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Xu SW, Wu YF. Effect of loading speed on gap resistance and tensile strength of flexor tendon repair under cyclic loading test. J Biomech 2023; 158:111749. [PMID: 37562275 DOI: 10.1016/j.jbiomech.2023.111749] [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: 12/29/2022] [Revised: 05/08/2023] [Accepted: 07/31/2023] [Indexed: 08/12/2023]
Abstract
Postoperative digit motion is important for the functional recovery of injured tendons. To date, it is unknown whether the loading speed impacts the biomechanical properties of a repaired tendon. This study investigated the effect of loading speed on the gap resistance and tensile strength of tendon repairs. One hundred porcine flexor tendons were repaired with two core sutures, 4-strand modified Kessler and double Q, and cyclically loaded at the speeds of 10, 40, 80, 160, and 320 mm/min. The number of tendons that formed an initial or 2 mm gap at the repair site during cyclic loading, stiffness at the 1st and 20th loading cycles, gap size between tendon ends when cyclic loading ended, and the ultimate strength were recorded. Under the lowest loading speed, the tendons repaired with the 4-strand modified Kessler suture developed significantly larger gaps and smaller stiffness than those with a greater loading speed. The loading speed did not affect the maximum strength of both tendon repairs. The findings suggest that very slow motion promotes gap formation of tendon repair with inferior gap resistance. The rate corresponds to regular hand action or the tendon core suture possessing a strong gap resistance increases the safety margin during early active finger movement. Our findings help to guide the exercise regimens after tendon surgery.
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Affiliation(s)
- Si Wei Xu
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China; Medical School, Nantong University, Nantong, Jiangsu, China
| | - Ya Fang Wu
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China.
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Henderson DJH, Christensen TJ, Vo A, Plath JE, Popescu IA, Lafosse L. The V-shaped subscapularis tenotomy for anatomic total shoulder arthroplasty. INTERNATIONAL ORTHOPAEDICS 2020; 45:199-208. [PMID: 33210169 DOI: 10.1007/s00264-020-04880-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 11/09/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE Management of the subscapularis tendon during anatomic total shoulder arthroplasty (TSA) remains controversial. In our unit, subscapularis tenotomy is the preferred technique; however, the potential for tendon gapping and failure is recognised. The purpose of this study is to describe and provide early clinical results of a novel, laterally based V-shaped tenotomy (VT) technique hypothesised to provide greater initial repair strength and resistance to gapping than a transverse tenotomy (TT), with both clinically and radiologically satisfactory post-operative tendon healing and function. METHODS A retrospective study of patients who underwent primary TSA with VT over a three year period was performed using shoulder and subscapularis-specific outcome scores, radiographs, and ultrasound. A separate cohort of patients who underwent TSA using a subscapularis sparing approach was also reviewed to provide comparative clinical outcomes of a group with TSA and an un-violated subscapularis. RESULTS Eighteen patients were reviewed at mean 30.4 months (± 11.7). Constant (78.2 ± 12.3), UCLA (8.4 ± 1.5), pain VAS (2.3 ± 2.8), and strength in internal rotation were no different from the comparison group. Likewise, neither were the clinical outcomes of range-of-motion, belly-press, lift-off, and shirt-tuck tests. One patient (5.5%) was found to have a failed subscapularis repair on ultrasound. CONCLUSION VT during TSA appears to provide healing rates at least equal to those reported for TT, and not dissimilar from those of lesser tuberosity osteotomy. Clinical outcomes are comparable to reported results in the literature for alternative techniques, and not different from those observed here in a comparison cohort with TSA performed without violating the subscapularis tendon. VT therefore potentially offers a more effective and secure tendon repair than a traditional TT, with at least comparable clinical outcomes.
