The Journal of Foot & Ankle Surgery 54 (2015) 143–144
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
A Simple Technique for Repair of Chronic Tendinopathy Jaclyn M. Schwartz, DPM 1, Matrona Giakoumis, DPM, AACFAS 1, Alan S. Banks, DPM, FACFAS 2 1 2
Resident, DeKalb Medical Residency, Podiatry Institute, DeKalb Medical Center, Decatur, GA Attending Surgeon, DeKalb Medical Residency, and Faculty, Podiatry Institute, DeKalb Medical Center, Decatur, GA; and Private Practice, Tucker, GA
a r t i c l e i n f o
a b s t r a c t
Keywords: tendon tubularization tendon tears suture technique
A large number of tendon repair techniques have been described for acute tendon injury. However, after reviewing the literature, it was noted that there were limited descriptions of specific suture techniques that address repair processes of chronic tendon pathology. Generally, in chronic tendinopathy, others have described a process known as tendon tubularization, which consists of a running stitch using a nonabsorbable suture material along the external surface of the tendon. We believe that leaving a nonabsorbable suture on the exterior surface of the tendon in this manner has the potential to disrupt the optimal gliding function. Furthermore, because additional damage could be present within the body of the tendon, this form of repair might not prove adequate to optimally appose the disrupted tendon segments internally. We have described a simple technique to repair chronic tendon injury from “the inside-out.” We believe this approach provides better augmentation of tendon strength and eliminates the nonabsorbable suture along the exterior surface of the tendon. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
The treatment of longitudinal tendon splitting involving less than 50% of the unit has typically consisted of a suture–tubularization technique. Tubularization has been described as a running baseball stitch along the superficial surface of the tendon to repair and restore a more normal shape to the unit (1–5). Historically, the suture used for tendon repair has consisted of a nonabsorbable braided synthetic polyester material, such as Ethibond (Ethicon Endo-Surgery, Inc, Blue Ash, OH) (6). More recently, tendon tubularization and repair has been described using absorbable suture (5). Previous reports have also advocated the use of either ProleneÒ (Ethicon End-Surgery) or nylon as the suture of choice, with the belief that these materials will generate less friction and cause less tendon deformation (7). Steel and DeOrio (2) reported, “the use of nonabsorbable suture (nine patients) or absorbable suture (six patients) in the repair and use of tenodesis or tubularization had no effect on the outcome.” Other investigators have described various techniques and surgical outcomes but without mention of the suture type or specific tubularization technique used (1,2,4,5). We believe that a more effective tubularization technique can be accomplished by repairing the damaged tendon internally using nonabsorbable suture, with a small absorbable suture used to simply approximate the tendon margins along the external surface. The purpose of the present report was to demonstrate that technique.
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Jaclyn M. Schwartz, DPM, DeKalb Medical Residency, Podiatry Institute, DeKalb Medical Center, Decatur, GA 30033. E-mail address: [email protected] (J.M. Schwartz).
Operative Technique The operative technique shown in the present case example involved repair of the peroneal tendons; however, this method can be used for primary repair of any chronic tendon pathologic entity. Partial tears of the tibialis posterior tendon represent another common site at which this approach can be used with frequency. Dissection should be conducted to the tendon level in the manner preferred by the surgeon. If the tendon demonstrates fusiform swelling associated with internal disruption, the tendon should be incised longitudinally and the degenerative segments debrided. If a longitudinal tear is present, the area should be debrided gently and any degenerative segments removed. Once adequate debridement has been achieved, the tendon is repaired from “the inside-out” to restore shape to the flattened tendon and to reapproximate the 2 sides of the tendon after removal of the degenerative segments (Fig. 1). A buried, box stitch should be initiated proximally and inside the tendon using no. 3-0 Ethibond (Ethicon Endo-Surgery) on an SH needle. A running stitch should then be continued distally at the same level, with care not to penetrate the exterior tendon surface (Fig. 1A and C). The continuous stitch should alternate medially and laterally to the midline. In some instances, a second, more superficial internal running suture might be required for complete apposition and enhanced strength. The result will be a well-apposed tendinous structure. The superficial margins of the tendon should then be reapproximated with a 5-0 Vicryl suture (Ethicon Endo-Surgery) in a running manner (Fig. 2). Because the structure has been repaired internally, the only function required of the external suture is to simply reapproximate the superficial margins.
