Presentation :

    J.C Guimberteau born in 1947 is cofounder and scientific director of the Aquitaine Hand Institute (I.A.M), member of the French Hand Society (GEM) and of the French Plastic and Reconstructive Society (SF.C.P.R.E).

    He was trained in the Hand and Plastic Surgery Department of the Bordeaux University (Dr.A.J.M. Goumain and Pr. J.Baudet) from 1973 to 1980.

 

    During this surgical training, he was one of the pionneers in microsurgery and transplantations.

    He spent a few month (1976) as visiting fellow with Pr. J.M. Converse in New York (USA) and Pr. R.Millard in Miami (USA).

 

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WHY A CHANGE OF BEHAVIOUR IS NECESSARY

    From the outset, surgical principles concerning the reconstruction of finger flexor tendons have centered on the tendon as a simple force transmission belt between the muscular structure, responsible for the creation of the force, and the mobile articulated structure, which is bent by this force.
    Consequently, this very mechanical concept led to the development of techniques with the main aim or rebuilding this transmission belt as solidly as possible.

    Since the beginning of the century, these techniques required avascular tendon grafts using different types of tendons; either the Palmaris brevis, Plantaris, or others.
    The difficulties encountered, the poor results, as well as surgical observations during some secondary procedures, led surgeons of later generations to wonder about the real physiological functioning of the tendon.
    Until then, the nature of tendon biology had not been questioned because everyone was convinced of its avascular nature and that its mechanical function simulated a transmission belt.

ADHESION-SURVICAL

    From the 1940’s onward, a significant body of research has accumulated confirming the difficulties of healing in tendon, the major reason being a lack of the requisite collagen production. Instead, so-called vascular survival connections developed through adhesion to the peripheral tissue. This largely diminished the sliding capacity of the tendons as well as their functional recovery.
    Potenza introduced this essential notion of vascular adhesion. From then on, the chosen way was to adapt to this apparently unavoidable concept of tendon adhesion and try to lessen its importance in order to optimize sliding capacities. Nevertheless, the concept of tendon adhesion was not completely suppressed.

MINIMIZATION OF THE IMPORTANCE OF BLOOD VASCULARIZATION IN FAVOUR OF THE ROLE OF THE SYNOVIAL FLUID

    Attempts to understand why tendon needs vascular or pseudo-vascular connections were put in abeyance. Indeed, some research quite frankly tended to minimize the role of vascularization, especially the research carried out by Lundborg and Manske on chicken tendon. It was found that isotopic impregnation of the tendon was more easily done with synovial fluid than by tendon vascularization. This discovery practically froze research and techniques for several years because it seemed pointless to carry out any research if one admitted that tendon is only very slightly vascularized and anyway sufficiently nourished by the synovial fluid.
    This was the mechanistic period.

THE MECHANISTIC PERIOD ACCEPTED THE DILEMNA BETWEEN A NONVASCULARIZED TENDON REQUIRING PERIPHERAL ADHESION IN ORDER TO SURVIVE AND ITS COROLLARY OF CONSTRAINTS TOWARDS GENERIC SLIDING.

    Thus everything was set up to diminish adhesion by limiting the contact between the transferred tendon and the receiver site. Catgut leaves, mersilene and silicon were gradually introduced and showed their efficacy but to the detriment of tendon solidity as they suppressed these adhering vascular connections. Rupture due to necrosis became a major complication. The fact that tendon needed this adhesion in order to survive was acknowledged as was its detrimental effect on sliding and the functional result.
    Throughout the following decades, research was aimed at diminution of adhesion frequency and the optimization of functional results.
    In order to achieve this, it was necessary to find another solution to reconcile these two antagonists: healing without sliding, or sliding with the risk of rupture.

ARTIFICIAL STRUGGLE OF THE SHEATH AGAINST ADHESION, TENDON REINFORCEMENT AND REPAIRING

    Numerous proposals were made but little by little, the two-stage techniques became popular. Firstly, it called for the creation of a peritendinous synovial pseudo-sheath that was capable of feeding the tendon thanks to a pseudo-synovial fluid, as Lundborg’s work advised, tendon being introduced in the second stage. This is the basic technique still used today.
    Known as two-stage tenoplasty by James Hunter and by Paneva Olevitch, it required a two-phased operational sequence: firstly, a silicon cord capable of recreating the conditions of a synovial sheath is inserted. In the second stage, tendon transfer is carried out either by grafting or by the transfer of a superficial flexor previously stitched to the remaining flexor profundus in the first stage and so ensuring the solidity of the suture.
    Despite all these precautions, the functional results are mediocre because, apart from Hunter’s series which forecast 80% good results, other teams only approached 50% to 60%. The daily practice of every surgeon demonstrates that the two-stage technique necessitates at least six months, thus discouraging numerous patients and numerous surgeons due both to the time factor and to the poor quality of the functional result.

    However, these techniques follow a certain mechanical logic. In fact, the transmission cord principle persists by optimizing the solidity of the stitching in the first stage of the operation. An attempt is made to solve the biological problem by trying to create sliding conditions with a synovial pseudo-sheath.

THE SURGICAL ATTITUDE IS TO ADAPT TO THE PROBLEM OF ADHESION FORMATION BY DOING EVERYTHING POSSIBLE TO OBTAIN THE RATHER STRANGE CONCEPT OF «SUPPLE ADHESION»

    Although this principle may represent enormous progress compared to the past, it remains progress without a future because biological realities and imperatives are not respected. This situation has persisted for over twenty years, representing an unacceptable stagnation in functional results.

FAILURES AND ATTEMPTED EXPLANATIONS

    In all these techniques, the tendon is always non vascularized, placed in a more or less sclerotic receiver site with the impossible mission of both healing and sliding at the same time.Other research which can no longer be ignored, especially by Peacock, then by Smith and Bellinger nd others, have demonstrated that the tendon is a perfectly vascularized organ with a vascular distribution that is both intrinsic and extrinsic, as well as having a very specific lymphatic drainage.Furthermore, no physiological or microanatomical explanations have been proposed for the concept of virtual space between the tendon and the sheath in zones III, IV and V.Present day techniques remain completely alien to these new biological realities and continue either to ignore them or, at least, to exclude them from surgical applications.

A CHANGE OF BEHAVIOR IS NECESSARY AT THIS LEVEL

    Not only is a better knowledge of the intimate physiology of the tendon vital, but also the conditions which favour optimum function must be understood. Afterwards, techniques must be developed which approximate to the ‘milieu interieure’ of Claude Bernard. This organic and physiological pathway has already been explored at a fundamental level. It only lacks the creation of a model and technico-surgical developments.

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