to orient the cerclage diagonally. After tension is locked by bending the wire back and flattening it, subsequent finishing off to increase wire tension is not possible. The Bowen-Loute and Osteo SA wire tensioners may also be used for eyelet bend-back tensioning and locking.
In a series of cerclage experiments, the mean retained compression for eyelet bend-back tensioning and locking of wires wrapped around twice was 2.5 times greater than for the same technique applied in the wrapped around once configuration (Fig. 6). The eyelet bend-back technique generated greater retained compression than the knot twist, but less than the symmetric twist completed with a finishing twist (see Research Methods and Results, Supplemental Digital Content 2, http://links.lww.com/INNOV/A196, for additional information).
A Crimped Double Barrel Sleeve
A crimped double barrel sleeve (Fig. 7) may be used to lock wire tension, after encircling the bone. In this method, the cerclage wire ends are crossed and fed in opposite directions through a double barrel sleeve (also called a “grip,” “wire plate,” or “swage”). A crossed-wire tensioning device holds tension as the sleeve is crimped (Video, Supplemental Digital Content 5, http://links.lww.com/INNOV/A199, crimped double barrel sleeve).
Wrapped Around Twice
Cerclage wire may be wrapped around the bone twice before it is tensioned and locked with 1 of 4 methods (symmetric twist, knot twist, eyelet bend-back, or crimped double barrel sleeve) described above for the wrapped around once pattern.
Doubled Symmetric Twist
To produce a doubled symmetric twist (Video, Supplemental Digital Content 6, http://links.lww.com/INNOV/A200, doubled symmetric twist), a wire strand is folded in half and passed around the bone. In contrast to the wrapped around twice pattern, this doubled configuration requires only one pass of the wire around the bone. The 2 free ends and the bend are gathered together and captured by heavy pliers (such as those of a spiral spindle wire twister) or within the chuck of a power drill. The wire is pulled and rotated until secondary twists develop. A doubled symmetric twist can also be created by capturing the bend with a hook or heavy pliers, and the 2 free ends with wire twister clamps, taking care to maintain equal tension while twisting. Alternatively, if a closed loop wire is folded in half and passed around the bone, both loop ends may be captured by a hook, pulled and twisted to form a doubled symmetric twist. A finishing twist may be applied with heavy pliers and is strongly recommended if space remains between the base of the twist and the bone (Fig. 8).
In cerclage experiments, the doubled symmetric twist finished with locking pliers generated greater force than the wrapped around once symmetric twist but less than the wrapped around twice-symmetric twist (Fig. 6). It produced double the compressive force when using 1.25-mm wire as compared with 1-mm wire (see Research Methods and Results, Supplemental Digital Content 2, http://links.lww.com/INNOV/A196, for additional information).
The hairpin loop configuration was first described by Cheng and Davey.12 A folded wire is looped around the bone in a single pass. One end of the wire is fed through the bend and secured to the other free end with a knot twist, using a Harris knotter. Roe’s6 variation, called “loop/twist cerclage,” starts with the same pattern but combines a bend-back and a symmetric twist to tension and secure the cerclage (Fig. 9). All of these authors reported exceptional mechanical performance in lab testing of hairpin configurations, but it is difficult to achieve equal tension on both strands of this double cerclage, particularly when using heavy gauge wire. To help distribute tension equally, sequentially take up slack in the 2 wire ends using peg cranks or wire clamps, beginning with the one which passed through the bend loop, and form a symmetric twist near the hairpin loop bend point rather than at a distance from it (•).
A small hook placed in the loop bend point and twisted can also be used to ensure both wire limbs are properly tensioned (•). Devices that tension before twisting, such as the ASIF handle with pegs, the Osteo SA, the Innomed Browner, and the Bowen-Loute are recommended for the hairpin loop locked with a symmetric twist (Video, Supplemental Digital Content 7, http://links.lww.com/INNOV/A201, hairpin loop).
