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Marie Williams: So I'm going to do tendon repair. If you have any questions at the end, I'll answer all the questions in both lectures, is that okay with all of you? Good. All right. So tendon repair is something that I personally love as a subject. There are so much about tendons. So basically these are the learning objectives and I'll run through them.
This is a very busy slide. I'm just going to point it out to you from here. There's all types of â there's the peritendinitis. There's peritendinitis with tendonosis, tendonosis, tendonitis, and then what they use to be called, what they're called now, this was really done well back definitions. So I just want to show that there's actually classifications of just tendon injuries. When we look at tendon injuries, we look at them usually, oh, you have a tendonitis, but it's more than that. So we're going to look at that a little bit.
Tendonosis is something that is usually caused by a chronic degenerative change in the tendon with very little pain. It's an overuse syndrome. There's microtrauma to a tendon and it's the national aging process. It's really commonly seen in the Achilles tendon in the â right in the back here where you get a lot of swelling and inflammation, thickening of the tendon. On occasion when they're working hard, pain will increase, but really the thickness is there more than the pain.
Tendonitis is a symptomatic degeneration of the tendon. It's an inflammatory process within the tendon itself. There's a chronic inflammation tendonitis with the peritenon and adjacent synovial structures becoming inflamed, disruption of the normal tendon glide. And here's a common place that nobody really â I get this a lot. I don't know if you could see it but at the base of the fifth metatarsal where the peroneal comes in, there's usually â there's areas there where will it become very, very thick, swollen and inflamed.
They even said that there's a lump there and you think it's the base of fifth metatarsal and it's actually a tendonitis of the peroneal tendon. Chronic tendonitis can come from being severely pronated where you'll get a posterior tibial tendonitis. And in here, this patient has â she doesn't think that there's any wrong except that her ankle hurts and it really is posterior tibial tendonitis. She has lymphedema and other comorbidities, but the tendon pain is from the posterior tibial tendon.
Tendon tears. You can get interstitial tears of the tendon from mostly due to a direct trauma, recurrent inflammatory changes, biomechanical dysfunction which leads to changes. This is actually tendon striations in the Achilles tendon, someone who is on many medications but you can see on posterior tibial tendonitis, a peroneal disease and people with equinus.
You'll see micro tendon tears or longitudinal tears sometimes in patients with a chronic heel pain and they'll keep coming to you treating them for plantar fasciitis. Don't forget that the peroneus longus and brevis can have striations in it and chronic tendon tears. So please make sure you do an MRI if you're not getting any relief with your classic treatment for heel pain.
I'm going to go through Achilles tendon ruptures pretty quickly. This is really the most common tendon injury though. It is actually a spontaneous rupture in the third to fifth decade of life, the weekend warrior, where they feel like someone kicked them or hit them in the back of the leg. They feel a pop and they immediately fall to the ground. That's pretty much classic for an acute Achilles tendon rupture. It's a forced plantar flexion of dorsiflexion and the blood supply arises from its osseous insertions at the myotendinous junction with multiple infiltrating meso external vessels, which cross the layers of the anterior peritenon.
And anywhere between two to six centimeters is called what we called the water shed area and that's where the most common area for tear. And testing it, you can basically palpate the defect. You can see the edema and swelling. You do not really need an MRI sometimes to identify these pretty much are clinical diagnosis as most accurate. I do, do MRIs mainly when I'm going to â mainly because as I repair it, I want to know how extensive the tear is. This is just an example and this is just basically the interior â the Achilles tendon ruptures are in the watershed area.
It's always a question on board's mechanism and injury is usually a forced plantar flexion, unexpected dorsiflexion or a violent dorsiflexion of a plantar flexed foot. And ideologies of any of the tendon deformities in most common the Achilles is use of fluoroquinolones, exercise-induced hyperthermia, mechanical abnormalities, metabolic problems such as gout or hyperthyroidism. Gouty patients sometimes get classifications within the tendon. They may get a rupture from the tendon, Achilles tendon to heel insertion, and I've seen that many times and you open it up, and there's all this in there. So that's one of the common problems.
Also direct trauma, the eccentric load, the muscle contracts, swell and stretch, that can cause it to become torn. And remember that you have the topical and oral steroids that might lead to weakness of the tendons. Injecting into the Achilles tendon is, in my opinion, contraindicated. It does lead to and I have seen it many times to tendon rupture. There's some generalized symptoms and weakness just around all the types of tendons this is most common with the Achilles.
