CHAPTER 52

PRINCIPLES AND TECHNIQUES OF

TENDON AND LIGAMENT REPAIR

Jay D. Ryan, DPM

INTRODUCTION It has been shown that the strength of tendon repair

is proportional to the number of sutures crossing the
Surgical repair of soft tissue structures, including tendon, repair site and that initial repair techniques require twice
ligament, or capsule can be quite challenging. Various the initial strength as what is required for active flexion.1
techniques may be utilized in a range of procedures, from Classic repair techniques, including Kessler and Tajima
emergent to elective, including laceration, retubularization, techniques, had only 2 suture arms spanning the repair site
lengthening, and transposition or transfer. Advancements in and represent weaker repair constructs. However, there
repair techniques have been made, as well as modifications of are disadvantages of the multi-strand repair, which include
standard repair techniques. It is the primary aim of this added bulk and uneven repair due to the complexity of
update to provide specific techniques for many commonly multiple tendon passes. It is generally recommended that
encountered podiatric procedures. Advancements in core 4 to 6 sutures cross the repair site, in addition to a running
suture techniques will be discussed for tendon laceration epitenon stitch.2
repair. Additionally, tendon retubularization, tendon Converse to the above recommendations, it has been
shortening or reefing, and capsule or tendon plication shown that the simplest and least traumatic repair constructs,
techniques will be discussed. Current recommendations of while initially weaker, allow for more rapid healing of
tendon repair guidelines, as well as the above mentioned tendon.3 Therefore, the surgeon must be prepared to
specific repair techniques will be reviewed. modify repair techniques for specific patient circumstances.
Additionally, increased tendon passes, as seen with the
CORE SUTURE TECHNIQUES Bunnell repair, have been shown to lead to decreased tendon
microcirculation. This suture repair type has been shown to
For tendon laceration or lengthening procedures, core lead to higher incidence of gap formation and tendomalacia.
suture repair techniques may be employed. Many The most common modes of failure include gliding
variations of tendon repair exist, including some described resistance and gap formation. Tendons with 3 mm or greater
by Kessler, Savage, Lee, Becker, Tajima, Tsuge, and gapping have been shown to have an increased rupture risk
Krakow (Figure 1). Numerous other repair techniques when compared to those repaired with less than 1 mm gap.3,4
have been described and modifications exist for some of Suture type for tendon repair traditionally consisted
these procedures. of non-absorbable braided synthetic polyester material,
such as ethibond suture. More recent tendon repair
descriptions have employed non-absorbable monofilament
material as the suture of choice. For example, prolene
suture has been shown to generate less friction and cause
less tendon deformation than braided suture.5 In certain
surgical settings, added strength from braided suture and
increased frictional force may be positive attributes for
tendon repair.
Suture placement must also been considered for
individual patient needs. Volar or plantar suture placement
has been shown to minimize interruption of blood flow.
However, dorsal suture placement creates pull out strength,
Figure 1. Various tendon repair techniques. which is 50% stronger than volar suture placement.6,7
 CHAPTER 52 291

TENDON RETUBULARIZATION #3-0 Ethibond, should be continuously run along the

interior surface with alternating superficial suture passes,
As briefly discussed above, tendon retubularization is about 2 to 3 mm on either side of the tendon midline. Next,
commonly performed in podiatric surgery for a variety of a second pass may be made slightly more laterally along the
etiologies. A repair technique commonly employed by The tendon in a similar manner as described above. If the repair
Podiatry Institute will be reviewed. Individual surgical site does not have a large width, then a single (rather than
approaches will vary based on the tendon affected, double) continuous suture line may adequately allow for
location of tear or disease, and other factors. However, repair, but this must be determined on an individual basis.
once the appropriate tendon has been identified, a The purpose of these suture passes is to provide retubular-
step-wise approach for repair may be implemented. The ization to a flattened tendon with a non-exposed or buried
tendon must first be visualized above and below the suture. The suture knots are placed in a horizontal fashion at
suspected location of pathology. It is also necessary to the interior aspects of the repair site. An absorbable suture,
inspect the tendon along all anatomic surfaces. Tendon such as a #5-0 Vicryl, is then run in a baseball stitch fashion
disease may occur on deep or superficial surfaces, along along then tendon edges to allow full reapproximation. This
bony prominences, or as intra-substance tears. Tendon final absorbable suture allows further contouring and
debridement follows visualization, with removal of all non- maintenance of the tendon repair site, which will not affect
viable or hypertrophic portions of tendon. If the tendon tendon glide function over the long term (Figures 2, 3).
appears heavily diseased, it may be necessary to perform Additional retubularization techniques have been
an anastamosis to a nearby tendon or graft the repair site, described, including techniques for Jones or Chrisman-
rather than attempt salvage. Snook procedures. This technique involves an interior
The area of tendon retubularization should then have running simple stitch, which is converted into an outer
the superficial epitenon fibers superficially debrided in order baseball stitch in the opposite direction. This application may
to promote adhesion of the deep surfaces and increase also provide beneficial in certain cases, but does not allow
frictional force. A running non-absorbable suture, such as for a combination of sutures as described above (Figure 4).8

Figure 2A. Podiatry Institute tendon Figure 2B. Running stitch.

retubularization sequence. Intital knot.
292 CHAPTER 52

Figure 2C. Final knot. Figure 2D. Baseball stitch.