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Affiliation(s)
- Daniel J H Henderson
- Alps Surgery Institute, Clinique Générale d'Annecy, 4 Chemin de la Tour la Reine, 74000, Annecy, France. .,Department of Trauma & Orthopaedics & Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, LS7 4SA, UK.
| | - Thomas J Christensen
- Alps Surgery Institute, Clinique Générale d'Annecy, 4 Chemin de la Tour la Reine, 74000, Annecy, France.,Reno Orthopaedic Clinic, Reno, NV, USA
| | - Austin Vo
- Alps Surgery Institute, Clinique Générale d'Annecy, 4 Chemin de la Tour la Reine, 74000, Annecy, France.,Austin & Monash Health, Melbourne, Australia
| | - Johannes E Plath
- Alps Surgery Institute, Clinique Générale d'Annecy, 4 Chemin de la Tour la Reine, 74000, Annecy, France.,Department of Trauma, Orthopaedic, Plastic & Hand Surgery, Zentralklinikum, Augsburg, Augsburg, Germany
| | - Ion-Andrei Popescu
- Alps Surgery Institute, Clinique Générale d'Annecy, 4 Chemin de la Tour la Reine, 74000, Annecy, France.,European Shoulder & Hand Unit, Bucharest, Romania
| | - Laurent Lafosse
- Alps Surgery Institute, Clinique Générale d'Annecy, 4 Chemin de la Tour la Reine, 74000, Annecy, France
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Chang MK, Lim ZY, Wong YR, Tay SC. A review of cyclic testing protocols for flexor tendon repairs. Clin Biomech (Bristol, Avon) 2019; 62:42-49. [PMID: 30685653 DOI: 10.1016/j.clinbiomech.2018.12.007] [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] [Received: 01/16/2018] [Revised: 11/08/2018] [Accepted: 12/07/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cyclic testing of flexor tendons aims to simulate post-operative rehabilitation and is more rigorous than static testing. However, there are many different protocols, making comparisons difficult. We reviewed these protocols and suggested two protocols that simulate passive and active mobilization. METHODS Literature search was performed to look for cyclic testing protocols used to evaluate flexor tendon repairs. Preload, cyclic load, number of cycles, frequency and displacement rate were categorised. FINDINGS Thirty-five studies with 42 different protocols were included. Thirty-one protocols were single-staged, while 11 protocols were multiple-staged. Twenty-nine out of 42 protocols used preload, ranging from 0.2 to 5 N. Preload of 2 N was used in most protocols. The cyclic load that was most commonly used was between 11 and 20 N. Cyclic load with increment of 10 N after each stage was used in multiple-staged protocols. The most commonly used number of cycles was between 100 and 1000. Most protocols used a frequency of <1 Hz and displacement rate between 0 and 20 mm/min. INTERPRETATION We propose two single-staged protocols as examples. Protocol 1: cyclic load of 15 N to simulate passive mobilization with preload of 2 N and 2000 cycles at frequency of 0.2 Hz.; Protocol 2: cyclic load of 38 N to simulate active mobilization, with the same preload, number of cycles, and frequency as above. This review consolidates the current understanding of cyclic testing and may help clinicians and investigators improve the design of flexor tendon repairs, allow for comparisons of different repairs using the same protocol, and evaluate flexor tendon repairs more rigorously before clinical applications.
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Affiliation(s)
- Min Kai Chang
- Duke-NUS Medical School, Singapore, 8 College Road, Singapore 169867, Singapore
| | - Zeus Yiwei Lim
- Biomechanics Laboratory, Level 1 Academia, 20 College Road, Singapore General Hospital, Singapore 169856, Singapore
| | - Yoke Rung Wong
- Biomechanics Laboratory, Level 1 Academia, 20 College Road, Singapore General Hospital, Singapore 169856, Singapore.
| | - Shian Chao Tay
- Biomechanics Laboratory, Level 1 Academia, 20 College Road, Singapore General Hospital, Singapore 169856, Singapore; Department of Hand Surgery, Level 4 Academia, 20 College Road, Singapore General Hospital, Singapore 169856, Singapore
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Peltz TS, Haddad R, Scougall PJ, Nicklin S, Gianoutsos MP, Oliver R, Walsh WR. Structural Failure Mechanisms of Common Flexor Tendon Repairs. ACTA ACUST UNITED AC 2016; 20:369-79. [PMID: 26387996 DOI: 10.1142/s0218810415400092] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND This study investigated the exact failure mechanisms of the most commonly used conventional tendon repair techniques. A new method, radiographing repair constructs in antero-posterior and lateral projections before and after tensioning was used. This allowed to precisely analyse failure mechanisms in regards to geometrical changes in all three dimensions. Additionally the biomechanical stability focusing on gapping was tested. METHODS Sheep fore limb deep flexor tendons were harvested and divided in eight groups of ten tendons. Three common variants of the Kessler repair method and four common 4-strand repair techniques were tested. Additionally a new modification of the Adelaide repair was tested. RESULTS Biomechanical testing showed no significant differences in gapping for the three tested 2-strand Kessler repair groups. Once a double Kessler or 4-strand Kessler repair was performed the stability of the repair improved significantly. Further significant improvements in biomechanical stability could be achieved by using cross locks in the repair like in the Adelaide repair method. Qualitative analysis using radiographs showed that all Kessler repair variants unfolded via rotations around the transverse suturing component, no matter which variant was used. CONCLUSIONS Additional to the commonly described constriction of the repair construct, the rotating deformation is the main reason for repair site gapping in Kessler tendon repair methods. The term "locking" in a Kessler repair is misleading. The cruciate repairs tended to loose grip and drag (cheese-wire) through the tendon and therefore lead to gapping. The most stable repair constructs in all three dimensions were the Adelaide repair and its interlocking modification. This is due to the superior anchoring qualities of its cross locks and three dimensional stability.
