1
|
Miller EA, Teal L. Principles for Achieving Predictable Outcomes in Flexor Tendon Repair. Clin Plast Surg 2024; 51:445-457. [PMID: 39216932 DOI: 10.1016/j.cps.2024.02.011] [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] [Indexed: 09/04/2024]
Abstract
Flexor tendon injuries require surgical repair. Early repair is optimal, but staged repair may be indicated for delayed presentations. Zone II flexor tendon injuries are the most difficult to achieve acceptable outcomes and require special attention for appropriate repair. Surgical techniques to repair flexor tendons have evolved over the past several decades and principles include core strand repair using at least a 4 strand technique, epitendinous suture to add strength and gliding properties, and pulley venting. Early postoperative active range of motion within the first 3 to 5 days of surgery is essential for optimizing outcomes.
Collapse
Affiliation(s)
- Erin A Miller
- Division of Plastic Surgery, Department of Surgery, University of Washington Medical Center, 325 9th Avenue, Seattle, WA 98104, USA.
| | - Lindsey Teal
- Division of Plastic Surgery, Department of Surgery, University of Washington Medical Center, 325 9th Avenue, Seattle, WA 98104, USA
| |
Collapse
|
2
|
Reed ER, Hendrycks R, Graham EM, Rosales M, Mendenhall SD. Wrist-Level Tendon Repairs Utilizing a Novel Tendon Stapler Device: An Efficiency and Biomechanical Study. Plast Reconstr Surg 2024; 154:582-591. [PMID: 37772910 DOI: 10.1097/prs.0000000000011102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
BACKGROUND A novel tendon stapler device (TSD) to improve the strength and consistency of primary tendon repairs was recently approved by the U.S. Food and Drug Administration. The authors hypothesized that this TSD would demonstrate faster and superior biomechanical properties compared with a standard suture coaptation. The authors also hypothesized that the TSD biomechanical properties would be consistent across participants with differing tendon repair experiences. METHODS Participants included a novice, intermediate, and expert in tendon repairs. Timed comparisons were performed in flexor zones IV and V and extensor zones VI and VII on human cadaver arms. Suture repairs were performed with a modified Kessler technique with a horizontal mattress. TSD repairs were performed on the matched donor arms. Biomechanical testing included 2-mm gap force, ultimate failure load, and mode of failure. RESULTS In total, 228 tendon coaptations from 12 donor arms were performed and analyzed. TSD coaptations were 3 times faster and withstood nearly 50% higher forces on 2-mm gap testing and roughly 30% higher forces on ultimate failure testing. These findings did not change when the repair times were analyzed by participant. Suture coaptations failed owing to suture pull-through, suture breakage, or knot failure. TSD coaptation failures only occurred from device pull-through. CONCLUSIONS The TSD produces significantly faster and stronger primary tendon coaptations compared with a standard 4-strand core suture repair in human donor arms. The findings demonstrated minimal variability among participants with differing tendon repair experience. Although further investigation is needed, this device has potential to revolutionize tendon repairs.
Collapse
Affiliation(s)
- Evelyn R Reed
- From the Division of Plastic Surgery, Department of Surgery
| | | | - Emily M Graham
- Division of Plastic, Reconstructive, and Oral Surgery, Division of Orthopaedic Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Megan Rosales
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine
| | - Shaun D Mendenhall
- From the Division of Plastic Surgery, Department of Surgery
- Division of Plastic, Reconstructive, and Oral Surgery, Division of Orthopaedic Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| |
Collapse
|
3
|
Wu YF. Effects of a Q Suture Technique as a Core Suture on Resistance to Gap Formation and Tensile Strength in an Ex Vivo Porcine Flexor Tendon Model. J Hand Surg Am 2024; 49:381.e1-381.e8. [PMID: 36180372 DOI: 10.1016/j.jhsa.2022.08.002] [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: 01/13/2022] [Revised: 06/21/2022] [Accepted: 08/03/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE The Q suture has been reported to be an effective alternative to conventional peripheral sutures in tendon repair. Whether the Q method can be used as a core suture rather than a peripheral suture by adjusting the purchase length is unknown. We tested a double Q suture technique with variable purchase length and studied its effects on gap formation and tensile strength using an ex vivo model. METHODS Forty pig flexor tendons were repaired using the double Q sutures with purchase lengths of 2, 4, 6, and 8 mm. Twenty tendons repaired using the double Tsuge and double Kessler sutures with an 8-mm purchase length were used as controls. The tendons were subjected to cyclic loading and load-to-failure. The number of tendons that formed an initial or 2-mm gap between the tendon ends, gap distance at the repair site, stiffness, and ultimate strength were recorded. RESULTS During cyclic loading, the double Q suture with a 4-8-mm purchase had fewer tendons form an initial or 2-mm gap and a smaller gap size at the repair site than the Tsuge and Kessler sutures. The stiffness of the double Q suture with a 6-8-mm purchase length and Tsuge suture was greater than those of the double Kessler suture. The double Q suture with a 2-mm purchase length had smaller ultimate strength than the other sutures. CONCLUSIONS The Q suture may be an effective tendon repair method whose role can be converted between peripheral and core sutures via adjusting the suture purchase length. With an optimal suture length of 4-6 mm, the double Q method had tensile resistance superior to 4-strand core sutures. CLINICAL RELEVANCE The double Q suture may be a viable option as a core suture in flexor tendon repair when the purchase length is appropriately adjusted.
Collapse
Affiliation(s)
- Ya Fang Wu
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China.
| |
Collapse
|
4
|
Brenac C, Pithioux M, Tomczak S, Lallemand M, Jaloux C, de Villeneuve Bargemon JB. Biomechanical evaluation of the ST-knot: A new suture for flexor tendon repair. HAND SURGERY & REHABILITATION 2024; 43:101650. [PMID: 38301768 DOI: 10.1016/j.hansur.2024.101650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/16/2024] [Accepted: 01/17/2024] [Indexed: 02/03/2024]
Abstract
PURPOSE Although tendon lacerations are common, there is currently no consensus on choice of suture. Easy and fast sutures that impart enough strength to allow mobilization are needed. This study compared the ex vivo biomechanical strength (force required to create a 2 mm tendon gap) of a novel suture (ST-knot) with that of a conventional suture (double Kessler). MATERIALS AND METHODS Forty fresh deep flexor tendons from porcine forelimbs were used. Both repaired tendon ends were mounted on standard traction jaws of an axial traction machine at an initial distance of 40 mm for all tendons. A high-definition camera was used to determine the force forming a 2 mm gap. Ten tendons in group 1 (ST-knot) and 10 in group 2 (double Kessler) were prepared with PDS 4.0 (single thread for Kessler, double thread for ST-knot). Tendons in groups 3 (ST-knot) and 4 (double Kessler) were repaired with PDS 1.0 using the same principle. RESULTS There was no significant difference in the force required to form a 2 mm tendon gap between groups 1 and 2, and this trend was identical when using a stronger thread in groups 3 and 4. The maximum force before rupture, mode of repair failure, stress and stiffness were also comparable, with no significant differences between groups 1 and 2, or between groups 3 and 4. CONCLUSIONS The ST-knot showed comparable results to the double-Kessler knot, whichever the thread used. Because it involves fewer steps than conventional techniques and is easy to perform, the ST-knot may offer a therapeutic solution, particularly in complex trauma with multiple tendon injury.
