General Principles Of

Tendon Repair

– Dr Monitosh Paul (dept of Surgery, SMCH)

Objectives:
• Tendon Anatomy

• Tendon Healing

• Tendon injury

• Principles of Repair

• Repair Techniques

• Rehabilitation
Tendon Anatomy
Tendon:
• Fibrous connective tissue that attaches
muscle to bone and transfers forces generated by
muscle to bone that produces movement of joint

Composition:
• Cellular(20%) – tenocytes & macrophages
• Extracellular components(80%) –
70% -water
30 % : 95% type1 collagen
5% GAG + proteoglycans (aggrecan &
decorin)- enhance water-binding capability
Depending upon coverings
Paratenon covered tendons
e.g., patellar, Achilles tendons
• rich vascular supply so heals better
• often injured due to trauma
Sheathed tendons
e.g., hand flexor tendons
• less vascularized with avascular areas that receive
nutrition by diffusion
• often injured due to laceration and at risk for adhesions
Microanatomy of tendon
Pulley system: (flexor compartment of digits)
Intermittent fibrous condensations that exist along the tendon sheath to
secure the tendon to the adjacent bone

• Digits 1-4 contain:

 5 annular pulleys (A1 to A5)

 3 cruciate pulleys (C1 to C3)

(A2 and A4 are the most important pulleys to

prevent flexor tendon bowstringing)

• Thumb contains

 2 annular pulley
Tendon nutrition

1. Blood supply
From segmental vessels arising from surrounding
vessels
- In digits, flexor tendons through vincula; these are
folds of mesotenon through which run the small
vessels that penetrate the tendons

2. Synovial fluid: Supplies sheathed tendons

Produced within tenosynovial sheath
Vincular system

Nutrition of tendon
Suspensory ligament of tendon
Stabilization of tendon
FLEXOR ZONES OF HAND (Verdan’s
zones): 5 zones

ZONE I: contains only FDP tendons

Extends from just distal to insertion of FDS tendon to site of

insertion of FDP tendon.

ZONE II: (bunnell’s“no man’s land”) critical area of pulleys

• Contains both FDP & FDS tendons

• Between distal palmar crease & insertion of superficialis tendon

ZONE III: Comprises area of lumbrical origin
Between distal margin of transverse carpal ligament &
beginning of critical area of pulleys or 1st annulus.

ZONE IV:
Zone covered by transverse carpal ligament

ZONE V:
Zone proximal to transverse carpal ligament and include
forearm
• Surgical repair or re-attachment of
FDP to bone
TENDON HEALING
Goal of tendon healing:
• Re establish tendon fiber continuity
• Restore gliding mechanism between tendon and surrounding
structure
• Obtain a satisfactory return of digital motion

Two Forms of Tendon Healing :

–Intrinsic healing
• through the activity of the fibroblasts derived from the
tendon.

–Extrinsic healing
• by proliferation of fibroblasts from the peripheral epitendon
• adhesions occur because of extrinsic healing of the tendon
and limit tendon gliding within fibrous synovial sheaths
 TENDON INJURY

• Tendon injuries are common in trauma cases presenting

to Casualty; they are usually open injuries requiring
surgical intervention.

• The neurovascular injury may be associated with the

tendon injury, so have to r/o NVB injury before repairing

tendon.
 CLASSIFICATION OF TENDON INJURY

Tendon injury may be classified as:

Open or closed, sharp or blunt, and traumatic or degenerative,

based on nature and etiology of injury

Extensor or flexor, based on the tendons are involved

 CLASSIFICATION OF TENDON INJURY

• Open injuries require primary surgical

treatment for exploration, lavage and repair if
indicated. Ultrasound scanning may be used to
locate the proximal end of the tendon but not as
routine
 CLASSIFICATION OF TENDON INJURY

• Closed tendon injuries: mallet fingers

Shearing stress to the tendon may result in

closed tendon injuries

eg.: mallet fingers, Boutonniere deformities

and avulsions, ultrasound scanning is useful to
know level of injury, also for measurement of
gap between the tendon ends and to identify
pulley lesions and inflammatory processes. Boutonniere
deformities
 COMPLETE AND PARTIAL TENDON INJURY

• Open or closed tendon injuries may be partial or

complete

• When movement is present but painful this can

indicate a partial tendon injury

• In complete tendon injury, generally

movement is restricted
 TENDON REPAIR
1.Primary repair:
Golden period
With in 24hrs in a clean wound
best results
2.Delayed primary repair
1-10 days
Done: suspicion of infection , viability questionable or came late
3.Secondary repair
10-14days up to 4wks
4.Late secondary
After 4 wks
Delay several days if wound infected
 TENDON REPAIR
Incision (Brunner incision)
 TENDON REPAIR

Ideal
• Gap resistant

• Strong enough to tolerate forces generated by early controlled active motion protocols

• 10-50% decrease in repair strength from day 5-21 post repair in immobilized tendons

• This is effect is minimized (possibly eliminated) through application of early motion stress

• Minimal bulk

• Minimal interference with tendon vascularity

 TENDON REPAIR
Strickland stresses six characteristics of an ideal tendon
repair:
(1) easy placement of sutures in the tendon,
(2) secure suture knots,
(3) smooth juncture of tendon ends,
(4) minimal gapping at the repair site,
(5) minimal interference with tendon vascularity, and
(6) sufficient strength throughout healing to permit application of early
motion stress to the tendon.
 TENDON REPAIR
Direct repair: Tendon advancement:
• if laceration is more than 1 cm • if the laceration is less then 1 cm
from insertion from insertion.
 TENDON REPAIR
Ideal Suture material:

 Non reactive
 Pliable
 Small calibre (4-0) for core sutures and (6-0) for epitendon
 Strong
 Easy to handle
Common material: Polyester (Ethibond), Nylon, prolene
Suture configuration
3 Groups

Group 1 (e.g. : simple sutures)

• the suture pull is parallel to the tendon collagen bundles, transmitting the stress of the repair directly
to the opposing tendon ends.

