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Sivakumar B, Graham DJ, Clarke E. Dorsal Plating, Lateral Plating, and Intramedullary Screw Fixation of Extra-Articular Proximal Phalangeal Fractures: A Cadaveric Biomechanical Comparison. J Hand Surg Am 2024; 49:247-252. [PMID: 38206273 DOI: 10.1016/j.jhsa.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 11/28/2023] [Accepted: 12/06/2023] [Indexed: 01/12/2024]
Abstract
PURPOSE To provide a biomechanical comparison of dorsal plating, lateral plating and intramedullary screw [IMS] fixation for extra-articular proximal phalangeal fractures. METHODS Midshaft osteotomies were performed on 36 cadaveric proximal phalanges. The phalanges were fixed by dorsal plating, lateral plating or IMS fixation, and subjected to a four-point bending force. Force was applied to achieve displacement of 1 mm/s, until construct failure or to a maximum of 10 mm of displacement. Clinical failure was defined as 2 mm of displacement, and force required to result in 1 mm and 2 mm of displacement was recorded, as was mode of failure. RESULTS Dorsal plating [127.5 N ± 52.6; 46.51-229.17] and lateral plating [77.1 N ± 25.1; 48.3-113.8] required significantly greater force to achieve 1 mm of displacement when compared to IMS [41.2 N ± 12.4; 20.6-62.3]. Dorsal plating [339.2 N ± 91.8; 158.5-538.6] required significantly greater force than lateral plating [154.5 N ± 33.8; 99.0 -204.4] and intramedullary screw fixation [110.0 ± 38.6; 51.1-189.3] to result in 2 mm of displacement. Lateral and dorsal plating constructs failed through plate bending, screw cut-out or plate failure, whilst IMS failed via implant deformity. All three constructs required greater force to result in even 1 mm of displacement than what is likely subjected through rehabilitation via active motion. CONCLUSIONS Lateral plating and IMS fixation offer sufficient stiffness to withstand the likely forces subjected via early active motion without displacement. CLINICAL RELEVANCE Dorsal plating required significantly greater force than lateral plating and intramedullary screw fixation to achieve 1 mm of displacement when used in extra-articular proximal phalangeal fractures in an in vitro setting. However, all three modalities confer enough stability to likely withstand the forces associated with active range of motion.
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Affiliation(s)
- Brahman Sivakumar
- Department of Hand and Peripheral Nerve Surgery, Royal North Shore Hospital, St Leonards, NSW, Australia; Australian Research Collaboration on Hands (ARCH), Mudgeeraba, QLD, Australia; Department of Surgery, Faculty of Medicine, the University of Sydney, Camperdown, NSW, Australia
| | - David J Graham
- Australian Research Collaboration on Hands (ARCH), Mudgeeraba, QLD, Australia; Department of Musculoskeletal Services, Gold Coast University Hospital, Southport QLD Australia; Griffith University School of Medicine and Dentistry, Southport, QLD, Australia; Department of Orthopaedic Surgery, Northern Beaches Hospital, Frenchs Forrest, NSW, Australia; Department of Medicine, University of Queensland, Herston, QLD, Australia; Department of Orthopaedic Surgery, Queensland Children's Hospital, South Brisbane, QLD, Australia.
| | - Elizabeth Clarke
- Murray Maxwell Biomechanics Laboratory, Kolling Institute, University of Sydney, Camperdown, NSW Australia
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Daghan B, Cinar F, Yalcin CE, Aydin SY, Acun O, Celik U, Baghaki S, Turkmen A. Morphological, histological and biomechanical comparison of bone marrow aspirate concentrate, micro-fragmented adipose tissue and platelet-rich plasma in prevention of tendon adhesion. J Plast Reconstr Aesthet Surg 2023; 87:1-9. [PMID: 37802016 DOI: 10.1016/j.bjps.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/30/2023] [Accepted: 09/07/2023] [Indexed: 10/08/2023]
Abstract
BACKGROUND Flexor tendon repair often leads to peritendinous adhesions, reducing finger motion and hand function. This study compares the effects of stromal cells from different sources and platelet-rich plasma (PRP) on adhesion formation after tendon repair. METHODS Forty rabbits had their flexor digitorum profundus tendons transected and repaired with a modified Kessler suture technique. The control group received an isotonic solution. PRP, bone marrow aspirate concentrate (BMAC), and micro-fragmented adipose tissue (MFAT) were injected in groups 2, 3, and 4, respectively. Rabbits wore casts for 2 weeks. Assessments included morphology, histopathology, range of motion (ROM), and biomechanical testing at the 3rd and 8th weeks. RESULTS At 3 weeks, the BMAC group had the thickest and longest adhesions, the highest Tang Score, and inflammation score. However, at 8 weeks, the BMAC group had the lowest Tang Score and inflammation score. ROM was higher in the PRP group at 3 weeks and BMAC group at 8 weeks. No significant differences were found between BMAC and MFAT groups in adhesion measurements. Biomechanical parameters were higher in BMAC and MFAT groups at 8 weeks compared to control. CONCLUSION BMAC therapy after primary flexor tendon repair improves adhesion formation and maintains ROM. It also enhances the biomechanical properties of the flexor tendon during the later stages of healing.
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Affiliation(s)
- Basak Daghan
- Department of Plastic, Reconstructive and Aesthetic Surgery, Burdur State Hospital, Burdur, Turkey
| | - Fatih Cinar
- Department of Plastic, Reconstructive and Aesthetic Surgery, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Can Ege Yalcin
- Department of Plastic, Reconstructive and Aesthetic Surgery, Cerrahpasa Medical Faculty, Istanbul University - Cerrahpasa, Istanbul, Turkey.
| | - Servet Yekta Aydin
- Department of Plastic, Reconstructive and Aesthetic Surgery, Cerrahpasa Medical Faculty, Istanbul University - Cerrahpasa, Istanbul, Turkey
| | - Osman Acun
- Department of Plastic, Reconstructive and Aesthetic Surgery, Cerrahpasa Medical Faculty, Istanbul University - Cerrahpasa, Istanbul, Turkey
| | - Ugur Celik
- Department of Plastic, Reconstructive and Aesthetic Surgery, Haseki Research and Training Hospital, Istanbul, Turkey
| | - Semih Baghaki
- Department of Plastic, Reconstructive and Aesthetic Surgery, School of Medicine, Koç University, Istanbul, Turkey
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Kusano N, Zaegel MA, Silva MJ. Cyclic testing of six-strand suture techniques for zone 2 flexor tendon lacerations. J Orthop Sci 2023:S0949-2658(23)00266-X. [PMID: 37845162 DOI: 10.1016/j.jos.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 09/03/2023] [Accepted: 09/24/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND Biomechanical analysis using cyclic testing for repaired flexor tendons is a clinically relevant method. The aim of this study was to evaluate the tensile properties of two six-strand suture techniques, the triple looped suture and Yoshizu #1 suture techniques using cyclic testing under simulating early active mobilization conditions. METHODS Twenty-five flexor digitorum profundus tendons harvested from fresh frozen human cadaver hands were repaired in zone 2 utilizing one of three repair techniques: the 2-strand modified Kessler (MK) technique as a control, the triple looped suture (TLS) and Yoshizu #1 suture (Y1) techniques. In each suture technique, 4-0 monofilament nylon sutures were used for core sutures and 6-0 monofilament nylon sutures for circumferential running sutures. Cyclic testing was performed using 20 N with 600 cycles at 1 Hz. RESULTS Five out of eight specimens in the MK group ruptured during cyclic testing. Thus, this group was excluded from analysis. On the other hand, all tendons in the TLS and Y1 groups tolerated cyclic testing. Average gaps of the TLS and Y1 groups were 0.5 ± 0.8 mm and 1.9 ± 2.2 mm, respectively. All tendons in the TLS group and six out of nine tendons in the Y1 group formed gaps less than 2 mm. Two tendons in the Y1 group formed a gap of 3.8 and 6.6 mm had breakage of peripheral sutures at the first cycle. Mean ultimate tensile force of the TLS and Y1 group measured after cyclic tensing, were 66.2 ± 9.0 N and 65.9 ± 13.1 N, respectively. No statistical difference between the two groups was found in gap and ultimate tensile forces. CONCLUSIONS This study suggested that the TLS and Y1 techniques have tensile properties to allow early active mobilization. None of tendons repaired with the TLS technique had gaps more than 2 mm.
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Affiliation(s)
- Nozomu Kusano
- Department of Orthopaedic Surgery, Tominaga Kusano Hospital, Sanjo, Niigata, Japan.
| | - Melissa A Zaegel
- Department of Orthopaedic Surgery, Barnes-Jewish Hospital at Washington University, St. Louis, Missouri, USA
| | - Matthew J Silva
- Department of Orthopaedic Surgery, Barnes-Jewish Hospital at Washington University, St. Louis, Missouri, USA
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Jo S, Dy CJ. Flexor Tendon Repair: Avoidance and Management of Complications. Hand Clin 2023; 39:427-434. [PMID: 37453769 DOI: 10.1016/j.hcl.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
The proper technique for flexor tendon repair has been well established through numerous bench science and clinical studies. However, less is known about strategies to avoid and manage postoperative complications. This article discusses the common complications after flexor tendon repair, such as repair site rupture and adhesion formation. This article also addresses strategies to prevent and manage these complications. The foundation for preventing many of these complications is ensuring a strong repair without gapping at time zero, which will enable the accrual of tensile strength through early initiation of motion.
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Affiliation(s)
- Sally Jo
- Department of Orthopaedic Surgery, Washington University in St. Louis, St Louis, MO, USA
| | - Christopher J Dy
- Department of Orthopaedic Surgery, Washington University in St. Louis, St Louis, MO, USA.
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Aletto C, Aicale R, Oliva F, Maffulli N. Hand Flexor Tendon Repair: From Biology to Surgery and Rehabilitation. Hand Clin 2023; 39:215-225. [PMID: 37080653 DOI: 10.1016/j.hcl.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
Tendon biology and anatomy are crucial to manage hand flexor tendon injuries, not only for surgical treatment but also for rehabilitation; surgeon and physical therapist have to choose zone by zone the best way to manage and restore the normal function of hand flexor tendons.
