Watkin's Manual of Foot and Ankle Surgery: Tendon Transfers
Terms in this set (33)
Tendon Anatomy: Epitenon (1)
Outer covering of a tendon within its sheath.
Most important structure in the tendon repair process.
Tendon Anatomy: Endotenon (2)
loose acellular tissue carrying blood vessels that surrounds small bundles of collagen fibers throughout the tendon.
Tendon Anatomy: Paratenon (3)
∙Loose elastic areolar tissue surrounding the entire tendon, which allows the tendon to slide.
blood supply to the tendon and should be reapproximated after tendon surgery.
majority of a tendon's blood supply.
Tendon Anatomy: Mesotenon (4)
∙Delicate connective tissue sheath attaching tendon to it fibrous sheath.
∙Part of paratenon that attaches the paratenon to epitenon, can stretch several centimeters
∙Allows blood supply to be transferred to paratenon to tendon.
∙Hilus: point where it attaches to epitenon
Tendon Anatomy: Peritenon (5)
All connective tissues associated with a tendon.
Tendon Anatomy: Fascicles (6)
Group of collagen fibers bundled together and surrounded by an endotenon.
Tendon Anatomy: Collagen fibers (7)
∙Formed from a
polymer of tropocollagen
n*, which the basic molecular unit of a tendon.
∙Healthy tendon is
mostly comprised of type I collagen.
∙Main collagens in connective tissue: Type I, II, and III. They form fibers that give tensile strength to tissues.
: Most abundant, found in skin, ligaments,
I*: found in articular cartilage (Hyaline cartilage)
: Skin, vessels, lymphatics, granulation tissue,
Tendonitis vs. Tendinosis:
Tendon Repair: End to end anastomosis
Anchoring Tendon to Bone: Trephine Plug
Round cortical plug is removed with a trephine, tendon is inserted, and plug is replaced.
Anchoring Tendon to Bone: Three-Hole Suture
Tendon is anchored to a piece of suture, tendon is inserted in a hole in the bone, and the two suture ends exit the bone through two additional holes are tied.
Anchoring Tendon to Bone: Buttress and Button Anchor
Tendon is anchored to a piece of suture, then tendon is inserted in a hole in the bone, and suture ends continue through the bone and exit the skin on the other side of the foot and is fixated with a button.
Anchoring Tendon to Bone: Tendon with Bony Insertion
Portion of bone is removed, and reinstered into a preformed hole of similar size and shape.
Anchoring Tendon to Bone: Tunnel with Sling
Hole is drilled though the entire bone; tendon is then passed through the bone and sutured back on itself.
Anchoring Tendon to Bone: Mason-Allen Stitch
Tendon-to-bone technique often used in rotator-cuff repair.
Anchoring Tendon to Bone: Screw and Washer Bone Anchor
Passing Tendon Through Bone: Chinese Finger Trap Technique
Suture is wrapped around tendon from proximal to distal in crisscross fashion. Ends suture are tied in a knot. Second piece of suture is wrapped around the tendon in identical fashion but out of phase with first piece of suture.
Passing Tendon Through Bone: Whip Stitch Technique
Tendon Lengthening Procedures:
∙Cuts are made no less than 51% of the way though the tendon, and ends are distracted away from one another, allowing central fibers to slide past one another.
∙During tendon transposition, the
paratenon should be preserved
d* to allow gliding of the tendon and preserve blood supply.
∙With tendon transfers, the involved
muscle loses 1 grade of strength.
qualify for a tendon transfer, a muscle must be of grade 4
4* or higher.
→CVA patients should not have tendon transfers for at least 6 months following the CVA.
∙Muscles are divided into two phases depending on their use: swing phase and stance phase.
∙A muscle transferred from
one phase to be used in the other phase is said to be transferred out of phase.
→It is easier to retrain a muscle transferred within the same phase.
∙Muscles transferred out of phase often never regain their activity but can still be beneficial by acting as a sling and eliminating the need for bracing.
Tendon Healing and Post-Op Care:
∙After a tendon has been transferred, the patient should be casted
NWB for 4 weeks.
Gentle passive ROM and/or isometric exercises
cast may be started at 3 weeks to prevent adhesions.
∙At 4 weeks active mobilization should begin, but maximum contracture should be postponed for several more weeks.
Adductor Tendon Transfer:
∙Adductor tendon is transected at its attachment to the lateral sesamoid and the lateral base of the proximal phalanx and
rerouted over the metatarsal head and attached to the medial capsule.
∙Performed with hallux abducto valgus surgery to
help realign the sesamoid apparatus under the metatarsal head.
Flexor Tendon Transfer: Girdlestone procedure
∙Flexor digitorum longus tendon is
transected close to its insertion on the distal phalanx.
∙Split longitudinally to the base of the proximal phalanx, wrapped around the proximal phalanx.
∙Aka Girdlestone procedure
∙EHL tendon is transected and
rerouted medial to lateral through the head of the 1st metatarsal
l* and sewed back on itself.
∙Kirk modification passes tendon from top to bottom (dorsal to plantar); this technique requires less tendon.
∙The distal stump of the EHL is then attached to the EHB to maintain some extensor function of the hallux.
∙Arthrodesis the first IPJ to prevent overpowering of the EHL and hammering.
pressure problems under the 1st metatarsal head
→Flexible cavus foot, flexible plantarflexed 1st ray
∙EDL tendon slips are detached from their insertion, combined, and reattached to the
3rd cuneiform or the base of the 3rd metatarsal.
∙The EDB tendons are transected and reattached to the stump of the corresponding EDL tendon; the 4th and 5th longus slips are both attached to the 4th EDB slip.
Releases the buckling force at the MPJs and elevates the forefoot
→Equinus with or without claw toes
Split Tibialis Anterior Tendon Transfer (STATT):
∙Tibialis anterior is split from its insertion up just proximal to the superior extensor retinaculum.
lateral fibers are passed through the peroneus tertius
sheath and sutured to the tendon or
attached to the cuboid.
procedure increases dorsiflexion of the foot
t* and balances the force laterally.
→Flexible rearfoot varus.
Peroneus Longus Tendon Transfer:
∙Peroneus longus is released at the level of the cuboid and transferred through the intermuscular septum down the EDL sheath and inserted into the lesser tarsus or base of the
∙may also be split, and half is anastomosed to the tibialis anterior at its insertion and the other half to peroneus tertius.
→Indications: Drop foot, pes cavus
Transfer all of long extensor tendons to their respective metatarsal heads.
Tibialis Anterior Tendon Transfer (TATT)
∙transferred to the
3rd cuneiform through the EDL tendon sheath.
∙Acts to reduce supination and increase dorsiflexion
→Indications: Drop foot, recurrent clubfoot, flexible forefoot equinus
Tibialis Posterior Tendon Transfer:
∙tendon is transferred through the interosseus membrane and
fixated to the 3rd cuneiform.
∙out of phase tendon transfer.
→Indication: Drop foot, recurrent clubfoot
∙A tendon interposition procedure used in
∙Involves rolling up a tendon graft from end to end like an anchovy and inserting it into a damaged or resected joint.
∙Convex reamer can be used to create two opposing concave surfaces to better hold the anchovy.
∙Capsule is closed to hold the interposing "anchovy" in place.
→percutaneous K-wire may be placed across the joint and through the graft for 6 weeks to hold the "anchovy in place.