- Email: [email protected]
Silastics in tendon surgery
Silastics in Tendon Surgery--Basil Helal
SILASTICS IN T E N D O N S U R G E R Y
B A S I L H E L A L , London In the presence of extensive damage to the flexor apparatus within the fingers, the results of conventional graft surgery are poor. The reason lies with the fundamental process of tendon repair. It has been shown that tenocytes do not contribute to the repair which depends upon invasion of the damaged tendon by vascular granulation tissue from without; adhesions arise as a result of this process. Various techniques have been used to try and overcome this by creating new tendon tunnels. Leo Mayer (1936) started this line of research by using celloidin tubes. The culmination of this approach to the problem came with the use of non-reactive silicone rubber artificial tendons developed by Carroll and Bassett (1965) and Hunter (1965).
Fig. 1. Artificial tendon. Made of silicone rubber and containing a core of Dacron. Fig. 2. A silastic tendon in place. An epithelial tunnel forms around the tendon which will be replaced by a conventional graft ten weeks later. OPERATIVE TECHNIQUE The following technique has been employed in difficult tendon injuries. The affected tendon and sheath are excised and a silastic tendon formed from a silicone rubber rod threaded with silk suture material is attached to the distal stump of the profundus and proximally to the profundus tendon at the level of the distal metacarpo-phalangeal joint flexion crease. Activity is encouraged and usually a good range of movement is achieved with the artificial tendon. At ten weeks the artificial tendon is replaced by an autograft, us,lng the plantaris or palmaris as donor tendon. The autograft is "railroaded" along the tunnel which has formed around the silastic tendon by attaching it to one end of the artificial tendon and drawing it into the tunnel as the sitastic tendon is withdrawn. The distal stump of profundus is excised and a small length of profundus is excised proximally, so that the proximal suture line can be enclosed in lumbrical muscle. The distal end of the autograft is anchored as described by Pulvertaft (1960). Movement is commenced at three weeks. CASES An account was given of four patients with difficult tendon injuries who were treated as described above. Two of these had division of all eight flexors to the four fingers of one hand with subsequent infection. The results were very pleasing with excellent return of function in three patients and a satisfactory result in the fourth.
120
Silastics in Tendon Surgery--Basil Helal
Fig. 3a. This patient divided all eight flexors of the ulnar four digits in this hand. The wound became infected. The flexor sheaths were obliterated by fibrous tissue. Fig. 3b. After preliminary replacement with silastic tendons, conventional grafts were inserted. The end result is illustrated.
o
~r
Iii
Fig. 4. The flexor apparatus to the middle finger was destroyed by a septic tenosynovitis. The end result after preliminary insertion of an artificial tendon and subsequent graft.
SUMMARY
I n the presence of extensive d a m a g e to the flexor a p p a r a t u s in the fingers, the results of c o n v e n t i o n a l t e n d o n grafting are poor. More satisfactory results have been obtained by t e m p o r a r y replacement of the t e n d o n by a silicone r u b b e r rod. M o v e m e n t is then encouraged a n d after ten weeks, the rod is replaced by an autograft. T h e m e t h o d described is r e c o m m e n d e d without reservation for the complicated flexor t e n d o n injury within the fibrous flexor tendon sheath.
REFERENCES MAYER, L., and RANSOHOFF, N. (1936) Reconstruction of the digital tendon sheath. Journal of Bone and Joint Surgery, 18: 607. BASSETT, C. A. L., and CARROLL, R. E. (1963) Formation of tendon sheath by silicone rod implants. Journal of Bone and Joint Surgery, 45A : 884. HUNTER, J. M. (1965) Artificial Tendons. Journal of Bone and Joint Surgery, 47A: 631. PULVERTAFT, R. G. (1960) The treatment of profundus division by free tendon graft. Journal of Bone and Joint Surgery, 42A: 1363. 121
SILASTICS IN T E N D O N S U R G E R Y
B A S I L H E L A L , London In the presence of extensive damage to the flexor apparatus within the fingers, the results of conventional graft surgery are poor. The reason lies with the fundamental process of tendon repair. It has been shown that tenocytes do not contribute to the repair which depends upon invasion of the damaged tendon by vascular granulation tissue from without; adhesions arise as a result of this process. Various techniques have been used to try and overcome this by creating new tendon tunnels. Leo Mayer (1936) started this line of research by using celloidin tubes. The culmination of this approach to the problem came with the use of non-reactive silicone rubber artificial tendons developed by Carroll and Bassett (1965) and Hunter (1965).
Fig. 1. Artificial tendon. Made of silicone rubber and containing a core of Dacron. Fig. 2. A silastic tendon in place. An epithelial tunnel forms around the tendon which will be replaced by a conventional graft ten weeks later. OPERATIVE TECHNIQUE The following technique has been employed in difficult tendon injuries. The affected tendon and sheath are excised and a silastic tendon formed from a silicone rubber rod threaded with silk suture material is attached to the distal stump of the profundus and proximally to the profundus tendon at the level of the distal metacarpo-phalangeal joint flexion crease. Activity is encouraged and usually a good range of movement is achieved with the artificial tendon. At ten weeks the artificial tendon is replaced by an autograft, us,lng the plantaris or palmaris as donor tendon. The autograft is "railroaded" along the tunnel which has formed around the silastic tendon by attaching it to one end of the artificial tendon and drawing it into the tunnel as the sitastic tendon is withdrawn. The distal stump of profundus is excised and a small length of profundus is excised proximally, so that the proximal suture line can be enclosed in lumbrical muscle. The distal end of the autograft is anchored as described by Pulvertaft (1960). Movement is commenced at three weeks. CASES An account was given of four patients with difficult tendon injuries who were treated as described above. Two of these had division of all eight flexors to the four fingers of one hand with subsequent infection. The results were very pleasing with excellent return of function in three patients and a satisfactory result in the fourth.
120
Silastics in Tendon Surgery--Basil Helal
Fig. 3a. This patient divided all eight flexors of the ulnar four digits in this hand. The wound became infected. The flexor sheaths were obliterated by fibrous tissue. Fig. 3b. After preliminary replacement with silastic tendons, conventional grafts were inserted. The end result is illustrated.
o
~r
Iii
Fig. 4. The flexor apparatus to the middle finger was destroyed by a septic tenosynovitis. The end result after preliminary insertion of an artificial tendon and subsequent graft.
SUMMARY
I n the presence of extensive d a m a g e to the flexor a p p a r a t u s in the fingers, the results of c o n v e n t i o n a l t e n d o n grafting are poor. More satisfactory results have been obtained by t e m p o r a r y replacement of the t e n d o n by a silicone r u b b e r rod. M o v e m e n t is then encouraged a n d after ten weeks, the rod is replaced by an autograft. T h e m e t h o d described is r e c o m m e n d e d without reservation for the complicated flexor t e n d o n injury within the fibrous flexor tendon sheath.
REFERENCES MAYER, L., and RANSOHOFF, N. (1936) Reconstruction of the digital tendon sheath. Journal of Bone and Joint Surgery, 18: 607. BASSETT, C. A. L., and CARROLL, R. E. (1963) Formation of tendon sheath by silicone rod implants. Journal of Bone and Joint Surgery, 45A : 884. HUNTER, J. M. (1965) Artificial Tendons. Journal of Bone and Joint Surgery, 47A: 631. PULVERTAFT, R. G. (1960) The treatment of profundus division by free tendon graft. Journal of Bone and Joint Surgery, 42A: 1363. 121