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Affiliation(s)
- Cristian Aletto
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Baronissi 84084, Italy; Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, Salerno 84131, Italy.
| | - Rocco Aicale
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Baronissi 84084, Italy; Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, Salerno 84131, Italy
| | - Francesco Oliva
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Baronissi 84084, Italy; Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, Salerno 84131, Italy
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Baronissi 84084, Italy; Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, Salerno 84131, Italy; Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, 275 Bancroft Road, London E1 4DG, England; Keele University, Faculty of Medicine, School of Pharmacy and Bioengineering, Guy Hilton Research Centre, Thornburrow Drive, Hartshill, Stoke-on-Trent ST4 7QB, UK
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Abstract
Over the years, various physical and chemical/biological methods of inhibiting adhesion formation have been developed, focusing on how to suppress healing around the tendon and not inhibit healing within the tendon. Unfortunately, however, these methods are accompanied by drawbacks, both large and small, and no absolute antiadhesion method capable of maintaining tendon repair strength has yet been developed. Recent innovations in biomaterials science and tissue engineering have produced new antiadhesion technologies, such as barriers combined with cytokines and cells, which have improved outcomes in animal models, and which may find clinical relevance in the future.
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Affiliation(s)
- Tomoyuki Kuroiwa
- Department of Orthopedic Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN, USA
| | - Peter C Amadio
- Department of Orthopedic Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN, USA.
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Jo S, Calfee RP. General Principles of Flexor Tendon Repair. Hand Clin 2023; 39:131-139. [PMID: 37080645 DOI: 10.1016/j.hcl.2022.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
Flexor tendon repair techniques and rehabilitation have advanced tremendously in the past 50 years. However, the attributes of the ideal tendon repair articulated by Dr Strickland in 1995 hold true today. The ideal repair requires sutures easily placed in the tendon, secure suture knots, a smooth juncture of the tendon ends, minimal gapping, least interference with tendon vascularity, and sufficient strength throughout healing. When accomplished, the modern flexor tendon repair is a stout repair, sufficient for early mobilization and intrinsic tendon healing.
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Affiliation(s)
- Sally Jo
- Department of Orthopedic Surgery, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8233, St. Louis, MO 631, USA
| | - Ryan P Calfee
- Department of Orthopedic Surgery, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8233, St. Louis, MO 631, USA.
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Janes LE, Mioton LM, Fracol ME, Ko JH. An In Vivo Comparison: Novel Mesh Suture Versus Traditional Suture-Based Repair in a Rabbit Tendon Model. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2022; 4:32-39. [PMID: 35415598 PMCID: PMC8991626 DOI: 10.1016/j.jhsg.2021.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 10/13/2021] [Indexed: 11/17/2022] Open
Abstract
Purpose Despite advancements in surgical techniques, suture pull-though and rupture continue to limit the early range of motion and functional rehabilitation after flexor tendon repairs. The aim of this study was to evaluate a suturable mesh compared with a commonly used braided suture in an in vivo rabbit intrasynovial tendon model. Methods Twenty-four New Zealand female rabbits (3–4 kg) were injected with 2 units/kg botulinum toxin evenly distributed into 4 sites in the left calf. After 1 week, the animals underwent surgical tenotomy of the flexor digitorum tendon and were randomized to repair with either 2-0 Duramesh suturable mesh or to 2-0 Fiberwire using a 2-strand modified Kessler and 6-0 polypropylene running epitendinous suture. Rabbits were killed at 2, 4, and 9 weeks after surgery. Results Grouping across time points, 58.3% (7 of 12) of Duramesh repairs were found to be intact for the explant compared with 16.7% (2 of 12) of Fiberwire repairs (P = .09). At 2 weeks, the mean Duramesh repairs were significantly stronger than the Fiberwire repairs with a mean failure load of 50.7 ± 12.7 N compared to 14.8 ± 18.3 N (P = .02). The load supported by the Duramesh repairs at 2 weeks (mean 50.7 ± 12.7 N) was similar to the load supported by both Fiberwire (52.2 ± 13.6 N) and Duramesh (57.6 ± 22.3 N) at 4 weeks. The strength of repair between Fiberwire and Duramesh at 4 weeks and 9 weeks was not significantly different. Conclusions The 2-strand tendon repair with suturable mesh achieved significantly greater strength at 2 weeks than the conventional suture material. Future studies should evaluate the strength of repair prior to 2 weeks to determine the strength curve for this novel suture material. Clinical Relevance This study evaluates the utility of a novel suturable mesh for flexor tendon repair in an in vivo rabbit model compared with conventional suture material.
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Chang YJ, Duffy DJ, Moore GE. Investigation of the effects of two-, four-, six- and eight-strand suture repairs on the biomechanical properties of canine gastrocnemius tenorrhaphy constructs. Am J Vet Res 2021; 82:948-954. [PMID: 34714764 DOI: 10.2460/ajvr.20.11.0199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine the effects of 2-, 4-, 6- and 8-strand suture repairs on the biomechanical properties of canine gastrocnemius tenorrhaphy constructs in an ex vivo model. SAMPLE 56 cadaveric gastrocnemius musculotendinous units from 28 adult large-breed dogs. PROCEDURES Tendons were randomly assigned to 4 repair groups (2-, 4-, 6- or 8-strand suture technique; n = 14/group). Following tenotomy, repairs were performed with the assigned number of strands of 2-0 polypropylene suture in a simple interrupted pattern. Biomechanical testing was performed. Yield, peak, and failure loads, the incidence of 1- and 3-mm gap formation, forces associated with gap formation, and failure modes were compared among groups. RESULTS Yield, peak, and failure forces differed significantly among groups, with significantly greater force required as the number of suture strands used for tendon repair increased. The force required to create a 1- or 3-mm gap between tendon ends also differed among groups and increased significantly with number of strands used. All constructs failed by mode of suture pull-through. CONCLUSIONS AND CLINICAL RELEVANCE Results indicated that increasing the number of suture strands crossing the repair site significantly increases the tensile strength of canine gastrocnemius tendon repair constructs and their resistance to gap formation. Future studies are needed to assess the effects of multistrand suture patterns on tendon glide function, blood supply, healing, and long-term clinical function in dogs to inform clinical decision-making.
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Affiliation(s)
- Yi-Jen Chang
- From the Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC 27607
| | - Daniel J Duffy
- From the Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC 27607
| | - George E Moore
- Department of Veterinary Administration, College of Veterinary Medicine, Purdue University, West Lafayette, IN 47906 (Moore)
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Abstract
Flexor tendon injuries are common and occur mostly by penetrating trauma. Suspected flexor tendon injuries require a thorough clinical assessment and often are not isolated injuries. A detailed understanding of flexor tendon anatomy and spatial relationships is essential, especially when repairing multi-tendon injuries. Principles of flexor tendon repair include a strong suture construct, minimising gap formation between tendon ends, preserving tendon blood supply and providing a smooth repair interface. Moreover, adequate exposure of the zone of injury using full-thickness skin flaps and preservation of neurovascular and pulley structures is essential. In this article an overview of contemporary management strategies is presented. Today's hand surgeons and therapists can choose from a variety of treatment options when managing these important and potentially life-changing injuries.
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Affiliation(s)
- Oliver Pearce
- Trauma Registrar, Trauma & Orthopaedic Department, Southmead Hospital, Southmead Road, Bristol BS10 5NB, UK
| | - Matthew T Brown
- Fellow in Hand & Wrist Surgery, Lothian Hand Unit, St John's Hospital, Livingston, West Lothian EH54 6PP, UK
| | - Katrina Fraser
- Clinical Specialist Occupational Therapist (Hand Therapy), Lothian Hand Unit, St John's Hospital, Livingston, West Lothian EH54 6PP, UK
| | - Luca Lancerotto
- Consultant Hand & Plastic Surgeon, Lothian Hand Unit, St John's Hospital, Livingston, West Lothian EH54 6PP, UK
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Shen H, Yoneda S, Sakiyama-Elbert SE, Zhang Q, Thomopoulos S, Gelberman RH. Flexor Tendon Injury and Repair. The Influence of Synovial Environment on the Early Healing Response in a Canine Model. J Bone Joint Surg Am 2021; 103:e36. [PMID: 33475308 PMCID: PMC8192118 DOI: 10.2106/jbjs.20.01253] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Environmental conditions strongly influence the healing capacity of connective tissues. Well-vascularized extrasynovial tendons typically undergo a robust wound-healing process following transection and repair. In contrast, avascular intrasynovial tendons do not mount an effective repair response. The current study tests the hypothesis that flexor tendons, as a function of their synovial environment, exhibit unique inflammatory, angiogenic, and metabolic responses to injury and repair. METHODS Flexor tendons present a distinct opportunity to test the study hypothesis, as they have proximal regions that are extrasynovial and distal regions that are intrasynovial. In an internally controlled study design, the second and fifth forepaw flexor tendons were transected and repaired in either the extrasynovial or the intrasynovial anatomical region. Histological, gene expression, and proteomics analyses were performed at 3 and 7 days to define the early biological events that drive synovial environment-dependent healing responses. RESULTS Uninjured intrasynovial tendons were avascular, contained high levels of proteoglycans, and expressed inflammatory factors, complement proteins, and glycolytic enzymes. In contrast, extrasynovial tendons were well vascularized, contained low levels of proteoglycans, and were enriched in inflammation inhibitors and oxidative phosphorylation enzymes. The response to injury and repair was markedly different between the 2 tendon regions. Extrasynovial tendons displayed a robust and rapid neovascularization response, increased expression levels of complement proteins, and an acute shift in metabolism to glycolysis, whereas intrasynovial tendons showed minimal vascularity and muted inflammatory and metabolic responses. CONCLUSIONS The regional molecular profiles of intact and healing flexor tendons revealed extensive early differences in innate immune response, metabolism, vascularization, and expression of extracellular matrix as a function of the synovial environment. These differences reveal mechanisms through which extrasynovial tendons heal more effectively than do intrasynovial tendons. CLINICAL RELEVANCE To improve outcomes after operative repair, future treatment strategies should promote features of extrasynovial healing, such as enhanced vascularization and modulation of the complement system and/or glucose metabolism.
