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===== Flexor Tendon Repair and Healing =====

==== Key Time Points ====

  - 1700s: John Hunter early work
  - 1940s?: Bunnell -- no man's land
  - 1967 ASSH Kleinert's paper (Singh 2015) -- clinical before experimental work
  
==== Tendons and Ligaments in General ====

   - Structure and function (Leong 2019) - differences between the two may be semantic and degrees

==== Healing ====
  - 3 phases (Leong 2019)
    - early -- pro-inflammatory cytokines: 
      - "Platelets and cells within the clot release transforming growth factor-β (TGF-β), insulin-like growth factor-I (IGF-I), and platelet-derived growth factor (PDGF), causing local inflammation.21,25" & 
      - "1 TGF‐β is responsible for regulating proteinase activity, stimulating collagen production, and later, recruiting of fibroblasts.21,22,27 Similarly, IGF‐I functions to stimulate ECM production and recruit fibroblasts to the area28,29 and, PDGF enhances DNA and protein synthesis, and therefore the expression of other growth factors.21 These factors work synergistically to initiate the healing process" (Leong 2019)
      - "While most vascularized tendons and ligaments have at least some capacity to heal and the ability to form scar that gets remodeled over time, avascular tendon such as the rotator cuff and intra‐articular ligaments generally do not have healing capacity"
  - extrinsic and intrinsic: TSPC (see Bi 2007 quoted in Leong 2019)
  - M1 and M2 macrophages
  - extrinsic --> adhesions
  - exercise increases tendon strength, immobilization decreases; rest is important
  - aging reduces strength, size, and increases risk of rupture


==== Surgical repair considerations ====

  - suture type, size
  - technique of repair
  - surgical handling
  - gapping at repair site -- Gelbermann's work on rupture; Silverskoild's - may not affect outcome
   
==== Rehabilitation ====

  - important --> Move to active; but verdict still out [[jnl:neiduski2019]]
  - Both motion and tension (Kubota in Singh 2015)

==== Outcomes ====

  * [[jnl:Teemu2019_correlations|Correlations Among Objectively Measured Impairment, Outcome Classification Systems, and Subjectively Perceived Disability After Flexor Tendon Repair]]
====Adhesions====
[[md:flexor_tendon_adhesions|Adhesions and its prevention]]

==== Adjuncts to Surgery ====

=== Biophysical ===

== Ultrasound ==

  * [[jnl:Gan1995|US on chicken flexor tendons]]
  * [[jnl:jiang2019|LIPUS for Therapeutic Applications]]

== Magnetic Field ==

  * [[jnl:henry2008|The Effect of Magnetic Fields on Wound Healing]]

from Henry 2008:

> Although there is ample experimental and clinical evidence supporting the use of magnetic fields to aid bone healing, its application for soft tissue healing, including skin and tendons, is still ambiguous. Promising research along these lines was first produced in the 1960s by Becker. Studying amphibians, he described the presence of an electromagnetic skin circuit, alterations which accompanied limb regeneration.18 Borgens et al confirmed that this current is essential for amphibian limb regeneration and that its reversal induces limb degeneration.19,20 In a study involving limb amputations in frogs, a species that does not naturally produce this current and that is normally incapable of limb regeneration, induction of this current stimulated the regeneration of a rudimentary limb that included cartilage, nerve, and skin tissues.20 These skin circuits have been identified in humans and are similar in magnitude to those demonstrated in amphibians.21 Given this fact, it is plausible that external magnetic therapy could influence soft tissue healing in humans as well.

 
    
====Results====

Singh 2015: 

> Current data suggests good or excellent outcomes in over 75% of flexor tendon repairs.54 Rupture occurs in 4-10% of finger flexor repairs and 4-17% of long thumb flexor repairs.54 Modern tissue engineering approaches and focused rehabilitation protocols are the future avenues for further improving recovery.






==== Sources =====

  *. Singh, R., Rymer, B., Theobald, P., & Thomas, P. B. M. (2015). A review of current concepts in flexor tendon repair: Physiology, biomechanics, surgical technique and rehabilitation. Orthopedic Reviews, 7(4). https://doi.org/10.4081/or.2015.6125
  * Leong, N. L., Kator, J. L., Clemens, T. L., James, A., Enamoto‐Iwamoto, M., & Jiang, J. (2020). Tendon and Ligament Healing and Current Approaches to Tendon and Ligament Regeneration. Journal of Orthopaedic Research, 38(1), 7–12. https://doi.org/10.1002/jor.24475



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  - created: 2021-04-11
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