1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2014.04.013
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J.M. Schwartz et al. / The Journal of Foot & Ankle Surgery 54 (2015) 143–144
Fig. 1. (A) On either side of the tendon midline, the first stitch was placed. (B) View showing a running stitch, which does not penetrate the exterior tendon surface. (C) A box or horizontal stitch was used to bury the knot.
Discussion A nonpathologic tendon is composed of 95% type I collagen; in contrast, a damaged tendon will repair itself by type III and V collagen scar proliferation (8,9). The scar tissue will be mechanically weaker and, therefore, can limit tendon resistance (9). Satomi et al (9) theorized that a repaired tendon will afford less mechanical strength because type III and V collagen consists of thinner tendon fibers than type I collagen. Tubularization apposes the tendon segments, enhances healing, and improves the tendon structure. Pace and Dhar (11) tubularized flat tendons into round structures to help protect the tendon from fraying and from damage when passing through bone tunnels. This technique has been reported for lateral ankle ligament tendon transfers; however,
the operative technique can be applied to other tendon structures and for additional indications (11). Their technique is one of the few that has been specifically defined in the literature, although the surgical outcomes were not reported. To the best of our knowledge, no studies comparing the outcomes for different tubularization techniques for the repair of chronic tendon pathologic features have been published. Although no direct complications were reported in earlier studies in which tubularized tendons were repaired with external nonabsorbable suture (1,4,5,10), we believe that the internal nonabsorbable suture repair appears to provide better strength to the tendon and, theoretically, will provide improved gliding function. The small gauge external absorbable suture will undergo hydrolysis over time and, therefore, will not impede the tendon’s mechanical function when passive range of motion is initiated. References
Fig. 2. (A) The superficial portion of the tear was retubularized using absorbable suture. (B) A running baseball stitch was used to complete the repair.
1. Dombek MF, Lamm BM, Saltrick K, Mendicino RW, Catanzariti AR. Peroneal tendon tears: a retrospective review. J Foot Ankle Surg 42:250–258, 2003. 2. Steel MW, DeOrio JK. Peroneal tendon tears: return to sports after operative treatment. Foot Ankle 28:49–54, 2007. 3. Krause JO, Brodsky JW. Peroneus brevis tendon tears: pathophysiology, surgical reconstruction, and clinical results. Foot Ankle 19:271–279, 1998. 4. Redfern D, Myerson M. The management of concomitant tears of the peroneus longus and brevis tendons. Foot Ankle 25:695–707, 2004. 5. Thomas JL, Lopez-Ben R, Maddox J. A preliminary report on intra-sheath peroneal tendon subluxation: a prospective review of 7 patients with ultrasound verification. J Foot Ankle Surg 48:323–329, 2009. 6. Ryan JD. Principles and techniques of tendon and ligament repair. In: Reconstructive Surgery of the Foot and Leg, Update 2010, The Podiatry Institute, Decatur, GA, 2010. 7. Singer G, Ebramzadeh E, Jones NF, Meals R. Use of the Taguchi method for biomechanical comparison of flexor-tendon-repair techniques to allow immediate active flexion. A new method of analysis and optimization of technique to improve the quality of repair. J Bone Joint Surg 80:1498–1506, 1998. 8. Miller SJ. Muscle-tendon transfers of the lower extremity. In: Reconstructive Surgery of the Foot and Leg, Update 1996, The Podiatry Institute, Tucker, GA, 1996. 9. Satomi E, Teodoro WR, Parra ER, Fernandes TD, Velosa AP, Capelozzi L, Yoshinari NH. Changes in histoanatomical distribution of types I, III, and V collagen promote adaptative remodeling in posterior tibial tendon rupture. Clinics (San Paulo) 63:9–14, 2008. 10. Grasset W, Mercier N, Chaussard C, Carpentier E, Aldridge S, Saragaglia D. The surgical treatment of peroneal tendinopathy (excluding subluxations): a series of 17 patients. J Foot Ankle Surg 51:13–19, 2012. 11. Pace A, Dhar S. Technique tip: tubularizing flat tendons in foot and ankle surgery. Foot Ankle 29:342–343, 2008.