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Affiliation(s)
- Tim Sebastian Peltz
- * Surgical & Orthopaedic Research Laboratories, University of New South Wales, Australia.,† Department for Plastic and Reconstructive Surgery, Prince of Wales Hospital, Australia.,‡ Department for Hand Surgery, Sydney and St Lukes Hospital, Sydney, Australia
| | - Roger Haddad
- * Surgical & Orthopaedic Research Laboratories, University of New South Wales, Australia
| | - Peter James Scougall
- * Surgical & Orthopaedic Research Laboratories, University of New South Wales, Australia.,‡ Department for Hand Surgery, Sydney and St Lukes Hospital, Sydney, Australia
| | - Sean Nicklin
- * Surgical & Orthopaedic Research Laboratories, University of New South Wales, Australia.,† Department for Plastic and Reconstructive Surgery, Prince of Wales Hospital, Australia.,‡ Department for Hand Surgery, Sydney and St Lukes Hospital, Sydney, Australia
| | - Mark Peter Gianoutsos
- * Surgical & Orthopaedic Research Laboratories, University of New South Wales, Australia.,† Department for Plastic and Reconstructive Surgery, Prince of Wales Hospital, Australia
| | - Rema Oliver
- * Surgical & Orthopaedic Research Laboratories, University of New South Wales, Australia
| | - William Robert Walsh
- * Surgical & Orthopaedic Research Laboratories, University of New South Wales, Australia
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Linnanmäki L, Göransson H, Havulinna J, Sippola P, Karjalainen T, Leppänen OV. Validity of parameters in static linear testing of flexor tendon repair. J Biomech 2016; 49:2785-2790. [PMID: 27395758 DOI: 10.1016/j.jbiomech.2016.06.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 06/13/2016] [Accepted: 06/18/2016] [Indexed: 10/21/2022]
Abstract
To study the biomechanical properties of flexor tendon repairs, static tensile testing is commonly used because of its simplicity. However, cyclic testing resembles the physiological loading more closely. The aim of the present study is to assess how the biomechanical competence of repaired flexor tendons under cyclic testing relates to specific parameters derived from static tensile testing. Twenty repaired porcine flexor tendons were subjected to static tensile testing. Additional 35 specimens were tested cyclically with randomly assigned peak load for each specimen. Calculated risks of repair failure during repetitive loading were determined for mean of each statically derived parameter serving as a peak load. Furthermore, we developed a novel objective method to determine the critical load, which is a parameter predicting the survival of the repair in cyclic testing. The mean of statically derived yield load equalled the mean of critical load, justifying its role as a valid surrogate for critical load. However, regarding mean of any determined parameter as a clinically safe threshold is arbitrary due to the natural variation among samples. Until the universal performance of yield load is verified, we recommend employing cyclically derived critical load as primary parameter when comparing different methods of flexor tendon repair.
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Affiliation(s)
| | - Harry Göransson
- Department of Hand and Microsurgery, Tampere University Hospital, Tampere, Finland
| | - Jouni Havulinna
- Department of Hand and Microsurgery, Tampere University Hospital, Tampere, Finland
| | - Petteri Sippola
- Department of Mechanical Engineering and Industrial Systems, Tampere University of Technology, Tampere, Finland
| | - Teemu Karjalainen
- Department of Surgery, Central Hospital of Central Finland, Jyväskylä, Finland
| | - Olli V Leppänen
- Medical School, University of Tampere, Tampere, Finland; Department of Hand and Microsurgery, Tampere University Hospital, Tampere, Finland.