Collapse
Affiliation(s)
- Camille Brenac
- Hospices Civils de Lyon, Hôpital Croix Rousse, Service de Chirurgie Plastique, Esthétique et Réparatrice, Lyon F-69003, France.
| | - Martine Pithioux
- Aix Marseille Univ, CNRS, ISM, 13009 Marseille, France; Aix Marseille Univ, APHM, CNRS, ISM, Mecabio Platform, Department of Orthopaedics and Traumatology, 13009 Marseille, France; Aix Marseille Univ, APHM, CNRS, ISM, Sainte-Marguerite Hospital, Institute for Locomotion, Department of Orthopaedics and Traumatology, 13009 Marseille, France
| | - Sacha Tomczak
- Plastic and Reconstructive Surgery Department, Hôpital Conception, AP-HM, Marseille, France
| | - Marylène Lallemand
- Ecole Centrale Marseille, 13013 Marseille, France; Aix Marseille Univ, APHM, CNRS, ISM, Mecabio Platform, Department of Orthopaedics and Traumatology, 13009 Marseille, France
| | - Charlotte Jaloux
- Hand Surgery and Limb Reconstructive Surgery, CHU de Timone, Aix-Marseille University, 264 Rue Saint Pierre, 13005 Marseille, France
| | - Jean Baptiste de Villeneuve Bargemon
- Hand Surgery and Limb Reconstructive Surgery, CHU de Timone, Aix-Marseille University, 264 Rue Saint Pierre, 13005 Marseille, France; Hand, Wrist and Elbow Surgery, Saint Roch Private Hospital, Toulon, 99 Avenue Saint Roch, 83100 Toulon, France
| |
Collapse
|
5
|
Sasor SE, Chung KC. Surgical Considerations for Flexor Tendon Repair: Timing and Choice of Repair Technique and Rehabilitation. Hand Clin 2023; 39:151-163. [PMID: 37080647 DOI: 10.1016/j.hcl.2022.08.016] [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 injuries are common and occur mostly due to penetrating trauma. Surgical repair is required for complete tendon lacerations, and many techniques exist. This article reviews the principles of tendon structure, function, healing, and anatomy. Repair techniques are discussed in detail for each flexor tendon zone. Postoperative rehabilitation greatly influences outcomes, and several protocols are described.
Collapse
Affiliation(s)
- Sarah E Sasor
- Department of Plastic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Kevin C Chung
- Department of Surgery, Section of Plastic Surgery, University of Michigan, 1500 E. Medical Center Dr., 2130 Taubman Center, SPC 5340, Ann Arbor, MI 48109, USA
| |
Collapse
|
6
|
Tang JB, Pan ZJ, Munz G, Besmens IS, Harhaus L. Flexor Tendon Repair Techniques: M-Tang Repair. Hand Clin 2023; 39:141-149. [PMID: 37080646 DOI: 10.1016/j.hcl.2022.08.015] [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: 04/22/2023]
Abstract
The authors present the methods and outcomes from six institutes where M-Tang repairs with early active flexion exercise are used for zone 2 digital flexor tendon repair. The authors had close to zero repair ruptures, and few digits needed tenolysis. The excellent to good results are generally between 80% and 90%. In the pandemic period, less stringent therapy supervision might have allowed some patients to move too aggressively, with repair ruptures not seen before the pandemic in one institute. In Nantong, Yixing, and Saint John, the rupture incidence is zero to 1%. In Florence and Heidelberg, the rupture incidence was 3%.
Collapse
Affiliation(s)
- Jin Bo Tang
- Department of Hand Surgery, The Hand Surgery Research Center, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China.
| | - Zhang Jun Pan
- Hand Surgery, Yixing City Hospital, Yixing, Jiangsu, China
| | - Giovanni Munz
- Azienda Ospedaliera Careggi: Azienda Ospedaliero Universitaria Careggi, Surgery and microsurgery of the hand, Largo Palagi 1, Firenze, Italy; Current position is: Unit of hand surgery, Santo Stefano Hospital, via Suor Niccolina Infermiera 22, Prato, Italy
| | - Inga S Besmens
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Switzerland
| | - Leila Harhaus
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Heidelberg, Germany; Department of Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| |
Collapse
|
7
|
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.
Collapse
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.
| |
Collapse
|
8
|
Huidan Z, Kang J, Kim N, Heo S. Ex Vivo Biomechanical Assessment of Various Repair Techniques in a Rabbit Calcaneal Tendon Avulsion Model: Application of Polycaprolactone Plate. Vet Sci 2023; 10:vetsci10040289. [PMID: 37104444 PMCID: PMC10146963 DOI: 10.3390/vetsci10040289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 04/08/2023] [Accepted: 04/11/2023] [Indexed: 04/28/2023] Open
Abstract
This study was aimed at evaluating the biomechanical properties and gapping characteristics of tendon repair methods using a combination of a three-loop pulley (3LP) pattern, a titanium plate, and a polycaprolactone (PCL) plate in a rabbit gastrocnemius tendon (GT) model (n = 50). GTs were randomly assigned to five groups (n = 10/group). Transected GTs were repaired with a 3LP pattern alone or in conjunction with an epitendinous suture (ES), a 5-hole 1 mm PCL plate, a 5-hole 2 mm PCL plate, or a 5-hole 1.5 mm titanium plate. The yield, peak, and failure force, as well as the occurrence and force of 1-mm and 3-mm gapping were examined. The mean yield, peak, and failure force of the 3LP + titanium plate group were higher than that of other groups. The biomechanical properties of a 3LP + a 2 mm PCL plate were similar to 3LP + ES constructs in this model. In all specimens in all groups, 1 mm gap formation was observed. The frequency of 3 mm gap formation was 70% and 90% in the 3LP + 2 mm PCL plate group and the 3LP + 1.5 mm titanium plate group, respectively. Additional studies evaluating PCL plates to determine the effect on the healing and blood supply of tendon are needed.
Collapse
Affiliation(s)
- Zheng Huidan
- Department of Veterinary Surgery, College of Veterinary Medicine, Jeonbuk National University, 79 Gobong-ro, Iksan 54596, Republic of Korea
| | - Jinsu Kang
- Department of Veterinary Surgery, College of Veterinary Medicine, Jeonbuk National University, 79 Gobong-ro, Iksan 54596, Republic of Korea
| | - Namsoo Kim
- Department of Veterinary Surgery, College of Veterinary Medicine, Jeonbuk National University, 79 Gobong-ro, Iksan 54596, Republic of Korea
| | - Suyoung Heo
- Department of Veterinary Surgery, College of Veterinary Medicine, Jeonbuk National University, 79 Gobong-ro, Iksan 54596, Republic of Korea
| |
Collapse
|
9
|
Lindsay C, Watson N, Yanik J, Glass N, Fowler T. Strength, bulk and surgery time of ex situ versus in situ flexor tendon repair in a cadaveric model. J Hand Surg Eur Vol 2023; 48:137-143. [PMID: 36281068 DOI: 10.1177/17531934221131376] [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: 02/03/2023]
Abstract
The purpose of this study was to compare strength, bulk and time of repair of human cadaveric flexor digitorum profundus tendons repaired in situ versus ex situ. Ninety-six human cadaveric flexor digitorum profundus tendons were transected 5 mm distal to the A2-pulley and randomized to 2-strand, 4-strand or 6-strand repairs. We found no significant differences in repair strength between in situ and ex situ repairs, but repair strength increased with increasing number of strands. The cross-sectional area of the repair was not significantly related to the number of strands, but 4- and 6-strand in situ repairs were bulkier than ex situ repairs. In situ repair took longer, and repair time increased with increasing number of strands. We suggest that cadaveric studies of flexor tendon repair should be performed in situ in order to better mimic the clinical reality of tissue handling and repair bulkiness.
