Exposed Necrotic Tendons

Tendon necrosis may be observed in several types of wounds, traumas, or chronic wounds like pressure ulcers, diabetic foot ulcers, or arterial leg ulcers, as a consequence of skin necrosis. The subcutaneous anatomical position of the tendons makes them directly exposed when the skin necroses. The origin of tendon necrosis is multifactorial, exposure to air, desiccation of poorly vascularized structures, and infection being most frequently observed. An appropriate debridement is possible when the deep parts of the tendons remain vascularized enough. A partial loss of depth of the tendon does not severely impact its mechanical resistance and function. Wound bed preparation using negative pressure wound therapy is necessary to enhance the tendon embedding into granulation tissue. Coverage can be done using dermal substitutes followed by split thickness skin grafts, a guarantee for tendon gliding recovery. Flaps are sometimes preferred but more invasive and needing secondary procedures. Direct skin grafting being not recommended as leading to secondary tendinous adherences. Immobilization of the tendon is the key element to prevent infection to spread along the tendon sheets and develop tunnels. Tendon necrosis should be considered as an emergency in order to preserve the functional results. The introduction of microsurgery and NPWT has drastically modified the capacity to conserve exposed tendinous structures and prevent loss of function.