Tendon Repair (Tendon Surgery)

At the Advanced Center for Orthopedics, several of our specialty-trained orthopedic surgeons specialize in performing an array of tendon repair procedures, including Dr. Blotter, Dr. Davenport, Dr. Doppelt, Dr. Leonard, and Dr. Taylor. The Advanced Center for Orthopedics has been performing tendon repair surgery for more than three decades. That means your surgery will be performed by a team whose experience and skill-set is virtually unmatched in Marquette, the surrounding Upper Peninsula, and throughout Northern Michigan. Tendon repair entails surgically reattaching damaged tendons in the foot, ankle, knee, elbow, and shoulder joints. Depending on the injury, an orthopedic surgeon typically performs tendon repair via open surgery or minimally invasive techniques. The surgeon creates an incision near the location on the body with the tendon laceration, and gently unites the torn tendon with fine sutures, which help advance the healing process. Our orthopedic surgeons specialize in the following tendon repair procedures:

Achilles Tendon Surgery Tendon Transfer of Foot & Ankle Tendon Transfers for Brachia Plexus Injury Tenosynovitis & Tendonitis of Hand & Wrist Tendon Reconstruction of Hand & Wrist Bicep Tendon Repair Most tendon repair procedures are outpatient procedures that require the patient to be under general anesthesia and/or a regional nerve block. This means you wont be awake for your surgery and will therefore be comfortable and feel no pain. Post-surgery, the patient is typically given pain medication, bandaged (often a splint or cast is applied depending on the situation), and is able to return home the same day. Because tendon repair usually involves cutting cartilage, ligaments, and tendons in the body, the patient generally has to undergo an recuperations process involving follow-up care and physical therapy that may last anywhere from several weeks to several months, depending on the individual situation and what the surgeon views as best. To learn more about what to expect when you undergo tendon repair surgery, please visit oursurgery prep and recovery page and interactive videos. Specialty Reference: Shoulder & Elbow Hip & Knee Foot & Ankle

Ruptured Tendon Overview A tendon is the fibrous tissue that attaches muscle to bone in the human body. The forces applied to a large tendon may be more than five times the body weight. In some rare instances, tendons can snap or rupture. Conditions that make a rupture more likely include the injection of steroids into a tendon, certain diseases (such as gout or hyperparathyroidism), and having type O blood.

Although fairly uncommon, a tendon rupture can be a serious problem and may result in excruciating pain and permanent disability if untreated. Each type of tendon rupture has its own signs and symptoms and can be treated either surgically or medically depending on the severity of the rupture and the confidence of the surgeon. The four most common areas of tendon rupture are as follows:

Quadriceps o A group of four muscles -- the vastus lateralis, vastus medialis, vastus intermedius, and the rectus femoris -- come together just above thekneecap (patella) to form the patellar tendon. o Often called the quads, this group of muscles is used to extend the leg at the knee and aids in walking, running, and jumping. Achilles o This tendon is located on the back (posterior) portion of the foot just above the heel. It is the site of attachment of the calf muscle (gastrocnemius muscle) to the heel of the foot (the calcaneus bone). o This tendon is vital for pushing off with the foot (this motion is known as plantarflexion). The Achilles helps you stand on your tiptoes and push off when starting a foot race. Rotator cuff o The rotator cuff is located in the shoulder and is actually composed of four muscles: the supraspinatus (the most common tendon ruptured), infraspinatus, teres minor, and subscapularis. o This group of muscles functions to raise your arm out to the side, helps you rotate the arm, and keeps your shoulder from popping out of its socket. o The rotator cuff tendon is one of the most common areas in the body affected by tendon injury. Some autopsy studies have shown that 8%-20% have rotator cuff tears. Biceps o The biceps muscle of the arm functions as a flexor of the elbow. This muscle brings the hand toward the shoulder by bending at the elbow. o Ruptures of the biceps are classified into proximal (close) and distal (far) types. Distal ruptures are extremely rare. The proximal rupture is at the attachment of the biceps at the top of the shoulder.

