A Closer Look At Orthobiologics For Tendon Repair

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Author(s): 
Michael Troiano, DPM, and Harold Schoenhaus, DPM, FACFAS

   When it comes to complete tendon ruptures, GraftJacket has virtually eliminated the need for cadaveric tendon grafts. Even if the rupture is old, the surgeon has a new alternative that did not exist several years ago. In the previous treatment of ruptured tendons, the surgeon’s choices were as follows:

   • transfer another tendon (which destabilized a different part of the foot); or
   • use a cadaveric graft (which often came with an undesirable immune response).

   If the surgeon performed a slide type lengthening, the tendon would inevitably weaken and the surgeon risked possible re-rupture.

   With the advent of GraftJacket, the surgeon has new choices. He or she has the opportunity to perform a slide-type lengthening of the tendon and augment the repair with the GraftJacket, or substitute GraftJacket as an interpositional graft in lieu of the cadaveric tendon. In either event, repairing the tendon with GraftJacket facilitates exceptional strength, preservation of length, no immune response and anatomic restoration.

Case Study: When A Patient Has A Ruptured Achilles Tendon

   In the following example, a 34-year-old male ruptured his Achilles tendon playing football.

   The surgeon made an incision over the Achilles tendon. The tendon was gapped significantly with necrosis of the ruptured ends. The surgeon debrided the necrotic tendon and performed a direct repair using a Krackow stitch. The surgeon proceeded to use a 4x7 cm GraftJacket MaxForce (the thickest and strongest version of GraftJacket) to encompass and augment the direct repair. Plantarflexing the ankle and suturing the MaxForce under tension facilitates this repair.

   The patient wore a cast in gravity equinus. The convalescence period was unremarkable for approximately three weeks. Against medical advice, the patient removed his own cast and subsequently slipped on his child’s toy. The tendon re-ruptured and required a second repair. Interestingly, upon surgical examination, the GraftJacket had fully incorporated at three weeks and was holding the ruptured ends in place and full tension (even though the intrasubstance of the tendon was completely torn).

   The surgeon obtained a biopsy of the tendon with the incorporated GraftJacket. Upon histologic examination, the biopsy showed full incorporation of the graft. Moreover, the GraftJacket was indistinguishable from the Achilles tendon for which it was grafted. Upon subsequent repair, the patient made a full recovery.

In Conclusion

   The advent of orthobiologics has obviated the result of some of the most complicating factors in the repair of tendons. With the use of Restore and GraftJacket, surgeons are now able to avoid the major reactions associated with allografts and autografts. One can restore mechanical function faster with virtually no risk of host rejection. These orthobiologics facilitate enhanced strength and stability, which are paramount to the repair. Surgeons can also preserve the gliding mechanism of tendons and their sheaths.

   All of these combined factors result in the patient’s improved result and return to function more quickly with ultimate remodeling of existing tissue being virtually indistinguishable from the original host tissue. In addition, these patients have been able to return to normal activity in less time with markedly reduced complications and restoration of normal function. Postoperatively, one must control or eliminate the underlying cause of tendon injury.

Dr. Troiano is affiliated with the Penn Wound Care Center and the Center for Foot and Ankle Disorders in Philadelphia. He is an Associate of the American College of Foot and Ankle Surgeons.

Dr. Schoenhaus is the Podiatric Medical Director of the Penn Wound Care Center in Philadelphia. He is a Fellow of the American College of Foot and Ankle Surgeons, and is board-certified by the American Board of Podiatric Surgery and the American Board of Podiatric Orthopaedics.

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