Collapse
Affiliation(s)
- Christopher Lindsay
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa, USA
| | - Nicole Watson
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa, USA
| | - John Yanik
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa, USA
| | - Natalie Glass
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa, USA
| | - Timothy Fowler
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa, USA
| |
Collapse
|
10
|
Practice Patterns in Operative Flexor Tendon Laceration Repair: A 15-Year Analysis of Continuous Certification Data from the American Board of Plastic Surgery. Plast Reconstr Surg Glob Open 2022; 10:e4558. [PMID: 36225846 PMCID: PMC9542854 DOI: 10.1097/gox.0000000000004558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 08/09/2022] [Indexed: 11/06/2022]
Abstract
The American Board of Plastic Surgery has been collecting practice data on operative repair of flexor tendon lacerations since 2006, as part of its Continuous Certification program.
Collapse
|
11
|
Marcoux JT, Tong L. Fibrocartilaginous Tissue: Why Does It Fail to Heal? Clin Podiatr Med Surg 2022; 39:437-450. [PMID: 35717061 DOI: 10.1016/j.cpm.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Tendons and ligaments are critical components in the function of the musculoskeletal system, as they provide stability and guide motion for the biomechanical transmission of forces into bone. Several common injuries in the foot and ankle require the repair of ruptured or attenuated tendon or ligament to its osseous insertion. Understanding the structure and function of injured ligaments and tendons is complicated by the variability and unpredictable nature of their healing. The healing process at the tendon/ligament to bone interface is challenging and often frustrating to foot and ankle surgeons, as they have a high failure rate necessitating the need for revision.
Collapse
Affiliation(s)
- John T Marcoux
- Division of Podiatry, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 185 Pilgrim Road, Span 3, Boston, MA 02215, USA.
| | - Lowell Tong
- Division of Podiatry, Department of Surgery, Beth Israel Deaconess Medical Center, 185 Pilgrim Road, Span 3, Boston, MA 02215, USA
| |
Collapse
|
12
|
Abstract
In this article, I review how my team and I addressed clinical concerns in Zone 2 flexor tendon repair, and how major findings in each step of our research were translated into clinical practice. The focus of the article is on the thought processes behind each new investigation, the interpretation of research findings and conclusions drawn from the basic and clinical studies.
Collapse
Affiliation(s)
- Jin Bo Tang
- Department of Hand Surgery, The Hand Surgery Research Center, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China
| |
Collapse
|
13
|
Chang YJ, Duffy DJ, Beamon W, Moore GE. Ex vivo biomechanical characteristics and effects on gap formation of using an internal fixation plate to augment primary three-loop pulley repair of canine gastrocnemius tendons. Am J Vet Res 2022; 83:305-311. [PMID: 35092666 DOI: 10.2460/ajvr.21.07.0088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
OBJECTIVE To evaluate the effects of using an internal fixation plate to augment primary 3-loop pulley (3LP) repair of canine gastrocnemius tendons (GTs). SAMPLE 48 cadaveric GTs from 24 adult dogs. PROCEDURES GTs were dissected free from other tissues, transected, and randomly assigned to 4 groups (n = 12/group). GTs were repaired with 2-0 polypropylene with a 3LP repair alone or a 3LP repair augmented with a 3-hole veterinary cuttable plate (3VCP), a 5-hole veterinary cuttable plate (5VCP), or a 7-hole veterinary cuttable plate (7VC P). Biomechanical loads, construct stiffness, gap formation, and failure modes were compared between groups. RESULTS Yield, peak, and failure loads were all significantly increased for the 5VCP and 7VCP groups, compared with the 3LP alone group. Increasing plate length from 3VCP to 5VCP and from 3VCP to 7VCP increased yield, peak, and failure loads. No differences were found between the 3LP and 3VCP groups with regard to yield and peak loads, but failure load was increased in the 3VCP group. Loads to create 1-mm and 3-mm gaps were significantly greater for the 5VCP and 7VCP groups, compared with the 3LP alone and 3VCP groups. Mode of plate attachment failure differed among groups. CLINICAL RELEVANCE Tendon plate augmentation may be a viable surgical option to increase the strength of the tenorrhaphy in dogs. However, in vivo studies evaluating the effects of plate augmentation on the tendon blood supply and progression of healing are needed prior to clinical application.
Collapse
Affiliation(s)
- Yi-Jen Chang
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC
| | - Daniel J Duffy
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC
| | - Wes Beamon
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC
| | - George E Moore
- Department of Veterinary Administration, College of Veterinary Medicine, Purdue University, West Lafayette, IN
| |
Collapse
|
14
|
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.
Collapse
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)
| |
Collapse
|
15
|
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.
Collapse
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
| |
Collapse
|
16
|
Duffy DJ, Chang YJ, Fisher MB, Chambers AR, Moore GE. Effect of epitendinous suture caliber on the tensile strength of repaired canine flexor tendons. Am J Vet Res 2021; 82:510-515. [PMID: 34032486 DOI: 10.2460/ajvr.82.6.510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine the effect of epitendinous suture (ES) caliber on the tensile strength of flexor tendon repairs in cadaveric specimens from dogs. SAMPLE 60 cadaveric superficial digital flexor tendons (SDFTs) from 30 skeletally mature dogs. PROCEDURES Specimens were randomly assigned to 5 suture caliber groups (n = 12 SDFTs/group). After sharp transection, SDFTs were repaired by placement of a simple continuous circumferential ES created with size-0, 2-0, 3-0, 4-0, or 5-0 polypropylene suture. Constructs were preloaded to 2 N and load tested to failure. Loads at yield, peak, and failure and mode of failure were compared among groups by statistical methods. RESULTS Yield, peak, and failure loads for SDFT repair constructs were positively correlated with ES caliber and did not differ between the size-0 and 2-0 groups on pairwise comparisons. Yield load was significantly greater for size-0, 2-0, and 3-0 groups than for the 4-0 and 5-0 groups. Peak and failure loads were significantly greater for the size-0 and 2-0 groups than for the remaining groups. Most size-0 (12/12), 2-0 (12/12), and 3-0 (10/12) group constructs failed because of ES pull-through; several constructs in the 4-0 group (5/12) and most in the 5-0 group (11/12) failed because of ES breakage. CONCLUSIONS AND CLINICAL RELEVANCE Results suggested size-0 and 2-0 sutures should be considered when placing an ES for flexor tendon repairs in dogs. However, in vivo studies are needed determine the effects of increasing ES caliber on clinical outcomes for dogs undergoing these procedures.
