6 STG Tendon Transfer Repair CPMS Student Copy PDF

Principles of Tendon Healing, Repairs and Transfers Sean T. Grambart DPM FACFAS Associate Dean of Clinical Affairs, DMU-CPMS Director of Research, CPMS Attending, IMMC Foot and Ankle Surgical Residency, Des Moines IA Diplomate, ABFAS AO Fellow, Dresden Germany Past-President, ACFAS 1 1 What can happ...

Principles of Tendon Healing, Repairs and Transfers Sean T. Grambart DPM FACFAS Associate Dean of Clinical Affairs, DMU-CPMS Director of Research, CPMS Attending, IMMC Foot and Ankle Surgical Residency, Des Moines IA Diplomate, ABFAS AO Fellow, Dresden Germany Past-President, ACFAS 1 1 What can happen to tendons??? 2 What do we do with tendons? 3 Gross Anatomy Tendon No question 4 Tendon Histology 55–70% water Extracellular matrix (ECM) Primarily of aligned Type I collagen fibers (65–80% dry weight) Elastin Aggrecan Decorin Biglycan Fibromodulin 5 Tendon Anatomy Epitenon (Synovial Layer) surround the tendon Paratenon (areolar tissue) continuous with epitenon contains nerve and blood vessels Mesotenon is epitenon + paratenon 6 Tendon Sheath vs Paratenon? example Achilles straight no 7 turn Paratenon Continuous with epitenon Contains nerve and blood vessels - Allows tendon to glide Only found on tendons with straight pull 8 Tendon Sheath Tubular structure prevents bowstringing Found in tendons that curve Lined with synovial cells Allows tendon to glide like a piston in a cylinder Epitenon and inner layer of sheath make up mesotenon Contains blood and lymphatics less vascular 9 Tendon Healing 10 Phases of Tendon Healing Inflammatory Proliferative Remodeling 11 Phase 1: Inflammatory The response to tendon injury can be divided into three overlapping stages (22). In the inflammatory stage, which typically spans a few days, the wound site is infiltrated by red blood cells, white blood cells (leukocytes), and platelets equipped with important growth factors and endothelial chemoattractants. Whereas a fibrin clot is formed to provide temporary stiffness, macrophages digest necrotic debris, and tenocytes are recruited to the wounded area and stimulated to proliferate, particularly in the epitenon 12 Phase 1: Inflammatory Starts at the moment of injury Last 2-3 days RBCs,WBCs, and Platelets Growth Factors Macrophages The response to tendon injury can be divided into three overlapping stages (22). In the inflammatory stage, which typically spans a few days, the wound site is infiltrated by red blood cells, white blood cells (leukocytes), and platelets equipped with important growth factors and endothelial chemoattractants. Whereas a fibrin clot is formed to provide temporary stiffness, macrophages digest necrotic debris, and tenocytes are recruited to the wounded area and stimulated to proliferate, particularly in the epitenon 13 Phase II: Proliferative Begins two days into the injury Macrophages Shift from phagocytic to reparative Tenocytes * Temporary matrix Type III collagen The second stage, known as the proliferative or repair stage, begins roughly two days into the injury response. This phase of healing is characterized by profuse synthetic activity and is directed by macrophages and tenocytes. Macrophages, whose role shifts from phagocytic to reparative a few days after injury, release growth factors and direct cell recruitment (24, 25). Meanwhile, tenocytes deposit a temporary, mechanically inferior matrix composed mostly of collagen III. 14 Phase III: Remodeling Starts 1-2 months after the injury Type I collagen synthesis Extracellular matrix (ECM) aligned Never regains pre-injury properties In the third and final stage, known as the remodeling phase, collagen I synthesis begins to dominate, and the extracellular matrix (ECM) becomes more aligned. In addition, cell density and general synthetic activity are gradually decreased. This phase begins 1–2 months after injury and can last more than a year. The repaired tissue appears scar-like and never completely regains the biomechanical properties it had prior to injury 15 Phases of Tendon Healing Inflammatory Proliferative Remodeling 16 What does this all mean? 17 What does this all mean as a surgeon? ↑ Begin ROM exercise 18 What do we do with tendons? 19 Type of Tendon Repair Debridement withTubulerization End to end Reconstruction 20 Type of Tendon Repair Debridement with Tubulerization End-to-end Reconstruction 21 Debridement/Tubulerization common most peroneal 22 Type of Tendon Repair Debridement/Tubulerization End-to-end Repair Reconstruction 23 End-to-End Repair achiles most common no questions 24 Krakow 25 Krakow 26 Type of Tendon Repair Debridement/Tubulerization End-to-end Reconstruction 27 Tendon Reconstruction Options? 28 more common than ↓ Allograft Reconstruction 29 autograft Tendon Transfers Purpose of tendon transfers?? eliminate deforming force 30 Types of Tendon Transfers think of this Tendon Transfer more Detachment of a tendon of a functioning muscle at its insertion and then its relocation to a new insertion or attachment Tendon Transposition Rerouting of the course of a normal muscle tendon without detachment to assist other functions Muscle-Tendon Transplantation The detachment of a muscle tendon at both its origin and its insertion and moving it to a new location along with its neurovascular support structures constitute a muscle–tendon transplantation Tendon Suspension Tendon procedures designed to support a structure Tenosuspension 31 "Important Principles of Tendon Transfers 1. Tendon to be transferred ideally should be phasic 32 Principles of Tendon Transfers "memorize" 1. Tendon to be transferred ideally should be phasic st In-phase Out-of-phase Invest/everit flex/dossiflex Plantar 33 Principles of Tendon Transfers 2. Adequate range of movement within the joint on which the transferred muscle will act should be remaining If rigid deformityTendon 34 transfer wont do anything Principles of Tendon Transfers 3. Muscle must have adequate power Lose at least 1 grade of power with the transfer Transfer only muscle tendon units with a power of M4 or M5 Recommend the transfer even for a weak muscle if it is considered to be the deforming force 35 Principles of Tendon Transfers 4. After the transfer, the tendon should run in as straight as a course as possible Straight line of pull Tendon is placed under “zero” tension 36 Types of Tendon Transfers Side-to-side/Tenodesis Tendon-to-bone 37 Types of Tendon Transfers Side-to-side/Tenodesis Tendon-to-bone 38 Side-to-Side Lengthening or transfers Most physiologic pull Problem is slippage DB to PL transfer 39 Type of Tendon Surgery Techniques Side-to-side Tendon-to-bone 40 How Do We Secure Tendons to Bone? 41 Trephine 42 Button 43 Screw and Washer 44 Suture Anchor 45 Biotenodesis/Interference Screw most common 46 FHL Short Transfer cut medial to lateral 47 Stop Recording! 48 Case 1 60 year old male presents to your office with for follow up on a right 1st MTPJ arthrodesis. His wife has a few complaints about him as well! tised of him PMAX : none limping and tripping on left foot Neurovasc : intact flex testdorsiflex TA rupture allograft repairs 49 50 Case 2 40 year old with a history of chronic lateral ankle instability. Limiting normal daily activities. Important FF carus Plantarflex + MT 51 What do you want to know? 52 Summary 53