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Affiliation(s)
- Hua Shen
- Washington University in St. Louis, St. Louis, Missouri
| | - Susumu Yoneda
- Washington University in St. Louis, St. Louis, Missouri
- University of the Ryukyus, Okinawa, Japan
| | | | - Qiang Zhang
- Washington University in St. Louis, St. Louis, Missouri
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Chinen S, Okubo H, Kusano N, Kinjo M, Kanaya F, Nishida K. Effects of Different Core Suture Lengths on Tensile Strength of Multiple-Strand Sutures for Flexor Tendon Repair. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2021; 3:41-46. [PMID: 35415532 PMCID: PMC8991872 DOI: 10.1016/j.jhsg.2020.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 10/14/2020] [Indexed: 12/05/2022] Open
Abstract
Purpose To compare 2 types of newly devised 8-strand quadruple-looped suture (QLS) techniques with a 6-strand triple-looped suture (TLS) technique; and to assess the effects of different core suture lengths (CSLs) (the length between 2 locking sites of a suture strand) within each suture row on tensile strength. Methods We repaired 24 flexor tendons from 12 rabbits using the TLS and QLS techniques, with equal CSL (QLS) or unequal CSL (unequal QLS) among each suture row. The QLS was composed of 4 looped sutures on the anterolateral and posterolateral aspects of the tendon. The cross-sectional area of the locking portion of each thread in the QLS was equal to that in the TLS. In the QLS technique, the CSL on each aspect of the tendon was 13 mm. In the unequal QLS technique, the CSL on each aspect of the tendon was 13 and 17 mm. The load at 1- and 2-mm gaps, the maximum load until the 3-mm gap, and the ultimate load were compared among the 3 techniques. Results The QLS was significantly stronger than the unequal QLS and the TLS for loads at 1-mm and 2-mm gaps, maximum load until 3-mm gap, and ultimate load. There was no significant difference between the unequal QLS and TLS techniques. The QLS technique showed an approximately 30% increase in gap resistance and ultimate strength compared with the TLS technique. Conclusions The QLS technique showed an estimated increase in tensile strength proportional to the number of suture strands compared with the TLS technique. Our study suggests that a consistent CSL in each suture row provides the highest strength in multistrand sutures consisting of the same configuration of suture rows. Clinical relevance The QLS technique may reduce the risk for tendon rupture associated with early active mobilization after flexor tendon repair.
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Strandenes E, Ellison P, Mølster A, Gjerdet NR, Moldestad IO, Høl PJ. Strength of Pulvertaft modifications: tensile testing of porcine flexor tendons. J Hand Surg Eur Vol 2019; 44:795-799. [PMID: 30971158 DOI: 10.1177/1753193419841522] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The aim of the study was to present two new modifications of the Pulvertaft weave, allowing a higher number of weaves without the need for a longer overlap. The mechanical properties were measured and compared with the traditional technique. Forty-five pairs of porcine flexor tendons were randomized to a Pulvertaft repair with three weaves, a Double Pulvertaft and Locking Pulvertaft repairs. In the last two repairs one of the tendons in each repair was split in two before weaving. A difference in the maximum stiffness was observed between the three groups (p = 0.024). All repairs failed by the sutures being sheared through the tendons splitting the tendon fibres longitudinally. The two modifications were both stronger than the Pulvertaft weave and provide an alternative when a strong connection is needed and a longer overlap is impossible.
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Affiliation(s)
- Eivind Strandenes
- Plastic-, Hand- and Reconstructive Department, Haukeland University Hospital, Bergen, Norway
| | - Peter Ellison
- Department of Mechanical Engineering, Imperial College London, London, UK.,Biomatlab, Haukeland University Hospital, Bergen, Norway
| | - Anders Mølster
- Biomatlab, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Nils R Gjerdet
- Department of Clinical Dentistry, University of Bergen, Bergen, Norway
| | | | - Paul J Høl
- Biomatlab, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Unhas Suture, A Novel Tendon Repair Technique: An In Vitro Experimental Study Comparing Unhas Suture and Bunnell Suture in Tensile Strength and Gap Formation. Tech Orthop 2019. [DOI: 10.1097/bto.0000000000000304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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15
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Bernstein DT, Alexander JJ, Petersen NJ, Lambert BS, Noble PC, Netscher DT. The Impact of Suture Caliber and Looped Configurations on the Suture-Tendon Interface in Zone II Flexor Tendon Repair. J Hand Surg Am 2019; 44:156.e1-156.e8. [PMID: 29891271 DOI: 10.1016/j.jhsa.2018.04.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 12/20/2017] [Accepted: 04/26/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the impact of suture caliber and looped configurations on the integrity of 4-strand modified Kessler zone II flexor tendon repairs during progressive cyclic loading. METHODS Seventy-two flexor digitorum profundus tendons from 18 fresh human cadaver hands were divided into 4 repair groups. Thirty-six matched tendons underwent repair using either a 4-0 looped or 4-0 single-stranded suture, and an additional 36 tendons underwent 3-0 looped or 3-0 single-stranded repairs. Repair strength was tested by progressive cyclic loading. The force generating 2-mm gap formation, ultimate failure, and the mechanism of failure were recorded for each test. The impact of looped versus single-stranded configurations and the effect of tendon cross-sectional area on repair integrity were analyzed for each suture caliber. RESULTS There was no statistically significant difference between groups regarding the force to 2-mm gap formation or ultimate failure, and all values exceeded the minimum threshold of 27 N required to withstand an early active range of motion rehabilitation protocol. The use of a 3-0 caliber suture resulted in a significantly higher proportion of repairs failing by suture pullout through the tendon substance, including 63.5% of looped and 38.9% of single-stranded core sutures. By comparison, this occurred in 11.1% of 4-0 looped and 0% of 4-0 single-stranded sutures. Larger tendon cross-sectional areas were associated with more robust repairs, particularly in the 3-0 looped group. CONCLUSIONS In a human cadaver flexor tendon repair model, there was no significant difference in the mean force to failure between all 4 flexor tendon repair constructs under progressive cyclic loading. However, the 3-0 caliber suture failed more frequently by suture pullout, particularly with the use of a looped suture. CLINICAL RELEVANCE Four-strand flexor tendon repairs using a 3-0 caliber suture are more prone to early failure by suture pullout under progressive cyclic loading compared with a 4-0 caliber suture.
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Affiliation(s)
- Derek T Bernstein
- Department of Orthopaedic Surgery, Houston Methodist Hospital, Houston, TX
| | | | - Nancy J Petersen
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, TX
| | - Bradley S Lambert
- Department of Orthopaedic Surgery, Houston Methodist Hospital, Houston, TX
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Fitzgerald MG, Hammond MA, Yang PW, Merrell GA. Suture constructs for rehabilitation using early active motion after tendon transfer surgery. J Hand Surg Eur Vol 2018; 43:931-935. [PMID: 29806521 DOI: 10.1177/1753193418773262] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The purpose of this study was to better define an ideal tendon transfer suture construct to allow for early active range of motion. A side-to-side tendon construct was used to test suture technique (cross stich vs. Krackow stitch), number of suture throws, and calibre of suture. A minimum load to failure of 100 N was used to comfortably allow early motion while minimizing rupture risk. All constructs tested, except the 4-0 Krackow construct, were strong enough to withstand 100 N of load. The choice of suture should be based on surgeon preference, patient compliance, and specific surgery, and 3-0 non-absorbable suture may be more suitable for tendon transfers from a yield force standpoint.
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Affiliation(s)
| | - Max A Hammond
- Indiana Hand to Shoulder Center, Indianapolis, Indiana, USA
| | - Patrick W Yang
- Indiana Hand to Shoulder Center, Indianapolis, Indiana, USA
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The effect of modified locking methods and suture materials on Zone II flexor tendon repair-An ex vivo study. PLoS One 2018; 13:e0205121. [PMID: 30289887 PMCID: PMC6173425 DOI: 10.1371/journal.pone.0205121] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 09/19/2018] [Indexed: 11/19/2022] Open
Abstract
The failure rate of intrasynovial tendon repair is high due to substantial elongation at the repair site and to the development of adhesions between the tendon’s surface and the surrounding digital sheath. To minimize these complications, we sought to reduce the incidence of gapping and to facilitate the initiation of early motion by improving the time zero structural properties of repair. The Winters-Gelberman 8-strand repair technique was modified by adding surface lock loops and by using Fiberwire suture material. Forty-eight canine flexor digitorum profundus tendons were transected and repaired with one of three 8-strand techniques (Pennington modified Kessler, half hitch loops, or surface locking Kessler) using either 3–0 Supramid or 4–0 Fiberwire suture. Biomechanical testing was performed to determine the physiologic and failure mode properties of the repairs. The surface locking Kessler technique improved repair maximum load, load necessary to create a 2 mm repair site gap, and yield force compared to the modified Kessler and half hitch loop techniques. Fiberwire suture improved maximum load, the load necessary to create a 2 mm repair site gap, stiffness, and yield force compared to Supramid suture. Failure occurred by both suture pull out and by suture breakage in the modified Kessler, Supramid suture repair group. Failure occurred consistently by suture breakage in the surface locking Kessler, Supramid suture repair group. These results reveal that a novel locking Kessler repair is significantly stronger than the current state-of-the art flexor tendon suture repair technique. The use of a surface locking Kessler technique with Fiberwire suture markedly improves the mechanical properties of intrasynovial tendon repair by reducing the risk of post-operative gapping and rupture.
