A Closer Look At Orthobiologics For Tendon Repair

Michael Troiano, DPM, and Harold Schoenhaus, DPM, FACFAS

The use of orthobiologics may facilitate enhanced tendon repair and minimize or eliminate common complications. Accordingly, these authors provide a step-by-step guide to the use of two orthobiologics and how they contribute to optimal outcomes.

   Tendon surgery is one of the most challenging paradigms for the podiatric surgeon. Whether the tendon injury is acute or chronic, the repair is based on a few simple parameters. These parameters include early range of motion, restoring the length-tension balance, restoration of the simple gliding mechanism associated with the tendon and, of course, adequate strength of the repair.

   Unfortunately, if one does not meet all the parameters, the patient will have an undesirable result and an inevitable future rupture, injury and/or continued pain. For some time after repair of the tendon, the body relies simply on the suture that the surgeon used to satisfy all of the aforementioned parameters. That is to say, the weakest link of the repair is often the type of suture the surgeon uses for the repair and/or the stitch technique he or she uses to facilitate the repair.

   One of the most exciting areas of science and medicine is the advent of orthobiologics. By definition, orthobiology is the inclusion of biology and biochemistry in the development of bone and soft tissue replacement materials for skeletal and tissue healing. With the advent of orthobiologics, the surgeon has a number of options for increasing the strength and ability of the repair while decreasing the length of the postoperative period.

   Accordingly, let us take a closer look at a couple of the major biologics surgeons use in tendon repair and effective techniques for use. This article is not all-inclusive as we will focus on our experience with Restore® (Depuy) and GraftJacket® (Wright Medical).

Examining The Benefits Of Restore

   Restore is porcine-derived small intestine submucosa (SIS). It is a resorbable, 10-ply, isotropic-designed extracellular matrix (ECM), which provides a scaffold conducive for quick remodeling. It is a non-cross-linked implant surgeons can use for reinforcement of weakened and/or damaged soft tissue.

   The implant is specifically intended for reinforcement of the soft tissues, which one repairs via suture or suture anchors. It is designed to provide a resorbable scaffold, which is gradually replaced by the body’s own soft tissue. It attracts host cell migration, resulting in a tissue that is structurally and functionally similar to the original host tissue. However, it is not intended to replace normal body structure or provide full mechanical strength.

   In regard to the soft tissue wound healing and remodeling response that occurs after implantation of the Restore orthobiologic implant, the surgeon should expect to see signs of active proliferation of responding cells and blood vessels (angiogenesis) at the repair site approximately two to four weeks postoperatively. Sometimes the cellular response may manifest in localized redness, swelling and warmth. If the patient has this angiofibrous proliferative response, it should resolve within four to six weeks postoperatively. Restore is contraindicated in patients with allergies to pork or pork products

   One can use Restore to augment a posterior tibial tendon intrasubstance repair. The repair begins with dissection down to the flexor retinaculum. Tag the retinaculum by using a non-absorbable suture for later identification and repair. Then incise the tendon with a scalpel at the area of the intrasubstance tear. After identifying any tendon degeneration, which manifests by thickening and fibrosis, repair the regeneration by first shelling out the pathology in a longitudinal fashion. In the effort of promoting angiogenesis, lightly curette the remaining tendon.

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