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  1. 1. T en on healing variables repair grafting mansoor khan August, 2010 HMC Plastic & reconstruction d
  2. 2. muscle to the bone glistening structure between muscle & bone which transmit force from “ ”
  3. 3. collagen fibrils fibers fasciles tertiary bundles Tendons endotenon histology of tendons
  4. 4. Loose areolar tissue encasing tendon in low mechanical stress area Paratenon..?
  5. 5. Paratenon Loose areolar tissue containing collagen & inner lining of synovial cells, containing synovium like fluid bathing the tendon.
  6. 6. Inner layer which in contact with the tendon is epitenon (mesotenon) containing lymphatics, vessels which dips inside the tendon as endotenon.
  7. 7. Tendon Sheath..? a dense fibrous tissue tunnel enclosing tendon in high mechanical stress area
  8. 8. Double layer, outer fibrous & inner synovial Synovial layer is parietal and visceral containing synovial fluid tendon sheath
  9. 9. B L O O D vessels from musculotendonous junctions Vessels from osseotendonous junctions vanicula (briva & longa) in compression areas (joints), loose areolar tissue vessels (non-compression areas) s u p p l y
  10. 10. nutrition sources vincular blood vessels synovialfluid blood vessels
  11. 11. Tendon & tendon graft healing clot and fibrin plug seals the tendon gap macrophages/neutroph ils appears Inflam m atory phase (48-72 hours): Stitch provide the whole strength
  12. 12. cells migrate into the wound from, peritenon (extrinsic healing), epitenon/endotenon/tenocytes (intrisic healing) Becomes fibroblasts produce collagen Proliferative phase (5 days-4 w ks): Tendon & tendon graft healing Stitch provide the whole strength
  13. 13. Strength is shifted to the scar gradually rem odelling phase (4 w ks-2years): Tendon & tendon graft healing
  14. 14. 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...? extrinsic..?
  15. 15. Tendon healing modulators hyluronic acid improveshealing
  16. 16. Indications: Lacerations with intact soft tissue, Digital re- implantation, Tendon laceration with fractured bones Goals: Tendon healing, effortless gliding, full joint motion Tendon epair
  17. 17. mobile digit with minimal scare at least one digital nerve intact meticulous surgical technique co-operative patient careful graduated mobalization requirmentsrepair
  18. 18. Guidelines Meticulous/atraumatic technique place 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
  19. 19. Guidelines Epitenon sutures decreases external healing (adhesions), adds to strength, Modified kessler + epitenon suture (low breaking strength & low gliding resistance) are adequate when passive mobilization is planned Multistrand repair (high breaking strength & low gliding resistance) when active mobilization
  20. 20. Blood supply: Critical factor for final results Hypovascularity > decreased matrix > decreased strength > decreased motion > greater adhesions variables oftendon heali
  21. 21. Preservation/reconstruction of flexorsheath: A2 & A4 must Sheath reconstruction restores nutrition, lubrication variables of tendon ealing
  22. 22. I ncreases healing, collagen deposit ion and remodelling, pumping of nut rient s inside t he t endon, disrupt ion of early vascular budding & adhesions f rmat ion Early Motion &tensilestrength variables of tendon ealing
  23. 23. strength P roportional number strands
  24. 24. Eight strand Kessler repair Four strand cruciate VS
  25. 25. Four strand cruciate light with composite grip easy to perform, knots outside, similar time as kessler and stronger
  26. 26. tendo n g rafting
  27. 27. When tendon ends can’t be approximated Necrotic stump graftingTendon Indications Complete wound healing with adequate soft tissue coverage Absent edema/induration Satisfactory & stable Skeletal alignment Full range of passive motion of joint Requirements
  28. 28. absence of indications adherent extensor tendons planned capsulotomy Contraindications:
  29. 29. DONOR SITES
  30. 30. palmarislongus
  31. 31. plantaris
  32. 32. xtensordigitorum
  33. 33. ten lengt tech tendon lengthening techniques tendon don hening niques tendon Lengthening/shotening techniques
  34. 34. Z tenotomy for tendon lengthening
  35. 35. Accordion technique
  36. 36. Modified Z tenotomy
  37. 37. Oblique section & sliding
  38. 38. W edgesection resection
  39. 39. Z- incision & resection for
  40. 40. Doubling technique
  41. 41. Hoffa’s method

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  • Kamutshatsha

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