Ruptured Tendon Causes In general, tendon rupture occurs in a middle-aged or older man. In the young, muscle tissue usually tears before the attached tendon willtear. But in older people and in those with certain diseases (such as gout and hyperparathyroidism), tendon rupture may occur.

Ruptured Tendon Symptoms and Signs

An injury that is associated with the following signs or symptoms may be a tendon rupture. o A snap or pop that you hear or feel o Severe pain o Rapid or immediate bruising o Marked weakness o Inability to use the affected arm or leg o Inability to move the area involved o Inability to bear weight o Deformity of the area Symptoms associated with specific injuries o Achilles tendon rupture: You will be unable to support yourself on your tiptoes on the affected leg (you may be able to flex your toes downward because supporting muscles are intact). o Rotator cuff rupture: You will be unable to bring your arm out to the side. o Biceps tendon rupture: You will have decreased strength of elbow flexion and decreased ability to raise the arm out to the side when the hand is turnedpalm up.

Ruptured Tendon Diagnosis Tendon rupture is usually diagnosed using a physical examination. Any imaging is done to confirm the diagnosis and decide the severity of the rupture.

Quadriceps o X-rays often show that the patella (kneecap) is lower than its normal position on a side view of the knee. o Using an MRI, your doctor can tell whether your rupture is partial or complete. Achilles tendon o Your doctor may do a Thompson test. In this test, your doctor will have you kneel on a chair and dangle your foot over the edge. The doctor will then squeeze your calf in a particular place. If the toes on your foot don't point downward when the doctor squeezes, then you probably have a ruptured Achilles tendon. o In a test called the blood pressure cuff test, your doctor will place a blood pressure cuff on your calf. The cuff is then inflated to 100 mm Hg. The doctor will then move your foot into a toes-up position. If your tendon is intact, it will cause the pressure to rise to about 140 mm Hg. If you have a tendon rupture, the pressure will increase only a small amount.

You may be able to flex your foot downward because your supporting muscles are intact. You will be unable to support yourself on your tiptoes on the affected side, however. o X-rays taken from the side may show darkening of the triangular fatty tissue-filled space in front of the Achilles tendon or a thickening of the tendon. o MRI or ultrasound may be used to determine the severity of the rupture, although these tests are usually not needed to make the diagnosis. Rotator cuff o You will be unable to initiate bringing your arm out to the side. o Your doctor may do a drop arm test. In this test, your arm is passively raised to 90 degrees, and you are asked to hold your arm at this position. If you have rotator cuff rupture, slight pressure on the forearm will cause you to suddenly drop the arm. o X-rays may show that the long bone in your upper arm (the humerus) is slightly out of place. o Shoulder arthrography is most helpful in identifying a suspected rotator cuff tear. In this test, a dye that shows up on X-rays is injected directly into the shoulder joint, and the joint is then moved around. Then an X-rayof the shoulder is taken. If any dye is seen leaking from the joint, then it is highly likely that you have a ruptured rotator cuff. o MRI provides a noninvasive means of assessing the integrity of the rotator cuff although it is more costly and not as specific as arthrography. Biceps o X-rays may show that your upper arm bone is out of place or that the site of muscle attachment has changed. o If your biceps tendon is completely ruptured, the biceps retracts toward the elbow causing a swelling just above the crease in your arm. This is called the Popeye deformity. o You will experience decreased strength of elbow flexion and armsupination (moving the hand palm up). o You will have decreased ability to raise the arm out to the side when the hand is turned palm up.

Definition
Tendon repair refers to the surgical repair of damaged or torn tendons, which are cord-like structures made of strong fibrous connective tissue that connect muscles to bones. The shoulder, elbow, knee, and ankle joints are the most commonly affected by tendon injuries.

