Tenorrhaphy by Means of the Snture a Distance of Catgnt, with Report of Case. Read before the Chicago Pathological Society, April 9, 1894. CHICAGO. INSTRUCTOR IN SURGICAL PATHOLOGY, RUSH MEDICAL COLLEGE ; HOUSE- -6 SURGEON, ST. JOSEPH’S HOSPITAL; MEMBER OP THE CHICAGO MEDICAL SOCIETY. EMANUEL J. SENN, M.D. REPRINTED FROM THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION APRIL 28, 18%. CHICAGO: PRINTED AT THE OFFICE OF THE JOURNAL OF THE ASSOCIATION 1894. Tenorrhaphy by Means of the Suture a Distance of Catgnt, with Report of Case. Read before the Chicago Pathological Society, April 9, 1894. EMANUEL J. SENN, M.D. INSTRUCTOR IN SURGICAL PATHOLOGY, RUSH M EDICAL COLLEGE ; HOUSE SURGEON, ST. JOSEPH’S HOSPITAL; MEMBER OF THE CHICAGO MEDICAL SOCIETY. CHICAGO. REPRINTED FROM THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION APRIL 2S, 18%. PRINTED AT THE OFFICE OF THE JOURNAL OF THE ASSOCIATION CHICAGO: 1894. TENORRHAPHY BY MEANS OF THE SUTURE A DISTANCE OF CATGUT, WITH REPORT OF CASE. Injuries to tendons and their sheaths is of fre- quent occurrence, and a perfect knowledge of anat- omy and method of repair of these structures for the requisite surgical treatment is of great importance to the practical surgeon. In studying our text-books of surgery, one is struck by the liberal space allotted to fractures; while the subjects of laceration of ten- dons and treatment are superficially dealt with in a few lines. Although injuries to tendons occur both in hospital and private practice far less often than fractures, this subject should receive comparatively more consideration from authors, both from a path- ological and surgical standpoint. It is not in re- cent cases where tendons are simply divided that surgeons meet with difficulties; but it is in old cases as in ancient fractures, where pathological conditions have manifested themselves and produce the many complications which call for difficult surgical inter- vention. Therefore, before considering the treat- ment by means of the suture d distance, I will comment lightly on the pathology and regeneration of divided tendons. Tendons are composed histolog- ically of connective tissue. The cells are not round, but elongated into fibrils which are firmly bound to- gether and give the appearance of white fibrous cords. They do not possess the quality of elasticity, and the vascular supply is very limited. Tendons in performing their physiological function, glide backward and forward; and like other parts of the body which are subject to motion are provided with a means intended to' place friction at a mini- 4 mum, that is, protection and lubrication. The ten- don sheath answers these two purposes well. In complete rupture of tendons there is a loss of func- tion and a consequent atrophy; followed later by a degeneration of the extremities to a limited extent. It is a law of nature that where a tissue irrespective of histological structure or vascular supply, and which has performed a customary amount of work is sud- denly put to rest, either through trauma or otherwise, there is always more or less involution of its cells. However, ruptured tendons differ from nerves in that the two ends only degenerate for about half an inch; while the medulla of the distal portion of a nerve degenerates into a granular mass, devoid of cellular organization. The sheath of Schwann which is composed of connective tissue, alone re- maining intact. This difference is most probably due to the different functions performed by the two structures and also to their difference in histology. The one composed of connective tissue whose func- tion is entirely mechanical, namely, that of moving the bone to which it is attached, through the con- traction of its muscle; while nerve cells are of a far more highly organized structure, and have vital properties for the transmission of peripheral and central stimuli. The cells of an injured tendon are surrounded by cells of their own kind, as connective tissue is omnipresent in the body and they accom- modate themselves according to circumstances by union with surrounding structures ; so that no mat- ter how far the tendon ends may have retracted, there will likely be some function performed through contraction of neighboring muscles. On the other hand, the distal end of a nerve, provided collateral anastomosis is not established, degenerates in the course of several weeks. This deterioration of nerve cells does not take place by reason of a deficient vas- cular supply, but as a result of loss of function. Cell life, either animal or vegetable, is only main- tained when metabolism is in progress; and metal 5 6 bolism is only performed as long as the cell acts the role destined for it by nature. Although tendon tissue is scantily supplied with blood vessels, it dif- fers from cartilage in being endowed with great in- trinsic vegetative capacity. This is well demonstrated in tenotomy of the tendo-Achilles for talipes equinus, where the tendon ends are oftentimes widely sepa- rated, and no attempt is made by the surgeon to facilitate regeneration by art; but within a short period this great gap is filled in with new tissue from the tendon ends and sheath. Regeneration of tendons, although not given as much individual at- tention as was given to other structures, neverthe- less was made the subject of some 'experimental investigation. It takes place by the production of embryonal