WELCOME TO ALL

TENDON INJURY & REPAIR

DR. MUHAMMED SAIFUL ISLAMPHASE A, RESIDENT,

PAEDIATRIC SURGERYBSMMU

TENDON STRUCTURE

• HEALTHY TENDONS ARE BRILLIANT WHITE IN COLOUR AND HAVE A FIBRO-ELASTIC TEXTURE.

• THEY CAN BE ROUNDED CORDS, STRAP LIKE BANDS, OR FLATTENED RIBBONS.

• CONSISTS OF MATRIX AND CELLULAR ELEMENTS. 90-95% OF CELLULAR ELEMENTS ARE TENOBLASTS AND

TENOCYTES. 5% TO 10% OF THE CELLULAR ELEMENTS OF TENDONS CONSISTS

OF CHONDROCYTES AT THE BONE ATTACHMENT AND INSERTION SITES, SYNOVIAL CELLS AND VASCULAR CELLS.

(REFF: JOURNAL OF BONE & JOINT SURGERY, NOV,2006)

• THE EPITENON, A FINE, LOOSE CONNECTIVE-TISSUE SHEATH CONTAINING THE VASCULAR, LYMPHATIC, AND NERVE SUPPLY TO THE TENDON, COVERS THE WHOLE TENDON.

• THE ENDOTENON IS A THIN RETICULAR NETWORK OF CONNECTIVE TISSUE INVESTING EACH TENDON FIBRE.

• THE PARATENON IS A LOOSE AREOLAR CONNECTIVE TISSUE LIES SUPERFICIAL TO EPITENON.

(REFF: JOURNAL OF BONE & JOINT SURGERY, NOV,2006)

SOME PHYSIOLOGICAL ASPECTS TO KEEP IN MIND

• THE OXYGEN CONSUMPTION OF TENDONS AND LIGAMENTS ARE 7.5 TIMES LOWER THAN THAT OF SKELETAL MUSCLES.

• THE LOW METABOLIC RATE AND WELL-DEVELOPED ANAEROBIC ENERGY-GENERATION CAPACITY ARE ESSENTIAL TO CARRY LOADS FOR LONG PERIODS, REDUCING THE RISK OF ISCHEMIA AND SUBSEQUENT NECROSIS.

• A LOW METABOLIC RATE RESULTS IN SLOW HEALING AFTER INJURY.• HEALING OF TENDON IN TWO FORMS:

A) INTRINSIC HEALING B) EXTRINSIC HEALING (OCCURS BY PROLIFERATION OF FIBROBASTS FROM THE EPITENON. ADHESIONS OCCUR BECAUSE OF EXTRINSIC HEALING OF THE TENDON AND LIMIT GLIDING WITHIN FIBROUS SYNOVIAL SHEATHS). (REFF: JOURNAL OF BONE & JOINT SURGERY,

NOV,2006)

SOME PHYSIOLOGICAL ASPECTS (CONTINUED...)

• PHASES OF INTRINSIC HEALINGA. INFLAMMATORY (0 TO 5 DAYS) : STRENGTHS OF THE REPAIR

IS RELIANT ON THE STRENGTH OF THE SUTURE ITSELF.B. FIBROBLASTIC (6 TO 28 DAYS) : SO CALLED COLLAGEN

PRODUCING PHASE.C. REMODELLING ( >28 DAYS).

(REFF: JOURNAL OF BONE & JOINT SURGERY, NOV,2006)

BLOOD SUPPLY OF TENDON

• THREE MAIN SOURCES: A) MYOTENDINOUS JUNCTION B) OSTEOTENDINOUS JUNCTION C) PARATENON OR THE SYNOVIAL SHEATH > EXTRINSIC SYSTEMS.• TENDON VASCULARITY IS COMPROMISED AT JUNCTIONAL ZONES AND

SITES OF TORSION, FRICTION, OR COMPRESSION.

INTRINSIC SYSTEMS.

(REFF: JOURNAL OF BONE & JOINT SURGERY, NOV,2006)

TENDON INJURY

• TENDON INJURIES CAN BE ACUTE OR CHRONIC.• CAUSED BY INTRINSIC OR EXTRINSIC FACTORS, EITHER ALONE OR IN

COMBINATION. • IN ACUTE TRAUMA, EXTRINSIC FACTORS PREDOMINATE.• MODES OF INJURY :

SEVERED BY LACERATION OR CUT INJURY SPORTS INJURY

TENDON RUPTURE TENDINOPATHY

(REFF: JOURNAL OF BONE & JOINT SURGERY, NOV,2006TEXTBOOK OF OPERATIVE SURGERY, FARQUHARSON’S)

TENDON INJURY (CONTINUED…)

• AN ACCELERATION-DECELERATION MECHANISM HAS BEEN REPORTED IN UP TO 90% OF SPORTS-RELATED ACHILLES TENDON RUPTURES.

• DEGENERATIVE TENDINOPATHY IS THE MOST COMMON HISTOLOGICAL FINDING IN SPONTANEOUS TENDON RUPTURES.

