Despite extraordinary advances in most hand and wrist surgery, when it comes to repairing severed hand tendons, orthopaedic surgeon Mohana Amirtharajah, M.D., thinks we've got to do better. "Severed tendons in the hand are very common injuries," she says. "But today we only have an imperfect surgical solution."
Frustrated that despite state-of-the-art care, many patients with tendon injuries never recover their full range of motion, Amirtharajah has embarked on a collaborative research program aimed at finding new ways to improve healing.
Advanced surgical techniques enable surgeons to repair a severed tendon in the hand by sewing it back together more tightly than ever before. For the best results, the surgery should occur within two weeks of the original injury. Carefully designed postoperative therapy typically begins a week later.
The problem, explains Amirtharajah, is a fundamental trade-off in the healing process that limits a full recovery far more often than many physicians realize. Even minimal movement of the hand can place enough tension on the tendon to cause the surgical repair to rupture, often within a month, yet patients must exercise the area or risk a buildup of scar tissue on and around the tendon that can permanently restrict or eliminate motion.
This is especially problematic for tendons that run along the palm side of the hand. These tendons are surrounded by a sheath, through which the tendons must glide smoothly. Too much scarring causes the tendons to become adherent to the tendon sheath.
"Even after several months of therapy, most people never regain full range of motion," says Amirtharajah. "This defines the problem with tendon healing. We have no biologic way to let the tendon heal for itself without scarring."
Overcoming this challenge is the motivation behind a collaborative research project that Amirtharajah has undertaken with molecular biologist Tamara Alliston, Ph.D., funded by the American Foundation for Surgery of the Hand. The work focuses on the transforming growth factor–beta (TGF–beta) pathway, which plays an important role in the formation of musculoskeletal tissue throughout the body.
The two researchers believe understanding how this pathway works in genetically engineered mice can unearth clues about tendon formation in humans, a process about which scientists still know very little.
They hope their findings can inform and direct clinical trials in tendon healing, and ultimately improve clinical practice, either by enabling surgeons to make stronger repairs or by preventing the formation of scar tissue. "And since the research studies the basic biological factors that influence tendon formation, we hope the work will help with the treatment of tendon injuries in other parts of the body as well," says Amirtharajah.
Dr. Mohana Amirtharajah can be contacted at (415) 353-2808.
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