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A Technique Of Atraumatic Tenorraphy

*B. Jagannath Kamath, +Praveen Bhardwaj

*Associate Professor of Orthopaedics, Kasturba Medical College, Mangalore, Karnataka, India.
+Assistant 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.
+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.

J.Orthopaedics 2006;3(3)e6


Results of primary tenorraphy depend on several factors. The treating surgeon has control over only some of these, namely:

  • Avoiding bulky tendon anastomosis

  • Preservation of smooth gliding surface of the tendon, by handling them delicately during repair.

  • Achieving maximum pullout strength at the anastomotic site using core and epitendinous stitches.

  • 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.


Once 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 the 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.

Discussion :

The 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 donning the tendon 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 Zone II. 


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.


Reference :

  1. Kamath BJ, Bhardwaj P. A simple and inexpensive nerve approximator. Plast. Reconstr. Surg., 2005; Vol. 116;No.6; 1721.
  2. LaLonde DH. A tendon approximator. Plast. Reconstr. Surg., 1989; Vol. 83;No.1; 912.
  3. Oudit D. A tendon approximator. Plast. Reconstr. Surg., 2005; Vol. 115;No.4; 1219.
  4. Lin G. The holding technique for flexor tendon repair. Plast. Reconstr. Surg., 1988; Vol. 82;No.5; 965.


This is a peer reviewed paper 

Please cite as : Jagannath Kamath: A Technique Of Atraumatic Tenorraphy

J.Orthopaedics 2006;3(3)e6





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