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Wieskötter B, Herbort M, Langer M, Raschke MJ, Wähnert D. The impact of different peripheral suture techniques on the biomechanical stability in flexor tendon repair. Arch Orthop Trauma Surg 2018; 138:139-145. [PMID: 29134318 DOI: 10.1007/s00402-017-2836-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Indexed: 12/15/2022]
Abstract
PURPOSE Flexor tendon repair consists of circumferential peripheral sutures in combination with core sutures to avoid fraying and reduces the exposure of suture material on tendon surface. The peripheral suture adds up to a tenfold increase of the biomechanical stability compared to the core suture alone. The purpose of our study was to determine the most favourable peripheral repair technique for tendon repair. METHODS Seventy-two porcine flexor tendons underwent standardized tenotomy and repair using one of the following six methods (n = 12): simple-running (SR), simple-locking (SL), Halsted-mattress (HM), lin-locking (LL), Lembert-mattress (LM), and Silfverskiöld cross-stich (SCS) suture technique. The SL- suture was placed 2 mm; the HM, LM, SC, and LL suture were placed 5 mm from the tendon gap. The SR suture was placed 1, 2, and 3 mm from tendon ends; no additional core suture was applied. For cyclic testing (1000 cycles), elongation was calculated; for load to failure construct stiffness, yield load and maximum load were determined. RESULTS The mean cyclic elongation for all tested suture techniques was less than 2 mm; there was no significant difference between the groups regarding elongation as well as yield load. The HM, LM, SCS, and LL suture techniques presented significantly higher maximum loads compared to the SR- and SL-sutures. The 3 mm SR showed significantly higher maximum loads compared to the 2 and 1 mm SR. CONCLUSIONS Beside the distance from tendon gap, the type of linkage of the suture material across and beneath the epitendineum is important for biomechanical stability. Simple-running suture is easy to use, even with a slight increase of the distance from tendon gap significantly increases biomechanical strength. For future repairs of flexor tendon injuries, 3 mm stitch length is highly recommended for simple peripheral suture, while the Halsted-mattress suture unites the most important qualities: biomechanically strong, most part of suture material placed epitendinous, and not too complicated to perform.
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Affiliation(s)
- B Wieskötter
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149, Muenster, Germany.
| | - M Herbort
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149, Muenster, Germany
| | - M Langer
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149, Muenster, Germany
| | - M J Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149, Muenster, Germany
| | - D Wähnert
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149, Muenster, Germany.,Institute of Experimental Musculoskeletal Medicine, Westfaelische-Wilhelms-University Muenster, Domagkstraße 3, 58149, Muenster, Germany
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Morrell NT, Hulvey A, Elsinger J, Zhang G, Shafritz AB. Team Approach: Repair and Rehabilitation Following Flexor Tendon Lacerations. JBJS Rev 2017; 5:01874474-201701000-00003. [PMID: 28135230 DOI: 10.2106/jbjs.rvw.16.00013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Nathan T Morrell
- 1Department of Orthopaedics & Rehabilitation, The University of Vermont College of Medicine, University of Vermont Medical Center, Burlington, Vermont
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Komatsu I, Wang JHC, Iwasaki K, Shimizu T, Okano T. The effect of tendon stem/progenitor cell (TSC) sheet on the early tendon healing in a rat Achilles tendon injury model. Acta Biomater 2016; 42:136-146. [PMID: 27329787 DOI: 10.1016/j.actbio.2016.06.026] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 06/13/2016] [Accepted: 06/17/2016] [Indexed: 02/08/2023]
Abstract
UNLABELLED Tissue-engineering approaches have a great potential to improve the treatment of tendon injuries that affect millions of people. The present study tested the hypothesis that introduction of a tendon derived stem/progenitor cell (TSC) sheet accelerates tendon healing and tendon regeneration in a rat model. TSC sheets were produced on temperature-responsive culture dishes. Then, they were grafted on unwounded Achilles tendons and at sites of a 3mm of Achilles tendon defect. At 2 and 4weeks after implantation tendons were examined by histology, immunohistochemistry, transmission electron microscopy (TEM) and mechanical testing. The results showed that the implanted TSC sheet remained stably attached on the tendon surface at 4 weeks after implantation. Moreover, in the tendon defect model, tendon defect area where TSC sheet was implanted was well regenerated and had better organized collagen fibers with elongated spindle shaped cells, compared to relatively disorganized collagen fibers and round shaped cells in the control group. TEM observations revealed longitudinally aligned collagen fibers and thick collagen fibrils in the TSC sheet implanted group. Finally, at 4weeks mechanical property of the TSC sheet implanted tendon had better ultimate load than the control. In conclusion, this study demonstrates the feasibility of implanting TSC sheets on tendons in vivo. Introduction of the cell sheets into a tendon defect significantly improved histological properties and collagen content at both 2 and 4 weeks after implantation, indicating that TSC sheets may effectively promote tendon remodeling in the early stages of tendon healing. STATEMENT OF SIGNIFICANCE Tendon injury is a highly prevalent clinical problem that debilitates millions of people worldwide in both occupational and athletic settings. It also costs billions of healthcare dollars in treatment every year. In this study, we showed the feasibility of using tendon derived stem cell sheet to deliver biologically active tenogenic-constructs and promote tendon regeneration. This work has the potential to impact the orthopaedic surgery and sports medicine fields in the treatment of tendon injury.
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Linderman SW, Gelberman RH, Thomopoulos S, Shen H. Cell and Biologic-Based Treatment of Flexor Tendon Injuries. ACTA ACUST UNITED AC 2016; 26:206-215. [PMID: 28042226 DOI: 10.1053/j.oto.2016.06.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The two primary factors leading to poor clinical results after intrasynovial tendon repair are adhesion formation within the digital sheath and repair-site elongation and rupture. As the outcomes following modern tendon multi-strand repair and controlled rehabilitation techniques are often unsatisfactory, alternative approaches, such as the application of growth factors and mesenchymal stem cells (MSCs), have become increasingly attractive treatment options. Successful biological therapies require carefully controlled spatiotemporal delivery of cells, growth factors, and biocompatible scaffold matrices in order to simultaneously (1) promote matrix synthesis at the tendon repair site leading to increased biomechanical strength and stiffness and (2) suppress matrix synthesis along the tendon surface and synovial sheath preventing adhesion formation. This review summarizes recent cell and biologic-based experimental treatments for flexor tendon injury, with an emphasis on large animal translational studies.
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Affiliation(s)
- Stephen W Linderman
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO, United States; Department of Biomedical Engineering, Washington University, St. Louis, MO, United States
| | - Richard H Gelberman
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO, United States
| | - Stavros Thomopoulos
- Department of Orthopaedic Surgery, Columbia University, New York, NY, United States; Department of Biomedical Engineering, Columbia University, New York, NY, United States
| | - Hua Shen
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO, United States
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23
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Kormpakis I, Linderman SW, Thomopoulos S, Gelberman RH. Enhanced Zone II Flexor Tendon Repair through a New Half Hitch Loop Suture Configuration. PLoS One 2016; 11:e0153822. [PMID: 27101409 PMCID: PMC4839582 DOI: 10.1371/journal.pone.0153822] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 04/04/2016] [Indexed: 11/19/2022] Open
Abstract
This study evaluated the impact of a new half hitch loop suture configuration on flexor tendon repair mechanics. Cadaver canine flexor digitorum profundus tendons were repaired with 4- or 8-strands, 4-0 or 3-0 suture, with and without half hitch loops. An additional group underwent repair with half hitch loops but without the terminal knot. Half hitch loops improved the strength of 8-strand repairs by 21% when 4-0, and 33% when 3-0 suture was used, and caused a shift in failure mode from suture pullout to suture breakage. 8-strand repairs with half hitch loops but without a terminal knot produced equivalent mechanical properties to those without half hitch loops but with a terminal knot. 4-strand repairs were limited by the strength of the suture in all groups and, as a result, the presence of half hitch loops did not alter the mechanical properties. Overall, half hitch loops improved repair mechanics, allowing failure strength to reach the full capability of suture strength. Improving the mechanical properties of flexor tendon repair with half hitch loops has the potential to reduce the postoperative risk of gap formation and catastrophic rupture in the early postoperative period.
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Affiliation(s)
- Ioannis Kormpakis
- Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri, United States of America
| | - Stephen W. Linderman
- Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri, United States of America
- Department of Biomedical Engineering, Washington University, St. Louis, Missouri, United States of America
| | - Stavros Thomopoulos
- Department of Orthopedic Surgery, Columbia University, New York, New York, United States of America
- Department of Biomedical Engineering, Columbia University, New York, New York, United States of America
| | - Richard H. Gelberman
- Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri, United States of America
- * E-mail:
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Biomimetic Approach to Designing Adhesive Hydrogels: From Chemistry to Application. SPRINGER SERIES IN BIOMATERIALS SCIENCE AND ENGINEERING 2016. [DOI: 10.1007/978-3-319-22861-7_15] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Bűhler M, Johnson G, Meikle G. Longitudinal In Vivo Ultrasound Observations of the Surgically Repaired Zone II Flexor Digitorum Profundus Tendon. ULTRASOUND IN MEDICINE & BIOLOGY 2015; 41:3018-3022. [PMID: 26304499 DOI: 10.1016/j.ultrasmedbio.2015.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Revised: 05/06/2015] [Accepted: 07/07/2015] [Indexed: 06/04/2023]
Abstract
The link between the healing process and functional outcomes in the surgically repaired digital flexor tendon is poorly understood. This clinical note describes those gray-scale and power Doppler (PD) ultrasound parameters that can be used to document longitudinal change in the morphologic and dynamic properties of the surgically repaired zone II flexor digitorum profundus (FDP) tendon. The method is supported by ultrasound data obtained from three participants at five points in time post-surgically (two, four, six, 12 and 18 weeks). Longitudinal documentation of the ultrasound properties of echogenicity, defect size, tendon excursion and power Doppler signal is feasible and has the potential to explore the possible link between changes in the structural status of surgically repaired flexor tendons and associated clinical outcomes.