Mittelmeier’s double loop bend-back with securing twist technique (Fig. 10) is another double cerclage pattern which, like the doubled symmetric twist and the hairpin loop, requires only a single pass of a folded wire around the bone. In contrast to the hairpin loop configuration, after the folded wire is looped around the bone, both free ends are fed through the loop, tensioned equally with 2 ASIF pegs, and bent back. With tension maintained, about 2 cm of wire is released from the pegs, flattened, and twisted to the bend point. The twist is then tamped down to bone (Video, Supplemental Digital Content 8, http://links.lww.com/INNOV/A202, double loop bend-back with twist).13
The Osteo SA and Bowen-Loute wire tensioners can also be used to produce a double loop bend-back with twist. Mittelmeier, Blass et al,14 and Roe6 tested the double loop bend-back without a twist, and reported favorable pretension (retained compression) and tensile strength. Using his technique of twisting the wire ends after bending them back, Mittelmeier and Hanser13 demonstrated significantly greater resistance to loosening from unbending and slippage under tensile loads.13
If using the double loop bend-back with twist technique to secure a plate, the twisted segment may be secured to the cerclage segment with a strong suture, exploiting the screw hole or plate-bone junction spaces for suture passage as seen in Figure 11 (•). If used without a plate, a strong suture or a wire may be positioned deep to the cerclage prior to tensioning, and subsequently secured over the twist (•).
Mittelmeier and Hanser,13 Incavo et al,15 Cheng et al,12 Roe,6 Liu et al,16 and Lenz et al17 all reported doubled wire patterns produce more than twice the compression and resist at least twice the tensile load as single wire patterns.
In a series of cerclage experiments (see Research Methods and Results, Supplemental Digital Content 2, http://links.lww.com/INNOV/A196, for additional information), symmetric twists formed with several different devices more than double the retained compression using wire wrapped around twice compared with wire wrapped around once (Fig. 3).
MODES OF WIRE FAILURE UNDER LOAD18
A strand of wire subjected to tensile loads may undergo plastic deformation (at the yield point), drastically reducing retained compressive force. If loading continues, ultimate failure (breakage) occurs (Video, Supplemental Digital Content 9, http://links.lww.com/INNOV/A203, failure modes).6,7
A wire wrap may unwind,3 then break. A symmetric twist may uncoil or break at its base.3,10 A doubled symmetric twist may uncoil or break at its base. The doubled symmetric twist functions like 2 separate wires, and if one strand fails, the other may remain intact (•). A square knot’s first throw cinches up towards the second throw (effectively elongating the working section of the wire and reducing compressive force) before the wire breaks at the base of the knot (•). A knot twist uncoils one-half turn (effectively elongating the working section of the wire and reducing compressive force) before breaking at the base of the knot. An eyelet bend-back may straighten out and slip; greater resistance is imparted by tucking the end.3 If the end is tucked, the eyelet may cinch down (effectively elongating the working section of the wire and reducing compressive force) before the wire breaks at the base of the eyelet (•). A double loop bend-back may unbend and slip14; greater resistance is imparted by twisting the free ends,13 especially if the twist is secured with a suture. A tensioned wire, securely locked in a crimped double barrel sleeve, breaks before the wires slip through (•).
Doubled configurations such as the hairpin loop,6,12 the double loop bend-back with twist,13 wrapped around twice patterns,15,16 and the doubled symmetric twist19 resist much greater tensile loads than do single cerclage patterns.
Encasing a wire twist, eyelet bend-back, or knot with methylmethacrylate bone cement increases resistance to unraveling under tensile loads and may be used to deliver antibiotics locally. By positioning the twist, bend, or knot over a plate hole or at the plate’s edge, access for circumferential cementation is facilitated (•).
TENSION BAND WIRING
Tension band wiring constructs are shown in (Video, Supplemental Digital Content 10, http://links.lww.com/INNOV/A204, tension band wiring) and (Fig. 12).
Crediting Friedrich Pauwels with introducing the technique of tension band wiring, Meuller et al19 wrote, “The Tension Band Wire provides dynamic compression and is indicated if it is able to neutralize all tension forces acting on the fracture, and if all the bending and shearing forces are excluded either by interfragmentary friction alone or by additional splintage with Kirschner wires.”
