Mastering Tendon Repairs: Essential Skills for Tomorrow’s Surgeons

MedSync
Apr 21
3 min read

Updated: May 5

Tendon repairs are an entry-level skill for trainees in plastic surgery and orthopaedics. However, they are often not practiced as frequently in simulations as other skills, like microsurgery. This lack of practice means tendon repairs can be poorly executed in the operating theater, particularly when trainees first encounter hand trauma as residents.

To perform these repairs effectively, you need to understand three crucial aspects:

The zones of the hand
The regional anatomy and the relationships between structures in each zone
The ability to execute a four-stranded repair independently, from exploration to splint application

Here is our cheat sheet to help you, along with a quick video showcasing the three most common techniques you absolutely need to know how to perform with confidence.

Key Concepts in Tendon Repairs

Understanding Tendon Injuries

Tendon injuries can significantly impact a patient's recovery and quality of life. Along with surgical skills, it's essential to foster an in-depth understanding of anatomy and the specifics of tendon repair techniques. This foundation ensures that you are prepared to handle various injury scenarios.

Types of Lacerations

🔹 Partial Lacerations:

If there is 50% tendon involvement, proceed with a core + epitendinous repair.
For oblique cuts that snag on pulleys, add a few simple sutures.
Early mobilization is essential to facilitate healing.

🔹 Zone I – FDP Injuries:

Ensure you have a ≥5 mm distal stump available for sutures.
If the stump is insufficient, consider using pull-out sutures or bone anchors such as micro or mini Mitek or Juggernaut.
Regarding avulsion types (Leddy I-IV):

- Type I: Urgent repair is necessary within one week.

- Types II-IV: Timing varies; consider options such as bone fixation or button techniques.

For late cases, contemplate using grafts, tenodesis, or DIP arthrodesis.

Navigating Complex Repairs

🔹 Zone II – “No Man’s Land”:

Once deemed impossible, this zone is now routinely repaired with promising outcomes.
Always repair both FDP and FDS unless the injury is significant.
If unable to fit FDP and FDS under the A3 pulley, consider suturing FDS on top.
Avoid cutting A2/A4 pulleys; create windows in other areas.
Employ 4-strand core sutures along with an epitendinous stitch to increase strength by approximately 15–20%.

🔹 Zone III:

Repairs in this zone are similar to Zone II but offer easier recovery.
There is a reduced risk of adhesion, resulting in a better prognosis.
Watch for associated nerve injuries, as they have a significant impact on function.

Advanced Techniques

🔹 Zone IV – Carpal Tunnel Zone:

This zone is similarly constrained as Zone II, hence the same repair techniques apply.

🔹 Zone V:

In this area, strong repairs allow for early motion.
An epitendinous suture is not mandatory.
Be vigilant regarding nerve injuries, as they affect outcomes more than tendon injuries do.

For further guidance, click here to access our comprehensive resource on Tendon Repairs.

Video Tutorial

Learn the critical tendon repair techniques by watching our educational video below.

Tendon Repairs: Cruciate/Adelaide/Modified Kessler

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