TENDON HEALING AND

SUTURING
Abdaud Rasyid Y
Pembimbing :
Dr. Tito Sumarwoto, Sp.OT(K)-Hand

ANATOMY of TENDON
Biology of Tendon
Anatomy of Flexor Tendons
Anatomy of Extensor Tendons

TENDON BIOLOGY
Collagen fibers
Rod/Spindle-shaped tenocytes
Extracellular matrix

TENDON BIOLOGY
Collagen fibers
Synthesized by tenocytes
Contain :
Glycine; Proline; Hydroxyproline amino acids

Type I
Two -1 + One -2 Triple-helix

Type III
Endotenon & Epitenon
early repair; if type I

Type V
Cell surfaces
Crosslinked to other type fibrillar structure

Chapter 24 : Anatomy, Biology,and Biomechanics of Tendon and Ligament.

Orthopaedic Basic Science

Journal of Hand Surgery

2008;33A:102112

Journal of Hand Surgery 2008;33A:102112

ANATOMY
Endotenon
Vascular,
Lymphatic,
Neural transmission routes

maintain tendon fibroblasts

ANATOMY
Epitenon
Binds the fascicles together
Supplies blood vessels
Supplies tracts for the lymphatics and

nerves

ANATOMY
Tendon Sheath
Covered with synovial cells
Lubricate and assist the enclosed tendons
Reduce sliding friction

Tendons in the hand

Chapter 24 : Anatomy, Biology,and Biomechanics of Tendon and Ligament.

Orthopaedic Basic Science

ANATOMY
Paratenon
a loose connective tissue through which

blood vessels enter and vascularize the

endotenon and epitenon
Achilles tendon

Chapter 24 : Anatomy, Biology,and Biomechanics of Tendon and Ligament.

Orthopaedic Basic Science

ANATOMY
Flexor Tendons
FDS
Two heads of origin.
Ulnar head
Radial head

Median nerve
loosely adherent to the deep surface of the FDS muscle.

Divides
At mid-forearm
middle and ring fingers (superficial)
index and small fingers (deep).

Innervation
the median nerve.

Blood supply
the radial and the ulnar arteries.

ANATOMY
Flexor Tendons
FDP
In the deepest layer of the volar forearm
adjacent to FPL.
Innervation
Ulnar nerve
ring and small fingers.
Anterior interosseous branch of the median

nerve
index and middle fingers.

Blood supply
ulnar artery

ANATOMY
Flexor Tendons
FPL
In deepest layer
Innervation
Anterior interosseous branch of the median

nerve
Blood supply
Radial artery

ANATOMY
Flexor Tendons
5 Anatomic zones
Kleinert & Verdan
Classifies injuries of the hand

Zone 1
Distal tip FDS insertion

Zone 2 No mans land

FDS insertion Fibro-osseus tunnel

Zone 3
Fibro-osseus tunnel Distal TCL/lumbricals origin

Zone 4
Transverse Carpal Ligament / Carpal tunnel

Zone 5
Proximal TCL muscle-tendon junction

Chapter 7 : Flexor Tendon Injury. Greens Operative Hand Surgery, 6th. Ed.

Chapter 7 : Flexor Tendon Injury. Greens Operative Hand Surgery, 6th. E

ANATOMY
Fibrous-Retinacular Sheath
Pulley System

Chapter 7 : Flexor Tendon Injury. Greens Operative Hand Surgery, 6th. E

ANATOMY
(Digital) Tendon Nutrition
Synovial fluid
produced within the

tenosynovial sheath
Blood supply via :
longitudinal vessels in the

paratenon,
intraosseous vessels at the
tendon insertion,
vincular circulation
VLS; VLP; VBS; VBP

ANATOMY
Blood Supply to Digital Tendons

Chapter 66 : Flexor and Extensor Tendon Injuries. Campbells Operative Orthopaedic, 12th.