Purpose
The goal of tendon repair is to restore the normal function of joints or their surrounding tissues following a tendon laceration.

Demographics
Tendon injuries are widespread in the general adult population. They are more common among people whose occupations or recreational athletic activities require repetitive motion of the shoulder, knee, elbow, or ankle joints. Injuries to the tendons in the shoulder often occur among baseball players, window washers, violinists, dancers, carpenters, and some assembly line workers. Rowers are at increased risk for injuries to the forearm tendons. The repetitive stresses of classical ballet, running, and jogging may damage the Achilles tendon at the back of the heel. So-called tennis elbow, which occurs in many construction workers, highway crews, maintenance workers, and baggage handlers as well as professional golfers and tennis players, is thought to affect 5% of American adults over the age of 30. Women in all age brackets are at greater risk than men for injuries to the tendons in the elbow and knee joints. It is thought that injuries in these areas are related to the slightly greater looseness of women's joints compared to those in men.

Description
Local, regional or general anesthesia is administered to the patient depending on the extent and location of tendon damage. With a general anesthetic, the patient is asleep during surgery. With a regional anesthetic, a specific region of nerves is anesthetized; with a local anesthetic, the patient remains alert during the surgery, and only the incision location is anesthetized. After the overlying skin has been cleansed with an antiseptic solution and covered with a sterile drape, the surgeon makes an incision over the injured tendon. When the tendon has been located and identified, the

surgeon sutures the damaged or torn ends of the tendon together. If the tendon has been severely injured, a tendon graft may be required. This is a procedure in which a piece of tendon is taken from the foot or other part of the body and used to repair the damaged tendon. If required, tendons are reattached to the surrounding connective tissue. The surgeon inspects the area for injuries to nerves and blood vessels, and closes the incision.

Diagnosis/Preparation
Diagnosis of a tendon injury is usually made when the patient consults a doctor about pain in the injured area. The doctor will usually order radiographs and other imaging studies of the affected joint as well as taking a history and performing an external physical examinationin the office. In some cases fluid will be aspirated (withdrawn through a needle) from the joint to check for signs of infection, bleeding, or arthritis. Prior to surgery, the patient is asked not to eat or drink anything, even water. A few days before the operation, patients are also instructed to stop taking such over-thecounter pain medications as aspirin or ibuprofen. If the patient has a splint or cast, it is removed before surgery. To prepare for surgery, the patient typically reports to a preoperative nursing unit, where he or she changes into a hospital gown. Next, the patient is taken to a preoperative holding area, where an anesthesiologist administers an intravenous sedative. The patient is then taken to the operating room .

Aftercare
Patients are asked to have someone drive them home after tendon repair surgery. Healing may take as long as 6 weeks, during which the injured part may be immobilized in a splint or cast. Patients are asked not to use the injured tendon until the physician gives permission. The physician will decide how long to rest the tendon. It should not be used for lifting heavy objects or walking. Patients are also asked to avoid driving until the physician gives the go-ahead. To reduce swelling and pain, they should keep the injured limb lifted above the level of the heart as much as possible for the first few days after surgery. Splints or bandages should be left in place until the next checkup. Patients are advised to keep bandages clean and dry. If patients have a cast, they are asked not to get it wet, to cover it with plastic while bathing, and to avoid exposing the cast to water. Fiberglass casts that get wet may be dried with a hair dryer. Patients are also instructed not to push or lean on the cast to avoid breaking it. If patients have a splint that is held in place with an Ace bandage, they are instructed to ensure that the bandage is not too tight. They are also asked to ensure that

To repair a torn tendon, incisions are made to expose the area for repair (A). Some tendons can be reattached through one incision (B), while others require two to access the severed point and

the remaining tendon (C). A special splint that minimizes stretching the tendons may be worn after surgery (E). ( Illustration by GGS Inc. ) splints remain in exactly the same place. Medications prescribed by the doctor should be taken exactly as directed. Patients who have been given antibiotics should take the complete course even if they feel well; this precaution is needed to minimize the risk of drug resistance developing in the disease organism. If patients are taking medicine that makes them feel drowsy, they are advised against driving or using heavy equipment. Aftercare may also include physical therapy for the affected joint. There are a variety of exercises, wraps, splints, braces, bandages, ice packs, massages, and other treatments that physical therapists may recommend or use in helping a patient recover from tendon surgery.