Figure 2E. Final appearance. Figure 3. Podiatry Institute technique for tendon
retubularization.
 CHAPTER 52 293

Figure 4. Pace’s technique for tendon retubularization.

Figure 5. Hoffa’s method of tendon shortening.

Figure 7. MTPJ capsular plication technique.

Figure 6. Double-over technique for tendon
shortening.

TENDON REEFING employed to provide a similar result. It will cause added bulk
OR SHORTENING in an isolated area, but less bulk along the tendon course as
the Hoffa technique will produce. Therefore, each procedure
Hoffa described a simplistic method for shortening a may be of greater benefit in certain surgical circumstances.
tendon. This method is performed by running suture along This technique is performed by overlapping the tendon in
the longitudinal axis of the tendon in a simple linear manner. an S-like fashion, and approximating the interior edges
After completing the desired length, a single suture pass is (Figure 6).
made in the transverse plane to the opposite side of the
tendon, and the same longitudinal simple running suture MTPJ CAPSULE PLICATION
technique is utilized in reverse. Once reaching the suture
origin, tension is placed as desired to shorten the tendon, It is also possible to repair soft tissue deficits utilizing
and the suture is tied. Shortening can also be controlled by simple suture techniques. This technique may be utilized
the length of suture passes (Figure 5).9 for correction of lateral deviation of digits at the metatarsal
Additionally, a doubling over procedure may be phalangeal joint level. An over and over suture technique
294 CHAPTER 52

is employed utilizing a # 2-0 Ethibond. It is important to REFERENCES

note that the first stitch may only remove slack in a
1. Boyer MI, Gelberman RH, Burns ME, Dinopoulos H, Hofem R,
moderately to severely deformed joint and a second over
Silva MJ. Intrasynovial flexor tendon repair. An experimental study
and over stitch may be needed to gain the desired comparing low and high levels of in vivo force during rehabilitation
correction (Figure 7). in canines. J Bone Joint Surg Am 2001;83:891-9.
2. Howard RF, Ondrovic L, Greenwald DP. Biomechanical analysis of
four strand extensor tendon repair techniques. J Hand Surg Am
CONCLUSION 1997;22:838-42.
3. Ditsios KT, Burns ME, Boyer MI, Gelbermann, RH, Silva MJ. The
It is important to incorporate and apply the above rigidity of repaired flexor tendons increases following ex vivo cyclic
loading. J Biomech 2002;35:853-6.
mentioned techniques to the appropriate surgical setting. 4. Haralambos T, Dinopoulos MI, Boyer ME, Burns RH, Gelberman
For laceration or rupture, core suture techniques should MJ, Silva MJ. The resistance of a four- and eight-strand suture
be employed, but will vary dependent on tendon, location technique to gap formation during tensile testing: an experimental
study of repaired canine flexor tendons after 10 days of in vivo
of rupture, and physical activity of patient. The principles
healing. J Hand Surg Am 2000;25:489-98.
mentioned above may be adapted or modified for 5. Singer G, Ebramzadeh E, Jones NF, Meals R. Use of the taguchi
individual patient circumstances. Additionally, specific method for biomechanical comparison of flexor-tendon-repair
tendon repair techniques commonly encountered in foot techniques to allow immediate active flexion. A new method of
analysis and optimization of technique to improve the quality of
and ankle surgery have been reviewed. repair. J Bone Joint Surg 1998;80:1498-506.
6. Diao E, Hariharan JS, Soejima O, Lotz JC. Effect of peripheral
suture depth on strength of tendon repairs. J Hand Surg Am
1996;21:234-9.
7. Soejima O, Diao E, Lotz JC, Hariharan JS. Comparative mechanical
analysis of dorsal versus palmar placement of core suture for flexor
tendon repairs. J Hand Surg Am 1995;20:801-7.
8. Pace A, Dhar S. Technique tip: tubularizing flat tendons in foot and
ankle surgery. Foot & ankle international/American
Orthopaedic Foot and Ankle Society and Swiss Foot and Ankle
Society. 01/04/2008.
9. Hoffa, A. Zur Statistik der Deformitaten. Munchener medicinische
Wochenschrift. 1890;37:237.