• A TENDON MAY ALSO DISRUPT AT ITS ATTACHMENT TO BONE OR IT MAY AVULSE THE FRAGMENT OF BONY CORTEX TO WHICH IT IS ATTACHED.

PATIENT CATEGORY

WEAKEST AREA (PRONE TO RUPTURE)

YOUNGER AGE GROUPS

APOPHYSEAL ATTACHMENT

ADULTS MUSCUOTENDINOUS JUNCTION

ADELOSCENTS SITE OF TENDON INSERTION

(REFF: JOURNAL OF BONE & JOINT SURGERY, NOV,2006TEXTBOOK OF OPERATIVE SURGERY, FARQUHARSON’SSHORT PRACTCE OF SURGERY, BAILY & LOVE’S)

PREDISPOSING FACTORS FOR TENDON RUPTURE

INTRINSICPREVIOUS INJURYINCREASING AGEGENDERGENETIC PREDISPOSITIONMUSCLE WEAKNESSTENDON STRUCTUREOBESITYDIABETESMEDICATIONS: FLUOROQUINOLONES,

STEROIDSLOWER LIMB BIOMECHANICS

EXTRINSICTRAINING ERRORSCOLD WEATHER

TRAININGFOOTWEARTRAINING

SURFACE

(REFF: JOURNAL OF BONE & JOINT SURGERY, NOV,2006)

TENDON REPAIR

• PROVIDED THE PATIENT IS HEMODYNAMICALLY STABLE ACCORDING TO ATLS GUIDELINE, PRIMARY REPAIR CAN BE ATTEMPTED.

• HOW TO UNDERSTAND A TENDON IS INJURED OR NOT ?• LOOK, FEEL & MOVE.

TENDON REPAIR (CONTINUED…)

• NON ABSORBABLE MONOFILAMENT OR MULTIFILAMENT SUTURES ARE OF CHOICE.

• REPAIR OF SPONTANEOUS RUPTURE OF A DEGENERATIVE TENDON IS UNSATISFACTORY.

• SUTURE CONFIGURATIONS THAT RESULT IN AT LEAST FOUR ‘CORE’ STRANDS CROSSING THE DEFECT ARE GIVEN ACCORDINGLY.

• CONTINUOUS CIRCUMFERENTIAL EPITENDINOUS SUTURE ADDS ADDITIONAL STRENGTH.

(REFF: TEXTBOOK OF OPERATIVE SURGERY, FARQUHARSON’S)

TENDON REPAIR (CONTINUED…)

• IF THE TENDON HAS SEVERED AT ITS BONY ATTACHMENT, THEN TENDON TO BONE FIXATION IS REQUIRED.

• WHICH IS ACHIEVED BY SUTURE ANCHOR (KIND OF BONE SCREW) OR DRILLING A HOLE THROUGH THE BONE.

(REFF: TEXTBOOK OF OPERATIVE SURGERY, FARQUHARSON’S)

SPECIAL CONCERNS• TENDO ACHILLIS:

MULTI STRAND CORE SUTURE IS RECOMMENDED.SPLINTAGE OF THE ANKLE IN PLANTAR FLEXION FOR 6 WEEKS.ANKLE BRACE OR HIGH HEEL SHOES ARE RECOMMENDED FOR

1 TO 2 MONTHS.

• EXTENSOR TENDONS IN HANDS:HEAL WELL.REPAIRED PRIMARILY.AVULSION OF THE EXTENSOR TENDON FROM THE BASE OF THE

TERMINAL CAN BE TREATED CONSERVATIVELY BY SPLINTING THE AFFECTED JOINT IN EXTENSION FOR 4 – 6 WEEKS.(REFF: TEXTBOOK OF OPERATIVE SURGERY,

FARQUHARSON’S)

• FLEXOR TENDON INJURY IN THE HAND :

PRIMARY REPAIR WITH EARLY ACTIVE MOBILIZATION OFFERS BETTER RESULT THAN DELAYED GRAFTING (KLEINERT ET AL).

ZONE 2, THE TENDONS AND THEIR SYNOVIAL SHEATHS ARE WITHIN THE FIBROUS FLEXOR SHEATH AND IN ZONE 4, BEHIND THE FLEXOR RETINACULUM, SO DENSE AND PERMANENT ADHESIONS DURING HEALING.

IF BOTH FLEXOR TENDONS ARE DIVIDED, ONLY THE PROFUNDUS TENDON SHOULD BE REPAIRED. (REFF: TEXTBOOK OF OPERATIVE SURGERY,

FARQUHARSON’S)

TAKE HOME MESSAGE

• PRIMARY REPAIR IS ALWAYS ENCOURAGED.• BUT PRIMARY REPAIR OF SPONTANEOUS RUPTURE OF TENDON IS

NOT ENCOURAGED.• IN CASE OF FLEXOR TENDON INJURY OF HAND JUNIOR SURGEONS

SHOULD NOT ATTEMPT TO PRIMARY REPAIR IN ZONE 2 AND 4.

THANK YOU ALL