Tendon surgery is done most commonly when injuries involving the tendon occur. Tendon injuries that frequently require surgery are:
Acute tendon ruptures Repairing the ruptured
tendon has numerous suture techniques with most
demonstrating adequate strength to maintain the
repair. Tendon allografts, autogenous tendon grafts,
or tendon transfers are well described to augment
the repair. The advent of biomaterials to augment
the repair have been popularized to supplement the
repair more recently. These techniques are especially
used when gaps within the tendon are present. This
graft supplementation is best documented in Achilles
tendon ruptures, but it is also being used for repair of
the posterior tibial tendon and other acute ruptures.
Chronic tendon injuries Surgical intervention
for these injuries is more common in the chronic
degenerative process of the posterior tibial tendon
when treating posterior tibial tendon dysfunction or
in chronic and recalcitrant Achilles tendinosis. The
technique for repairing the chronic degenerative
process usually involves excision of the degenerative
tendon with some suture technique to repair the
remaining tendon. Again, augmentation of the
repair has been popularized with the new graft
materials available.
OrthoWrap™ Bioresorbable Protective Sheet
The OrthoWrap™ Bioresorbable Protective Sheet can be utilized for the management and protection of tendon
injuries where there has been no substantial loss of tendon
tissue. The OrthoWrap™ sheet
minimizes soft tissue attachments
to the device in case of direct
contact with other tissues. It
can be cut with sterile scissors,
shaping the material according
to the preference of the surgeon
for the anatomic considerations
of the patient and surgical
procedure. The OrthoWrap™
sheet is then sutured into place
using absorbable suture. This clear
sheet allows for good visualization
of the tissues to ensure proper
placement. However, the mechanical integrity and handling
of the material is simple and allows for repositioning as often
as necessary to ensure proper placement is achieved.
Discussion
Whether the tendon is repaired with suturing techniques
or with suturing and graft supplementation, post-operative
complications can occur. Fibrosis leading to soft tissue
attachments or scar tissue between the repaired tendon
and neighboring tissues are most concerning and limiting
during the rehabilitation period. In addition, the period of
immobilization immediately following the procedure lends
itself to developing fibrosis and attachments. Scar tissue and
subsequent soft tissue attachments have both been shown to
limit the potential for complete recovery.
At a minimum, these complications can
delay the success of the rehabilitation
secondary to negative effects on the
tendon, muscle, joint and ligaments.
Immobilization causes intra-substance
fibrosis of the tendons increasing the
risk of re-rupture. The muscle weakens
with stiffness, more rapid fatigue and
decreased metabolic capacity. Joints
have stiffness and increased joint
compression and lastly, ligaments have
decreased strength and mass with
increased stiffness.
Minimizing the occurrence of fibrosis and soft tissue
attachments may greatly improve the success of the tendon
repair, whether the repair involved an acute rupture or a
chronic degenerative process using any repair technique
preferred by the surgeon. By using the OrthoWrap™
Bioresorbable Protective Sheet around the tendon as
demonstrated below, it is less likely that fibrosis from adjacent
bleeding bone or from surrounding soft tissues will attach to
the tendon.
The OrthoWrap™ sheet is made from 70:30 Poly
(L-lactide-co-D,L-lactide), more commonly known
as PLA. This material has been used in other podiatric
and orthopedic devices such as fixation implants. This
material has a non-porous hydrophobic nature that
resists attachments. The degradation of PLA weakens
the OrthoWrap™ sheet, however it is impermeable
throughout the critical healing period and up to 8
weeks, retaining nearly 80% of the original mechanical
strength for the 0.02mm sheet and nearly 100% of the
mechanical strength for the 0.05mm sheet. Loss of 50%
of the mechanical strength is not seen in either size until
after 20 weeks. The retention of mechanical strength is
adequate since it functions during the main period of
scar tissue formation. Normal tendon healing occurs
over a period of months. However the inflammatory
process and infiltration of fibroblasts occurs within the
first two weeks; then for the next few weeks, cross linking
of the collagen fibrils and scar tissue formation occurs.
While this can be minimized with motion, Achilles tendon
repair has documented that with the usual length of
immobilization, scar tissue forms in approximately 11%
of cases. The use of the OrthoWrap™ Sheet can assist in
minimizing the soft tissue attachments to the device, thus helping to
alleviate the effects of the immobilization.
Summary
The OrthoWrap™ Bioresorbable Protective Sheet has proven to be a cost effective and inert product. It can be wrapped
around the various tendons in acute and chronic repairs to help manage and protect injured tendons while minimizing
soft tissue attachments to the device that may impede the recovery of the patient. While early success has been
observed, further investigation is required to determine the efficacy of the OrthoWrap™ sheet in tendon surgery of the
foot and ankle as well as in other foot and ankle surgery procedures.