Risks
Tendon repair surgery includes the risks associated with any procedure requiring anesthesia, such as reactions to medications and breathing difficulties. Risks associated with any surgery are also present, such as bleeding and infection. Additional risks specific to tendon repair include: formation of scar tissue that may prevent smooth movements (adequate tendon gliding); nerve damage; and partial loss of function in the involved joint.

Normal results
Tendon injuries represent a difficult and frustrating problem. Conservative treatment has little if any chance of restoring optimal range of motion in the injured area. Even after surgical repair, a full range of motion is usually not achieved. Permanent loss of motion, joint contractures, weakness and stiffness may be unavoidable. Scar tissue tends to form between the moving surfaces within joints, resulting in adhesions that hamper motion. The surgical repair may also split apart or loosen. Revision surgery may be required to remove scar tissue, insert tendon grafts or other reconstructive procedures. Thus, successful tendon repair depends on many factors. Recovery of the full range of motion is less likely if there is a nerve injury or a broken bone next to the tendon injury; if a long period of time has elapsed between the injury and surgery; if the patient's tissues tend to form thick scars; and if the damage was caused by a crush injury. The location of the injury is also an important factor in determining how well a patient will recover after surgery.

Morbidity and mortality rates

Mortality rates for tendon repairs are very low, partly because some of these procedures can be performed with local or regional anesthesia, and partly because most patients with tendon injuries are young or middle-aged adults in good general health. Morbidity varies according to the specific tendon involved; ruptures of the Achilles tendon or shoulder tendons are more difficult to repair than injuries to smaller tendons elsewhere in the body. In addition, some postoperative complications result from patient noncompliance; in one study, two out of 50 patients in the study sample had new injuries within three weeks after surgery because they did not follow the surgeon's recommendations. In general, tendon repairs performed in the United States are reported as having an infection rate of about 1.9%, with other complications ranging between 5.8% and 9.5%.

Alternatives
There are no alternatives to surgery for tendon repair as of 2003; however, research is providing encouraging findings. Although there is no presently approved drug that targets this notoriously slow and often incomplete healing process, a cellular substance recently discovered at the Lawrence Berkeley National Laboratory may lead to a new drug that would improve the speed and durability of healing for injuries to tendons and ligaments. The substance, called Cell Density Signal-1, or CDS-1, by its discoverer, cell biologist Richard Schwarz, acts as part of a chemical switch that turns on procollagen production. Procollagen is a protein manufactured in large amounts by embryonic tendon cells. It is transformed outside the cell into collagen, the basic component of such connective tissues as tendons, ligaments or bones. Amgen Inc. is planning to use genetic engineering to bring CDS-1 into mass production. Prolotherapy represents a less invasive alternative to surgery. It is a form of treatment that stimulates the repair of injured or damaged structures. It involves the injection of dextrose or natural glycerin at the exact site of an injury to stimulate the immune system to repair the area. Thus, prolotherapy causes an inflammatory reaction at the exact site of injuries to such structures as ligaments, tendons, menisci, muscles, growth plates, joint capsules, and cartilage to stimulate these structures to heal. Specifically, prolotherapy causes fibroblasts to multiply rapidly. Fibroblasts are the cells that actually make up ligaments and tendons. The rapid production of new fibroblasts means that strong, fresh collagen tissue is formed, which is what is needed to repair injuries to ligaments or tendons. See also Orthopedic surgery

Read more: http://www.surgeryencyclopedia.com/St-Wr/Tendon-Repair.html#b#ixzz1kX0hGpCx

Introduction

Hand splints

You will need to wear a hand splint after surgery to protect the repaired tendons from damage. In cases of extensor tendon repair, you will need to wear the splint all the time for at least four weeks, then at night for a further two weeks. In cases of flexor tendon repair, you will need to wear the splint all the time for at least four to five weeks, then at night for a further two weeks.