• Weakest
 Group 2 (e.g. : Bunnell suture)
• stress is transmitted directly across the juncture by the suture material and depends on the strength of the
suture itself.

 Group 3 e.g. : Pulvertaft technique (fish-mouth weave);

• sutures are placed perpendicular to the tendon collagen bundles and the applied stress
• Strongest & most suitable
 Suture configuration
Modified suture configs.

 Multiple-strand modifications
• Savage (six strands)
• Lee (four strands)

 The Tang and Cruciate repairs

• better tensile strength and elastic properties

 A four-strand adaptation of the Kessler repair

• significantly stronger than the Kessler technique
 Suture configuration

DEPENDING UPON APPROACHES

• Epitenon-first technique
22% stronger than the modified Kessler
technique

• Circumferential suture :
Interlocking horizontal mattress suture
• greatest resistance to gap formation,
• highest stiffness
best overall
Suture technique

• End-to-End
• End-to-Side
• Tendon-to-Tendon
• Tendon-to-Bone
End to end technique

• Kessler & Modified Kessler

• Bunnel Crisscross

• Kleinert modification of Bunnel

• Tajima

• Strickland (modified Kleinert-Tajima)

• Fishmouth (Pulvert)

• Roll Suture
End to end technique
SUTURE TECHNIQUE (End-to-End)

Kessler
• Mainly used for tendon repair in the fingers and palm.
• disadvantage: knots being left exposed on the tendon surface

Modified Kessler (Smith-Evans

modification)
Advantage:
• A single piece of suture material is used.
• knot is left in the cut surface of the tendon.
• minimize the problem of exposed suture material
Disadvantage: difficulty to achieve satisfactory approximation
of the tendon ends.
 Kessler Technique:

3
1 2

6 5 4
SUTURE TECHNIQUE (End-to-End)

Crisscross Bunnel
SUTURE TECHNIQUE (End-to-End)

Kleinert (Bunnel crisscross modification)

• easier, less intratendinous ischemia, gap formation are possible.

SUTURE TECHNIQUE (End-to-End)

Tajima
Since two knots are made at cut ends, easy to approximate even the tendons at
difficult locations.
SUTURE TECHNIQUE (End-to-End)

• Strickland (Modified Kessler-Tajima)

Strickland 1995 : (modified)

Strickland 1995 : (modified) Strickland 1993

SUTURE TECHNIQUE (End-to-End)
Fishmouth (Pulvertaft):
• A tendon of small diameter can be sutured to one of large diameter.
• commonly used to suture tendons of unequal size.
SUTURE TECHNIQUE (End-to-End)

Roll-Stitch

• Tendon and skin sutured together

• Useful for suturing extensor tendons

over or near the metacarpophalangeal
joints
SUTURE TECHNIQUE
(End-to-Side)

• Used in tendon transfers

• when one motor must
activate several tendons.
Tendon-to (other) Tendon Suture

Chapter 66 : Flexor and Extensor Tendon Injuries. Campbell’s Operative Orthopaedic, 12th. Ed
Tendon-to-Bone Attachments

Chapter 66 : Flexor and Extensor Tendon Injuries. Campbell’s Operative Orthopaedic, 12th.
Ed
Tendon Attachment in Fingers

Chapter 66 : Flexor and Extensor Tendon Injuries. Campbell’s Operative Orthopaedic, 12th. Ed
One method of attaching tendon to bone

• A, Small area of cortex is raised with

osteotome.

• B, Hole is drilled through bone with

Kirschner wire in drill.

• C, Bunnell crisscross stitch is placed

in end of tendon, and wire suture is
drawn through hole in bone.

• D, End of tendon is drawn against

bone, and suture is tied over button
COMPLICATIONS

Short term: Long term:

• Infection • Adhesion
• Injury to • Rupture
neurovascular • Joint contracture
structures or • triggering
pulley system
• Abnormal scarring
Rehabilitation
Goal:
-promote intrinsic tendon healing & minimize extrinsic scarring to
optimize tendon gliding & functional range of motion

Early post-repair motion stress

– biologically alter the process of scar formation and maturation at the repair site
such that collagen is laid down parallel to the axial forces (increase strength), and
decrease adhesions i.e., tendon adhesions are stretched (increased tendon glide)
Methods of post-op tendon management are:
• Immobilization: Complete immobilization of tendon for 3 ½ weeks after Surgery; but
greater chances of production of scar adherence; greater incidence of tendon rupture

• Controlled passive motion: passive flexion and extension followed by active

extension and passive flexion

• Early active motion: early active extension but passive flexion, Method minimizes
scar adhesions while enhancing tendon nutrition and blood flow