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Affiliation(s)
- Miranda Bűhler
- Centre for Health, Activity and Rehabilitation Research, University of Otago, Dunedin, New Zealand; Physiotherapy Outpatient Department, Dunedin Hospital, Southern District Health Board, Dunedin, New Zealand.
| | - Gillian Johnson
- Centre for Health, Activity and Rehabilitation Research, University of Otago, Dunedin, New Zealand
| | - Grant Meikle
- Radiology Department, Dunedin Hospital, Southern District Health Board, Dunedin, New Zealand; Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
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Asmus A, Kim S, Millrose M, Jodkowski J, Ekkernkamp A, Eisenschenk A. Rehabilitation nach Beugesehnenverletzungen an der Hand. DER ORTHOPADE 2015; 44:786-802. [DOI: 10.1007/s00132-015-3160-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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27
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Wong YR, Lee CS, Loke AMK, Liu X, Suzana MJ I, Tay SC. Comparison of Flexor Tendon Repair Between 6-Strand Lim-Tsai With 4-Strand Cruciate and Becker Technique. J Hand Surg Am 2015; 40:1806-11. [PMID: 26142080 DOI: 10.1016/j.jhsa.2015.05.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 05/02/2015] [Accepted: 05/04/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the strength of 6-strand Lim-Tsai repair with 4-strand cruciate and Becker repair, which were done using braided polyblend. We hypothesized that the biomechanical strength of 4-strand repair could be as strong as 6-strand repair because of different flexor tendon repair configurations and uneven load bearing. METHODS We harvested 60 porcine flexor tendons. A transverse cut at the middle of the tendons was made to perform tendon repair. Six-strand Lim-Tsai repair (consisting of 2 Lim-Tsai locking loops), 4-strand cruciate repair (with 3 cross-stitch loops), and 4-strand Becker repair (with 2 double cross-stitch locking loops) were used for the repairs. The repaired tendons were pulled until failure using a mechanical tester. We recorded ultimate tensile strength, load to 2-mm gap force, stiffness, and mechanism of failure. RESULTS The Becker repairs had significantly greater tensile strength than the cruciate and Lim-Tsai repairs. The load to 2-mm gap force and stiffness were significantly greater for cruciate repairs and Becker repairs than Lim-Tsai repairs. CONCLUSIONS The biomechanical strength of 4-strand and Becker repairs could be as strong as 6-strand Lim-Tsai repairs. This study implies that the number of strands crossing the repair site of tendons may not be proportional to the biomechanical strength of flexor tendon repair. CLINICAL RELEVANCE Hand surgeons are urged to be aware of the biomechanic characteristics of different flexor tendon repair techniques used in the clinical setting.
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Affiliation(s)
- Yoke-Rung Wong
- Biomechanics Laboratory, Singapore General Hospital, Singapore
| | - Chuan Shing Lee
- Department of Hand Surgery, Singapore General Hospital, Singapore
| | - Austin M K Loke
- Biomechanics Laboratory, Singapore General Hospital, Singapore
| | - Xuan Liu
- Department of Hand Surgery, Singapore General Hospital, Singapore
| | - Ita Suzana MJ
- Biomechanics Laboratory, Singapore General Hospital, Singapore
| | - Shian Chao Tay
- Biomechanics Laboratory, Singapore General Hospital, Singapore; Department of Hand Surgery, Singapore General Hospital, Singapore.
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Edsfeldt S, Rempel D, Kursa K, Diao E, Lattanza L. In vivo flexor tendon forces generated during different rehabilitation exercises. J Hand Surg Eur Vol 2015; 40:705-10. [PMID: 26115682 DOI: 10.1177/1753193415591491] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 04/27/2015] [Indexed: 02/03/2023]
Abstract
UNLABELLED We measured in vivo forces in the flexor digitorum profundus and the flexor digitorum superficialis tendons during commonly used rehabilitation manoeuvres after flexor tendon repair by placing a buckle force transducer on the tendons of the index finger in the carpal canal during open carpal tunnel release of 12 patients. We compared peak forces for each manoeuvre with the reported strength of a flexor tendon repair. Median flexor digitorum profundus force (24 N) during isolated flexor digitorum profundus flexion and median flexor digitorum superficialis force (13 N) during isolated flexor digitorum superficialis flexion were significantly higher than during the other manoeuvres. Significantly higher median forces were observed in the flexor digitorum superficialis with the wrist at 30° flexion (6 N) compared with the neutral wrist position (5 N). Median flexor digitorum profundus forces were significantly higher during active finger flexion (6 N) compared with place and hold (3 N). Place and hold and active finger flexion with the wrist in the neutral position or tenodesis generated the lowest forces; isolated flexion of these tendons generated higher forces along the flexor tendons. LEVEL OF EVIDENCE III (controlled trial without randomization).
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Affiliation(s)
- S Edsfeldt
- Department of Surgery, University of California at San Francisco, San Francisco CA, USA
| | - D Rempel
- Department of Surgery, University of California at San Francisco, San Francisco CA, USA
| | - K Kursa
- Department of Surgery, University of California at San Francisco, San Francisco CA, USA
| | - E Diao
- Department of Surgery, University of California at San Francisco, San Francisco CA, USA
| | - L Lattanza
- Department of Surgery, University of California at San Francisco, San Francisco CA, USA
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Manning CN, Martel C, Sakiyama-Elbert SE, Silva MJ, Shah S, Gelberman RH, Thomopoulos S. Adipose-derived mesenchymal stromal cells modulate tendon fibroblast responses to macrophage-induced inflammation in vitro. Stem Cell Res Ther 2015; 6:74. [PMID: 25889287 PMCID: PMC4416344 DOI: 10.1186/s13287-015-0059-4] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 09/25/2014] [Accepted: 03/20/2015] [Indexed: 01/14/2023] Open
Abstract
Introduction Macrophage-driven inflammation is a key feature of the early period following tendon repair, but excessive inflammation has been associated with poor clinical outcomes. Modulation of the inflammatory environment using molecular or cellular treatments may provide a means to enhance tendon healing. Methods To examine the effect of pro-inflammatory cytokines secreted by macrophages on tendon fibroblasts (TF), we established in vitro models of cytokine and macrophage-induced inflammation. Gene expression, protein expression, and cell viability assays were used to examine TF responses. In an effort to reduce the negative effects of inflammatory cytokines on TFs, adipose-derived mesenchymal stromal cells (ASCs) were incorporated into the model and their ability to modulate inflammation was investigated. Results The inflammatory cytokine interleukin 1 beta (IL-1β) and macrophages of varying phenotypes induced up-regulation of pro-inflammatory factors and matrix degradation factors and down-regulation of factors related to extracellular matrix formation by TFs in culture. ASCs did not suppress these presumably negative effects induced by IL-1β. However, ASC co-culture with M1 (pro-inflammatory) macrophages successfully suppressed the effects of M1 macrophages on TFs by inducing a phenotypic switch from a pro-inflammatory macrophage phenotype to an anti-inflammatory macrophage phenotype, thus resulting in exposure of TFs to lower levels of pro-inflammatory cytokines (e.g., IL-1β, tumor necrosis factor alpha (TNFα)). Conclusions These findings suggest that IL-1β and M1 macrophages are detrimental to tendon healing and that ASC-mediated modulation of the post-operative inflammatory response may be beneficial for tendon healing. Electronic supplementary material The online version of this article (doi:10.1186/s13287-015-0059-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Cionne N Manning
- Department of Orthopedic Surgery, Washington University, 425 S Euclid, Box 8233, St Louis, MO, 63110, USA.
| | - Catherine Martel
- Department of Pathology and Immunology, Washington University, 425 S Euclid, Box 8233, St Louis, MO, 63110, USA. .,Current address: Montreal Heart Institute, Université de Montréal, Montréal, Quebec, Canada.
| | - Shelly E Sakiyama-Elbert
- Department of Biomedical Engineering, Washington University, One Brookings Drive, Campus Box 1097, St Louis, MO, USA.
| | - Matthew J Silva
- Department of Orthopedic Surgery, Washington University, 425 S Euclid, Box 8233, St Louis, MO, 63110, USA.
| | - Shivam Shah
- Department of Orthopedic Surgery, Washington University, 425 S Euclid, Box 8233, St Louis, MO, 63110, USA.
| | - Richard H Gelberman
- Department of Orthopedic Surgery, Washington University, 425 S Euclid, Box 8233, St Louis, MO, 63110, USA.
| | - Stavros Thomopoulos
- Department of Orthopedic Surgery, Washington University, 425 S Euclid, Box 8233, St Louis, MO, 63110, USA.
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Das S, Thorne R, Langley-Hobbs SJ, Perry KL, Burton NJ, Mosley JR. Patellar ligament rupture in the cat: repair methods and patient outcomes in seven cases. J Feline Med Surg 2015; 17:348-52. [PMID: 25074568 PMCID: PMC11104159 DOI: 10.1177/1098612x14544345] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
The medical records of cats receiving surgical treatment for unilateral patellar ligament rupture between 1999 and 2012 at 12 referral centres in the UK and Ireland were reviewed. Seven cases were identified: six were caused by trauma and one was iatrogenic, occurring as a complication following surgical stabilisation of a tibial fracture. All cases were treated by sutured anastomosis of the ruptured ligament, with six of the repairs protected by a circumpatellar and/or transpatellar loop of suture. The stifle was immobilised by transarticular external skeletal fixation in three cases. No cases required revision surgery. No complications were reported. Final evaluation, performed at a median time of 31 days, determined five patients to have returned to acceptable or good limb function; two cases were lost to follow-up. The data suggest that, in cats, the current surgical techniques extrapolated from their canine counterparts for repair of a completely or partially ruptured patellar ligament are successfully used and result in acceptable limb function.
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Affiliation(s)
- Smita Das
- Royal (Dick) School of Veterinary Studies, Division of Veterinary Clinical Sciences, University of Edinburgh, Hospital for Small Animals, Easter Bush Campus, Roslin, UK
| | - Rebecca Thorne
- Davies Veterinary Specialists, Manor Farm Business Park, Higham Gobion, UK
| | - Sorrel J Langley-Hobbs
- Queen's Veterinary School Hospital, Department of Veterinary Medicine, University of Cambridge, Cambridge, UK Small Animal Hospital, Langford House, Langford, UK
| | - Karen L Perry
- Queen Mother Hospital for Animals, Royal Veterinary College, Hatfield, UK
| | | | - John R Mosley
- Royal (Dick) School of Veterinary Studies, Division of Veterinary Clinical Sciences, University of Edinburgh, Hospital for Small Animals, Easter Bush Campus, Roslin, UK
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Abstract
Injuries to the flexor tendons remain among the most difficult problems in hand surgery. Historically, lacerations to the intrasynovial portion of the flexor tendons were thought to be unsuitable for primary repair. Despite continuing advances in our knowledge of flexor tendon biology, repair, and rehabilitation, good results following primary repair of flexor tendons remain challenging to achieve.