ANATOMY
EXTENSOR TENDONS
Anatomical zones
Kleinert & Verdan
8 Zones
Doyle
+ Zone IX

Zone I
DIP joint

Zone II
Middle phalanx

Zone III
PIP joint

Zone IV
Proximal phalanx

ANATOMY
EXTENSOR TENDONS
Zone V
MCP joint

Zone VI
Metacarpal

Zone VII
Wrist (under DCL / extensor retinaculum)

Zone VIII
Distal forearm proximal DCL

+ Zone IX (Doyles Zone)

Extensor muscle bellies in forearm

or tendon injuries. : Hand surgery update, 3rd ed, Rosemont, Ill, 2003, American Society for Surgery of

ANATOMY
Extensor Tendons Entrance
6 Compartments
1st
EPB & AbPL

2nd
ECRL & ECRB

3rd
EPL

4th
Common ED & EIP

5th
EDM / ED quinti
Fibrous tunnel only no insertion to bone

6th
ECU
+ subsheath relate to ulna

apter 6 : Extensor Tendon Injury. Greens Operative Hand Surgery, 6th. Ed

ANATOMY
Junctura Tendinae
Proximal to MCP joint level,
Interconnecting band between
EDC IV V & III,

less substantial band

EDC III II

The importance
Surgical recognition of the proprius tendon of the index

finger
Preserves finger extension
if the EDC is lacerated proximal to the juncturae tendinae

The juncturae tendinae also restrict independent

extension of the ring and middle fingers when the

other digits are flexed at the MP joints.

TENDON HEALING
3 sequences :
Inflammatory
Proliferation
Remodelling

TENDON HEALING

Journal of Hand Surgery 2008;33A:102112.

TENDON HEALING
Inflammatory Stage
Injuries formation of a hematoma (Clot).
Activation of Chemotatic factors

Phagocytosis
Of Clot, cellular debris, and foreign body matter
By Erythrocytes, platelets, neutrophils, monocytes, and

macrophages
Fibroblasts
recruited to the site
Synthesize components of ECM

Formation of vascular netwoek

Angiogenic factors
Released and initiate the formation of a vascular network.

These processes include an increase in DNA and in ECM

establishes continuity and partial stability at the site of injury.

TENDON HEALING
Proliferative Stage
Fibroblast

= synthesis of collagens, proteoglycans, and

ECM.
arranged in a random manner.
largely of type III collagen.
Blood vessel network
Wound : scar-like appearance.
At the end of the proliferative stage :
the repair tissue is highly cellular
Contains water
ECM components

TENDON HEALING
Remodelling Stage
6-8 weeks after injury
cellularity,
matrix synthesis,
type III collagen,
type I collagen synthesis

Organized longitudinally

TENDON HEALING
Mechanism
Extrinsic
fibroblasts and inflammatory cells migration
to invade the healing site and initiate, and later
promote, repair and regeneration.
includes the initial formation of adhesions
requires a well-established vascular network

for the tissue to heal effectively

Intrinsic
migration and proliferation of cells from the

endotenon and epitenon into the injury site;

establish an ECM and an internal neovascular
network

TENDON HEALING
Molecular Mechanism
Growth factors
TGF- (Transforming Growth Factor )
Activation and regulation cellular responses
Cytokines bind to specific receptor
The initiation or release of these factors is stimulated

by cells mechanical loading of the injured tendon

initial inflammatory phase after trauma,
TGF expression
stimulates cellular migration and proliferation, as well

as interactions within the repair zona.

Later phase
Synthesis of collagen type I and collagen type III

TENDON HEALING
MOLECULAR MECHANISM
IGF-1 (Insulin-like Growth Factor - 1)
Early phase
stimulate the migration and proliferation of fibroblasts
and inflammatory cells to the wound site.
Later phases (remodeling),
synthesis of collagen and other extracellular matrix

components

VEGF (Vascular Endothelial Growth Factor)

Early phase
neovascularization
later phases,
establishment and maintenance of the vasculature

present in the endotenon and epitenon

TENDON SUTURING
Suture Material
Suture Configuration
Suture Technique

SUTURE MATERIAL
Monofilament stainless steel
Catgut (& Polyglycolic acid group)
Caprolactam & Nylon (synthetic)
Polydioxanone (PDS)
Braided polyethylene

Most suitable

SUTURE STRENGTH
Taras et.al
Noted a 49% increase in suture strength when caliber

was increased from 4-0 to 3-0.

the strength of a braided, nonabsorbable suture is
related to its cross-sectional area
Nelson et.al
Primary factors
core suture caliber,
number of core suture strands,
peripheral suture purchase
Secondary factors
core suture purchase
peripheral suture caliber

Repair technique ?