Sudden increase in pain around the tendon weakness in the lower leg, poor balance especially with the Achilles, an audible pop or snap and inability to weight bear on the affected part. This is just a classification of the tendon injuries. If you look here, you have the grade one where you have fibers to the tendon. They're stretched more than they're not torn. There's little tenderness and the joint is not unstable.
In grade two, the fibers to the tendon are partially torn. That's most common with the peroneals. You'll see that in your MRIs, seeing partially torn striations in the peroneal tendons but anyway they're partially torn. The joint may feel unstable or give way during when found in a grade two. But in grade three, the fibers are completely torn. You have weakness and tenderness. There maybe a little swelling to extensive swelling depending on the injury. They're unable to really contract the muscles. It's very obvious deformity and may lead to surgical repair.
So this is just a basic grade one, two and three tendon classification. Common causes as we talked about, basic tendon healing is just like any type of wound healing. You go through the inflammatory phase in the first one to three days, followed by the granular phase by the three to 10, to 14-day period. And then you're going to start to go into the collagen phase and remodeling phase between 10 and up to 100 days.
So tendon healing is important to understand. I know that within three weeks the tendon technically should be healed. That's when you start to do active range of motion according to physiology of tendon healing. Basically in the first week, the tendons are when you have rupture of the tendon or you lose tensile strength in the first 10 days, the first week the tendons are joined when you put them together and there's a very small amount of granulation tissue.
In the second week, the peritenon vascularity increases. By the third week, you have moderate strength. And then by the fourth week, the edema decreases. You have less guarding and increased strength. So I usually use the three to four week guide from my post-op healing in tendon healing.
Some of the disadvantages and advantages to surgical intervention, so the operative treatments, it was shown that when you have a surgery to a ruptured tendon like in Achilles tendon, the rerupture rate is decreased as opposed to not during surgery, where you have a higher incidents of rupture. I have a patient who had a complete six centimeter tear of the Achilles tendon who had stents and medical condition, which I could not actually bring him to surgery.
So what I did is I put a collagen injection within the tendon itself and within three to four weeks I actually have some tendon regeneration and scarring, which she has no pain, no swelling, and I can't even feel the defect. So there's something said about some of the biologics that we have which we'll talk about later.
On physical exam, some of the common things, pain, ecchymosis, swelling, and there's usually palpable gaps in the areas of torn or ripped tendons. When you actually put them through range of motion and you're testing the areas, there's weakness on active motion of the affected tendon, unable to stand on the toes, I think Achilles, unable to invert, evert the foot, posterior tibial tendon.
In the posterior tibial tendonitis, people complain of ankle pain most commonly. That's what they say, "I have ankle pain." And then you invert and evert the foot and they can't take it. Unable to just evert the foot, you're thinking of peroneal tendon problems, also chronic heel pain, maybe peroneal tendonitis.
And unable to dorsiflex the foot, you have the extensor tendons, the extensor hallucis longus and extensor digitorum longus predominantly. Inversion of the foot by the way which is not a common injury, but unable to dorsiflex and invert the foot, anterior tibial tendon, I don't want to leave that out. Some of the imaging studies, you have the MRIs and ultrasonic testing for tendons to basically see how big the defect is, how much you have to repair it. And if there's a defect at all, whether it's swollen or is it really torn?
And x-rays don't really help. You do have soft tissue swelling. You might have in an Achilles an increased dorsiflexion. Sometimes classifications at the Achilles calcaneal insertion. So Haglund's deformity might lead to some of these problems in the posterior heel. Just an MRI, you saw a lot of radiology today so we won't belabor that point but it's always good to evaluate your tendons with an MRI.
On non-operative and operative treatments are your best choices. In the elderly, maybe a non-operative cast, immobilization, or bracing might be the treatment. I've had elderly patients who I couldn't bring to surgery. I couldn't do an MRI because they had pacemakers so you have to do an ultrasound that's kind of diagnose your problem, and then cast them or put them in the cast boot. That might just be the best alternative.
Open surgery with or without augmentation is usually used for the young patients and/or the athletes, and there's also a lot out there about percutaneous repair, especially of the Achilles which I don't do. Non-operative treatment for tendonitis, ice, rest, immobilization and compression. That's just with the pure tendonitis. Remember that you have alternative treatments. You have the PRP injections, coblation. There's a lot that you can offer. Remember that surgical intervention in especially ruptured Achilles is usually more indicated because you have less rupture rate.
And there's open repair and then there's percutaneous repair. This is just an example of an Achilles being opened, preserve that peritenon. When you open it, you always see this. I can open up every single Achilles, they all have that fraying at the distal lens of the tendon where they're torn. You're going to have to bring this end-to-end and remove some of those phrase, and that's what you're doing here.