The basic tension band wiring configuration is a figure-of-8 wire positioned on the tension side of the fracture, and 2 parallel interfragmentary K-wires. The figure-of-8 narrows the pattern and prevents the wire from slipping off the tension surface, as might otherwise occur with an uncrossed loop pattern of wire passage.19 To optimize construct strength, the position of the transverse drill hole, capstan screw, or pin used to anchor a figure-of-8 wire within the stable fragment, should not be farther than necessary from the fracture or osteotomy site.
The following are variations of this basic configuration:
- The figure-of-8 tension band wire may be tensioned and locked with a symmetric twist (or eyelet bend back) on one or both of its limbs.19
- Two figures-of-eight20 or a figure-of-8 wire plus a separate, uncrossed loop wire may be used.
- The tensioned wire may be anchored around both ends of the same interfragmentary pins or around separate pins inserted from opposite directions.
- One or 2 transverse drill holes may be used for passage of 1 or 2 wires in the stable fragment.21
- A transversely oriented cannulated screw or a capstan screw with a washer may be used for capture of wire(s) in the stable fragment.22
- One, 2, ≥3 interfragmentary pins may be inserted to counteract torsional, bending, and shear forces. Tip-threaded K-wires may be used to decrease the chance of interfragmentary pin loosening (•).
- If the osteotomy or fracture fragment is amenable to screw fixation, interfragmentary lag screw(s) with washer(s) may be used to supplement or substitute for K-wires in tension band wiring constructs.23
- Vertically and horizontally oriented interfragmentary pins captured by a figure-of-8 wire or wires positioned over the tension surface of the bone can be used to stabilize a fracture with axial, coronal, and sagittal plane comminution (•).24
- To prevent K-wire migration, the tension band wire may be reeved through rings formed at the ends of the interfragmentary pins.25–27
WIRE PASSAGE TIPS
For cerclage applications, maintain wire orientation perpendicular and not diagonal to the bone. For doubled cerclage configurations, keep the 2 passes close together and for figure-of-8 tension band configurations, minimize pattern width and length.
Where a bone tapers, prevent cerclage wire migration to a region of smaller bone circumference by exploiting bone surface protrusions, drill holes, plate holes, pins or screw heads, and bone cement. Wire can be reeved through perforations in small implants (Synthes, Paoli, PA) which thread or fit into plate holes or screw heads (Fig. 11).
Cerclage wire passage can be facilitated by tubes of varying lengths and radii of curvature; detachable, 2 piece, semicircular tubes that interconnect (Synthes); curved passers with eyelet openings; and open section, curved, slotted passers.
For tension band wiring applications, large-bore metal needles (16 or 14 g) and needle-bearing cardiothoracic wires (#7 wire=18 G=1 mm and #5 wire=20 G=0.8 mm) are useful for passing wire through tendons or ligaments, close to the bone-pin interface.
A fine gauge wire may be folded in half and used as a suture passer.
Brown & Sharpe or AWG is the gauge-millimeter conversion scale used by the American Society for Testing and Materials28 (Table 1). Other conversion scales exist (eg, SWG, BWG, and W&M), resulting in some confusion in the literature and in product identification. In general, 16- or 18-G wire is appropriate for most femoral applications and 18- or 20-G wire is used for other large bones. A 24- and 26-G wire may be used for the metacarpals and phalanges.
CONTEMPORARY WIRE PRICES
A 40-cm wire, which currently costs <$2 (Synthes), is long enough for any figure-of-8 or doubled cerclage pattern and can be made into an eyelet wire or closed loop wire. Pricing information obtained from the operating room business office, Guthrie Clinic, Sayre, PA. In a recent 12-month period, 98 cables were used in surgery at the guthrie clinic’s Robert Packer Hospital, costing ~$40,000.
Ethicon (Somerville, NJ) sells 45 cm lengths of #7 (=18 G=1 mm) and #5 (=20 G=0.8 mm) cardiothoracic wire with a needle for $2.12 each.