OrthoWrap™ Bioresorbable Protective Sheet
The OrthoWrap™ Bioresorbable Protective Sheet can be utilized for the management and protection of tendon
injuries where there has been no substantial loss of tendon tissue. The bioresorbable protective sheet minimizes soft
tissue attachments to the device in case of direct contact with other tissues.
Plantar fibromatosis is a connective tissue disorder
that involves proliferation of fibroblasts. Excision is
frequently done when the mass has become painful
to bear weight or when entrapment of the plantar
medial neurovascular bundle occurs. The fibromas
are located within the plantar fascia, adjacent to the
superficial layer of the intrinsic musculature and during
the excision these muscles are exposed. In addition,
the neurovascular bundle of the plantar medial foot
is also frequently exposed. It is typical to remain nonweight
bearing after the excision secondary to the
plantar incision, which provides maximum exposure
to the mass. The effects of immobilization have been
shown to impact the fibrosis and scarring that can
occur following any surgical procedure, especially
when surgery involves well vascularized tissue such as
skeletal muscle.
OrthoWrap™ Bioresorbable Protective Sheet
The OrthoWrap™ Bioresorbable Protective Sheet can be utilized for the management and protection of tendon
injuries where there has been no substantial loss of tendon
tissue. The OrthoWrap™ sheet
minimizes soft tissue attachments
to the device in case of direct
contact with other tissues. It
can be cut with sterile scissors,
shaping the material according
to the preference of the surgeon
for the anatomic considerations
of the patient and surgical
procedure. The OrthoWrap™
sheet is then sutured into place
using absorbable suture. This clear
sheet allows for good visualization
of the tissues to ensure proper
placement. However, the mechanical integrity and handling
of the material is simple and allows for repositioning as often
as necessary to ensure proper placement is achieved.
Discussion
When excising a plantar fibroma,
a section of the plantar fascia
is removed. Wide margins are desired to help prevent
recurrence. This leaves direct contact between the
subcutaneous tissue in the plantar arch and the superficial
layer of the intrinsic musculature. The highly vascular muscle
layer and the vascularity of the subcutaneous tissues lend
itself to forming fibrotic tissue. This coupled with the period
of immobilization following the surgery increases the risk of
forming scar tissue. Fibrosis in this area may lead to other
complications as well. Since the plantar medial neurovascular
bundle is located between the abductor hallucis and flexor
digitorum brevis muscles in the superficial muscle layer, fibrosis
can cause neuritic symptoms. This complication is more likely
in the procedures involving recurrent fibromas secondary to
the more extensive dissection and greater
exposure of the first layer of intrinsic
muscles. Limiting the chance of fibrosis
and subsequent soft tissue attachments
may increase the overall success of the
fibroma excision.
The OrthoWrap™ Bioresorbable Protective
Sheet is made from 70:30 Poly (L-lactideco-
D,L-lactide), more commonly known
as PLA. This material has been used
in other podiatric and orthopedic
materials such as fixation implants. The
OrthoWrap™ sheet has a non-porous hydrophobic nature
that resists attachments. The degradation of PLA weakens
the OrthoWrap™ sheet, however it is impermeable throughout
the critical healing period and up to 8 weeks, retaining nearly
more than 80% of the original mechanical strength for the
0.02mm sheet and nearly 100% of the mechanical strength
for the 0.05mm sheet. Loss of 50% of the mechanical strength
is not seen in either size until after 20 weeks. The retention
of mechanical strength is adequate since it functions
during the main period of scar tissue formation.
By using the OrthoWrap™ sheet to cover the intrinsic
muscles, as demonstrated in the cases above, formation
of fibrotic tissue and subsequent soft tissue attachments
between the tissue layers is less likely. This is important
when the disorder being treated is one of exuberant
fibrotic tissue in an area that is likely to develop soft tissue
attachments.
Summary
The OrthoWrap™ Bioresorbable Protective Sheet has
proven to be a cost effective and inert product. It can
be used as a protective sheet overlying the intrinsic
muscles and neurovascular bundle potentially exposed
during plantar fibroma excision to prevent soft tissue
attachments to the device. While early success has been observed
with this technique, further investigation is required
to determine the efficacy of the OrthoWrap™ sheet in
plantar fibroma excision and in other foot and ankle
surgery procedures.
OrthoWrap™ Bioresorbable Protective Sheet
The OrthoWrap™ Bioresorbable Protective Sheet can be utilized for the management and protection of tendon
injuries where there has been no substantial loss of tendon tissue. The bioresorbable protective sheet minimizes soft
tissue attachments to the device in case of direct contact with other tissues.