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Viinikainen A, Göransson H, Taskinen HS, Röyttä M, Kellomäki M, Törmälä P, Rokkanen P. Flexor tendon healing within the tendon sheath using bioabsorbable poly-L/D-lactide 96/4 suture. A histological in vivo study with rabbits. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2014; 25:1319-1325. [PMID: 24477875 DOI: 10.1007/s10856-014-5160-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2013] [Accepted: 01/20/2014] [Indexed: 06/03/2023]
Abstract
The bioabsorbable poly-L/D-lactide (PLDLA) 96/4 suture has good biomechanical and knot properties, and sufficient tensile strength half-life for flexor tendon repair. In the present study, the biocompatibility of PLDLA suture was compared with that of coated braided polyester suture in the rabbit flexor digitorum profundus tendon repaired within the tendon sheath. Postoperative unrestricted active mobilization was allowed. The tendons were studied histologically after 1-, 3-, 6-, 12-, 26-, and 52-week follow-ups. No differences were found in the biocompatibility between the suture materials, with only scattered multinuclear giant cells near the sutures in both groups from 6 weeks onwards. At 52 weeks, most of the PLDLA material was absorbed and the histological structure of the tendon appeared normal, whereas in the polyester repairs the suture knots filled the repair site, causing bulking of the tendon surface, and the collagen alignment appeared disoriented. The results suggest that the PLDLA 96/4 is a suitable suture material for flexor tendon repair.
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Affiliation(s)
- Anna Viinikainen
- Department of Hand Surgery, Helsinki University Central Hospital, P.O. Box 266, 00029 HUS, Helsinki, Finland,
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Ellä V, Annala T, Länsman S, Nurminen M, Kellomäki M. Knitted polylactide 96/4 L/D structures and scaffolds for tissue engineering: shelf life, in vitro and in vivo studies. BIOMATTER 2014; 1:102-13. [PMID: 23507732 PMCID: PMC3548249 DOI: 10.4161/biom.1.1.17447] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
This study covers the whole production cycle, from biodegradable polymer processing to an in vivo tissue engineered construct. Six different biodegradable polylactide 96/4 L/D single jersey knits were manufactured using either four or eight multifilament fiber batches. The properties of those were studied in vitro for 42 weeks and in 0- to 3-year shelf life studies. Three types (Ø 12, 15 and 19 mm) of cylindrical scaffolds were manufactured from the knit, and the properties of those were studied in vitro for 48 weeks. For the Ø 15 mm scaffold type, mechanical properties were also studied in a one-year in vivo experiment. The scaffolds were implanted in the rat subcutis. All the scaffolds were γ-irradiated prior to the studies. In vitro, all the knits lost 99% of their mechanical strength in 30 weeks. In the three-year follow up of shelf life properties, there was no decrease in the mechanical properties due to the storage time and only a 12% decrease in molecular weight. The in vitro and in vivo scaffolds lost their mechanical properties after 1 week. In the case of the in vivo samples, the mechanical properties were restored again, stepwise, by the presence of growing/maturing tissue between weeks 3 and 12. Faster degradation was observed with in vitro scaffolds compared to in vivo scaffolds during the one-year follow up.
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Affiliation(s)
- Ville Ellä
- Department of Biomedical Engineering, Tampere University of Technology, Tampere, Finland.
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Hoppe A, Sadaka F, Brachais CH, Boni G, Couvercelle JP, Plasseraud L. 1-n-Butyl-3-methylimidazolium-2-carboxylate: a versatile precatalyst for the ring-opening polymerization of ε-caprolactone and rac-lactide under solvent-free conditions. Beilstein J Org Chem 2013; 9:647-54. [PMID: 23616809 PMCID: PMC3628682 DOI: 10.3762/bjoc.9.73] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Accepted: 03/07/2013] [Indexed: 11/23/2022] Open
Abstract
The ring-opening polymerization of ε-caprolactone (ε-CL) and rac-lactide (rac-LA) under solvent-free conditions and using 1-n-butyl-3-methylimidazolium-2-carboxylate (BMIM-2-CO2) as precatalyst is described. Linear and star-branched polyesters were synthesized by successive use of benzyl alcohol, ethylene glycol, glycerol and pentaerythritol as initiator alcohols, and the products were fully characterized by 1H and 13C{1H} NMR spectroscopy, gel permeation chromatography (GPC), and differential scanning calorimetry (DSC). BMIM-2-CO2 acts as an N-heterocyclic carbene precursor, resulting from in situ decarboxylation, either by heating under vacuo (method A) or by addition of NaBPh4 (method B). Possible catalytic and deactivation mechanisms are proposed.