SUTURE STRENGTH
Winters et al
8-strand repair is stronger than 4-strand

repair
at 3 weeks (49% greater ultimate load)
at 6 weeks (117% greater ultimate load)

8-strand 3-0 difficult in practice

3-0 suture
mechanically advantageous

8-strand 4-0 suture

43% stronger than 4-strand 3-0

The Effect of Suture Caliber and Number of Core Suture Strands on Zone II Flexor Tendon Repair : A
Study in Human Cadavers.
Journal of Hand Surgery Am. 2014;39(2):262e268

mechanical Evaluation of Flexor Tendon Repair Using Barbed Suture Material:AComparative Ex Vivo Stud
nal of Hand Surgery 2011;36A:446449

SUTURE CONFIGURATION
3 Groups
Group 1
Ex

: simple sutures;
the suture pull is parallel to the tendon collagen bundles,
transmitting the stress of the repair directly to the opposing tendon
ends.
Weakest
Group 2
Ex

: Bunnell suture;
stress is transmitted directly across the juncture by the suture
material and depends on the strength of the suture itself.
Group 3
Ex

: Pulvertaft technique (fish-mouth weave);

sutures are placed perpendicular to the tendon collagen bundles and
the applied stress
Strongest & most suitable

Chapter 66 : Flexor and Extensor Tendon Injuries. Campbells Operative Orthopaedic, 12th.

SUTURE CONFIGURATION
Multiple-strand modifications
Savage (six strands)
Lee (four strands)
Cross stitch of 6-0 braided polyester

117% stronger than a modified Kessler

core suture with a conventional

epitendinous repair

Chapter 66 : Flexor and Extensor Tendon Injuries. Campbells Operative Orthopaedic, 12th.

SUTURE CONFIGURATION
The Tang and cruciate repairs
better tensile strength and elastic properties
compared with the Silfverskild, Robertson,

and modified Kessler repairs

A four-strand adaptation of the Kessler

repair (Smith-Evans modification)

significantly stronger than the Kessler

technique

Chapter 66 : Flexor and Extensor Tendon Injuries. Campbells Operative Orthopaedic, 12th.

Chapter 66 : Flexor and Extensor Tendon Injuries. Campbells Operative Orthopaedic, 12th.

SUTURE CONFIGURATION
Epitenon-first

technique
22% stronger than

the modified Kessler

technique
Circumferential

suture :
Interlocking

horizontal mattress
suture
highest load to failure,
greatest resistance to
Chapter 66gap
: Flexor
and Extensor Tendon Injuries. Campbells Operative Orthopaedic, 12th.
formation,

highest stiffness

SUTURE TECHNIQUE
Strickland :
6 characteristics of ideal tendon repairs
(1) easy placement of sutures in the tendon,
(2) secure suture knots,
(3) smooth juncture of tendon ends,
(4) minimal gapping at the repair site,
(5) minimal interference with tendon

vascularity,
(6) sufficient strength throughout healing to
permit application of early motion stress to
the tendon

SUTURE TECHNIQUE
End-to-End
End-to-Side
Tendon-to-Tendon
Tendon-to-Bone

SUTURE TECHNIQUE
Commonly Used End-to-End

Chapter 66 : Flexor and Extensor Tendon Injuries. Campbells Operative Orthopaedic, 12th.

SUTURE TECHNIQUE
End-to-End (Crisscross Bunnel)

Chapter 66 : Flexor and Extensor Tendon Injuries. Campbells Operative Orthopaedic, 12th.

SUTURE TECHNIQUE
End-to-End
Kleinert (Bunnel crisscross modification)
easier to insert
probably causes less intratendinous

ischemia.
Because of the single crisscross,
straightening of the suture within the tendon and

gap formation are possible.

