The Phases of Tissue Healing and The Healing Process of Various Body Tissues

Understanding the Healing Process
The Phases of Tissue Healing and The Healing Process of Various Body
Tissues
Phases of the Healing Process
Inflammatory Response Phase
Fibroblastic Repair Phase
Maturation/RemodelingPhase
Inflammatory Response Phase
A series of events occurring in vascular tissues in response to injury or

antigen, pathogen or allergen which causes infection, illness or allergic
reaction
Contrasting Immune & Inflammatory Response:
KEY POINT: Inflammation is an immediate response whereas an immune

response develops more slowly
When does it Begin?
KEY POINT: Inflammation is essential for tissue repair-without inflammation

healing does not occur
Chemical Mediators
 Histamine:increased permeability, vasodilation
 Leukotaxin:increased local permeability, leukocytes line up

along cell walls
 Necrosin:controls phagocytic activity
What are the characteristics of inflammation?
How and why do they occur?
Characteristics of Inflammation
 Swelling:
 Redness:
 Heat:
 Pain:
 Loss of Function:
What is the purpose of the inflammatory phase?

 Control effects of injury
 Return tissue to normal state by localizing & disposing of injury by-

products to set stage for repair
Steps in Inflammatory Response
 Immediate vasoconstriction (5-10’)
 Vasodilation
 Clot formation (platelet plug)
 Phagocytosis
Chronic Inflammation
State in which the s/sxs of inflammation persist beyond the “normal”

length of time
Sources of Chronic Inflammation:
 Contamination by foreign body or bacteria
 Invasion by microorganism able to survive within large

phagocytes
 Antigen-Antibody Reactions
 Constant irritation by mechanical stresses or chemical and

particulate matter
 Fibroplasia
 Regenerative activity that leads to scar formation/repair of injured

tissues
 Characterized:
Decrease s/sxs of inflammation
Decreased pt. Tenderness
Decreased pain w/movements that stress tissue
 When does it occur?
Fibroblastic Repair Process
 Capillary Buds grow into area
 Fibroblasts accumulate at wound site
 Matrix is synthesized
 Fibroblasts: glue ends together
 Type III Collagen
 Stable scar is created/fibroblasts diminish
 Remodeling ready to begin
Remodeling/Maturation Phase
When does it occur?

Maturation/Remodeling Process
 Realignment/Remodeling of collagen fibers
Type III collagen replaced w/ Type I collagen
 Remodeling is dependent on forces to which scar is subjected

during maturation process: Wolff’s Law
 Assumes “normal” tissue type & function
What is the role of progressive mobility during the healing process?
Sample Time Frame

MCL Injury
0-30 min Injury/Degeneration
0-36 hrs Coagulation/Platelet Plug
2h-2 wks Inflammatory Phase
48h-6 wks Repair Phase
3wks-2yrs Maturation/Remodeling
*6 wks: Tensile strength of healing tissue relatively normal
Tissue Repair Issues:
 Regeneration v. Scarring:
 Stabile Cells:
 Labile Cells:
 Permanent Cells:
Factors Which Impede Healing
 Extent of Injury
 Edema
 Hemorrhage
 Poor Vascular Supply
 Tissue Separation
 Muscle Spasm
 Atrophy
 Health, Age, Nutrition
 Corticosteroids
 Keloids/Hypertrophic Scars
 Infection
 Climate
Healing Process of Various Body Tissues
Ligament Healing
What do ligaments do?
 Healing Process
What effect does surgical repair have on ligament healing?
What effect does exercise have on ligament healing?
Insertion Healing: Ligament/Capsule/Tendon into Bone
What is the purpose of insertions?
Direct Insertions
 Insert perpendicularly into bone
 Low number of fiber attachments
 4 Zones
 Tendon/Ligament
 Fibrocartilage
 Mineralized Fibrocart.
 Bone
Superficial Insertions
 Blend in gradually w/periosteum
 Superficial and Deep Layers
Insertion Healing Concerns
 Avascular Tissue
 PAINFUL-slows healing
 Immobilization may be required