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Affiliation(s)
- Kevin F Lutsky
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut Street, 5th floor, Philadelphia, PA 19107, USA
| | - Eric L Giang
- Department of Orthopedics, Rowan University, School of Osteopathic Medicine, Stratford, NJ 08084, USA
| | - Jonas L Matzon
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut Street, 5th floor, Philadelphia, PA 19107, USA.
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Abstract
Flexor tendon repair in zone II is particularly challenging because tendon gliding must be restored within a tight fibro-osseous sheath while minimizing the formation of adhesions in surrounding tissues. Meticulous surgical technique using a multistrand core suture and a peripheral suture is needed to produce a tendon that is strong enough to withstand early mobilization. Mechanical strength increases with the number of strands crossing the repair, regardless of the core suture configuration. Early mobilization after flexor tendon repair enhances the strength of the repair and decreases the risk of adhesions and joint stiffness. Satisfactory results have been achieved with either early passive or early active motion rehabilitation protocols; therefore, the choice of postoperative rehabilitation program is at the discretion of the surgeon. Factors such as repair integrity, concurrent injuries, and anticipated patient compliance should be considered in the decision-making process.
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Arenhart R, Severo AL, Maia PEC, Silveira DA, Lopez RR, Bocaccio D. Thermographic and histological analysis of rabbit different tenorrhaphies techniques (4 and 6 strands) after early active mobilization. FISIOTERAPIA EM MOVIMENTO 2014. [DOI: 10.1590/0103-5150.027.004.ao13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Introduction This research is based on the results of the surgeries of tenorraphy, which have been improved due to the association between strong and not voluminous sutures and physiotherapic protocols, which preconize the early active motion to the postoperative period. Objective To evaluate the healing process in vivo in different types of tenorraphies. Methods Thirty-six rabbits that underwent early active motion after tenorraphy. The sample was constituted of 3 groups of 12, in accordance with the 3 different types of suture (Brasil, Indiana and Tsai). Results On the 15th and 30th days after the surgery, thermographic and histological analyses revealed similar results that all groups showed similar behaviors in the same time of surgical repair, just differentiating between the periods. On the 30th day analysis were observed that collagen fibers being more exuberant thickening, thus being able to offer higher tensile strength to the tendon. Conclusion That suggests early active motion may be increased gradually to around the 30th day taking this as clinical relevance.
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Das S, Thorne R, Lorenz ND, Clarke SP, Madden M, Langley-Hobbs SJ, Perry KL, Burton NJ, Moores AL, Mosley JR. Patellar ligament rupture in the dog: repair methods and patient outcomes in 43 cases. Vet Rec 2014; 175:370. [DOI: 10.1136/vr.102385] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- S. Das
- Division of Veterinary Clinical Sciences; Royal (Dick) School of Veterinary Studies; University of Edinburgh; Hospital for Small Animals, Easter Bush Campus Roslin Midlothian EH25 9RG UK
| | - R. Thorne
- Davies Veterinary Specialists Limited; Manor Farm Business Park Higham Gobion Hertfordshire SG5 3HR UK
| | - N. D. Lorenz
- University of Liverpool; Small Animal Teaching Hospital; Leahurst Campus, Chester High Road Neston Wirral CH64 7TE UK
| | - S. P. Clarke
- Willows Veterinary Centre and Referral Service; Highlands Road, Shirley Solihull West Midlands B90 4NH UK
| | - M. Madden
- NorthWest Surgeons; Delamere House, Ashville Point Sutton Weaver Cheshire WA7 3FW UK
| | - S. J. Langley-Hobbs
- Department of Veterinary Medicine; Queens Veterinary School Hospital; University of Cambridge; Madingley Road Cambridge Cambridgeshire CB3 0ES UK
- Small Animal Hospital; Langford House Langford North Somerset BS40 5DU UK
| | - K. L. Perry
- Queen Mother Hospital for Animals; Royal Veterinary College; Hawkshead Lane, North Mymms Hatfield Hertfordshire AL9 7TA UK
| | - N. J. Burton
- Small Animal Hospital; Langford House Langford North Somerset BS40 5DU UK
| | - A. L. Moores
- Anderson Moores Veterinary Specialists; The Granary; Bunstead Barns, Poles Lane, Hursley Winchester Hampshire SO21 2LL UK
| | - J. R. Mosley
- Division of Veterinary Clinical Sciences; Royal (Dick) School of Veterinary Studies; University of Edinburgh; Hospital for Small Animals, Easter Bush Campus Roslin Midlothian EH25 9RG UK
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Wilson L, Banks TA, Luckman P, Smith B. Biomechanical evaluation of double Krackow sutures versus the three-loop pulley suture in a canine gastrocnemius tendon avulsion model. Aust Vet J 2014; 92:427-32. [DOI: 10.1111/avj.12255] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2014] [Indexed: 11/27/2022]
Affiliation(s)
- L Wilson
- Veterinary Teaching Hospital and Small Animal Clinic; School of Veterinary Science; The University of Queensland; St Lucia Campus Queensland 4072 Australia
| | - TA Banks
- The University of Queensland; School of Veterinary Science Building; Gatton Campus Queensland Australia
| | - P Luckman
- The University of Queensland; Australian Institute for Bioengineering and Nanotechnology (AIBN); St Lucia Campus Queensland Australia
| | - B Smith
- Veterinary Teaching Hospital and Small Animal Clinic; School of Veterinary Science; The University of Queensland; St Lucia Campus Queensland 4072 Australia
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Use of acoustoelastography to evaluate tendon healing after surgical repair of an Achilles mechanism laceration and rehabilitation with a custom tarsal orthotic splint in a dog. VETERINARY RECORD CASE REPORTS 2014. [DOI: 10.1136/vetreccr-2014-000046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Abstract
BACKGROUND Platelet-rich plasma (PRP) has shown promise in the treatment of tendinopathy, including rotator cuff and lateral epicondylitis. Here, we evaluate the effect of PRP on healing in a rabbit zone II flexor tendon model. METHODS Thirty New Zealand white rabbits underwent transection and repair of the second and fourth flexor digitorum profundus. Half of the rabbits received autologous PRP intraoperatively, while the other half underwent standard four-strand tendon repair. Tendons were examined at 2, 4, and 8 weeks postoperatively. Range of motion and ultimate tensile strength were assessed on the fourth toes, while second toes underwent histologic analysis with hematoxylin and eosin, Masson Trichrome, and Picrosirius Red, for assessment of cell count, collagen content, and collagen maturity. RESULTS There were no significant differences in ultimate tensile strength between treatments at 2, 4, or 8 weeks. There was a trend towards lower tensile strength in the PRP group at 2 weeks. There was no statistically significant difference in excursion or range of motion between PRP and control tendons. Cell counts at 4 weeks were statistically significantly reduced in the PRP tendons as compared to controls. No difference in collagen content or maturity was detected. CONCLUSIONS In contrast to previous studies, PRP did not significantly improve ultimate tensile strength. PRP-treated tendons exhibited trends towards reduced healing, including a significant reduction in cell counts as well as a smaller increase in collagen deposition over time as compared to controls. Further study is needed to determine the precise effect of PRP on intrasynovial flexor tendon repairs.
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Manning CN, Havlioglu N, Knutsen E, Sakiyama-Elbert SE, Silva MJ, Thomopoulos S, Gelberman RH. The early inflammatory response after flexor tendon healing: a gene expression and histological analysis. J Orthop Res 2014; 32:645-52. [PMID: 24464937 PMCID: PMC4076155 DOI: 10.1002/jor.22575] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Accepted: 12/05/2013] [Indexed: 02/04/2023]
Abstract
Despite advances in surgical techniques over the past three decades, tendon repairs remain prone to poor clinical outcomes. Previous attempts to improve tendon healing have focused on the later stages of healing (i.e., proliferation and matrix synthesis). The early inflammatory phase of tendon healing, however, is not fully understood and its modulation during healing has not yet been studied. Therefore, the purpose of this work was to characterize the early inflammatory phase of flexor tendon healing with the goal of identifying inflammation-related targets for future treatments. Canine flexor tendons were transected and repaired using techniques identical to those used clinically. The inflammatory response was monitored for 9 days. Temporal changes in immune cell populations and gene expression of inflammation-, matrix degradation-, and extracellular matrix-related factors were examined. Gene expression patterns paralleled changes in repair-site cell populations. Of the observed changes, the most dramatic effect was a greater than 4,000-fold up-regulation in the expression of the pro-inflammatory factor IL-1β. While an inflammatory response is likely necessary for healing to occur, high levels of pro-inflammatory cytokines may result in collateral tissue damage and impaired tendon healing. These findings suggest that future tendon treatment approaches consider modulation of the inflammatory phase of healing.