Collapse
|
17
|
Curcillo CP, Duffy DJ, Chang YJ, Moore GE. Ex Vivo Biomechanical Assessment of a Novel Multi-Strand Repair of Canine Tendon Lacerations. Vet Comp Orthop Traumatol 2021; 34:248-256. [PMID: 33792007 DOI: 10.1055/s-0041-1725014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE This study aimed to evaluate the effect of increasing the number of suture strands traversing the transection site, level of suture purchase and depth of suture penetrance on the biomechanical properties of repaired gastrocnemius tendons. STUDY DESIGN Thirty-eight adult cadaveric gastrocnemius tendons were randomized, transected and repaired with either two-, four- or six-strand locking multi-level repair. Tensile loads required to create a 1 and 3 mm gap, yield, peak and failure loads and failure mode were analysed. Significance was set at p < 0.05. RESULTS Mean ± standard deviation yield, peak and failure force for six-strand repairs was 90.6 ± 22.1 N, 111.4 ± 15.2 N and 110.3 ± 15.1 N respectively. This was significantly greater compared with both four-strand (55.0 ± 8.9 N, 72.9 ± 7.8 N and 72.1 ± 8.2 N) and two-strand repairs (24.7 ± 8.3 N, 36.5 ± 6.0 N and 36.1 ± 6.3 N) respectively (p < 0.001). Occurrence of 3 mm gap formation was significantly less using six-strand repairs (p < 0.001). Mode of failure did not differ between groups with all repairs (36/36; 100%) failing by suture pull-through. CONCLUSION Pattern modification by increasing the number of suture strands crossing the repair site, increasing points of suture purchase from the transection site and depth of suture penetrance is positively correlated with repair site strength while significantly reducing the occurrence of gap formation in a canine cadaveric model. Additional studies in vivo are recommended to evaluate their effect on tendinous healing, blood supply and glide resistance prior to clinical implementation.
Collapse
Affiliation(s)
- Chiara P Curcillo
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, United States
| | - Daniel J Duffy
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, United States
| | - Yi-Jen Chang
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, United States
| | - George E Moore
- Veterinary Administration, College of Veterinary Medicine, Purdue University, West Lafayette, Indiana, United States
| |
Collapse
|
18
|
Duffy DJ, Chang YJ, Gaffney L, Fisher MB, Moore GE. Evaluation of a continuous locking novel epitendinous suture pattern with and without a core locking-loop suture on the biomechanical properties of tenorrhaphy constructs in an ex vivo model of canine superficial digital flexor tendon laceration. Am J Vet Res 2021; 82:302-309. [PMID: 33764835 DOI: 10.2460/ajvr.82.4.302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate the effect of a continuous locking novel epitendinous suture (nES) pattern with and without a core locking-loop (LL) suture on the biomechanical properties of ex vivo canine superficial digital flexor tendon (SDFT) tenorrhaphy constructs. SAMPLE 54 cadaveric forelimb SDFTs from 27 musculoskeletally normal adult dogs. PROCEDURES Tendons were assigned to 3 groups (18 SDFTs/group): sharply transected and repaired with a core LL suture alone (group 1), an nES pattern alone (group 2), or a combination of a core LL suture and nES pattern (group 3). All constructs underwent a single load-to-failure test. Yield, peak, and failure loads; gap formation incidence; and mode of failure were compared among the 3 groups. RESULTS Mean yield, peak, and failure loads differed significantly among the 3 groups and were greatest for group 3 and lowest for group 1. Mean yield, peak, and failure loads for group 3 constructs were greater than those for group 1 constructs by 50%, 47%, and 44%, respectively. None of the group 3 constructs developed 3-mm gaps. The most common mode of failure was suture pulling through the tendon for groups 1 (12/18) and 2 (12/18) and suture breakage for group 3 (13/18). CONCLUSIONS AND CLINICAL RELEVANCE Results suggested augmentation of a core LL suture with an nES pattern significantly increased the strength of and prevented 3-mm gap formation at the tenorrhaphy site in ex vivo canine SDFTs. In vivo studies are necessary to assess the effectiveness and practicality of the nES pattern for SDFT repair in dogs.
Collapse
|
19
|
Getting Better Results in Flexor Tendon Surgery and Therapy. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3432. [PMID: 33680676 PMCID: PMC7929554 DOI: 10.1097/gox.0000000000003432] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 12/23/2020] [Indexed: 11/25/2022]
Abstract
Recently, better outcomes have been reported when up-to-date developments in flexor tendon surgery and therapy were followed. Slightly tensioned multistrand repairs, judicious venting of pulleys, and early active motion are widely accepted principles. In addition to these principles, tailoring of the repair according to intraoperative active movement with wide awake local anesthesia no tourniquet (WALANT) surgical setting is recommended for better results. We aimed to describe our up-to-date approach to flexor tendon surgery and therapy with the help of visual communication tools of this age. The ideal primary repair of flexor tendons, the management of delayed presentation flexor tendon injuries, the key steps to achieve better results with flexor tendon therapy, and the tele-rehabilitation experience during COVID-19 pandemic will be highlighted. Zone 2 flexor tendon injuries are the most demanding part and will be focused on.
Collapse
|
20
|
Abstract
This article provides a comprehensive overview of hand tendon injuries. It has been tailored towards healthcare professionals who will be the first to assess these injuries and instigate appropriate management. It discusses the essential hand anatomy to be aware of, how to assess tendon injuries, their initial management and also the definitive surgical interventions used, if required. Rehabilitation techniques are also discussed, as this is also key to good functional outcomes. Missed injuries, or delay in their diagnosis and referral to specialist hand surgeons, can cause a large amount of morbidity for patients and therefore it is important that they are picked up in a timely manner.
Collapse
Affiliation(s)
- E Campbell
- Department of Plastic Surgery, Royal London Hospital, London, UK
| | - S Pillai
- Department of Plastic Surgery, Royal London Hospital, London, UK
| | - S V Vamadeva
- Department of Plastic Surgery, Royal London Hospital, London, UK
| | - G S Pahal
- Department of Plastic Surgery, Royal London Hospital, London, UK
| |
Collapse
|
21
|
Barbed sutures versus conventional tenorrhaphy in flexor tendon repair: An ex vivo biomechanical analysis. Arch Plast Surg 2019; 46:228-234. [PMID: 30913576 PMCID: PMC6536874 DOI: 10.5999/aps.2018.00962] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 02/16/2019] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND The management of flexor tendon injuries has evolved in recent years through industrial improvements in suture materials, refinements of repair methods, and early rehabilitation protocols. However, there is no consensus on the ideal suture material and technique. This study was conducted to compare the tensile strength, repair time, and characteristics of 4-strand cruciate, modified Kessler, and 4-strand horizontal intrafiber barbed sutures for flexor tenorrhaphy with a 12-mm suture purchase length in an animal model. METHODS The right third deep flexors of 60 adult Leghorn chicken feet were isolated and repaired with a 12-mm suture purchase length. The tendons were randomly assigned to three groups of equal number (n=20 each). Groups 1 and 2 received 4-strand cruciate and modified Kessler repair with conventional suture materials, respectively. A 4-strand horizontal intrafiber barbed suture technique was used in group 3. The repaired tendons were biomechanically tested for tensile strength, 2-mm gap resistance, and mode of failure. Repair times were also recorded. RESULTS The maximum tensile strength until failure was 44.6±4.3 N in group 1, 35.7±5.2 N in group 2, and 56.7±17.3 N in group 3. The barbed sutures were superior to the other sutures in terms of the load needed for 2-mm gap formation (P<0.05). Furthermore, the barbed sutures showed the shortest repair time (P<0.05). CONCLUSIONS This study found that 4-strand horizontal intrafiber barbed suture repair with a 12-mm purchase length in a chicken flexor tendon injury model showed promising biomechanical properties and took less time to perform than other options.