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
A Simple Technique for Repair of Chronic Tendinopathy Jaclyn M. Schwartz, DPM 1, Matrona Giakoumis, DPM, AACFAS 1, Alan S. Banks, DPM, FACFAS 2 1 2
Resident, DeKalb Medical Residency, Podiatry Institute, DeKalb Medical Center, Decatur, GA Attending Surgeon, DeKalb Medical Residency, and Faculty, Podiatry Institute, DeKalb Medical Center, Decatur, GA; and Private Practice, Tucker, GA
a r t i c l e i n f o
a b s t r a c t
Keywords: tendon tubularization tendon tears suture technique
A large number of tendon repair techniques have been described for acute tendon injury. However, after reviewing the literature, it was noted that there were limited descriptions of specific suture techniques that address repair processes of chronic tendon pathology. Generally, in chronic tendinopathy, others have described a process known as tendon tubularization, which consists of a running stitch using a nonabsorbable suture material along the external surface of the tendon. We believe that leaving a nonabsorbable suture on the exterior surface of the tendon in this manner has the potential to disrupt the optimal gliding function. Furthermore, because additional damage could be present within the body of the tendon, this form of repair might not prove adequate to optimally appose the disrupted tendon segments internally. We have described a simple technique to repair chronic tendon injury from “the inside-out.” We believe this approach provides better augmentation of tendon strength and eliminates the nonabsorbable suture along the exterior surface of the tendon. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
The treatment of longitudinal tendon splitting involving less than 50% of the unit has typically consisted of a suture–tubularization technique. Tubularization has been described as a running baseball stitch along the superficial surface of the tendon to repair and restore a more normal shape to the unit (1–5). Historically, the suture used for tendon repair has consisted of a nonabsorbable braided synthetic polyester material, such as Ethibond (Ethicon Endo-Surgery, Inc, Blue Ash, OH) (6). More recently, tendon tubularization and repair has been described using absorbable suture (5). Previous reports have also advocated the use of either ProleneÒ (Ethicon End-Surgery) or nylon as the suture of choice, with the belief that these materials will generate less friction and cause less tendon deformation (7). Steel and DeOrio (2) reported, “the use of nonabsorbable suture (nine patients) or absorbable suture (six patients) in the repair and use of tenodesis or tubularization had no effect on the outcome.” Other investigators have described various techniques and surgical outcomes but without mention of the suture type or specific tubularization technique used (1,2,4,5). We believe that a more effective tubularization technique can be accomplished by repairing the damaged tendon internally using nonabsorbable suture, with a small absorbable suture used to simply approximate the tendon margins along the external surface. The purpose of the present report was to demonstrate that technique.
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Jaclyn M. Schwartz, DPM, DeKalb Medical Residency, Podiatry Institute, DeKalb Medical Center, Decatur, GA 30033. E-mail address: [email protected] (J.M. Schwartz).
Operative Technique The operative technique shown in the present case example involved repair of the peroneal tendons; however, this method can be used for primary repair of any chronic tendon pathologic entity. Partial tears of the tibialis posterior tendon represent another common site at which this approach can be used with frequency. Dissection should be conducted to the tendon level in the manner preferred by the surgeon. If the tendon demonstrates fusiform swelling associated with internal disruption, the tendon should be incised longitudinally and the degenerative segments debrided. If a longitudinal tear is present, the area should be debrided gently and any degenerative segments removed. Once adequate debridement has been achieved, the tendon is repaired from “the inside-out” to restore shape to the flattened tendon and to reapproximate the 2 sides of the tendon after removal of the degenerative segments (Fig. 1). A buried, box stitch should be initiated proximally and inside the tendon using no. 3-0 Ethibond (Ethicon Endo-Surgery) on an SH needle. A running stitch should then be continued distally at the same level, with care not to penetrate the exterior tendon surface (Fig. 1A and C). The continuous stitch should alternate medially and laterally to the midline. In some instances, a second, more superficial internal running suture might be required for complete apposition and enhanced strength. The result will be a well-apposed tendinous structure. The superficial margins of the tendon should then be reapproximated with a 5-0 Vicryl suture (Ethicon Endo-Surgery) in a running manner (Fig. 2). Because the structure has been repaired internally, the only function required of the external suture is to simply reapproximate the superficial margins.