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Affiliation(s)
- CN Manning
- Dept. of Orthopaedic Surgery, Washington University, St Louis, MO
| | - N Havlioglu
- Dept. of Pathology, Saint Louis University Hospital, St Louis, MO
| | - E Knutsen
- Dept. of Orthopaedic Surgery, Washington University, St Louis, MO
| | | | - MJ Silva
- Dept. of Orthopaedic Surgery, Washington University, St Louis, MO
| | - S Thomopoulos
- Dept. of Orthopaedic Surgery, Washington University, St Louis, MO
,Corresponding Authors: Stavros Thomopoulos, Ph.D. (study design and in vivo studies), Richard H. Gelberman, M.D. (clinical relevance and surgical methods). Washington University, 425 South Euclid, Campus Box 8233, St Louis, MO 63110, Phone: 314-362-8605, Fax: 314-362-0334,
| | - RH Gelberman
- Dept. of Orthopaedic Surgery, Washington University, St Louis, MO
,Corresponding Authors: Stavros Thomopoulos, Ph.D. (study design and in vivo studies), Richard H. Gelberman, M.D. (clinical relevance and surgical methods). Washington University, 425 South Euclid, Campus Box 8233, St Louis, MO 63110, Phone: 314-362-8605, Fax: 314-362-0334,
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Hu JZ, Zhou YC, Huang LH, Lu HB. Development of biodegradable polycaprolactone film as an internal fixation material to enhance tendon repair: an in vitro study. BMC Musculoskelet Disord 2013; 14:246. [PMID: 23957758 PMCID: PMC3751937 DOI: 10.1186/1471-2474-14-246] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Accepted: 08/06/2013] [Indexed: 12/03/2022] Open
Abstract
Background Current tendon repair techniques do not provide sufficient tensile strength at the repair site, and thus early active motion rehabilitation after tendon repair is discouraged. To enhance the post-operative tensile strength, we proposed and tested an internal fixation technique using a polycaprolactone (PCL) biofilm. PCL was chosen for its good biocompatibility, excellent mechanical strength, and an appropriate degradation time scale. Methods PCL biofilms were prepared by a modified melt-molding/leaching technique, and the physical and mechanical properties and in vitro degradation rate were assessed. The pore size distribution of the biofilm and the paratenon of native tendons were observed using scanning electron microscopy. Next, we determined whether this biofilm could enhance the tensile strength of repaired tendons. We performed tensile tests on rabbit Achilles tendons that were first lacerated and then repaired: 1) using modified Kessler suture combined with running peripheral suture (‘control’ group), or 2) using biofilm to wrap the tendon and then fixation with sutures (‘biofilm’ group). The influence of different repair techniques on tendon tensile strength was evaluated by mechanical testing. Results The novel biofilm had supple texture and a smooth surface. The mean thickness of the biofilm was 0.25 mm. The mean porosity of the biofilm was 45.3%. The paratenon of the rabbit Achilles tendon had pores with diameters ranging from 1 to 9 μm, which were similar to the 4–12 μm diameter pores in the biofilm cross-section. The weight loss of the biofilms at 4 weeks was only 0.07%. The molecular weight of PCL biofilms did not change after immersion in phosphate buffered saline for 4 weeks. The failure loads of the biofilm were similar before (48 ± 9 N) and after immersion (47 ± 7 N, P > 0.1). The biofilm group had ~70% higher mean failure loads and 93% higher stiffness compared with the control group. Conclusions We proposed and tested an internal fixation technique using a PCL biofilm to enhance tendon repair. Internal fixation with the biofilm followed by standard suturing can significantly increase the tensile strength of tendon repair sites. This technique has the potential to allow active motion rehabilitation during the early post-operative period.
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Abstract
In this article, a group of international leaders in tendon surgery of the hand provide details of their current methods of primary flexor tendon repair. They are from recognized hand centers around the world, from which major contributions to the development of methods for flexor tendon repair have come over the past 2 decades. Changes made since the early 1990s regarding surgical methods and postoperative care for the flexor tendon repair are also discussed. Current practice methods used in the leading hand centers are summarized, and key points in providing the best possible clinical outcomes are outlined.
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Gordon L, Matsui J, McDonald E, Gordon JA, Neimkin R. Analysis of a knotless flexor tendon repair using a multifilament stainless steel cable-crimp system. J Hand Surg Am 2013; 38:677-83. [PMID: 23453895 DOI: 10.1016/j.jhsa.2013.01.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Revised: 01/05/2013] [Accepted: 01/07/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the biomechanical and technical properties of flexor tendon repairs using a 4-strand cruciate FiberWire (FW) repair and a 2-strand multifilament stainless steel (MFSS) single cross-lock cable-crimp system. METHODS Eight tests were conducted for each type of repair using cadaver hand flexor digitorum profundus tendons. We measured the required surgical exposure, repair time, and force of flexion (friction) with a custom motor system with an inline load cell and measured ultimate tensile strength (UTS) and 2-mm gap force on a servo-hydraulic testing machine. RESULTS Repair time averaged less than 7 minutes for the 2-strand MFSS cable crimp repairs and 12 minutes for the FW repairs. The FW repair was performed with 2 cm of exposure and removal of the C-1 and A-3 pulleys. The C-1 and A-3 pulleys were retained in each of the MFSS cable crimp repairs with less than 1 cm of exposure. Following the FW repair, the average increase in friction was 89% compared with an average of 53% for the MFSS repairs. Six of the 8 MFSS specimens achieved the UTS before any gap had occurred, whereas all of the FW repairs had more than 2 mm of gap before the UTS, indicating that the MFSS was a stiffer repair. The average UTS appeared similar for both groups. CONCLUSIONS We describe a 2-strand multifilament stainless steel single cross-lock cable crimp flexor repair system. In our studies of this cable crimp system, we found that surgical exposure, average repair times, and friction were reduced compared to the traditional 4-strand cruciate FW repair. While demonstrating these benefits, the crimp repair also produced a stiff construct and high UTS and 2-mm gap force. CLINICAL RELEVANCE A cable crimp flexor tendon repair may offer an attractive alternative to current repair methods. The benefits may be important especially for flexor tendon repair in zone 2 or for the repair of multiple tendons.
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Affiliation(s)
- Leonard Gordon
- Department of Anatomy and Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA 94115, USA
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Fufa DT, Osei DA, Calfee RP, Silva MJ, Thomopoulos S, Gelberman RH. The effect of core and epitendinous suture modifications on repair of intrasynovial flexor tendons in an in vivo canine model. J Hand Surg Am 2012; 37:2526-31. [PMID: 23174065 PMCID: PMC3513918 DOI: 10.1016/j.jhsa.2012.09.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Revised: 09/15/2012] [Accepted: 09/18/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine in vivo effects of modifications to core and epitendinous suture techniques in a canine intrasynovial flexor tendon repair model using clinically relevant rehabilitation. Our null hypothesis was that gap formation and rupture rates would remain consistent across repair techniques. METHODS We evaluated gap formation and rupture in 75 adult mongrel dogs that underwent repair of intrasynovial flexor tendon lacerations followed by standardized postoperative therapy. The current suture technique was a 4-0, 8-strand core suture with a purchase of 1.2 cm and a 5-0, epitendinous suture repair with a 2-mm purchase length and depth. We compared gap and failure by chi-square analysis to a historical group of in vivo repairs (n = 76) from the same canine model using 8-strand core suture repair with purchase of 0.75 cm and 6-0 epitendinous suture with a 1-mm purchase length and depth. RESULTS A total of 93% of tendons (n = 70) demonstrated gapping of less than 3 mm using the current suture technique. Five percent of tendons (n = 4) had a gap of 3 mm or greater, and there was 1 repair site failure. This was significantly improved over the comparison group of historical 8-strand core repair technique, which resulted in 82% (n = 62) of repairs with a gap of less than 3 mm and 7 failures (9%). CONCLUSIONS In an in vivo model, current modifications to suture techniques for intrasynovial flexor tendon repair demonstrated significant improvements in gap formation and rupture compared with a similar technique using shorter purchase lengths and shallower purchase depth. CLINICAL RELEVANCE Suggested repair modifications for the treatment of zone II flexor tendon transections demonstrate improvements in gap formation and tendon rupture in vivo.
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Matarrese MR, Hammert WC. Flexor tendon rehabilitation. J Hand Surg Am 2012; 37:2386-8. [PMID: 22995701 DOI: 10.1016/j.jhsa.2012.07.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2011] [Accepted: 07/21/2012] [Indexed: 02/02/2023]
Affiliation(s)
- Marissa R Matarrese
- Department of Orthopaedic Surgery and Division of Plastic Surgery, University of Rochester Medical Center, Rochester, NY 14642, USA
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Nelson GN, Potter R, Ntouvali E, Silva MJ, Boyer MI, Gelberman RH, Thomopoulos S. Intrasynovial flexor tendon repair: a biomechanical study of variations in suture application in human cadavera. J Orthop Res 2012; 30:1652-9. [PMID: 22457145 PMCID: PMC3621034 DOI: 10.1002/jor.22108] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2011] [Accepted: 02/23/2012] [Indexed: 02/04/2023]
Abstract
To improve the functional outcomes of intrasynovial tendon suture, prior experiments evaluated individual technical modifications used in the repair process. Few studies, however, have assessed the combinatorial effects of those suture modifications in an integrated biomechanical manner, including a sample size sufficient to make definitive observations on repair technique. Two hundred fifty-six flexor tendon repairs were performed in human cadavera, and biomechanical properties were determined. The effects of five factors for flexor tendon repair were tested: core suture caliber (4-0 or 3-0), number of sutures crossing the repair site (four- or eight-strand), core suture purchase (0.75 or 1.2 cm), peripheral suture caliber (6-0 or 5-0), and peripheral suture purchase (superficial or 2 mm). Significant factors affecting the properties of the repair were the number of core suture strands and the peripheral suture purchase. The least significant factors were core suture purchase and peripheral suture caliber. The choice of core suture caliber affected the properties of repair marginally. Based on these results, we recommend that surgeons continue to focus on multi-strand repair methods, as the properties of eight-strand repairs were far better than those of four-strand repairs. To resist gap formation and enhance repair strength, a peripheral suture with 2 mm purchase is also recommended. Finally, since core suture caliber affected some biomechanical properties, including the failure mode, a 3-0 suture could be considered, provided that future in vivo studies can confirm that gliding properties are not adversely influenced.
