Jagannath Kamath, +Praveen
*Associate Professor of Orthopaedics,
Kasturba Medical College, Mangalore, Karnataka,
Professor of Orthopaedics, Kasturba
Medical College, Mangalore, Karnataka, India.
Address for Correspondence
Dr. B. Jagannath Kamath
Jyothi Mansion, Opposite Prabhat Theatre,
K. S. Rao Road, Mangalore, India. Pin- 575001.
Phone: +91-0824-2440233; +91-9845235747
Two important aspects of tendon repair, which
are very less often talked about, are, bulky anastomotic site
and surface injury to the tendon occurring while handling the
tendon during suturing. These can be detrimental to the final
outcome. We herein describe a simple and easy technique to
overcome these two problems.
Key words: tendon injury; tendon repair;
surface injuryto tendon.
Results of primary tenorraphy depend on
several factors. The treating surgeon has control over only some
of these, namely:
Avoiding bulky tendon
Preservation of smooth
gliding surface of the tendon, by handling them delicately
pullout strength at the anastomotic site using core and
Assisted active or
controlled passive movements of the digits post operatively.
Though there is plenty of
literature dealing with the later two factors, there has been
considerable paucity of material in the literature dwelling into
the first two factors. Conventional methods of handling the cut
ends of the tendon using forceps during the process of obtaining
the bite, and excising the handled tendon tissue while tying the
knot is far from ideal. Such core stitches will not only shorten
the tendon but also make the cut ends of the tendon ragged and
irregular for epitendinous sutures. We are describing a method
being regularly used at our department for tenorraphy, it
involves use of a tendon approximator designed by us (Figure 1),
which when used along with the method described avoids bulky and
irregular anastomotic site, and maintains the smooth glistening
surface of the tendon. This tendon approximator is a
modification of the nerve approximator described by us earlier
1. It consists of a fixed post and a slid-able post (Figure 1).
The two posts have fixed needles, which get hold in the cut ends
of the tendon. The slid-able post can be used to bring
approximation of the cut ends and later fixed to maintain the
position to avoid tense and bulky anastomotic site. The use of
fixed needles in the posts instead of hypodermic needles as
described by LaLonde 2 and as in the nerve approximator
described by us 1 makes the construct stronger and rigid, thus
more appropriate to hold the tendons, which are more elastic.
The steps of the technique described have been shown in
laboratory to make understanding easy.
the proximal and distal cut ends of the tendon are retrieved
through the pulleys and are brought through the same window in
the fibrous flexor sheath in case of the flexor tendon (Zone II)
in the volar aspect of the fingers, the cut ends are held and
stabilized using a tendon approximator. To allow atraumatic
handling of the cut ends of the tendon, a small piece of rubber
glove from the finger tip of the glove with a small aperture
just big enough to accept the cut ends of the tendon is used as
shown in the figure (Figure 2). The width of the sleeve of the
glove piece on the tendon can be tailored according to the need
of the surgeon. Both cut ends are transfixed by the needles of
the approximator about 0.75-1cm from the cut ends of the tendon
(Figure 3). Minimal venting of
FFS at this stage on both sides (diagonally opposite sides) of
the proposed anastomotic site would be advisable if needed. The
tendon cut ends are now easily manoeuvred for repair by handling
the glove piece both for core and epitendinous stitches (Figure
4). Though it may be slightly easier to use “epitendinous first
and core later” repair using this method, with reasonable care
the conventional “core first and epitendinous next” repair can
also be performed atraumatically. With the tendon approximator,
the tension at the anastomotic site can be controlled easily
(especially in oblique tendon injuries) and more importantly,
handling the cut ends of the tendon at the anastomotic site can
be prevented resulting in aesthetically neat looking and
functionally better performing tenorraphy. The maintenance of
the virginity of the smooth glistening surface of the tendon
along with less bulky repair should theoretically and
practically give better results.
uses of tendon approximator 2,3 and different tendon forceps
have made the tenorraphy less traumatic. But the physical insult
in the form of surface injuries to the uninjured glistening part
of the cut ends of the tendon during tenorraphy is still a major
factor worrying the surgeon. A protective gloved cut ends of the
tendon incorporated in the tendon approximator can to some
extent mitigate this problem. The tendon approximator in the
described method not only helps to align the cut ends of the
tendon and control end point of the core stitch knot to avoid
bulky tenorraphy but also to incorporate the cuff of glove tip
cut ends. This protective glove cuff helps the surgeon to handle
the tendon cut ends atraumatically during core and epitendinous
stitches. The small extra time consumed for this manoeuvre is
considered well spent for the kind of benefit it provides. It is
preferable to use non-toothed Adson’s forceps to handle the
gloved tendon cut ends during repair to avoid glove tear while
using toothed forceps. We felt that the holding technique
described by Lin G 4 is more tedious in respect to the
approximation of the cut ends and also the limited space
available for the flexor tendon repair in the hand especially in
In conclusion, small yet
important contribution for making the tenorraphy atraumatic has
been described. The technique is easy, practical, user friendly
and available in any operation theatre. The tendon approximator
used in the above-described method is particularly useful in
oblique tendon injuries, which in practice are more commonly
encountered and more likely to result in bulky anastomosis.
- Kamath BJ, Bhardwaj P. A simple and
inexpensive nerve approximator.
Plast. Reconstr. Surg., 2005; Vol. 116;No.6; 1721.
- LaLonde DH. A tendon approximator.
Plast. Reconstr. Surg., 1989; Vol. 83;No.1; 912.
- Oudit D. A tendon approximator. Plast.
Reconstr. Surg., 2005; Vol. 115;No.4; 1219.
- Lin G. The holding technique for flexor
tendon repair. Plast. Reconstr. Surg., 1988; Vol. 82;No.5;