1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2014.04.013
144
J.M. Schwartz et al. / The Journal of Foot & Ankle Surgery 54 (2015) 143–144
Fig. 1. (A) On either side of the tendon midline, the first stitch was placed. (B) View showing a running stitch, which does not penetrate the exterior tendon surface. (C) A box or horizontal stitch was used to bury the knot.
Discussion A nonpathologic tendon is composed of 95% type I collagen; in contrast, a damaged tendon will repair itself by type III and V collagen scar proliferation (8,9). The scar tissue will be mechanically weaker and, therefore, can limit tendon resistance (9). Satomi et al (9) theorized that a repaired tendon will afford less mechanical strength because type III and V collagen consists of thinner tendon fibers than type I collagen. Tubularization apposes the tendon segments, enhances healing, and improves the tendon structure. Pace and Dhar (11) tubularized flat tendons into round structures to help protect the tendon from fraying and from damage when passing through bone tunnels. This technique has been reported for lateral ankle ligament tendon transfers; however,
the operative technique can be applied to other tendon structures and for additional indications (11). Their technique is one of the few that has been specifically defined in the literature, although the surgical outcomes were not reported. To the best of our knowledge, no studies comparing the outcomes for different tubularization techniques for the repair of chronic tendon pathologic features have been published. Although no direct complications were reported in earlier studies in which tubularized tendons were repaired with external nonabsorbable suture (1,4,5,10), we believe that the internal nonabsorbable suture repair appears to provide better strength to the tendon and, theoretically, will provide improved gliding function. The small gauge external absorbable suture will undergo hydrolysis over time and, therefore, will not impede the tendon’s mechanical function when passive range of motion is initiated. References
Fig. 2. (A) The superficial portion of the tear was retubularized using absorbable suture. (B) A running baseball stitch was used to complete the repair.
1. Dombek MF, Lamm BM, Saltrick K, Mendicino RW, Catanzariti AR. Peroneal tendon tears: a retrospective review. J Foot Ankle Surg 42:250–258, 2003. 2. Steel MW, DeOrio JK. Peroneal tendon tears: return to sports after operative treatment. Foot Ankle 28:49–54, 2007. 3. Krause JO, Brodsky JW. Peroneus brevis tendon tears: pathophysiology, surgical reconstruction, and clinical results. Foot Ankle 19:271–279, 1998. 4. Redfern D, Myerson M. The management of concomitant tears of the peroneus longus and brevis tendons. Foot Ankle 25:695–707, 2004. 5. Thomas JL, Lopez-Ben R, Maddox J. A preliminary report on intra-sheath peroneal tendon subluxation: a prospective review of 7 patients with ultrasound verification. J Foot Ankle Surg 48:323–329, 2009. 6. Ryan JD. Principles and techniques of tendon and ligament repair. In: Reconstructive Surgery of the Foot and Leg, Update 2010, The Podiatry Institute, Decatur, GA, 2010. 7. Singer G, Ebramzadeh E, Jones NF, Meals R. Use of the Taguchi method for biomechanical comparison of flexor-tendon-repair techniques to allow immediate active flexion. A new method of analysis and optimization of technique to improve the quality of repair. J Bone Joint Surg 80:1498–1506, 1998. 8. Miller SJ. Muscle-tendon transfers of the lower extremity. In: Reconstructive Surgery of the Foot and Leg, Update 1996, The Podiatry Institute, Tucker, GA, 1996. 9. Satomi E, Teodoro WR, Parra ER, Fernandes TD, Velosa AP, Capelozzi L, Yoshinari NH. Changes in histoanatomical distribution of types I, III, and V collagen promote adaptative remodeling in posterior tibial tendon rupture. Clinics (San Paulo) 63:9–14, 2008. 10. Grasset W, Mercier N, Chaussard C, Carpentier E, Aldridge S, Saragaglia D. The surgical treatment of peroneal tendinopathy (excluding subluxations): a series of 17 patients. J Foot Ankle Surg 51:13–19, 2012. 11. Pace A, Dhar S. Technique tip: tubularizing flat tendons in foot and ankle surgery. Foot Ankle 29:342–343, 2008.