Background
Compression neuropathy of the posterior tibial
nerve and/or its terminal branches is a common
problem. The posterior tibial nerve usually
bifurcates within the third compartment of the
flexor retinaculum, but it can divide proximal to the
flexor retinaculum. The posterior tibial nerve or the
terminal branches can be entrapped within the
tarsal tunnel or at the more commonly implicated
site distal to the tarsal tunnel at the abductor hiatus
(porta pedis). Frequently the sometimes vague
and clinically progressive symptoms respond to
conservative care of corticosteroid injections
custom molded orthotics, NSAIDs, and/or physical
therapy.
When the conservative care fails surgical release
of the nerve entrapment is necessary. The flexor
retinaculum is released and any structures or fibrosis
compressing the posterior tibial nerves are released
or excised. Skin and subcutaneous closure is then
done without closing the flexor retinaculum. One
of the most common complications is recurrence,
which is usually caused by fibrosis within the tarsal
tunnel. Recurrence has been reported in the
literature to be 5-20%.
OrthoWrap™ Bioresorbable Protective Sheet
The OrthoWrap™ Bioresorbable Protective Sheet can
be utilized for the management and protection of
tendon injuries where there has been no substantial
Background
loss of tendon tissue. The OrthoWrap™ sheet
minimizes soft tissue attachments to the device
in case of direct contact with other tissues. It can
be cut with sterile scissors, shaping the material
according to the preference of the surgeon for the
anatomic considerations of the patient and surgical
procedure. The OrthoWrap™
sheet is then sutured into place
using absorbable suture. This
clear sheet allows for good
visualization of the tissues to
ensure proper placement.
However, the mechanical
integrity and handling of the
material is simple and allows
for repositioning as often as
necessary to ensure proper
placement is achieved.
Discussion
When decompressing the affected nerve, there is
a potential for bleeding from small capillaries, veins
and potentially the presence of varicosities removed
from around the posterior tibial nerve. While the flexor
retinaculum is not repaired over the third compartment
of the tarsal tunnel, additional scarring can occur. If
this fibrosis is present it tends to increase the chance
of recurrence of the same problem. This coupled with
the short period of immobilization following the surgery
increases the risk of forming scar tissue around the
nerve. Limiting the chance of fibrosis and subsequent
scar tissue may increase the overall success of the
surgery. Other concepts have been used, such as
corticosteroid within the tarsal tunnel after the release,
however no other modalities have
been clinically proven to reduce the
recurrence rate of the problem.
The OrthoWrap™ Bioresorbable
Protective Sheet is made from
70:30 Poly (L-lactide-co-D,L-lactide),
more commonly known as PLA.
This material has been used in
other podiatric and orthopedic
materials such as fixation implants.
This material has a non-porous
hydrophobic nature that minimizes
attachments to the device. The degradation of
PLA weakens the OrthoWrap™ sheet, however it is
impermeable throughout the critical healing period
and up to 8 weeks, retaining more than 80% of the
original mechanical strength for the 0.02mm sheet and
nearly 100% of the mechanical strength for the 0.05mm
sheet. Loss of 50% of the mechanical strength is not
seen in either size until after 20 weeks. The retention
of mechanical strength is adequate since it functions
during the main period of tissue healing.
By placing the OrthoWrap™ sheet in the tarsal tunnel
compartment, formation of undesirable scar tissue
attachments within the tarsal tunnel is less likely.
This is important to attempt to decrease the high
recurrence rate for this procedure.
Summary
The OrthoWrap™ Bioresorbable Protective Sheet has
proven to be a cost effective and inert product. It
can be used to reinforce soft tissues and minimize
tissue attachments to the device. While early
success has been observed with this technique,
further investigation is required to determine the
efficacy of the OrthoWrap™ sheet in foot and ankle
surgery procedures.
OrthoWrap™ Bioresorbable Protective Sheet
The OrthoWrap™ Bioresorbable Protective Sheet can be utilized for the management and protection of tendon
injuries where there has been no substantial loss of tendon tissue. The bioresorbable protective sheet minimizes soft
tissue attachments to the device in case of direct contact with other tissues.
The OrthoWrap™ Bioresorbable Protective Sheet can be utilized for the management and protection of tendon
injuries where there has been no substantial loss of tendon
tissue. The OrthoWrap™ sheet
minimizes soft tissue attachments
to the device in case of direct
contact with other tissues. It
can be cut with sterile scissors,
shaping the material according
to the preference of the surgeon
for the anatomic considerations
of the patient and surgical
procedure. The OrthoWrap™
sheet is then sutured into place
using absorbable suture. This clear
sheet allows for good visualization
of the tissues to ensure proper
placement. However, the mechanical integrity and handling
of the material is simple and allows for repositioning as often
as necessary to ensure proper placement is achieved.