cells from the mature cells of both ex- tremities, and also probably to a lesser degree from the tendon sheath. In injury of tendons there is generally hemorrhage from neighboring blood ves- sels simultaneously cut or lacerated. This depends upon the anatomical location of the trauma. M. Saint Germain speaks of a hemorrhage continu- ing eleven days after subcutaneous division of the tendo-Achilles. Blood filling up the intervening space between tendon ends, naturally suggested the “organization” theory of Hunter, who maintained that the coagulum became vascular and in time was directly trans- formed into new tissue. This theory was supported by d’Ammon in 1837, Thierfelder in 1852, and Jobert in 1864; although not without some modifications. While they thought it very probable that blood was gradually merged into tissue, they were positive that it was the active factor in cicatrization. Later Pirogoff, Dembrosky and Volkmann gave insufficient blood extravasation as a cause for incomplete regen- eration. Pirogoff asserted that blood between the tendon ends acted like a sequestrum in bone necrosis by stimulating tissue proliferation. Very recently Walter also encouraged this idea by recommending 7 in tenotomy, non-ligature of vessels, in order to pro- duce a clot as devised by Schede in the treatment of bone cavities. The inter-tendinous bloody effusion disappears by absorption about the fifth or sixth day according to observations of Lebert. Bouvierin 1837 insisted that regeneration was affected by the cellular sheath, which through a process of corruga- tion and thickening, developed into a tendinous cord. The blastema theory for a time found many ad- herents, championed by Henle in Germany, Robin in France and Brodhurst, Adams and Paget in Eng- land. This hypothesis was founded on the supposi- tion that protoplasm was spontaneously developed into cells. This reasoning rested on a weak founda- tion when it came to practical demonstration and was soon exploded. Bizzozero in 1868 already looked upon the principle of this theory in the light of a second role. Cohnheim made a step in advance to- ward the true law of regeneration when he affirmed that leucocytes which had emigrated from the blood vessels surrounding the interval between the two ten- don extremities were changed into granulation tissue through their own innate powers. The cellular theory is the last promulgated and has been faithfully de- fended by Tiircher, Bonders, Virchow, Remak, Kol- liker, Cornil and Ranvier. Regeneration of connec- tive tissue is analogous to regeneration of any other tissue, in that it can only generate from mature cells of its own kind. The blood clot acts in a passive manner by forming a temporary matrix for the imma- ture cells and also in the capacity of an irritant; thus provoking a hypersemia which is favorable to the production of new tissue. The iodoform gauze tam- pon accomplishes the same effect; only one is arti- ficially produced, while the other is nature’s effort to accomplish the same purpose. After injury there is always more or less para-vas- cular extravasation of blood; which is not essential for regeneration, but is a great auxiliary. Karyoki- netic figures are seen in the cells of the tendon ex- 8 tremities and also in the tendon sheath within forty-eight hours after the trauma, followed by the production of bud-like processes which extend into the blood clot. These are embryonal cells and being of connective tissue origin, are called fibro-blasts. They are round or angular in shape, multi-nucleated and are composed of the elementary matter of all animal and vegetable life, protoplasm. All prolifer- ation is followed by vascularization, that is exten- sion of blood vessels from the neighboring mature tissue into the mass of granulation tissue. Cicatri- zation next becomes manifest. The embryonal cells after having supported themselves through metabol- ism for a certain length of time, by their own nat- ural inherent quality evolutionize into mature cells or fixed permanent tissue. The large round or an- gular cells gradually merge into fibrils. In this metamorphosis each cell draws its neighbor into closer relation ; thereby producing cicatricial or scar contraction. In this instance nature again centers her efforts to a good purpose; for by the mechanism of contraction the two tendon extremities are brought nearer toward each other. The suture d distance as a means of establishing communication between ruptured tendons was inaug- urated by Gluck in 1884. He operated successfully upon a case where the extensor tendon of the index finger was separated eight centimeters. This mode of suture was studied experimentally by Forgin, Assaki, Jeannel and Van Haecke. Where the di- vided ends are not too far apart, a plastic operation should always be resorted to; that is the procedure devised by Czerny, of splitting the tendon upon one side for some distance, and turning the divided flap over to its fellow of the opposite side and suture. If the flap does not reach, the other tendon should be treated in the same manner and both flaps united end to end. In cases where approximation can not be secured, the suture d distance is the most useful, in fact it is the only operation which can be resorted to 9 under the circumstances. An absorbable suturing material, such as sterilized catgut or kangaroo ten- don should be used. The tendon ends are united