Tendon repair of the hand is surgery to repair damaged or divided tendons. Most tendon damage is caused by cuts to the hands from glass or knives.

What are tendons?

Tendons are tough cords of tissue that connect muscles to bones. When you contract (tighten) a group of muscles, the attached tendons will pull on certain bones, allowing you to make a wide range of physical movements. There are two groups of tendons in the hand:

extensor tendons which run from the forearm, across the back of your hand to your fingers and thumb, allowing you to straighten your fingers and thumb

flexor tendons which also run from your forearm, through your wrist and across the palm of your hand, allowing you to bend your fingers

Why do I need tendon repair surgery?

Tendon repair of the hand is necessary when one or more tendons in your hand are divided or ruptured (split), leading to loss of normal hand movements. If your extensor tendons are damaged, you will be unable to straighten one or more of your fingers. If your flexor tendons are damaged, you will be unable to bend one or more of your fingers. Tendon damage can cause pain and inflammation (swelling) in your hand. Some common causes of tendon injuries are described below.

Cuts Cutting your hand can result in an injury to your tendons. Sports injuries Tendons can be overstretched and rupture when you take part in sport. This is more common in contact sports such as football and rugby, or activities that involve a lot of gripping, such as rock climbing. Bites Animal bites can cause tendon damage. However, human bites are a more common cause and most often occur when a person punches another person in the teeth, cutting their hand in the process. Crushing injuries Jamming your finger in a door or having your hand crushed in a car accident can divide or rupture a tendon. Rheumatoid arthritis Rheumatoid arthritiscan cause your tendons to become inflamed. In the most severe cases, this can lead to tendons rupturing.

Tendon repair surgery

Tendon repair involves making an incision in your hand to locate the ends of the divided tendon, and then stitching the tendon ends together. Extensor tendons are easy to reach, so repairing them is relatively straightforward. Depending on the type of injury, it may be possible to repair extensor tendons in an accident and emergency (A&E) department using a local anaestheticto numb the affected area. Repairing flexor tendons is more complex because they can be difficult to get to and, in many cases, are located near important nerves. Flexor tendon repair usually needs to be carried out under general anaesthetic in an operating theatre by an experienced plastic or orthopaedic surgeon who specialises in hand surgery. Read more information about how hand tendon repair is performed.

Recovering from surgery

Both types of tendon surgery require a lengthy period of recovery (rehabilitation) because the repaired tendons will be very weak until the ends heal together. Depending on the location of the injury, recovery can take between one and three months. Rehabilitation involves protecting your tendons from overuse using hand splints. A hand splint is a rigid support worn around the hand, which is designed to hold your hand securely in position to prevent excessive movements that could cause the tendon to rupture while it is healing. You will also need to do hand exercises regularly to prevent the repaired tendons from sticking to nearby tissue. When you can return to work will depend on your job. Light activities can often be resumed after 68 weeks and heavy activities and sport after 1012 weeks. Read more aboutrecovering from tendon repair of the hand.

Outlook

After an extensor tendon repair you should have a working finger, but may not regain full movement. The outcome is often better when the injury is a clean cut to the tendon rather than one that involves crushing or damage to the bones and joints. A flexor tendon injury is generally more serious as they are responsible for carrying more force than an extensor tendon. After a flexor tendon repair it is quite common for some fingers not to regain full movement, although the tendon repair will still give a better result than no surgery. In some cases there are complications after surgery, such as infection or the repaired tendon snapping or sticking to nearby tissue. Read more information about thecomplications of tendon repair of the hand.