Advances in Tendon Repair

Techniques and Implications for

Postoperative managment

Disclosure
No funds received in support
of this study

Michael Sandow FRACS

Royal Adelaide Hospital &
Wakefield Orthopaedic Clinic
ADELAIDE

Porcine tendon obtained

as a culinary byproduct

Flexor tenorrhaphy
One of the most baffling problems in
surgery is to restore normal function
to a finger in which the tendons have
been injured
Stirling Bunnell

1918

Royal Adelaide Hospital

Orthopaedic / Plastic Hand Service
Flexor Tenorrhaphy
Outcome review 1989
Poor follow-up
Overall Bad results
20% Rupture rate !!
Only tracked down about 50%

Difficult operation
Unpredictable outcome
Major functional deficit if tendon lost
Careful repair does not guarantee a good
result but it helps!
Bad repair produces predictable bad
outcome

Royal Adelaide Hospital

Orthopaedic / Plastic Hand Service
Technique at that time
Modified Kessler core
4-0 nylon or similar
Kleinert traction
Flexed wrist splint
Poor follow-up arrangements

Failed tenorrhaphy
Bad planning
Bad technique
Bad execution
Bad tendon
Bad patient
Bad luck

Flexor Tenorrhaphy Failure

The cause of failure could be seen to
relate to one or more of:
1. Surgical technique error
a. Planning / grasp morphology
b. Execution

2. Inadequate suture strength

3. Inadequate coaptation of the tendon
4. Inadequate tendon healing response

Royal Adelaide Hospital

Unsatisfactory
Reviewed:
Suture technique
Material used
Rehabilitation and Follow-up
Supervision and teaching

Royal Adelaide Hospital

Orthopaedic / Plastic Hand Service

Adelaide Flexor Tenorrhaphy

Outcome review 2002
87% follow-up
71% good excellent
5% Rupture rate

Orthopaedic / Plastic Hand Service

Current predominant technique
4 strand single cross grasp repair
(Adelaide Repair)
3-0 braided polyester (Ethibond or similar)

Immediate active mobilisation

Extension block splint with wrist extended
Better tracking and follow-up

Flexor tenorrhaphy
Best chance is early primary repair
by competent surgeon
using a good technique
supported by skilled therapist

Delayed primary repair acceptable

Secondary repair: UNPREDICTABLE > BAD

Flexor Tenorrhaphy
How to repair
How to mobilise
What results can be expected
Motion vs. Rupture

What follow-up is appropriate

Flexor Tenorrhaphy
Core suture:
1. easy placement
2. secure knots
3. smooth tendon junction
4. minimal gapping
5. minimal biological interference
6. sufficient strength
Strickland 1995

Flexor Tenorrhaphy
...during the first 3 or so weeks the
integrity of the tenorrhaphy relies
primarily on the suture technique
and less on the healing response of
the tendon...
Wagner, Strickland et al JHS 1994

Flexor Tenorrhaphy
Core suture:

6. sufficient strength

Flexor Tenorrhaphy
Early active motion
Better excursion / strength
Repair reliant on suture until tendon healed
1. biomechanically sound
2. biologically inert
3. user friendly

1. easy placement
2. secure knots
3. smooth tendon junction
4. minimal gapping
5. minimal biological interference

Components of the repair

Lots of information
Where do you start?

Flexor Tenorrhaphy
Active mobilization after flexor
tendon laceration repair places
significant demand on the
tenorrhaphy,
as it is the suture, and its hold on
the tendon that maintains the
repair integrity until healing is
sufficiently advanced.

Flexor Tenorrhaphy
1. biomechanically sound, to
maintain integrity of the tenorrhaphy until
healing is sufficiently advanced;
2. biologically inert,

to facilitate normal

tendon healing processes; and

3. user friendly,

to allow the repair to be

performed by most surgeons
Sandow, APHSS, 1997

Approach
Repair material
Repair morphology
grasp (actual hold on the tendon)
number of strands
Strength
Gapping potential
(Inherent Gapping potential IGP)
Repair creep
Repair elongation
Concertinaing
Tendon trauma

Core suture you need to hold the

tendon together strongly enough
Tenorrhaphy technique
Grasp - performance as a knot
Strand stiffness multi-strand
Stand loading characteristics
Suture material

Flexor Tenorrhaphy
Multiple parts of a repair that can fail
1. Grasp
Loss of the hold on the tendon
2. Suture strand
Strand ruptures
3. Knot
Knot comes undone!

mod. Kessler repair

mod. Kessler repair

- simple repair
- poor biomechanics

- simple repair
- poor biomechanics

Core suture:
Inherent Gapping Potential
transverse suture pass
redundant suture - deformable grasps
suture-locking methods did not improve
strength (Wagner, Strickland et al 1994)

mod. Kessler repair

- simple repair
- poor biomechanics

Savage repair
- good biomechanics
- technically difficult

Flexor Tenorrhaphy
Savage too complex
Single-cross Grasp adequate
Superior to modified Kessler

Flexor Tenorrhaphy
The Savage method uses six strands
... intricate grasping weave
... stronger repair
... technically very difficult
... excessive manipulation
... learning curve...
Wagner, Strickland et al 1994