Chapter 66 : Flexor and Extensor Tendon Injuries. Campbells Operative Orthopaedic, 12th.

SUTURE TECHNIQUE
End-to-End
Kessler
A modification of the Mason-Allen suture.
Effective for tendon repair in the fingers and palm.
In the fingers, (-) knots being left exposed on the tendon
surface

Modified Kessler (Smith-Evans modification)

(+)
A single piece of suture material is used.
Another advantage is that the knot is left in the cut surface of

the tendon.
minimize the problem of exposed suture material

(-)
difficulty of sliding the tendon on some suture materials to

achieve satisfactory approximation of the tendon ends.

Chapter 66 : Flexor and Extensor Tendon Injuries. Campbells Operative Orthopaedic, 12th.

SUTURE TECHNIQUE
End-to-End
Tajima
Allows the placement of two

pieces of suture material in

the ends of the cut tendon.
This

permits the use of the

suture for traction to pass the
tendon through the sheath and
beneath the pulleys in difficult
locations.

It also has the advantage of

allowing the knots to be

placed within the cut surface
of the tendon
Chapter 66 : Flexor and Extensor Tendon Injuries. Campbells Operative Orthopaedic, 12th.

SUTURE TECHNIQUE
End-to-End
Strickland (Modified Kessler-Tajima)
incorporates several advantages of each.
Separate sutures are introduced in each

tendon end at distance of 0.5 to 1 cm

so that the tendon ends can be passed within the

flexor sheath, using the free ends of the suture as

traction sutures.

The knots are tied within the tendon.

The sutures are locked with each exit from

the tendon

Strickland 1983 :
Separate sutures are introduced in each

tendon end at distance of 0.5 to 1 cm.

Approximately 25% of diameter of tendon
is grasped by separate needle passage and
locked on side of tendon.
Suture is passed transversely behind knot
across tendon, where second-needle passand-lock suture is used to grasp tendon
side.
Finally, suture is passed behind second
knot and down tendon-to-tendon end.
After placement of similar suture in
opposite end, two tendon ends can be
brought together, and repair usually is
tidied up by small circumferential suture.
When in place in end of given tendon,
protruding suture ends can be used to pass
tendon through tendon sheath and position
it for repair without needing to damage
tendon with further instrumentation
Chapter 66 : Flexor and Extensor Tendon Injuries. Campbells Operative Orthopaedic, 12th.

Strickland 1995 :
Perform
the
Strickland
modification of the KesslerTajima
core
sutures
as
described previously.
Add
a running-lock dorsal
epitendinous suture of 5-0 or 60 nylon.
On completion of the back wall
suture,
add
a
horizontal
mattress suture of 4-0 braided
polyester to the core suture
configuration.
Tie all knots of the core sutures.
Complete the palmar (volar)
running-lock
peripheral
epitendinous suture.
Chapter 66 : Flexor and Extensor Tendon Injuries. Campbells Operative Orthopaedic, 12th.

SUTURE TECHNIQUE
End-to-End
Double-right Angled
To suture the severed ends

of a tendon together
without shortening,
(+)
useful proximal to the palm.
easier and is used more often

when several tendons have

been severed in the distal
forearm and proximal palm.

(-)
apposition of the tendon ends

is not neat.
Chapter 66 : Flexor and Extensor Tendon Injuries. Campbells Operative Orthopaedic, 12th.

SUTURE TECHNIQUE
End-to-End
Fishmouth (Pulvertaft)
A tendon of small diameter can be sutured to

one of large diameter.

commonly used to suture tendons of unequal
size.

Chapter 66 : Flexor and Extensor Tendon Injuries. Campbells Operative Orthopaedic, 12th.

SUTURE TECHNIQUE
End-to-Side
Used in tendon

transfers
when one motor
must activate
several tendons.

Chapter 66 : Flexor and Extensor Tendon Injuries. Campbells Operative Orthopaedic, 12th.

