Procedures

Intermediate Format:

Tenorrhaphy

Achilles Tendon Repair

                                                                                                                                                                                                                                   

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Objectives• Assess the related terminology and

pathophysiology of the tenorrhaphy_.

• Analyze the diagnostic interventions for a patient undergoing a tenorrhaphy.

• Plan the intraoperative course for a patient undergoing tenorrhaphy.

• Assemble supplies, equipment, and instrumentation needed for the procedure.

Objectives

• Choose the appropriate patient position

• Identify the incision used for the procedure

• Analyze the procedural steps for tenorrhaphy.

• Describe the care of the specimen

Terms and Definitions• Tendon

– Long, tough strands of fibers that form ends of muscles. Tendons connect muscles to their bony origins and insertions

• Paratenon– Fatty and areolar tissue

that fills the spaces withing the facscia around a tendon

• Equinus– Tightness (loss of

flexibility) in calf and Achilles Tendon (results in “toe-walking”

Definition/Purpose of Procedure

• The goal of tendon repair is restoration of normal function of joints or surrounding tissues following a tendon laceration

PathophysiologyRepair of Tendons in the Left Shoulder

                                                                                                             

From nucleusinc.com

Surgical Intervention:Special Considerations

• Patient Factors– Surgical time frame: considered an emergency—must

be performed asap before tendon atrophies

• Room Set-up

• Prep: from mid-thigh to toes and draped w/extremity drape.

Surgical Intervention: Positioning

• Position during procedure– Depends on site of injury– Achilles Tendon: Prone ; if surgical assistant not

available, position so that dorsum of forefoot remains on the table (not dangling) so that foot can be held in equinus during the tendon repair

• Supplies and equipment– Esmark and Tourniquet upper thigh

• Special considerations: high risk areas—chest rolls and padding for bony prominences, proper head alignment

Surgical Intervention: Special Considerations/Incision

• Special considerations– When tendon is still of full length, the torn ends are

sutured together

– If ruptured near calcaneous, will need to reinsert the proximal end of the tendon into the bone

• State/Describe incision– longitudinal incision is made just medial to achilles

tendon

Surgical Intervention: Supplies

• General

• Specific– Suture: strong polyester braided suture– Medications on field (name & purpose)– Catheters & Drains– Cast material: Orthoglass Splint 6” x 15”

Surgical Intervention: Instruments

• General– Basic ortho set

• Specific– Miltex tendon-pulling forceps (Fig 21-28)—

flexible or rigid

Surgical Intervention: Equipment

• General: Hand, Foot, Shoulder set—depends on location of tendon laceration or rupture; Tourniquet w/supplies (place before pt is turned prone)

• Specific

Surgical Intervention: Procedure Steps

Incision, Hemostasis, Retract

Irrigate, Hemostasis, Close Wound in Layers

Surgical Intervention: Procedure Steps• If no assistant, STSR holds foot in equinus position during

surgery• Longitudinal incision is made w/ #10 knife blade medial to

Achilles Tendon and carried down to the paratenon. • Note: in comparison w/ flexor tendons in the hand which

have an outside synovial sheath covering the tendon, the Achilles Tendon has no such sheath and is covered by the paratenon.

• Ruptured ends of Achilles Tendon are identified.• Proximal end may be explored• Due to constant tension on Achilles Tendon, proximal end

may retract upward along gastrocenemius muscle and require retrieval with tendon-pulling forceps or other atraumatic clamp

Surgical Intervention: Procedure Steps

• Another atraumatic clamp is placed on the other end of the ruptured tendon and ends are brought together to achieve original length

• Surgeon has several suture repair techniques to choose from.

Krachow whip stitchConsider using a Krachow whip stitch, along each tendon edge, using No 5 Tycron or Ethibond on a Non Cutting Needle; - alternatively consider a running "Tajima stitch" which provides good strength but does not create the overlying prominent sutures

Procedural Steps

• Next surgeon closes paratenon over the site of the tendon repair to aid in healing and preventing adhesions from forming.

• Wound closed in layers and splint dressing is applied while in equinus position

Counts

• Initial: sharps and sponges—instruments depends on site

• First closing

• Final closing– Sponges– Sharps

Specimen & Care

• Identified as N/A

• Handled: routine, etc.

Expected Outcome

Most tendon repairs are successful, allowing full joint function: for Achilles Tendon: after 10 days the splint is removed and approx 6 weeks post op pt may be able to perform gradual weight bearing

Possible complications

Postoperative Care

Resources

• www.Allrefer.com

• Community.healthgate.com

• STST pp. 841-842

• www.stoneclinic.com

• Dr Calkins Preference Card

• MAVCC Unit 10, OBJ 21

• Myfootshop.com

• www.wheelessonline.com