Marie Williams, DPM discusses etiology and approaches to tendon rupture repairs and the goals of repair and rehabilitation. Dr Williams also discusses surgical techniques for the tendon repair, using specific cases to support her statements.
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Marie Williams, DPM, DHL
Director, Podiatric Medical Education
Aventura Hospital and Medical Center
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Female Speaker: Just the repair of ruptured tendon. It kind of segues right in to what we’ve just talked about. I have a couple different types of tendon repairs that I want to show you. These are the learning objectives. So you’ll have them as we go. The goal of repairing a tendon is important so you want to provide adequate tensile strength. You definitely want to restore gliding function to the tendon because if you don’t restore gliding function, no matter what you’ve done, you really haven’t helped the patient in function. Your repair should be done in a timely fashion. You shouldn’t wait weeks to have something repaired. Your results are going to be far better if you can get a very fresh ruptured tendon repaired quickly. You want to limit any kind of further trauma to the area by getting there quick. So you don’t want a lot of edema, hematoma formation, things like that that are going to actually slow or delay your healing. Some of the common causes of a tendon rupture and we’re talking about all types of tendons but we have eccentric load on a tendon or a muscle interface, similar to that of an Achilles tendon rupture. Sharp object is very common. Someone dropping something on their foot, a knife, mother cooking. I have those examples and you’ll see that but a direct blow to the tendon by a sharp object. An open laceration where you’ll see these open wounds that are lacerated, sometimes they don’t even know they have actually a tendon tear. And then the one that I hate the most is the iatrogenically created laceration of a tendon. I find that the most common tendon that cut like that iatrogenically is the extensor hallucis longus tendon. I’ve had this happen to me a few times where you’re actually working and all of a sudden you go, “Where did that tendon go?” I probably hope this isn’t on tape. But, anyway, you’re actually doing surgery and you might be directing your resident and maybe someone hasn’t pulled that tendon back. I’ve had that happen with hemi and total implants where all of a sudden I don’t find that tendon. Iatrogenic tear of an extensor tendon to me is disastrous. But it’s just because it seems to take so long to heal and otherwise easy surgery turns to be complex. Healing of tendon, you’ve heard of lectures this week on how things heal biologically. You have your inflammatory phase, your granulation phase and your collagen and remodeling phases. The first 21 days of a tendon is really important. From the first day to the third week in healing is when you’re developing your granular tissue and then beginning to get some tensile strength to the tendon-tendon interface and that’s the important time to immobilize. The critical time to move the tendon is sometimes after three weeks so that you don’t get a lot of scar. You don’t get a lot of scar because you want to get increased strength to the tendon itself. The first 10 days relies on your tensile strength of the suture and the technique of opposing the tendon in. How well did you suture that tendon? I had an experience once where we actually did a tendon lengthening. It’s kind of a funny story because I did a tendon lengthening on extensor tendon on a patient who had a longstanding bunion deformity bilaterally and thought we were doing a really good job and we closed it and the patient came in. The first week, she looked pretty good, the second week, she couldn’t move her toe. I'm like, “Oh, that’s really strange because we had a really good result.” Actually, that week that I was having trouble with this patient, I was talking to Dr. Josh Gerbert and I said, “Jeez, I don’t understand why I have no motion to this toe. The bunion was perfect.” And he said, “Well, did you lengthen the extensor tendon?” I said of course. He says, “Well, 50 bucks.” He bet me 50 bucks that extensor tendon tore and it’s not functioning anymore. I’m like, “Really?” And I wasn’t this really young in practice and I was like, “Really?” I went back in there and both of those extensor tendons were torn and I had to repair them. And I have to tell you that the function of that was not as good as it could have been without that tear. Anyway, the first 10 days to the first week, you get the granulation tissue. It’s loosely around the tendon suture interface. It’s the most important time to make sure you’re not moving this around. By the second and third week, second week, the paratenon becomes more vascular. You have increased vascularity around the tendon healing, especially tendon suture interface. By the third week, now, you’re starting to get some tensile strength to the tendon and tendon suture interface and now you can start to move it.