Collapse
|
22
|
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.
Collapse
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
| | | | | |
Collapse
|
23
|
Venkatramani H, Varadharajan V, Bhardwaj P, Vallurupalli A, Sabapathy SR. Flexor tendon injuries. J Clin Orthop Trauma 2019; 10:853-861. [PMID: 31528057 PMCID: PMC6739511 DOI: 10.1016/j.jcot.2019.08.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 08/09/2019] [Accepted: 08/09/2019] [Indexed: 10/26/2022] Open
Abstract
Flexor tendon injuries have constituted a large portion of the literature in hand surgery over many years. Yet many controversies remain and the techniques of surgery and therapy are still evolving. The anatomical and finer technical considerations involved in treating these injuries have been put forth and discussed in detail including the rehabilitation following the flexor tendon repair. The authors consider, recognition and mastery of these facts form the foundation for a successful flexor tendon repair. The trend is now towards multiple strand core sutures followed by early active mobilization. However, the rehabilitation process appears to be one of the major determinant of the success following a flexor tendon repair. Early mobilization is essential for all the flexor tendon repairs as it is proved to improve the quality of the repaired tendon. The art of achieving the harmony between a stronger repair and unhindered gliding of the repair site through the narrow flexor tendon sheath simultaneously can be mastered with practice added to the knowledge of the basic principles.
Collapse
|
24
|
Abstract
New developments in primary tendon repair in recent decades include stronger core tendon repair techniques, judicious and adequate venting of critical pulleys, followed by a combination of passive and active digital flexion and extension. During repair, core sutures over the tendon should have sufficient suture purchase (no shorter than 0.7 to 1 cm) in each tendon end and must be sufficiently tensioned to resist loosening and gap formation between tendon ends. Slight or even modest bulkiness in the tendon substance at the repair site is not harmful, although marked bulkiness should always be avoided. To expose the tendon ends and reduce restriction to tendon gliding, the longest annular pulley in the fingers (i.e., the A2 pulley) can be vented partially with an incision over its distal or proximal sheath no longer than 1.5 to 2 cm; the annular pulley over the middle phalanx (i.e., the A4 pulley) can be vented entirely. Surgeons have not observed adverse effects on hand function after judicious and limited venting. The digital extension-flexion test to check the quality of the repair during surgery has become increasingly routine. A wide-awake surgical setting allows patient to actively move the digits. After surgery, surgeons and therapists protect patients with a short splint and flexible wrist positioning, and are now moving toward out-of-splint freer early active motion. Improved outcomes have been reported over the past decade with minimal or no rupture during postoperative active motion, along with lower rates of tenolysis.
Collapse
|
25
|
The effect of increasing the contact surface on tendon healing. Arch Plast Surg 2018; 45:357-362. [PMID: 30037197 PMCID: PMC6062695 DOI: 10.5999/aps.2017.01284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Accepted: 04/30/2018] [Indexed: 11/29/2022] Open
Abstract
Background The most common complication after tendon repair is the development of adhesion, with subsequent rupture. Methods In this study, we present a new method in which the tendon healing contact surface is increased to reduce these complications. The tendons of chickens in groups 1, 3, and 5 were transversely cut and repaired with in the traditional fashion with double-modified Kessler method and 5/0 polypropylene. In the other groups, 3 mm of the tendon was removed from the proximal half of the upper end and from the distal half of the lower end of the tendon, and they were repaired with the modified Kessler method. The tendons of the chickens in groups 1 and 2 were evaluated immediatelly after surgery. Groups 3 and 4 were evaluated at 4 weeks after surgery. Groups 5 and 6 were evaluated at 6 weeks. Results Increases in transient inflammation and connective tissue formation were observed more clearly in the group treated with the new method in histopathological investigations at weeks 4 and 6. The stretching test showed statistically significant differences between groups 3 and 4 (P<0.05) and groups 5 and 6 (P<0.05). Conclusions When repairing tendons with the new method, the healing surface increases and the direction of collagen fibers at the surface changes. Because of these effects, the strength of the tendon healing line increases; we therefore expect that this technique will enable patients to safely engage in early active exercise after the operation, with less risk of tendon rupture.
Collapse
|
26
|
Sirisena R, Lahiri A, Chong AKS, Foo TL. Surmounting the Learning Curve of Core Suture Placement with Tendon Repair Simulator. J Hand Surg Asian Pac Vol 2018; 23:217-220. [PMID: 29734899 DOI: 10.1142/s2424835518500236] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Attaining competency in placement of core suture with adequate distance from juncture is a key skill for learners of tendon repair. Currently, this is most commonly practiced on animal models in wet laboratory environment. To improve accessibility and availability, we developed a tendon repair trainer that aims to guide learners in obtaining this key competency. METHODS A customized tendon dock was designed and manufactured with additive method that permits insertion of 6mm silicon tendon rods to simulate flexor tendon repair along a digit. Four residents, divided into two groups, were instructed to repair two sets of tendon rods (60 rods per resident) with Kessler suture loop placed at 10 mm from juncture (Group A: rods marked at 10 mm, Group B: unmarked rods). The main criterion for passing was a loop placed within 1 mm of the target distance (10 mm). At a second session, both groups repaired unmarked tendons, and these were marked based on similar criterion. RESULTS At the first session, 100% of those who repaired marked rods (Group A) passed while 25% of unmarked rods (Group B) attained a pass. At the second session, where both groups repaired unmarked rods, residents from group A achieved a pass rate of 95% while group B achieved 33.3% pass. CONCLUSIONS Learners who had previously repaired marked rods were able to retain their experience when repairing unmarked rods. This suggest that the proposed model may be a helpful adjunct to sharpen learners' skills prior to practicing tendon repairs in more costly animal or cadaveric models.
Collapse
Affiliation(s)
- Renita Sirisena
- * Department of Hand and Reconstructive Microsurgery, National University Hospital, Singapore
| | - Amitabha Lahiri
- * Department of Hand and Reconstructive Microsurgery, National University Hospital, Singapore.,† Department of Orthopaedic Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Alphonsus Khin-Sze Chong
- * Department of Hand and Reconstructive Microsurgery, National University Hospital, Singapore.,† Department of Orthopaedic Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Tun-Lin Foo
- * Department of Hand and Reconstructive Microsurgery, National University Hospital, Singapore
| |
Collapse
|
27
|
Kang GHY, Wong YR, Lim RQR, Loke AMK, Tay SC. Cyclic Testing of the 6-Strand Tang and Modified Lim-Tsai Flexor Tendon Repair Techniques. J Hand Surg Am 2018; 43:285.e1-285.e6. [PMID: 28967444 DOI: 10.1016/j.jhsa.2017.08.014] [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] [Received: 02/03/2017] [Revised: 07/18/2017] [Accepted: 08/14/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE In this study, we compared the Tang repair technique with the 6-strand modified Lim-Tsai repair technique under cyclic testing conditions. METHODS Twenty fresh-frozen porcine flexor tendons were randomized into 2 groups for repair with either the modified Lim-Tsai or the Tang technique using Supramid 4-0 core sutures and Ethilon 6-0 epitendinous running suture. The repaired tendons were subjected to 2 stage cyclic loading. The survival rate and gap formation at the repair site were recorded. RESULTS Tendons repaired by the Tang technique achieved an 80% survival rate. None of the modified Lim-Tsai repairs survived. The mean gap formed at the end of 1000 cycles was 1.09 mm in the Tang repairs compared with 4.15 mm in the modified Lim-Tsai repairs. CONCLUSIONS The Tang repair is biomechanically stronger than the modified Lim-Tsai repair under cyclic loading. CLINICAL RELEVANCE The Tang repair technique may exhibit a higher tolerance for active mobilization after surgery with less propensity for gap formation.