SUTURE TECHNIQUE
Roll-Stitch
especially useful for suturing extensor

tendons over or near the

metacarpophalangeal joints

Chapter 66 : Flexor and Extensor Tendon Injuries. Campbells Operative Orthopaedic, 12th.

SUTURE TECHNIQUE
Pull-out Technique
For Tendon repairs or grafting
Tendon-to-tendon repair
in children
to avoid physeal injury.

Tendon-to-bone repairs,
the core suture techniques
Kessler
modification of the Bunnell crisscross suture
the pull-out wire is looped over a straight needle that is
passed transversely through the tendon approximately
10 mm from the cut end.
pull-out wire attached to a loop of the suture proximally
in the tendon to be passed into the bone distally

Tendon-to-Tendon Suture

Chapter 66 : Flexor and Extensor Tendon Injuries. Campbells Operative Orthopaedic, 12th.

Tendon-to-Bone Attachments

Chapter 66 : Flexor and Extensor Tendon Injuries. Campbells Operative Orthopaedic, 12th.

Tendon Attachment in Fingers

Chapter 66 : Flexor and Extensor Tendon Injuries. Campbells Operative Orthopaedic, 12th.

One method of
attaching tendon to
bone.
A, Small area of cortex is
raised with osteotome.
B, Hole is drilled through
bone with Kirschner wire
in drill.
C, Bunnell crisscross
stitch is placed in end of
tendon, and wire suture is
drawn through hole in
bone.
D, End of tendon is drawn
against bone, and suture
is tied over button
Chapter 66 : Flexor and Extensor Tendon Injuries. Campbells Operative Orthopaedic, 12th.

TENDON REHABILITATION
Method of Rehablitation
Significantly influenced by the
compliance of the patient,
the nature of the wound,
method of the repair.

Accelerate and decelerate patients'

regimens
based on their individual response to

treatment.

Controlled Passive Motion

Controlled Place-and-hold

TENDON REHABILITATION
Excursion
Duran and Houser protocol
3 to 5mm of tendon excursion was sufficient

to prevent restrictive adhesions after repair.

More recently,
6 to 9mm of excursion
maximal limit
further excursion was not beneficial

TENDON REHABILITATION
Flexor Tendons
(Passive flexion & Active extension)
1 5 days after surgery
A wrist-neutral dorsal blocking splint is applied.
MP joints are 70 degrees of flexion,
IP joints in extension.

Until 3 weeks,
Given hourly home exercise program
initially of passive positioning of the fingers
Next is passive flexion and active extension movements
Edema is addressed in the first 2 weeks
elevation, exercises, and gentle compression of the gauze.

After 2 weeks postoperatively, compressive bandages

can be applied as needed

TENDON REHABILITATION
Flexor Tendons (Cont.)
At 3 weeks postoperatively,
Isolated and composite active joint range of

motion exercises that are done hourly

6 to 8 weeks postoperatively.
dorsal protective splint usually is

discontinued
10 weeks postoperatively
Isolated strength exercises are gradually

introduced

TENDON REHABILITATION
Extensor Tendons
(Active flexion & Passive extension)
Controlled mobilisation using a dynamic
outrigger splint (+elastic bands).
2nd day after surgery ~ 5 weeks
Mobilisation active flexion and passie

extension
+ 3 weeks of active extension exercises
Then, unrestricted movement.

TENDON REHABILITATION
Extensor Tendons (Cont.)
(Controlled active extension)
No elastic bands
Resting position
Palmar splint
Wrist in 45o of extension,
MCP in at least 50o of flexion
IP in extension. Active extension is started the

Active extension
starts in a day after surgery,

Two types of exercise:

MCP and IP are extended together;
MCP are extended and the IP flexed.
Each exercise : 4x with 4 sessions of exercise each day

The splint is worn for 5 weeks and 2 further weeks at night only.

TENDON REHABILITATION
Timing and Type of Program
Designed individually
Based on physiologic healing response
Groth :
High physiologic response
Quick progress through the pyramid of excersise
adhesion
Low physiologic response
Less risk is required in therapy to maintain ROM

TERIMA KASIH