Tendon Repair

1. Flexor tendon repairs
Tony Barabás
Colville Team teaching
St George’s Hospital
19th June 2009

2. Principles of tendon repair
• Number and size of incisions in sheath
kept to minimum
• A2 and A4 preserved if possible
• Make incisions in sheath between annular
pulleys
• Minimal touching of tendon ends
• Reconstruct the sheath if possible but
don’t compromise glide

3. Principles of tendon repair
• Epitendinous suture of back-wall first to
correctly align tendon, inverting,
continuous
• Core suture → Bunnell, Kessler, Modified
Kessler (self-locking), Strickland
• 2, 4 or 6 strand repair.

4. Characteristics of ideal repair
Strickland
• Sutures easily placed in tendon
• Secure suture knots
• Smooth juncture of tendon ends
• Minimal gapping at the repair site
• Minimal interference with tendon
vascularity
• Sufficient strength throughout healing to
permit early motion stress on tendon

5. Core Sutures

6. With increasing strands
• ↑ technical difficulty
• ↑ damage to tendon ends
• Compromises nutrition and ability to heal

7. Modified Kessler

8. Grip Strength by strand #’s over
weeks since repair
0 1 3 6
0
4000
2000
6000
8000
Force
in
grams
Time in weeks
2 strand
4 strand
6 strand
. .
.
. .
.
.
.
.
Passive
.
.
. .
.
.
.
Strong
grip
. .
. .
Light
active
. .
. .

9. Suture materials
• Size 3.0 or 4.0
• Monofilament passes thru tendon more easily,
however knots slip more easily
• Braided/polyfilament hold knots better, but ?
more trauma to tendon on insertion

10. Epitendinous sutures
Why use them?

11. 1. To stop gapping!
• Gapping → considerable weakening of repair
• Unfavourably alters tendon mechanics
• ↑’s adhesion formation → ↓ tendon excursion
Silfverskoild et al, Pruitt et al, Lin et al
• Poorer clinical outcomes after gapping Seradge

12. 2. Increase repair strength
• 10 – 50% ↑ in repair strength Silfverskoild et al, Dial et
al, Wade et al

13. 3. To smooth edges
• Doesn’t catch on pulleys
• Glides more smoothly

14. Simple running

15. Silfverskiold

16. Sheath repair advantages
• = barrier to extrinsic adhesions
• Quicker return to synovial nutrition
• Acts as a mold for the remodelling tendon
• Results in better tendon-sheath
biomechanics

17. Sheath repair disadvantages
• Technically difficult
• May narrow and restrict tendon gliding