Collapse
Affiliation(s)
| | - Yoke-Rung Wong
- Biomechanics Laboratory, Singapore General Hospital, Singapore
| | | | | | - Shian-Chao Tay
- Department of Hand Surgery, Singapore General Hospital, Singapore; Biomechanics Laboratory, Singapore General Hospital, Singapore; Duke-NUS Medical School, Singapore.
| |
Collapse
|
28
|
|
29
|
Gil-Santos L, Monleón-Pradas M, Gomar-Sancho F, Más-Estellés J. Positioning of the cross-stitch on the modified Kessler core tendon suture. J Mech Behav Biomed Mater 2018; 80:27-32. [PMID: 29414472 DOI: 10.1016/j.jmbbm.2018.01.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 01/14/2018] [Accepted: 01/17/2018] [Indexed: 11/16/2022]
Abstract
Cryopreserved human tendons were sutured with different variations of a modified Kessler-type grasping suture in a series of different designs in order to assess the influence of the distance between the cross-stitch on the core suture (5 and 10 mm from the cut tendon edge) on the peripheral suture. An original mathematical model was employed to explain the mechanical behavior (strength, deformation, and distribution of load) of the different suture designs. The effect of the peripheral epitendinous suture, combined with the distance of the core suture, was evaluated. The variation of core suture distance had no relevant consequences on the overall resilience of the design. However, increasing the distance between the cross-stitches of the core suture reduces the deformation that is absorbed not only by the core suture itself but also by the peripheral suture. Adding a peripheral epitendinous suture to a 10-mm design almost doubles the breaking load in absolute values. The mathematical model predicts that the peripheral suture will support a greater load when the distance of the core suture cross-stitches is increased. The evidence level is II.
Collapse
Affiliation(s)
- L Gil-Santos
- Hospital Intermutual de Levante, CV-35, Km 11, Valencia, España; Centro de Biomateriales e Ingeniería Tisular, Universitat Politécnica de València, Camino de vera s/n, 46022 Valencia, España; Instituto Universitario de Investigación en Enfermedades Músculo-esqueléticas Universidad Católica de Valencia (San Vicente Mártir), C/Quevedo, 2, 46001 Valencia, España
| | - M Monleón-Pradas
- Centro de Biomateriales e Ingeniería Tisular, Universitat Politécnica de València, Camino de vera s/n, 46022 Valencia, España
| | - F Gomar-Sancho
- Departamento de Cirugía, Facultad de Medicina y Odontología. Universitat de València, Avda. Blasco Ibáñez, 15, 46010 Valencia, España
| | - J Más-Estellés
- Centro de Biomateriales e Ingeniería Tisular, Universitat Politécnica de València, Camino de vera s/n, 46022 Valencia, España.
| |
Collapse
|
30
|
Abstract
Flexor tendon injuries of the hand are uncommon, and they are among the most challenging orthopaedic injuries to manage. Proper management is essential to ensure optimal outcomes. Consistent, successful management of flexor tendon injuries relies on understanding the anatomy, characteristics and repair of tendons in the different zones, potential complications, rehabilitation protocols, recent advances in treatment, and future directions, including tissue engineering and biologic modification of the repair site.
Collapse
|
31
|
A Biomechanical Comparison Between Asymmetric Pennington Technique and Conventional Core Suture Techniques: 6-Strand Flexor Tendon Repair. J Hand Surg Am 2018; 43:79.e1-79.e8. [PMID: 28807348 DOI: 10.1016/j.jhsa.2017.06.104] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 06/01/2017] [Accepted: 06/28/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the fatigue strength and gap sizes of the asymmetric Pennington technique compared with 2 conventional 6-strand core suture techniques: the triple-looped suture and the Yoshizu #1. METHODS We recorded the fatigue strength (forces × cycles) and gap sizes of a 6-strand flexor tendon repair with different core suture techniques under cyclic loading in 30 porcine tendons. The asymmetric Pennington technique was performed with a Pennington repair of equal suture purchase in the 2 tendon stumps, with the 2 other Pennington repairs shifted by 3 mm, respectively, along the longitudinal axis of the tendon in relation to the first Pennington repair. The triple-looped suture technique was made with triple Tsuge sutures. The Yoshizu #1 technique was performed with a combined Pennington repair (using a double strand) and Tsuge suture. RESULTS The asymmetric Pennington technique showed significantly greater fatigue strength and significantly smaller gaps in comparison to the triple-looped suture and Yoshizu #1 techniques. CONCLUSIONS This study demonstrated that the asymmetric Pennington technique generated increased fatigue strength and reduced gap sizes compared with 2 conventional 6-strand core suture techniques, the triple-looped suture and Yoshizu #1. CLINICAL RELEVANCE The asymmetric Pennington technique may permit an early active motion rehabilitation protocol similar to the triple-looped suture and Yoshizu #1 techniques.
Collapse
|
32
|
Corella F, Renner C, del Cerro M, Ocampos M. Técnica de sutura tendinosa «un paso, 4-hilos Kessler-Tsuge». REVISTA IBEROAMERICANA DE CIRUGÍA DE LA MANO 2017. [DOI: 10.1016/j.ricma.2015.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A pesar de haber numerosas técnicas de sutura tendinosa y de no existir un acuerdo general sobre cuál es la mejor, sí hay acuerdo en las características generales que debe tener una buena sutura. Debe ser sencilla su realización, tener nudos bloqueados, conseguir una aposición sin tensión y perfecta de los extremos tendinosos con un mínimo o ningún «gap» en el sitio de la reparación sin producir una lesión de la vascularización del tendón y con una fuerza y resistencia suficientes para permitir una movilización precoz.En este trabajo presentamos una nueva técnica quirúrgica cuyo diseño sigue 5 principios: (1) cruzar la zona de reparación solo 2 veces para hacer más sencilla la técnica y la aposición perfecta de los cabos tendinosos; (2) conseguir una sutura de 4 hilos de un material resistente; (3) evitar nudos abultados en el sitio de reparación, para facilitar la reparación con el menor material interpuesto; (4) evitar nudos abultados sobre la superficie del tendón, de tal forma que la sutura deslice mejor bajo las poleas; y (5) con una resistencia y fuerza superiores a las admitidas como óptimas.
