T en on healing variables

repairgrafting

mansoor khanAugust,

2010

HMC Plastic& reconstruction

d

muscle to the bone

glistening structurebetween muscle

& bone whichtransmit force from

“”

collagen

fibrils

fibers

fasciles

tertiary bundles

Tendons

endotenon

histology of tendons

Loose areolar tissue

encasing tendon in low mechanical stress area

Paratenon..?

Paratenon

Loose areolar

tissue containing

collagen & inner

lining of synovial

cells, containing

synovium like

fluid bathing the

tendon.

Inner layer which in contact with the tendon is epitenon (mesotenon) containing lymphatics, vessels which dips inside the tendon as endotenon.

Tendon Sheath..?

a dense fibrous

tissue tunnel

enclosing tendon in

high mechanical

stress area

Double layer, outer fibrous & inner synovial Synovial layer is parietal and visceral

containing synovial fluid

tendon sheath

BLOOD

vessels from musculotendonousjunctions Vessels fromosseotendonous junctions

vanicula (briva & longa) incompression areas (joints),

loose areolar tissue vessels(non-compression areas)

s u p p l y

nutrition

sources

vincular blood vesse

ls

synovial fluid blood vesse

ls

Tendon & tendon graft healing

clot and fibrin plug seals the tendon gap

macrophages/neutrophils appears

Inflammatory phase

(48-72 hours):

Stitch provide the whole strength

cells migrate into the wound from, peritenon (extrinsic healing), epitenon/endotenon/tenocytes

(intrisic healing) Becomes fibroblasts produce collagen

Prolif

erativ

e phase

(5 d

ays-4 w

ks):

Tendon & tendon graft healing

Stitch provide the whole strength

Strength is shifted to the scar gradually

rem

odelling p

hase

(4 w

ks-2years

):

Tendon & tendon graft healing

Idea of tendon’s incapability of intrinsic healing leading to extrinsic healing and

adhesions formation CHANGED

Both intrinsic & extrinsic healing are responsible but we have to minimize extrinsic healing to prevent adhesions

intrinsic

...?

extrin

sic..?

T endon healing modulators

hyluronic acid improves healing

Indications: Lacerations with intact soft tissue, Digital re-implantation, Tendon laceration with fractured bones

Goals: Tendon healing,

effortless gliding, full joint motion

Tendon

Repair

mobile digit with minimal scare at least one digital nerve intactmeticulous surgical techniqueco-operative patientcareful graduated mobalization

requirmentsrepair

Guid

elines

Meticulous/atraumatic

techniqueplace

sutures in

the

avascular

portion

anteriorly, good exposure

as retrieval

leads to

trauma, core suture with

4/0 monofilament and 3/0 if

early active

motion

planned, aim for smooth

repair edges

Guidelines

Epitenon su

ture

s decre

ases

external h

ealing

(adhesions),

adds to

strength

,

Modified kessler +

epitenon su

ture

(low

breaking st

rength

& lo

w

gliding re

sistance

) are

adequate when pass

ive

mobilizatio

n is planned

Multistra

nd repair

(high

breaking st

rength

& lo

w

gliding re

sistance

) when

active m

obilizatio

n

Blood supply:

Critical factor for final

results Hypovascularity

> decreased matrix >

decreased strength >

decreased motion > greater

adhesions

variables of tendon healing

Preservation/

reconstruction of flexor

sheath: A2 & A4 must

Sheath

reconstruction restores

nutrition, lu

brication

variables

of tendon

healing

Increases healing, collagen deposition and remodelling, pumping of nutrients inside the tendon, disruption of early vascular budding & adhesions frmation

Early Motion & tensile strength

variables

of tendon

healing

strengthP roportional

number strands

Eight strand

Kessler repairFour strand

cruciate

VS

Four strand cruciate

light with composite grip easy to perform, knots outside, similar time as kessler and stronger

tendo ng rafting

When tendon ends can’t be approximatedNecrotic stump

graftingTendon

Indications

Complete wound healing with adequate soft tissue coverageAbsent edema/induration Satisfactory & stable Skeletal alignmentFull range of passive motion of joint

Requirements

absence of indicationsadherent extensor tendons

planned capsulotomy

Contr

ain

dic

ati

ons:

DONOR

SITES

palmaris longus

plan

taris

ext

enso

r

dig

itoru

m

tendon lengthening techniques

tendon lengthening techniques

tendon lengthening techniques

tendon lengthening techniques

tendon Lengthening/shotening

techniques

Z tenotomy for tendon

lengthening

Accordion technique

Modified Z

tenotomy

Oblique section &

sliding

Wed

ge s

ection

rese

ctio

n

Z- incision & resection for shortening

Doubling technique

Hoffa’s method