d distance by several sutures in order to make a firm bridge-work. Catgut becomes entirely absorbed by phagocytosis in a short time. The operation meets several important indications, namely: 1, it pre- vents the tendon ends from retracting through elas- ticity of the muscle; 2, it forms a passage way for tissue proliferation; 3, it establishes a barrier, by which the embryonal cells secure protection from atrophy, caused by pressure of surrounding parts; 4, the suture being a foreign body, acts as a stimu- lant to the mature cells. The following case is of interest, as there was ex- tensive loss of substance of the extensor tendons of the hand, and this was entirely remedied by the ab- sorbable suture d distance. Mr. G. H., young man, English, miner by occupa- tion; residence Northern Michigan. Entered St. Joseph’s Hospital Jan. 6, 1894. Three months pre- viously while at work in a mine, he accidentally thrust his wrist against a jagged, sharp rock, making a complete transverse incision of the extensor com- munis digitorum tendon at its junction with the muscle just below the middle of the fore-arm. The extensor indicis tendon was also severed. After the accident the integument was stitched and the wound bandaged. According to the patient’s statement no attention wras given to the deeper structures. The dressings were removed several days later and the wound found healed ; but the three fingers supplied by the extensor communis digitorum were abso- lutely useless as far as extension was concerned. The patient waited three months in the hope of again recovering the use of his disabled hand, but to no avail. Operation; Incision of three inches in the area of the old scar, parallel with the tendons. After carefully dissecting away the scar tissue, the proxi- 10 mal end was found. It did not consist of connec- tive tissue, but was true muscular structure. Then came a tedious search for the four distal extremities, the three tendons of the extensor communis digi- torum and the extensor indicis. After searching for some time without success, I carried the incision further in the distal direction and found the tendon ends about two inches above the metacarpo-phalan- geal line. The perplexing problem of securing union between the distal ends and the proximal end now presented itself, as the intervening space was four inches in length. Splicing after the method of Czerny could not possibly be practiced here, and under the circumstances, I resorted to multiple sutures d distance, as the means of indirect approxi- mation. Medium sized catgut, sterilized according to Bergmann’s method was used. I made eight sutures, connecting the extensor communis digitorum and the extensor indicis tendons to the extensor communis digitorum muscle. The external wound was closed with an interrupted row of silkworm sutures and a continued row of catgut. No provision was made for drainage, as hemostasis had been well effected by ligature and hot water irrigation. The hand was dressed in an extended position upon an anterior splint. The dressing was removed upon the fourth day and the wound presented a favorable appear- ance, except for a small suppurating focus around one stitch. This suture was removed and after thor- ough disinfection with a solution of bromin and in- sertion of a small iodoform gauze tampon, the dress- ing was re-applied. The wound was irrigated the subsequent three days and I succeeded in aborting a diffuse suppuration, the wound healing intact. The sutures were removed upon the ninth day. On the twelfth day the patient could extend the three fingers upon the splint with slight effort. He speedily recov- ered the use of his fingers and at the end of a month was discharged from the hospital with function 11 entirely restored. Patient could lift a glass of water to his mouth and even write with perfect ease. Remarks:—Although I did not have the opportunity of making an examination in vivo of the regenerative process which took place, I am satisfied that there was new tendon tissue produced to the extent of over four inches. When the patient made extension, by placing a finger at the muscle extremity, the impulse was perceptible along the whole route of the tendons, showing that there was direct communication. The new fibrous cords when in action would bulge and become prominent to such an extent as to be- come visible through the skin. These tests were convincing proofs. This case is also of pathological interest by reason of the sutures uniting muscle with tendon. Muscle cells are endowed with very limited intrinsic vegetative capacity, and do not ex- tend further than an inch from the ruptured end; so that in this case proliferation from the distal extremity was the prime factor in effecting repo- sition, as connective tissue is the most prolific of all tissues. I wish also to dwell on the importance of making as many sutures as possible in order to construct a canal, thereby securing a line of least resistance for the embryonal cells. If I had secured each tendon with but one suture, I am certain that there would have been very probably an oblitera- tion of the canal by neighboring tissues, and con- sequent failure of the operation. An interval of four inches is an unusual occurrence. It is seldom that tendons become separated for more than one or two inches at the most; and when united by this method, the operation will yield encouraging results.