Bone Healing
 Fracture Occurs
 Clot is formed
 Matrix synthesized by Fibroblasts
 Chondroblasts enter area
 Callus is formed
 Stage of Clinical Union
 Osteoblasts calcify callus
 Remodeling: Osteoblasts/Osteoclasts
Factors Affecting Bone Healing
 Age
Femoral Shaft Fx
Time to Clinical Union
Birth 3 wks
8 yoa 8 wks
12 yoa 12wks
20 yoa 20 wks
 Site/Configuration
 Surrounding tissues
 Surface area
 Initial Displacement
 Continuity
 Blood Supply
 Mal Union
 Delayed Union
 Non-Union
 Fibrous Union
 Pseudo Union
Articular Cartilage Structure
 4-5 layers (1-5 mm thick)
Jt Space
20% Superficial Zone
50% Middle Transitional
30% Deep (Radial)
Tidemark
Calcified Cartilage
Subchondral Bone
Articular Cartilage Healing
 Does injury involve subchondral bone?
Cartilage alone
 no clot
 Neighboring chondrocytes
Subchondral Bone
 Inflammatory Process
 Defect replaced w/fibrocartilage
 Volume & Surface area
 Location of Injury to Joint
Methods for Facilitating Articular Cartilage Healing
 Shaving
 Drilling
 K-wire
 Osteochondral Autograft
 Autologous Cartilage Cell Implantation
Meniscus Structure
FEMUR
Superficial
Surface
Middle
Surface
Superficial
TIBIA
Factors Affecting Meniscus Healing
 Vascularity
 Extent of Tear
 Age
 Communication w/other Tissue
Muscle Healing
Muscle Healing Process:
 Follows standard healing process
 Fibroblasts lay down scar
 Myoblasts enter scar (new muscle cells)
 Responds to Wolff’s Law
 Fairly lengthy rehab process (Why??)
 4-8 wks until return to full activity
Tendon
 Purpose?
 Injuries include:
 Acute strain
 Tendinitis
Tendon Healing Process:
Extrinsic
 Disrupts blood supply
 Follows standard phases
 Tenocytes (repair cell)
 Requires strong union
 Problems w/adhesions
Why?? Related to anatomy.
Intrinsic
 No vessel damage
 Neighboring tenocytes attempt to fill in defect
 More prone to chronic inflammatory condition (Why?)
Tendon Healing Time Frame
Dependent Upon:
 Cross sectional area of injury
 Amount of force to be imposed
 Minimum 4-5 wks to resist forces that might pull it apart

Myotendinous Junction
 Common site of repeat failure & inflammation
 Scar less elastic than original tissue
 Responds to Wolff’s Law
Epithelial Tissue
 Covers all internal & external body surfaces
 Fibers arranged in a meshwork
 Resist stretch/failure in many directions
 Langer’s Lines: predominate lines in mesh
 Trunk: circumferential
 Extremities: longitudinal
What effect will this have on the way incisions are/should be made?
Epithelial Tissue Healing
 No true blood supply
 Receives nutrients/eliminates waste by diffusion
 Scar Tissue: more collagen than normal skin therefore less elastic
 APPROXIMATION is the Key!

Nerve Healing
 Once nerve cell dies cannot regenerate
 If cell body is not involved, peripheral nerves can regenerate some
 SLOW PROCESS, 3-4 mm/day
 CNS: SLOWER!

The Phases of Tissue Healing and The Healing Process of Various Body Tissues

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The Phases of Tissue Healing and The Healing Process of Various Body Tissues

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Understanding the Healing Process

Phases of the Healing Process

Inflammatory Response Phase

Fibroblastic Repair Phase

Inflammatory Response Phase

A series of events occurring in vascular tissues in response to injury or

Contrasting Immune & Inflammatory Response:

KEY POINT: Inflammation is an immediate response whereas an immune

When does it Begin?

KEY POINT: Inflammation is essential for tissue repair-without inflammation

 Histamine:increased permeability, vasodilation

 Leukotaxin:increased local permeability, leukocytes line up

 Necrosin:controls phagocytic activity

What are the characteristics of inflammation?

How and why do they occur?

What is the purpose of the inflammatory phase?

 Return tissue to normal state by localizing & disposing of injury by-

Steps in Inflammatory Response

 Immediate vasoconstriction (5-10’)

 Clot formation (platelet plug)

State in which the s/sxs of inflammation persist beyond the “normal”

Sources of Chronic Inflammation:

 Contamination by foreign body or bacteria

 Invasion by microorganism able to survive within large

 Constant irritation by mechanical stresses or chemical and

 Regenerative activity that leads to scar formation/repair of injured

Fibroblastic Repair Phase

Decrease s/sxs of inflammation

Decreased pt. Tenderness

Decreased pain w/movements that stress tissue

 When does it occur?

Fibroblastic Repair Process

 Capillary Buds grow into area

 Fibroblasts accumulate at wound site

 Fibroblasts: glue ends together

 Type III Collagen

 Stable scar is created/fibroblasts diminish

 Remodeling ready to begin

When does it occur?

 Realignment/Remodeling of collagen fibers

Type III collagen replaced w/ Type I collagen

 Remodeling is dependent on forces to which scar is subjected

 Assumes “normal” tissue type & function

What is the role of progressive mobility during the healing process?

Sample Time Frame

0-30 min Injury/Degeneration

0-36 hrs Coagulation/Platelet Plug

2h-2 wks Inflammatory Phase

48h-6 wks Repair Phase

*6 wks: Tensile strength of healing tissue relatively normal

Tissue Repair Issues:

Factors Which Impede Healing

 Poor Vascular Supply

 Health, Age, Nutrition

Healing Process of Various Body Tissues

What do ligaments do?

What effect does surgical repair have on ligament healing?

What effect does exercise have on ligament healing?

Insertion Healing: Ligament/Capsule/Tendon into Bone

What is the purpose of insertions?

 Insert perpendicularly into bone

 Low number of fiber attachments