You can see here there's stitches called the Krackow stitch which is one of the most common suture materials. The way you suture the tendon is it's strong. There's the Bunnell. There's Krackow. There's many types but this is a modified Krackow just to show you and there it is in real life where you're actually looping around the outer edges of the tendon, walking them in, and you're going to come through the bottom, and then do the same thing and tie in the middle.
So here's a picture of that. And then, here's a picture in real life. And then, here's the two ends coming together. And then you can see it here. Now of course the weak point where the two ends are coming together is a very, very weak point and has a high rate of rerupture but I think nowadays with the advent of the tissue augmentation and all the amnions, and everything else that we can put in there to increase strength to the tendon, our rerupture rates are going down.
This is just that. One of the most important things is once you do an end-to-end, make sure that peritenon is close. That's really an example of how well that peritenon. That's all the blood supply to the tendon. You really want to put that back and that's that peritenon closed completely. I do acellular tissue grafting in tendons where there's been articles out there showing the rerupture rate is less, the healing time is increased. So I just want to show you this is actually an Achilles tendon with an acellular dermis. That acellular dermis is what actually causes strength to the tendon and regeneration.
Just for completeness sake, remember that there's a percutaneous treatment. I think several companies have a percutaneous tools like Arthrex. I'm not very â I rather open it up and do an end-to-end myself. Postop rehab is very different depending. I mean, in the early days of repair of Achilles. you had them six weeks non-weight bearing, very little range of motion, took three and half to four months of just getting back to normal activity. Six to nine months of physical therapy, it has really changed.
In a study that [Sorenti] [14:46] did in 2006, he had no reruptures in his study although there are a small percentage of rerupture rates. But if you really immobilize them and get early mobilization without standing on it, and getting movement, they found that the rerupture rate was a lot less. Decreased scar was the whole point of that paper.
Remember, physical therapy is very important. Resistive therapy after the first â in my treatment plan, I don't even use a cast anymore. I use a CAM boot with gentle range of motion with the Achilles. And then, for about six weeks and then they're walking, so I do it a little bit different now.
Just to show you a couple â this is an Achilles tendon rupture. They all look the same to me. They're all bloody at the end. They're all fragmented end-to-end. This is acellular dermis being wrapped like a burrito and then sutured intact. This lady at the time, I thought she was old, she was about 75. She came to my office 80 years old, five years later, you couldn't even tell she had an Achilles rupture and she had full strength to that foot and ankle.
Another one where there are mid substance again, this was actually look like a rope so we had to actually repair the tear that was interstitial and then put an end-to-end, so that's that. Here's one where I want to back up. This lady had scar within the tendon and she had a very large posterior fragment. And we opened her up, repaired the tendon, repaired the scar tissue and then got her back into her shoe.
And I follow these people years later, four years later, five years. I can't even tell that they had surgery. The peroneal tendon, this is a really interesting case because this guy actually had chronic painful plantar fasciitis and what he had is longitudinal tear of the peroneus brevis tendon with a bulbous thickening and striations in the tendon itself. So I had to debulk the tendon and repair that tendon. Of course I used an acellular dermis. I use that all the time now.
With my results, they're so good that I do that because it reduces scar inflammation and increases tendon strength, and there it is. And these people get up walking very fast. Here's a patient who had longitudinal tears in the Achilles. It was very thick and fibrotic so what you're going to do is you take out that thick fibrotic tendon and then you can repair it, and they do very well.
You've seen this where we've had large heel spurs with Achilles enthesopathy or tendonosis. So you want to take out the spur and then what you do is you have to actually denude the tendon off the bone, and you need an anchor system of tendon to bone anchor and place that tendon back in. Remove the spur. Remove the tendon. Clean up the tendon ends and then replace it.
And this is it being put back into the bone with acellular dermis once again. This is an interesting case of a gunshot wound in a young kid. Here, his peroneal tendons were completely gone and his fascia was torn.
And so that's just another type of injury where you have a blowout. The bullet went in and out of the front to the posterior leg. And what was interesting is once we got this tendon ends together and the fascia together, he had very little to no pain. Within three weeks, he was walking around like he never had an injury.
Posterior tibial tendon repair, this is a typical Kidner type procedure. This is a tendon with large striations in the tendon. This is all like bulbous. We took out those pieces of tendon and then I saw tendon to tendon, and then I put an acellular dermis around it, and that's that tendon debulked and then some.