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Affiliation(s)
| | | | | | | | | | - RH Gelberman
- Corresponding Authors: Biomechanics, Stavros Thomopoulos, Ph.D., Washington University, Department of Orthopaedic Surgery, 660 South Euclid, Campus Box 8233, St. Louis, MO 63110, Phone: 314-362-8605, ; Clinical Relevance, Richard H. Gelberman, Washington University, Department of Orthopaedic Surgery, 660 South Euclid, Campus Box 8233, St. Louis, MO 63110, Phone: 314-747-2531,
| | - S Thomopoulos
- Corresponding Authors: Biomechanics, Stavros Thomopoulos, Ph.D., Washington University, Department of Orthopaedic Surgery, 660 South Euclid, Campus Box 8233, St. Louis, MO 63110, Phone: 314-362-8605, ; Clinical Relevance, Richard H. Gelberman, Washington University, Department of Orthopaedic Surgery, 660 South Euclid, Campus Box 8233, St. Louis, MO 63110, Phone: 314-747-2531,
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Evans RB. Managing the injured tendon: current concepts. J Hand Ther 2012; 25:173-89; quiz 190. [PMID: 22326362 DOI: 10.1016/j.jht.2011.10.004] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Accepted: 10/31/2011] [Indexed: 02/03/2023]
Abstract
Despite advances in understanding of the mechanical aspects of tendon management with improved suture technique and early stress application with postoperative therapy, clinical results remain inconsistent after repair, especially within the synovial regions. Complementary research to enhance the intrinsic pathway of healing, suppress the extrinsic pathway of healing, and manipulate frictional resistance to tendon gliding is now the focus of current basic science research on tendons. In the future, application of these new biologic therapies may increase the "safety zone" (or tolerance for load and excursion without dysfunctional gapping) as therapists apply stress to healing tendons and may alter future rehabilitation protocols by allowing greater angles of motion (and thus tendon excursion), increased external load, and decreased time in protective orthoses (splints). However, at this time, the stronger repair techniques and the application of controlled stress remain the best and most well-supported intervention after tendon injury and repair in the recovery of functional tendon excursion and joint range of motion. The hand therapist's role in this process remains a critical component contributing to satisfactory outcomes.
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Affiliation(s)
- Roslyn B Evans
- Indian River Hand and Upper Extremity Rehabilitation, Vero Beach, Florida 32960, USA.
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46
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Affiliation(s)
- Pramod B. Voleti
- McKay Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania 19104-6081;
| | - Mark R. Buckley
- McKay Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania 19104-6081;
| | - Louis J. Soslowsky
- McKay Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania 19104-6081;
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Sardenberg T, Muller SS, Garms LZ, Miduati FB. IMMEDIATE AND LATE EFFECT OF SUTURES IN EXTRASYNOVIAL TENDONS: BIOMECHANICAL STUDY IN RATS. REVISTA BRASILEIRA DE ORTOPEDIA (ENGLISH EDITION) 2011; 46:305-8. [PMID: 27047823 PMCID: PMC4799230 DOI: 10.1016/s2255-4971(15)30200-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/02/2010] [Accepted: 11/03/2010] [Indexed: 11/28/2022]
Abstract
Objective: The aim of this study was to evaluate the effects on the mechanical properties of rats’ calcaneus tendons, of repair arrangements using suture material in the absence of any healing process. Method: Twelve male Wistar rats were used. They were subjected to placement of a modified Kessler suture stitch in the calcaneus tendon. The sacrifices were performed immediately after and six weeks after the operation. The mechanical properties studied were maximum load, tension in the maximum load and module of elasticity. The contralateral tendon was used as a control. Results: The statistical analysis showed that for the times studied, the values for mechanical properties did not present any significant differences. In relation to the control, i.e. the contralateral tendon without a suture, the results demonstrated that, six weeks after the operation, the values for the modulus of elasticity were lower, whereas there were no significant variations in maximum load or tension at maximum load. Conclusion: Placement of suture material on an extrasynovial tendon without lesions decreased the modulus of elasticity, but it did not interfere with the maximum load or tension at maximum load, six weeks after the operation.
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Affiliation(s)
- Trajano Sardenberg
- Botucatu Medical School, UNESP, São Paulo, Brazil
- Correspondence: Departamento de Cirurgia e Ortopedia da Faculdade de Medicina de Botucatu – UNESP - Distrito de Rubião Junior, s/n – 18603-970 – Botucatu, SPCorrespondence: Departamento de Cirurgia e Ortopedia da Faculdade de Medicina de BotucatuUNESPDistrito de Rubião Junior s/nBotucatuSP18603-970
| | | | - Luciana Zauhy Garms
- Physician and former resident in Orthopedics and Traumatology, Botucatu Medical School, UNESP, São Paulo, Brazil
| | - Francini Belluci Miduati
- Physician and former resident in Orthopedics and Traumatology, Botucatu Medical School, UNESP, São Paulo, Brazil
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Katzel EB, Wolenski M, Loiselle AE, Basile P, Flick LM, Langstein HN, Hilton MJ, Awad HA, Hammert WC, O’Keefe RJ. Impact of Smad3 loss of function on scarring and adhesion formation during tendon healing. J Orthop Res 2011; 29:684-93. [PMID: 20842701 PMCID: PMC3191491 DOI: 10.1002/jor.21235] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2009] [Accepted: 07/01/2010] [Indexed: 02/04/2023]
Abstract
Studies were performed evaluating the role of Smad3, a transcription factor mediating canonical TGF-β signaling, on scarring and adhesion formation using an established flexor digitorum longus (FDL) tendon repair model. In unoperated animals the metatarsophalangeal (MTP) range of motion (ROM) was similar in Smad3(-/-) and wild-type (WT) mice while the basal tensile strength of Smad3(-/-) tendons was significantly (39%) lower than in WT controls. At 14 and 21 days following repair Smad3(-/-) MTP ROM reached approximately 50% of the basal level and was twice that observed in WT tendon repairs, consistent with reduced adhesion formation. Smad3(-/-) and WT maximal tensile repair strength on post-operative day 14 was similar. However, Smad3(-/-) tendon repairs maximal tensile strength on day 21 was 42% lower than observed in matched WT mice, mimicking the relative decrease in strength observed in Smad3(-/-) FDL tendons under basal conditions. Histology showed reduced "healing callus" in Smad3(-/-) tendons while quantitative PCR, in situ hybridization, and immunohistochemistry showed decreased col3a1 and col1a1 and increased MMP9 gene and protein expression in repaired Smad3(-/-) tendons. Thus, Smad3(-/-) mice have reduced collagen and increased MMP9 gene and protein expression and decreased scarring following tendon FDL tendon repair.
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Affiliation(s)
- Evan B. Katzel
- Department of Orthopaedics, Center for Musculoskeletal Research, University of Rochester
,Division of Plastic and Reconstructive Surgery, Department of General Surgery, University of Rochester
| | - Matthew Wolenski
- Department of Orthopaedics, Center for Musculoskeletal Research, University of Rochester
| | - Alayna E. Loiselle
- Department of Orthopaedics, Center for Musculoskeletal Research, University of Rochester
| | - Patrick Basile
- Department of Orthopaedics, Center for Musculoskeletal Research, University of Rochester
,Division of Plastic and Reconstructive Surgery, Department of General Surgery, University of Rochester
| | - Lisa M. Flick
- Department of Orthopaedics, Center for Musculoskeletal Research, University of Rochester
| | - Howard N. Langstein
- Division of Plastic and Reconstructive Surgery, Department of General Surgery, University of Rochester
| | - Matthew J. Hilton
- Department of Orthopaedics, Center for Musculoskeletal Research, University of Rochester
| | - Hani A. Awad
- Department of Orthopaedics, Center for Musculoskeletal Research, University of Rochester
,Department of Biomedical Engineering, University of Rochester
| | - Warren C. Hammert
- Department of Orthopaedics, Center for Musculoskeletal Research, University of Rochester
| | - Regis J. O’Keefe
- Department of Orthopaedics, Center for Musculoskeletal Research, University of Rochester
,Corresponding Author: Center for Musculoskeletal Research, University of Rochester, 601 Elmwood Ave., Box 665, Rochester, NY 14642, , Phone: 585-275-5167, Fax: 585-756-4721
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Brodie M, Vollenweider L, Murphy JL, Xu F, Lyman A, Lew WD, Lee BP. Biomechanical properties of Achilles tendon repair augmented with a bioadhesive-coated scaffold. Biomed Mater 2011; 6:015014. [PMID: 21266745 DOI: 10.1088/1748-6041/6/1/015014] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The Achilles tendon is the most frequently ruptured tendon. Both acute and chronic (neglected) tendon ruptures can dramatically affect a patient's quality of life, and require a prolonged period of recovery before return to pre-injury activity levels. This paper describes the use of an adhesive-coated biologic scaffold to augment primary suture repair of transected Achilles tendons. The adhesive portion consisted of a synthetic mimic of mussel adhesive proteins that can adhere to various surfaces in a wet environment, including biologic tissues. When combined with biologic scaffolds such as bovine pericardium or porcine dermal tissues, these adhesive constructs demonstrated lap shear adhesive strengths significantly greater than that of fibrin glue, while reaching up to 60% of the strength of a cyanoacrylate-based adhesive. These adhesive constructs were wrapped around transected cadaveric porcine Achilles tendons repaired with a combination of parallel and three-loop suture patterns. Tensile mechanical testing of the augmented repairs exhibited significantly higher stiffness (22-34%), failure load (24-44%), and energy to failure (27-63%) when compared to control tendons with suture repair alone. Potential clinical implications of this novel adhesive biomaterial are discussed.
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Giambini H, Ikeda J, Amadio PC, An KN, Zhao C. The quadriga effect revisited: designing a "safety incision" to prevent tendon repair rupture and gap formation in a canine model in vitro. J Orthop Res 2010; 28:1482-9. [PMID: 20872585 PMCID: PMC3591491 DOI: 10.1002/jor.21168] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Loss of experimental animals due to tendon repair failure results in the need for additional animals to complete the study. We designed a relief proximal to the flexor digitorum profundus (FDP) tendon repair site to serve as a "safety incision" to prevent repair site ruptures and maximize safety incision-to-suture strength. The FDP tendons were dissected in 24 canine forepaws. The 2nd and 5th tendons were lacerated at the proximal interphalangeal joint level and sutured using a modified Kessler technique and peripheral running suture. Tendon width was measured where the FDP tendon separates into each individual digit and a safety incision, equal to the 2nd and 5th tendon widths, was performed 3, 4, or 5 mm (Groups 1, 2, and 3) proximal to the separation. The tendons were pulled at a rate of 1 mm/s until either the "safety incision" ruptured or the repair failed. There was no gap formation at the repair site in Groups 1 and 2. However, all Group 3 tendons failed by repair site rupture with the safety incision intact. An adequate safety incision to protect repair gap and rupture and maintain tendon tension for the FDP animal model should be about 4 mm from where the FDP tendon separates.
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Affiliation(s)
- Hugo Giambini
- Biomechanics Laboratory, Division of Orthopedic Research, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905, USA
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