By the fourth week, the edema reduces. You have some guarded motion but you do not need to be moving these tendons at that point. Surgical intervention, the goal is basically when you look at the goals of restoring a preinjured strength and function, you have advantages of operating. There’s a lot of literature on the advantages of like repairing an Achilles tendon versus not repairing it. This is where this literature comes from but you have less re-rupture rate. You have strength to the tendon. Of course in an athlete, you’re going to bring them back and surgically repair them because they can go back to strength, endurance and power much faster. Some of the disadvantages to an operative treatment. Let’s talk about Achilles tendon for a minute. You might have an elderly patient who may not heal well, where you might have considerations on cost and wound complications, adhesions. Basically, you have advantages and disadvantages to both. I definitely am toward the repair, surgical repair because I find that that is the thing that repairs quicker. There’s less disability overall as opposed to not repairing this at all surgically. In an Achilles, you have the medial incision. You have the incision that is actually midline or just off midline medially. You may need a tourniquet to actually evaluate the tendon without bleeding and you should really restore the paratenon, which is really, really critical and important in any tendon repair. The paratenon gives vascularity to the tendon in the second week of healing. If you don’t really find that paratenon and put it back, your tendon heal slower, less vascularity and function. In an open repair, these are the considerations you should have. This is the actual incision in the Achilles tendon. It’s opened. When you see a ruptured tendon, what you’ll commonly see is hematoma formation under the paratenon and you’ll see a bloody bluish discoloration, that’s where your tendon is usually ruptured. When you open it up, you’re going to preserve your paratenon. And then as you’re bringing your paratenon, opening it, you can see now the fragmented ends of the tendon. It’s sort of like the horsetail. I don’t know how else to explain it but it’s very loose spaghetti-like, you need to actually make sure that those ends are fresh and cleaned up if it’s a little bit older. If you get it right away, you can just do a nice end to end repair. Here you are cleaning up the ends and then you’re going to take the two ends and pull them together. I like to, when I pull these two ends together, make sure that your foot is not plantar flexed too much because you don’t want to give them a toe equinus, although you do plantar flex them in healing. When you’re putting the tendon back, I like to keep the foot as neutral as I can. This is an example of what we call a Krackow type stitch where you’re coming in from the tendon end and then doing somewhat like a locking or just a baseball stitch that the actual threads are within the tendon itself. It’s a very strong construct for end-to-end repair in an Achilles type tendon or any tendon. I use this type of stitch routinely for everything that I do even if it’s a short Krackow so that we’re all maybe doing two or three throws. In an Achilles, I'll do a very much longer throw. You can see here the actual Krackow stitch wrapped in and around the tendon on each side and you’ll see threads coming out the tendon ends. Here you’ll see you’ll do it on both sides and then you’re going to pull your threads together and tie it on each end. The weak point of course is in the middle, so you have to be really cautious about that and cautious about your thread materials. Absorbable or non-absorbable, it needs to be strong. I think when it comes to thread, it’s definitely surgeon preference, whether they’re going to use a FiberWire type or an Ethibond or a 2-0 Vicryl and I think that’s just surgeon choice. Literature states that the non-absorbable threads, of course, give you more strength and stability to your tendon healing. You can see here the tendon ends are being pulled together. Now, you see that small little section, that’s a weak point. When I see that, what I do is l put acellular biological tissue for tendon repair and tie it into tendon ends. It does strengthen my tendon repairs. I feel more confident in getting patients up and going much faster. Here’s just an example. Once you then close and get the tendon ends together, very important that you close the paratenon over the tendon that is your bloodspot of the tendon. No matter what you’re covering the tendon with, your paratenon is very vital structure and you need to appreciate that. So that’s closed completely.