Modified Savage Single Cross Grasp 6 strand

Modified Savage -

Flexor Tenorrhaphy

Single Cross Grasp 6 strand

Six strand single cross grasp

active mobilisation
32 zone I and II FDP repairs
78% good / excellent (Strickland)
no ruptures - 100% follow-up
(Sandow , McMahon Atlas of Hand Clinics 1997)

4 strand single cross grasp repair

(Adelaide Repair)

Flexor Tenorrhaphy
Suture material Specifications:
strong and reliable hold
persistent
inert
stiff
secure knot
readily available

Suture material

Suture material

Prolene

Nylon

BPS

Steel

Specials

Availability

+++

+++

+++

++

Slide

+++

++

+/-

Ease of
use
Knot
security

+++

+++

++

++

++

+++

+++

+++

Prolene

Nylon

BPS

Steel

Specials

Availability

+++

+++

+++

++

Slide

+++

++

+/-

+++

+++

++

++

++

+++

+++

+++

Ease of
use
Knot
security

Elongation

+++

+++

+++

Elongation

+++

+++

+++

Strength

++

++

+++

++++

+++

Strength

++

++

+++

++++

+++

3-0 B.P.S. (Ethibond)

Effect of the knot

3-0 BPS (Ethibond)

17.2 N

34.2 N

4 X 34.2 = 136.8 N

4 X 17.2 = 68.8 N

73.0 N

136.2 N

4 strand single cross grasp

- Adelaide Tenorrhaphy 3-0 Ethibond
Tensile strength 78 N
Tensile Strength 78N

( Light active > 30 N )

Modified Kessler
Gapping 5 N
Rupture 35 N

(Tip Pinch 100 N)

90
80

Gapping 32N

2 STRAND

Porcine Ex-vivo Flexor Tendon (STT)

80

2 STRAND

Porcine Ex-vivo Flexor Tendon (STT)

4 STRAND
70

6 STRAND

Moderate
Active

60

50

6 STRAND

Moderate
Active

60

50

40

Light Active

30

40

Light Active

30

20

10

Gapping ( 1mm ) 32N

(Tip Pinch 100 N)

90

4 STRAND
70

Light Active 30N

20

4
Passive

10

4
Passive

0
4-0 BPS

3-0 BPS

4-0 BPS

3-0 BPS

Modified
Kessler

Tsuge
(loop
type)
46

Adelaide Strickland

Savage

Modified
Kessler

Strands

+++

+++

++++

Strength

4-0 +
3-0 ++

++

++

4-0 +
3-0 ++
-

+++

Gapping

Ease of
use

+++

++

+++

Material
availably

+++

+++

+++

+++

Strands

Strength

4-0 +
3-0 ++

Gapping

Adelaide Strickland

Savage

+++

+++

++++

++

++

4-0 +
3-0 ++
-

Ease of
use

+++

++

+++

Material
availably

+++

+++

+++

+++

Tenorrhaphy Ruptures
Recorded findings
Retrieved sutures

Tsuge
(loop
type)
46

+++

Type 2 : Rupture
at Knot

Type 1 : Knot
unraveling

Type 2 : Suture strand

damage

Type 4 : Strand Complete

-grasp failure

Flexor Tenorrhaphy Failure

variety of causes of flexor tenorrhaphy
failure
suture repair must have an adequate
mechanical performance and be
performed correctly

failure of the tendon to heal due to biological

shortcomings may mean that a proportion of
failures will be unavoidable

Single Cross Grasp 4 Strand

- Adelaide Repair -

Adelaide Flexor
Tenorrhaphy Protocol
modified mid-lateral incision
pulley retention (esp. A2), repair FDS
3-0 braided polyester suture
(preferred)
4 strand single-cross-grasp
single knot in repair site
5-0 epitendinous (non-cutting needle)

Incisions
Factors
Avoid crossing joints
at 90 deg.
Preference
Existing lacerations
Need to expose other
structures
Avoid Brunner

Modified Mid-lateral incision

Primary wound

Primary wound- closed

Modified Mid-lateral incision

Adelaide Flexor Tenorrhaphy

(4 strand Single cross grasp)
Immediate Active Motion
Dorsal Splint: Wrist 200 ext
MCP flexed 800
IP straight
Ext. strapping
Splint removed at 6 weeks

Flexor Tenorrhaphy
What sort of repair
How to mobilise
What results can be expected
What follow-up is appropriate

Loss to Follow-up

Flexor Tenorrhaphy
THM

Original 6 strand series:

(100% follow-up)

Easy to find (75%)

Last 25%
Overall (100%)

89%Good / Exc
50%Good / Exc
78%Good / Exc

..disproportionately poorer results in those

patient that failed to attend routine follow-up.
(Sandow, McMahon 1996)

Do a good repair and do it early and well

No urgency quality more than expedience
Atraumatic technique, retain pulleys
Repair FDS and nerves
Active mobilisation
Adequate supervision and follow-up
Patient education at least try!

Royal Adelaide Hospital

Orthopaedic / Plastic Hand Service
Variably skilled hand all comers

Flexor Tenorrhaphy
Outcome review 2002
87% follow-up
71% good excellent
20+
5% Rupture rate

END