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Affiliation(s)
- Astrid Hoppe
- Institut de Chimie Moléculaire de l'Université de Bourgogne (ICMUB), UMR CNRS 6302, Avenue A. Savary, BP 47870, F-21078 Dijon, France
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Mao WF, Wu YF, Zhou YL, Tang JB. A study of the anatomy and repair strengths of porcine flexor and extensor tendons: are they appropriate experimental models? J Hand Surg Eur Vol 2011; 36:663-9. [PMID: 21768214 DOI: 10.1177/1753193411414117] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Although both porcine flexor and extensor tendons have been used in tendon repair research, no studies have specifically studied the anatomical differences and repair strengths in both types of tendons. We used 12 pig trotters to observe the anatomy of these tendons and compared the 2 mm gap and ultimate strengths of flexor and extensor tendons. There were four annular (A1, A2, A3, and A4) pulleys and one oblique pulley, which form a fibro-osseous tunnel for the flexor tendons, but the anatomy of the porcine extensor tendons was markedly different from the human flexor or extensor tendons. The diameter of flexor tendons was significantly greater than that of the extensors. The 2 mm gap and ultimate strengths of the flexor tendon with either two-strand or four-strand repairs were significantly greater than those of the extensor tendon. We conclude that the porcine flexor tendon systems are similar to those in the human, but the extensor tendons are not similar to either the flexor or extensor tendons in humans. Flexor and extensor tendons have different repair strengths which should be taken into account when interpreting findings from investigations using these tendons.
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Affiliation(s)
- W F Mao
- The Hand Surgery Research Center and Department of Anatomy, Nantong University, Nantong, Jiangsu, China
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Peltz TS, Haddad R, Scougall PJ, Nicklin S, Gianoutsos MP, Walsh WR. Influence of locking stitch size in a four-strand cross-locked cruciate flexor tendon repair. J Hand Surg Am 2011; 36:450-5. [PMID: 21333462 DOI: 10.1016/j.jhsa.2010.11.029] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2010] [Revised: 11/15/2010] [Accepted: 11/19/2010] [Indexed: 02/02/2023]
Abstract
PURPOSE The 4-strand cross-locked cruciate technique (Adelaide technique) for repairing flexor tendons in zone II is a favorable method in terms of strength and simplicity. The purpose of this study was to investigate the effects of varying the cross-lock stitch size in this repair technique. Outcomes measured were load to failure and gap formation. METHODS We harvested 22 deep flexor tendons from adult pig forelimbs and randomly allocated them into 2 groups. After cutting the tendons at a standard point, we performed a 4-strand cross-locked cruciate repair using 3-0 braided polyester with either 2-mm cross-locks (n = 11) or 4-mm cross-locks (n = 11). All repairs were completed with a simple running peripheral suture using 6-0 polypropylene. Repaired tendons were loaded to failure and the mechanism of failure, load to failure, stiffness, and load to 2-mm gap formation were determined. RESULTS All repairs failed by suture breakage; we noted no suture pullout. There was no difference in load to failure (71.7-71.1 N; p = .89) or stiffness (4.1-4.6 N/mm; p = .23) between the 2-mm cross-lock and the 4-mm cross-lock groups. There was a trend toward higher resistance to 2-mm gap formation with the 4-mm cross-locks (55-62.2 N; p = .07). CONCLUSIONS Four-strand cross-locked cruciate repairs with cross-lock sizes of 2 and 4 mm provide high tensile strength and are resistant to pullout. Repairs with 4-mm cross-locks tend to provide a more central load distribution and better gapping resistance than repairs with 2-mm cross-locks.
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Affiliation(s)
- Tim S Peltz
- Surgical and Orthopaedic Research Laboratories, University of New South Wales, Prince of Wales Hospital, Sydney, Australia
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