Are Clips Used For Extensor Repair

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Many techniques are used to repair lacerated tendons. All of the original techniques were described with reference to flexor tendons. These techniques have been extended to include the repair of the extensor tendons. Four mutual suture techniques used for a "core" repair of the extensor tendon include the mattress stitch, the figure-of-viii stitch, the modified Bunnell sew, and the modified Kessler sew together (Effigy 76-5). No single stitch is optimal for any 1 zone of injury. The type of stitch must be individualized based on the properties of the tendon at the site of injury. While evidence exists that the modified Kessler and Bunnell stitches produce the greatest strength for a cadre-type tendon repair,5 they may not be best suited for extremely thin tendons (such equally in zones iv or 6). Instead, a figure-of-eight or mattress stitch may be necessary. The Bunnell and Kessler techniques are more useful in round, thicker tendons such as the flexor tendons or more proximal extensor tendons.5,10

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Figure 76-5.

Graphic Jump Location

Suture techniques for extensor tendon repair. A. Mattress stitch. B. Figure-of-eight sew together. C. The modified Kessler sew together. The numbers correspond the sequence of steps. D. The modified Bunnell stitch. The numbers represent the sequence of steps.

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Modified Kessler Stitch

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This "core" stitch is designed to place the direction of forcefulness perpendicular to the longitudinal centrality of the tendon (Figure 76-5C). If the force of the suture is placed in the tendon's longitudinal axis, there is a trend for the suture to pull through and shred the tendon.

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Identify the ii ends of the lacerated extensor tendon. Handle the cut ends with maximal care. Blindly or bluntly grabbing the ends traumatizes the tendons and compromises the repair. A retracted tendon tin can exist held in place with a needle piercing information technology perpendicularly. Judiciously debride the tendon ends if they are jagged or dirty. This tin can be performed with a fresh eleven-blade scalpel, cutting down against a wooden natural language depressor. Do not remove too much length from the tendon. Place the afflicted digit and wrist in maximum extension to facilitate approximation of the tendon ends.

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Concord 1 end of the tendon gently with your fingers or a stitch. Introduce the needle into the cutting terminate of the tendon (Effigy 76-5C(one)). The entrance point should be about i-third of the diameter of the tendon, beginning on either its ulnar or radial side. For simplicity, nosotros begin on the radial side. Laissez passer the suture approximately 1 cm through the length of the tendon and get out dorsally (Figure 76-5C(2)). Wrap the suture around the tendon (Figure 76-5C(3)). Reenter the radial side of the tendon perpendicularly and 1 to 2 mm closer to the tendon end (Figure 76-5C(3)). Pull the suture directly through the tendon to exit on its ulnar side (Effigy 76-5C(4)). Wrap the suture effectually the tendon (Figure 76-5C(v)). Enter the dorsal aspect of the ulnar one-half of the tendon (Figure 76-5C(five)). This entrance sew together must line up with the first dorsal stitch (Effigy 76-5C(ii)). Pass the needle through the length of the tendon to exit the end of the tendon (Figure 76-5C(six)). The needle must exit on the ulnar one-third of the tendon.

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Repeat the same run up on the opposing piece of the tendon. Pass the needle into the ulnar one-third of the tendon (Figure 76-5C(7)). Pass the suture approximately one cm through the length of the tendon and get out dorsally (Figure 76-5C(eight)). Wrap the suture around the tendon (Figure 76-5C(9)). Reenter the ulnar side of the tendon perpendicularly and 1 to ii mm closer to the tendon cease (Figure 76-5C(9)). Pull the suture straight through the tendon to exit its radial side (Effigy 76-5C(10)). Reenter the dorsal aspect of the radial one-half of the tendon (Figure 76-5C(11)). The stitch must line up with the previous dorsal sew together (Effigy 76-5C(viii)). Pass the needle through the length of the tendon to leave the end of the tendon (Figure 76-5C(12)). The needle must exit on the radial one-third of the tendon.

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The two gratis ends of the suture should be on the radial side of the tendon. Apply tension to the two free ends of the suture to gently gauge the ends of the lacerated tendon. Do not apply and then much force that the ends agglomeration up. Secure the stitch with a knot that will remain cached betwixt the tendon ends (Figure 76-5C(13)).

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Modified Bunnell Stitch

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This stitch follows the same principle every bit the Kessler stitch. It incorporates a crossing of the suture in its pathway (Figure 76-5D). Call back to minimize the handling of the tendon in performing this stitch. Instrumentation of the tissue is detrimental to its nutritional supply and can lead to adhesions. Ideally, one should immobilize the tendon ends with ane's fingers or a single suture.

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Enter the tendon cease on the radial half and at approximately one-third of the bore of the tendon (Figure 76-5D(1)). Pass the needle diagonally through the tendon and exit on the ulnar side (Effigy 76-5D(2)). Wrap the suture around the tendon (Figure 76-5D(3)). Reenter the tendon on its dorsal half (Figure 76-5D(three)). Pass the needle directly through the tendon to leave the dorsal surface of the radial attribute of the tendon (Figure 76-5D(iv)). Enter the radial side of the tendon (Figure 76-5D(five)). Cantankerous the suture diagonally through the tendon to exit its ulnar terminate (Effigy 76-5D(6)). The needle must exit through the ulnar 1-third of the tendon end.

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Repeat the same stitch on the opposing piece of the tendon. Laissez passer the needle into the ulnar one-tertiary of the tendon (Figure 76-5D(7)). Pass the needle diagonally through the tendon and get out on the radial side (Figure 76-5D(eight)). Wrap the suture around the tendon (Effigy 76-5D(9)). Reenter the tendon on its dorsal half (Figure 76-5D(9)). Laissez passer the needle directly through the tendon to exit the dorsal surface of the ulnar attribute of the tendon (Effigy 76-5D(10)). Wrap the suture around the tendon (Figure 76-5D(eleven)). Enter the ulnar side of the tendon (Figure 76-5D(xi)). Cross the suture diagonally through the tendon to exit the radial end of the tendon (Figure 76-5D(12)). The needle must exit through the ulnar ane-third of the tendon end.

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The two free ends of the suture should be on the radial side of the tendon. Pull gently on the suture ends to approximate the ends of the lacerated tendon. Exercise not employ and so much strength that the ends agglomeration up. Secure the stitch with a knot, which volition remain buried within the tendon ends (Effigy 76-5D(13)).