Synthes 1 mm and 1.25 mm eyelet-wires, 28 cm in length, cost $6.65 each.
Zimmer (Warsaw, IN) sells closed-loop stainless steel 1.2-mm wire, 30-cm long, for $48 each. Zimmer sells Vitallium (65% cobalt, 30% chrome, 5% molybdenum alloy), beaded-tipped 16-G (1.22 mm) wire, 61 cm in length, for $13.18 each.
Teleflex (Morrisville, NC) sells Pilling “wire plates” (double barrel crimp sleeves) accommodating 20-G (0.8 mm) wire for $6.70 each.
A single Synthes 1.7-mm stainless steel or cobalt chrome cable with crimp sleeve costs $413.56, and a single Zimmer (Cable-Ready) cable with crimp sleeve costs $417.75.
Therefore, the price of a cable with crimp sleeve is ~200 times that of a wire.
The techniques and tips for cerclage and tension band wiring described above, have many potential uses.
Cerclage Wiring Applications
Cerclage wire may be used for:
- Prophylactic femoral fixation (or prophylaxis against propagation of an intraoperatively detected calcar crack) in primary total hip arthroplasty.29,30
- Plate fixation of periprosthetic (Vancouver B) femoral or humeral fractures around a canal-filling stem, preferably in conjunction with angled bicortical, or straight unicortical screws to increase resistance to torsion, bending, and shear.31
- Reduction of spiral subtrochanteric femur fractures treated with cephalomedullary-interlocking nails.32
- Conventional trochanteric osteotomy (including trochanteric advancement),33,34 and extended trochanteric osteotomy35,36 fixation in complex and revision THR. To avoid using braided cables when fixing extended trochanteric osteotomies in infected cases, monofilament wire may be used with antibiotic-impregnated bone cement encasing the twists.
- Wiring cortical strut grafts to reinforce mechanically compromised or deficient bone around a stemmed prosthesis.
- Tibial tubercle osteotomy fixation in revision TKR,37 and allograft knee extensor mechanism reconstruction.38
- Internal fixation of acetabular fractures, for transverse,23 associated both column,39 and quadrilateral plate fracture patterns.40
- Reduction and fixation of fractures and osteotomies by tensioning a wire looped around 2 screws (eyelet wire tensioning recommended for this application).22
- Monofilament wire has been used for the atlantoaxial arthrodesis technique of Brooks and Jenkins.41 Luque42 described a segmental spinal instrumentation technique using sublaminar wires for deformity correction and spinal fusion.
- Monofilament wire is commonly used by cardiothoracic surgeons for median sternotomy repair, and by oral maxillofacial surgeons for maxillomandibular fixation.
Tension Band Wiring Applications
Tension band wiring in conjunction with interfragmentary pins, is an effective fixation technique for osteotomies and fractures subject to tensile loads. It is particularly useful for repair of avulsion fractures or exposure osteotomies of the anterior superior iliac spine, greater trochanter of femur,19,33,34 lesser trochanter of the femur,23 patella,19 tibial tubercle, Gerde’s tubercle, fibular head, medial malleolus,43 lateral malleolus,19,23 base of fifth metatarsal,23 navicular tuberosity, calcaneal tuberosity,23 acromion,44 greater tuberosity of humerus,23 lesser tuberosity of humerus, medial epicondyle of humerus, olecranon,19,21 and ulnar styloid.
Transosseous fine gauge wire suture, cerclage, tension band, and composite wiring (monofilament wire wrapped around interfragmentary pins) techniques have been described for metacarpal and phalangeal fractures and for small joint arthrodeses.45–47
Monofilament wire is a versatile implant which can be used in many orthopedic procedures and remains a valuable, cost-effective resource in our surgical armamentarium. Clinical equivalence and similar in vitro mechanical performance have been reported for doubled cerclage wire configurations and significantly more expensive cable constructs.16,17,30 Tension band wiring is particularly useful for the fixation of bone fragments which may not be amenable to other methods of internal fixation due to location, size, comminution, or bone quality.
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