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======Preventing adhesions after flexor tendon repair ======

====Key points====
  * Injury (including surgery) 
    * breaches cell basement membrane
    * sparks inflammatory response
  * Interaction between inflammatory response, coagulation cascade, and angiogenesis
  * Hypoxia drives fibroblast differentiation to adhesion phenotype fibroblasts

====Basic science====
  * besides tendons also important in abdominal, intrauterine, pericardial surgery
  * disruption of epithelial or mesothelial layer leads to fibrin adhesions due to
    * downregulation of fibrinolytic activity
    * increase in fibrin deposition
  * key metabolic activities affecting adhesions: tissue healing, coagulation, inflammation, fibrinolysis, angiogenesis

====Modalities====

  * Mechanical barriers
  * Anti-adhesive agents
  * Combination
  * Others: e.g. gene therapy

====Examples====
  * Heparin
  * Hyaluronic acid
  * [[jnl:yangqq2021|Rhy]]

====Other important aspects of adhesions==== 
 
  * Chemokines
  * Protein c anticoagulation pathway
  * Fibrinolytic pathway

====Adhesion pathophysiology====
  * Fibrin clot forms scaffold for deposition of organized matrix and then adhesions
  * M1 (pro) vs M2 (anti) macrophages

====Preventing adhesions====
  * Surgical technique e.g AT, Kessler
  * Barriers: polymer – natural (HA, gelatin, collagen) and synthetic (PLA, PEG), tissue grafts (allogeneic amniotic membranes)
  * Commercial: hyaloglide, adcon gel, tenoglide
  * Other Adjuvants
    * Fibrinolysis, anti-inflammatory, anticoagulants, antioxidants, others
  * Molecular biology techniques: gene therapy

  
====References====
  - Capella-Monsonís, H., Kearns, S., Kelly, J. et al. Battling adhesions: from understanding to prevention. BMC biomed eng 1, 5 (2019). https://doi.org/10.1186/s42490-019-0005-0

====See also====

[[md:flexor_tendon|Flexor Tendon Healing]]

====History====
  * created 2021-06-05
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