Surgical Skills - Tendon repair
Written by Prof. A.H.M. Shamsul Alam
Sunday, 26 August 2012 02:00
Page 12 of 15
Techniques of tendon repair
Tendons are composed of dense metabolically active aligned collagen and elastic fibers which are oriented in spiraling pattern. These individual bundles of collagen are covered with endotenon and the surface of this tendon is covered with epitenon. Tendon heals rapidly when held in apposition and excellent healing and return of tensile strength occurs in six weeks of time. The ideal characteristics of primary tendon repair are:
- Easy suture placement
- Secure suture knots
- Smooth juncture of tendon ends
- Minimum of gapping potential at the repair site
- Minimal interference with tendon vascularity
- Sufficient strength throughout healing, to permit application of early motion stress to the tendon
Two types of sutures are applied to achieve a secured tendon repair.
- Core suture
- Peripheral sutures on epitenon
Suture material used is a 4/0 proline with a 3/8th circle taper cut needle. This is used for both core and epitenon sutures.
The instruments required for this exercise are
- Bird parker handle no. 20 blade
- BP Handle with no. 15 blade
- Two no. 21 sized hypodermic needles
- 2/0 black silk sutures on a half circle cutting needle
- Adson forceps
- Needle holder
Techniques of tendon repair
This exercise is performed on a porcine trotter mounted on a hard-board. Steps are as follows
- Make a longitudinal incision on the ventral aspect of the trotter with a no. 20 blade. a wide exposure is necessary for an adequate repair
- Suture the wound margins to the adjacent skin on both sides of the incision at 4cm intervals to achieve adequate retraction. Use 2/0 black silk
- The superficial palmaris tendon is usually used for this exercise.
- The epitenon is the smooth gliding surface of the tendon. Avoid all temptation to handle this with forceps or haemostats.
- Divide the tendon sharply in a transverse fashion using no. 15 blade. Make sure that you divide the tendon in the middle of the wound.
- Stabilize both ends of the tendon by passing no.21 needles into the tendon ends.
- There should be at least 2cm of tendons available for repair on either side.
- Application of the core suture: a modified Kessler's suture is applied using 4/0 proline on a 3/8 circle needle. Take a firm grip on the transected surface of the tendon with the Adson's forceps and insert the needle through this surface through the equator of the transected tendon around 1/3rd the distance away from the circumference.
- The needle should pass parallel to the long axis of the tendon and exit the circumference laterally at least 1cm from the point of entry.
- The needle then re-entered the tendon 2-3 mm away from the exit closer to the transected end. This is the horizontal pass which exits the tendon at a point diametrically opposite to this point. Take care to pass the needle carrying this transverse suture superficial to the longitudinal suture. This arrangement grasps about 25percent of the cross-sectional area of the tendon.
- The longitudinal pass is now made on the opposite side of the tendon circumference bringing the needle out through the equator of the cross-section of the tendon, one-third the distance away from the circumference, diametrically opposite to where you entered the tendon. Ensure that this path is made deep to traverse suture line.
- This procedure is repeated on the opposite cut end. Finally the tendon ends are brought together and the tension of the suture it adjusted to eliminate gaps.
- Suture on the epitenon: running an epitendinous suture using 4/0 proline completes the tendon repair. Take care to start the suture from the inside of the cut end in order that the knot be buried.
- Applying tension stress on the tendon can test the strength of the repair.
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Last Updated on Friday, 16 August 2013 11:17