Collapse
Affiliation(s)
- F. Corella
- Servicio de Traumatología, Hospital Infanta Leonor, Madrid, España
- Unidad de Cirugía de Mano, Hospital beata María Ana, Madrid, España
| | - C. Renner
- Departamento de Extremidad distal Arthrex, Munich, Alemania
| | - M. del Cerro
- Unidad de Cirugía de Mano, Hospital beata María Ana, Madrid, España
| | - M. Ocampos
- Servicio de Traumatología, Hospital Infanta Leonor, Madrid, España
- Unidad de Cirugía de Mano, Hospital beata María Ana, Madrid, España
| |
Collapse
|
33
|
|
34
|
Kozono N, Okada T, Takeuchi N, Shimoto T, Higaki H, Nakashima Y. Effect of the Optimal Asymmetry on the Strength of Six-Strand Tendon Repair: An Ex Vivo Biomechanical Study. J Hand Surg Am 2017; 42:250-256. [PMID: 28242243 DOI: 10.1016/j.jhsa.2017.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 01/12/2017] [Accepted: 01/16/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the mechanical properties of a 6-strand core suture repair with asymmetric purchase in the 2 tendon ends, in comparison with a repair with symmetric suture purchases. METHODS Under cyclic loading of the tendons, we recorded the fatigue strength (Forces × Cycles) of a 6-strand flexor tendon repair with different symmetry in the lengths of suture purchase in 60 porcine tendons. The symmetric repair was made with 3 groups of parallel Kessler repairs of equal suture purchase (10 mm from the cut end) in the 2 tendon stumps. The asymmetric core suture repairs were then made with a Kessler repair of equal suture purchase (10 mm from the cut end) in the 2 tendon stumps, and shifting 2 other Kessler repairs by 1, 2, 3, 4, or 5 mm, respectively, along the longitudinal axis of the tendon in relation to the first (symmetric) Kessler repair. RESULTS The core repairs with 2 mm or more asymmetry in suture purchases in 2 tendon ends showed significantly greater fatigue strength compared with those with symmetric suture placement. The core repairs with 3 mm or more asymmetry in suture purchases in 2 tendon ends showed significantly smaller gaps compared with those with symmetric suture placement. CONCLUSIONS The core repairs with 3 mm or more asymmetry in suture purchases in 2 tendon ends generated increased fatigue strength and reduced gap sizes compared with those with symmetric suture placement in an ex vivo porcine model. CLINICAL RELEVANCE An asymmetric core suture repair with 3 mm or more difference in purchase length may allow for earlier rehabilitation and reduce the risk of postoperative complications.
Collapse
Affiliation(s)
- Naoya Kozono
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takamitsu Okada
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Naohide Takeuchi
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takeshi Shimoto
- Department of Information and System Engineering, Faculty of Information Engineering, Fukuoka Institute of Technology, Fukuoka, Japan
| | - Hidehiko Higaki
- Department of Biorobotics, Faculty of Engineering, Kyushu Sangyo University, Fukuoka, Japan
| | - Yasuharu Nakashima
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| |
Collapse
|
35
|
Kozono N, Okada T, Takeuchi N, Hanada M, Shimoto T, Iwamoto Y. Asymmetric six-strand core sutures enhance tendon fatigue strength and the optimal asymmetry. J Hand Surg Eur Vol 2016; 41:802-8. [PMID: 26896454 DOI: 10.1177/1753193416631454] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 09/30/2015] [Indexed: 02/03/2023]
Abstract
Under cyclic loading, we recorded the fatigue strength of a six-strand tendon repair with different symmetry in the lengths of suture purchase in two stumps of 120 dental rolls and in 30 porcine tendons. First, the strengths of the repairs with 1, 2, 3, 4 and 5 mm asymmetry were screened using the dental rolls. The asymmetric core suture repairs were then made with a Kessler repair of equal suture purchase (10 mm) in two tendon stumps, and shifting two other Kessler repairs by 1, 3 or 5 mm, respectively, along the longitudinal axis of the tendon in relation to the first (symmetric) Kessler repair. The core repairs with 3 mm or more asymmetry in suture purchases in two tendon ends showed significantly greater fatigue strength and significantly smaller gaps compared with 1 mm asymmetry in core suture repair. Our results support that asymmetric placement of core sutures in two tendon ends favour resisting gapping at the repair site and 3 mm or more asymmetry is needed to produce such beneficial effects.
Collapse
Affiliation(s)
- N Kozono
- Department of Orthopaedic Surgery, Kyushu University, Fukuoka, Japan
| | - T Okada
- Department of Orthopaedic Surgery, Kyushu University, Fukuoka, Japan
| | - N Takeuchi
- Department of Orthopaedic Surgery, Kyushu University, Fukuoka, Japan
| | - M Hanada
- Department of Orthopaedic Surgery, Kyushu University, Fukuoka, Japan Department of Plastic Surgery, Kyushu University, Fukuoka, Japan
| | - T Shimoto
- Department of Information and System Engineering, Fukuoka Institute of Technology, Fukuoka, Japan
| | - Y Iwamoto
- Department of Orthopaedic Surgery, Kyushu University, Fukuoka, Japan
| |
Collapse
|
36
|
O'Brien FP, Parks BG, Tsai MA, Means KR. A knotless bidirectional-barbed tendon repair is inferior to conventional 4-strand repairs in cyclic loading. J Hand Surg Eur Vol 2016; 41:809-14. [PMID: 26936746 DOI: 10.1177/1753193416631440] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 12/09/2015] [Indexed: 02/03/2023]
Abstract
UNLABELLED We divided 21 flexor digitorum profundus tendons in the index, middle and ring fingers in seven cadaver hands into three groups. The tendons were cut in zone 2 and repaired using a 4-strand cruciate core suture repair with one of the following three materials in each group: (1) a knotless repair with a 2-0 bidirectional-barbed suture, which has similar tensile strength as a 4-0 non-barbed suture used in the other two groups; (2) a knotted locking repair with a non-barbed 4-0 conventional suture; and (3) a non-locking repair with a non-barbed 4-0 knotless suture. The repaired fingers were cyclically loaded through a simulated active range of motion to a 5 N load. We monitored and recorded the gap sizes at regular intervals during the test. The 2-0 bidirectional-barbed suture group and non-barbed suture groups developed gaps of 2.2 mm after 10 cycles and 2.4 mm after 20 cycles, respectively. Over 1000 cycles, the mean gaps were 3.2 mm in the 4-0 conventional suture group and 9.1 mm in the 2-0 bidirectional-barbed group. The tendons in the 2-0 bidirectional-barbed group gapped earlier, with statistically significant differences compared with those in the locking repair with a non-barbed 4-0 knotless suture group. The repair strength of the barbed suture technique was inferior to the cruciate repairs using a conventional 4-0 non-barbed suture tested in this cyclic-loading model. LEVEL OF EVIDENCE Level V.