Extensor tendons are the worst I think because they retract quite a bit. This was somebody who dropped a knife on her foot and cut her tendon right in half. So you can see here where the tendon that was actually cut and then we were pulling it end-to-end, and then we put that back together.
What's interesting is on these of course, when you do the end-to-end, the toe immediately comes back into normal dorsal flexion, plantar flexion as opposed to being stuck in plantar flexion. Very rewarding. Here's another person with an extensor tendon tear that nobody could figure out and she came in with her toe down like that. So we opened her up and you can see here where there's no â I couldn't find the extensor tendon in the sheath.
So once I opened up the sheath I had to go looking for the ends which were up here and down here. And so this is us looking for the sheath and there you have two ends of the tendon with the sheath dissected out. Now there's a problem, how are you going to get the tendons end-to-end? You really can't. I mean, we tried everything so you have options. You can take the peroneus brevis and transfer it over. What we did is recreated a tendon with an acellular tissue that I've done many, many times.
So we made a tendon and then we wrapped it just like that and covered, sutured it all back. But what was really interesting is now the toes are in normal position and she had normal strength even though the two tendon ends never came together. Scar formation in the tendon, you can repair it. Make sure you dissect it out. This is the amount of tendon that's being removed and that was scarred. This is from a dog bite and then the actual scar was repaired, so there you go.
And augmentation of the tendon, this is an interstitial tendon that was torn and missed, and the patient had her hallux â the extensor hallucis longus tendon was taking over for the entire tendon and so her hallux is always stuck up. So we found her tendon, it was a very thin tendon. By the time we got to it, that atrophied so much and it was ripped off here. So what we did is we actually brought it back and tenodesed it to the bone.
There's a lot of literature out here that states that tendon to bone, tenodising is a much stronger strength, pull out strength than just end-to-end tendon. So we put that right into the bone. And there it is in the bone itself. You can see here how we actually drilled a hole and then we use a little bone anchor, and then placed that tendon right into the bone.
Now, my favorite case is just recent. This lady I was trying to take her to surgery for about three months. She came in with a large abscess in the posterior heel, 20 years ago she had an Achilles tendon rupture and the doctors put the Achilles back together. But for almost 15 years she had this little bubble and stuff that would drain out. So it looked like a full blown abscess because it was purulent but when you cultured it, it was sterile.
So it was a sterile abscess and then you right away that she had reaction to fiber wire. We see this commonly. I have many pictures of these types of cases but this was fun because I just opened her up and like you see here is you can see the back of the Achilles here. And then right here, you can see the thread coming out. You see the thread right here?
That's fiber wire stuck in the tendon and then tendon eating apart. I don't know if you can picture that very well but let me just go to the next picture. So this is cool because you can see the fiber wire sticking out and the tendon was all eating, like they had to actually debride out the granular tissue of the tendon and remove it. And then pull all that wire out, fiber wire out.
And once I did that, then I took my â I actually debulked that whole tendon and I put graft material inside the tendon, and then I sutured it over. So that would actually cause some regeneration of the new tendon. And there's the thread, it's quite a bit actually, and I pulled some tendon out in the office but that's 20 years of fiber wire sitting in there just eating out her tendon.
And you could see here, this here was where I pulled a lot of the tendon out here. There were holes in the tendon and on the very medial, lateral side, but we had it all out now and I took all the dead tendon away so I debrided the tendon. And then I put this little amnion product over it because that reduces scar. So I'm just giving her a little bit of a better chance of healing and then we closed her.
So time will tell on how well she progresses but my feeling is, is that when you remove a lot of that dead, necrotic tissue like fiber wire that causes sterile granulation and granulomas, that they do a lot better, so I'm not quite worried about that. But it was very interesting case and I have several of those cases and if you ask if I really like fiber wire I probably would tell you, no, because I see so many rejections.
Any on my tendon augmentations, I don't care what one it is. Three weeks non-weight bearing and a CAM boot or a cast, and three weeks of partial weight bearing and a CAM boot with active â with passive range of motion.
And I always get early active motion to the tendon and within 68 weeks return to full weight bearing, the patient tolerance with physical therapy and strengthening.
Remember that your goal, no matter what type of tendon, is to maintain strength, reduce scar, and reduce the chance for rerupture, because if they rerupture, it's just a miserable nightmare. And there's a lot of literature on all types of tendon and tendon repairs that I left there for you. Thank you so much for being the warriors, I say the weekend warriors that hang in there right to the end. I appreciate that. And I know super bones crew also appreciate you, so thank you and have the rest of the day. Have fun.
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