Then you’re going to just conventionally close your skin and soft tissue as you normally do. Now, there’s a lot of literature and there’ll probably be a lot more literature coming out as post to end-to-end versus an augmented tendon repair. Dr. Lee in 2007 was one of the first to start to document some of the repairs. You have the primary Krackow end-to-end and then augmenting it with a plantaris tendon was one of the most common things. You take the plantaris, fan it out and then wrap it. That helped to increase tensile strength and collagen to the tendon. You allowed earlier, faster weightbearing of the tendon. It actually strengthened the tendon at the tendon repair interface. The plantaris was used for augmentation. And then as I said, Dr. Lee in 2007 talked about using acellular matrix for augmentation. There’s some disadvantages to that but one of the advantages is that the recovery time and the strength and the tendon and I have a lot of research on that myself, which is going to be published early but the tendon is very, very strong with this acellular matrix. It doesn’t re-rupture. Commonly, I haven’t had any re-ruptures in that area. If it’s going to rupture, you’ll find that that’s still intact in the tendon rupture somewhere else. This is the acellular matrix in place but we’ll go over that. There’s open procedures now and there’s percutaneous operative procedures in the Achilles particularly. I have to tell you that I’m not experienced in the percutaneous procedure, although, I do know that there’s a lower rate of wound infection. You have to be careful of the sural nerve and others and definite improve cosmetics. I don’t know because I can’t really answer to you whether this is a better or more advanced technology since I don’t do that type of procedure. But they’re out there and you need to know about it especially as residents. Maybe you’ve had more experience on that, I don’t know. Postoperatively, there’s all types of things. I mean, there’s all kinds of discussions about postoperative rehabilitation. One of the things that I find most important no matter what articles are written is that you want to get early mobilization of the tendon. I tend to follow that three-week rule on all my tendons where I keep them immobile for three weeks and then I’ll get them returning to a range of motion and strengthening from the three-week period on to the next three to four-month period. I find very good results in that with very little re-rupture. But Sorrenti had an article in 2006 that had surgery combined with early mobilization before six weeks which reduced range of motion loss, and also increased blood supply and reduced actually the atrophy of the muscle and the time to actually get back to normal activity. I think that if you start to read a lot about tendon pathology, early active motion and function is very key. There’s also very important, physical therapy. No matter what type of tendon repair you do, physical therapy. Your physical therapist is your best friend. Some of them are so advanced in some of the technologies to get things strengthened that I basically say to my physical therapists, send me the treatment plan, and they know a lot of the modalities a lot better than I am. And then here’s a couple of pictures of some Achilles tendon rupture. This is a 65-year-old female who had ruptured her tendon spontaneously mid-substance. You’ll always see that hematoma-like formation. We did an end-to-end repair with a Krackow stitch and reinforced it with an acellular dermis. Interestingly enough, I’ve followed her through and through. I’ve seen her five years postop. The interesting thing about that is the side that she ruptured is stronger than the side that hasn’t been ruptured. There’s very little swelling and scar at the tendon. Even after five years, I mean she’s still going strong. That’s a five-year follow-up. That’s just probably now eight or nine years follow-up. This is an interesting case that got missed in the emergency room. This is a young girl. She was cooking in her kitchen, dropped the knife on her big toe, had a little stab incision. Went to the emergency room, thought it was really a big deal. They said, “Oh, it’s a little poke hole, no big deal.” What happened was it was actually a lot bigger, the laceration is a lot bigger than she thought and her toe is starting to bend where she couldn’t dorsiflex the toe. She came to us and I said the tendon is torn, cut, ruptured. She’s like, “It’s impossible. It wasn’t a very big cut.” I said, “I guarantee it is.” Went back in. She had no function and dorsiflexion. When I went in, found the two tendon ends. These are very little tendon but you know it’s really important to have your extensor hallucis longus functioning, especially for push-off gait, your windlass mechanism. There’s just about everything about that extensor tendon that is important to repair.
You don’t want her to have a hallux malleus. We do this end-to-end repair and found the two ends, modified Krackow suture. The thing that’s really important to point out here is now we have the tendon and you can see how nice and straight the toe is. And the interphalangeal joint is now no longer in plantar flexion motion. And then what we did is repaired it with a small acellular matrix. This is a young girl. She’s a bartender and someone dropped their beer bottle on her and lacerated her medial ankle. She went to the workers’ comp physician and basically said, “Okay, so your laceration is healing well. Go back to work.” She said, “But I can’t walk. I’m in a lot of pain. My foot looks like it’s rolling in.” So I took a look at her and I said, “Well, you know what, I’m sure this tendon is lacerated.” Okay. So I said, “Let’s prove it by MRI.” We got an MRI and it was a ruptured and torn posterior tibial tendon. So what we did at the medial malleolar area, found the tendon ends. When I first opened it up, I thought, “Oh, my god, I'm probably not right because it looks like a deltoid tear.” But then as I started to really look, I found the one-tenth, the piece of the tendon sitting there nice and shiny. But when I lifted up the soft tissue and the fascia, I found the other tendon end. We pulled it together and did an end-to-end repair and we augmented that of course. But the funny thing was is that I would have probably just closed it up but my suspicions were that there is definitely something more to that even though the tendon was sitting there looking very nice. It retracted back but the flap that didn’t retract back made it look like it was completely not affected. So be cautious on that. In conclusion, identify the tendon injuries early. You may get these patients coming from the emergency room where the emergency room physicians have sutured up the skin. If you find there's no function, definitely, be cautious that there’s a tendon tear, maintain good strong tendon end-to-end repair and get the acute injury handled quickly. Maintain immobilization for at least three weeks and then get to early range of motion passively and then actively to reduce scar. There’s some references for you. I appreciate you being here as well. If you have any questions, this is a good time to ask. Okay, thank you.