Collapse
Affiliation(s)
- F P O'Brien
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD, USA Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - B G Parks
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - M A Tsai
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - K R Means
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD, USA
| |
Collapse
|
37
|
Four-Strand Core Suture Improves Flexor Tendon Repair Compared to Two-Strand Technique in a Rabbit Model. BIOMED RESEARCH INTERNATIONAL 2016; 2016:4063137. [PMID: 27446949 PMCID: PMC4944031 DOI: 10.1155/2016/4063137] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 06/08/2016] [Accepted: 06/09/2016] [Indexed: 12/03/2022]
Abstract
Introduction. This study was designed to investigate the influence of the amount of suture material on the formation of peritendinous adhesions of intrasynovial flexor tendon repairs. Materials and Methods. In 14 rabbits, the flexor tendons of the third and the fourth digit of the right hind leg were cut and repaired using a 2- or 4-strand core suture technique. The repaired tendons were harvested after three and eight weeks. The range of motion of the affected toes was measured and the tendons were processed histologically. The distance between the transected tendon ends, the changes in the peritendinous space, and cellular and extracellular inflammatory reaction were quantified by different staining. Results. A 4-strand core suture resulted in significantly less gap formation. The 2-strand core suture showed a tendency to less adhesion formation. Doubling of the intratendinous suture material was accompanied by an initial increase in leukocyte infiltration and showed a greater amount of formation of myofibroblasts. From the third to the eighth week after flexor tendon repair, both the cellular and the extracellular inflammation decreased significantly. Conclusion. A 4-strand core suture repair leads to a significantly better tendon healing process with less diastasis between the sutured tendon ends despite initially pronounced inflammatory response.
Collapse
|
38
|
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.
Collapse
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:
| |
Collapse
|
39
|
Prsic A, Chen J, Sun YC. Mechanical Properties of Currently Popular Materials for Digital Flexor Tendon Repairs. J Hand Surg Am 2016; 41:487. [PMID: 26920115 DOI: 10.1016/j.jhsa.2015.12.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 12/04/2015] [Accepted: 12/08/2015] [Indexed: 02/02/2023]
Affiliation(s)
- Adnan Prsic
- Department of Plastic and Reconstructive Surgery, Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI
| | - Jing Chen
- Department of Hand Surgery, Nantong University Hospital, Nantong, Jiangsu, China
| | - Yu Cheng Sun
- Department of Hand Surgery, Nantong University Hospital, Nantong, Jiangsu, China
| |
Collapse
|
40
|
Myer C, Fowler JR. Flexor Tendon Repair: Healing, Biomechanics, and Suture Configurations. Orthop Clin North Am 2016; 47:219-26. [PMID: 26614935 DOI: 10.1016/j.ocl.2015.08.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Successful outcome after flexor tendon repair requires a delicate balance between tendon healing and limiting scar tissue formation. Recent studies have highlighted the importance of the number of core sutures crossing the repair and the benefits of specific suture configurations in determining the strength of tendon repair. Researchers have attempted to augment the biological environment to improve the speed and strength of tendon repair.
Collapse
Affiliation(s)
- Christopher Myer
- Department of Orthopaedics, University of Pittsburgh, Suite 1010, Kaufmann Building, 3471 Fifth Avenue, Pittsburgh, PA 15213, USA
| | - John R Fowler
- Department of Orthopaedics, University of Pittsburgh, Suite 1010, Kaufmann Building, 3471 Fifth Avenue, Pittsburgh, PA 15213, USA.
| |
Collapse
|
41
|
Tang JB. Wide-Awake Primary Flexor Tendon Repair, Tenolysis, and Tendon Transfer. Clin Orthop Surg 2015; 7:275-81. [PMID: 26330947 PMCID: PMC4553273 DOI: 10.4055/cios.2015.7.3.275] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 06/17/2015] [Indexed: 11/06/2022] Open
Abstract
Tendon surgery is unique because it should ensure tendon gliding after surgery. Tendon surgery now can be performed under local anesthesia without tourniquet, by injecting epinephrine mixed with lidocaine, to achieve vasoconstriction in the area of surgery. This method allows the tendon to move actively during surgery to test tendon function intraoperatively and to ensure the tendon is properly repaired before leaving the operating table. I applied this method to primary flexor tendon repair in zone 1 or 2, tenolysis, and tendon transfer, and found this approach makes tendon surgery easier and more reliable. This article describes the method that I have used for tendon surgery.
Collapse
Affiliation(s)
- Jin Bo Tang
- Department of Hand Surgery, The Hand Surgery Research Center, Affiliated Hospital of Nantong University, Nantong, China
| |
Collapse
|
42
|
Ex-VivoEvaluation of a Modified Teno Fix®Device Repair Pattern Versus a 3-Loop Pulley for Repair of Equine Flexor Tendons. Vet Surg 2015; 44:803-8. [DOI: 10.1111/vsu.12350] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
43
|
Abstract
The goal of flexor tendon repair is to achieve normal range of motion of the finger or thumb. The surgical approach depends on the level of injury. Multistrand core suture repairs are recommended for primary flexor tendon repair. It is evident that at least 4 strands are required to an initiate and active range of motion protocol. The epitendinous suture can also increase the strength of the repair. Careful attention to the post-operative therapy regiment is critical to a successful repair.
Collapse
Affiliation(s)
- Isabella M Mehling
- Department of Plastic, Hand and Reconstructive Surgery, Hand Trauma Center, BG Trauma Center Frankfurt am Main, Friedberger Landstrasse 430, Frankfurt am Main 60389, Germany
| | - Annika Arsalan-Werner
- Department of Plastic, Hand and Reconstructive Surgery, Hand Trauma Center, BG Trauma Center Frankfurt am Main, Friedberger Landstrasse 430, Frankfurt am Main 60389, Germany
| | - Michael Sauerbier
- Department of Plastic, Hand and Reconstructive Surgery, Hand Trauma Center, BG Trauma Center Frankfurt am Main, Friedberger Landstrasse 430, Frankfurt am Main 60389, Germany.
| |
Collapse
|
44
|
Dwyer CL, Dominy DD, Cooney TE, Englund R, Gordon L, Lubahn JD. Biomechanical comparison of double grasping repair versus cross-locked cruciate flexor tendon repair. Hand (N Y) 2015; 10:16-22. [PMID: 25762882 PMCID: PMC4349906 DOI: 10.1007/s11552-014-9728-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE This study was conducted to compare the in vitro biomechanical properties of tensile strength and gap resistance of a double grasping loop (DGL) flexor tendon repair with the established four-strand cross-locked cruciate (CLC) flexor tendon repair, both with an interlocking horizontal mattress (IHM) epitendinous suture. The hypothesis is that the DGL-IHM method which utilizes two looped core sutures, grasping and locking loops, and a single intralesional knot will have greater strength and increased gap resistance than the CLC-IHM method. METHODS Forty porcine tendons were evenly assigned to either the DGL-IHM or CLC-IHM group. The tendon repair strength, 2-mm gap force and load to failure, was measured under a constant rate of distraction. The stiffness of tendon repair was calculated and the method of repair failure was analyzed. RESULTS The CLC-IHM group exhibited a statistically significant greater resistance to gapping, a statistically significant higher load to 2-mm gapping (62.0 N), and load to failure (99.7 N) than the DGL-IHM group (37.1 N and 75.1 N, respectively). Ninety percent of CLC-IHM failures were a result of knot failure whereas 30 % of the DGL-IHM group exhibited knot failure. CONCLUSIONS This study demonstrates that the CLC-IHM flexor tendon repair method better resists gapping and has a greater tensile strength compared to the experimental DGL-IHM method. The authors believe that while the DGL-IHM provides double the number of sutures at the repair site per needle pass, this configuration does not adequately secure the loop suture to the tendon, resulting in a high percentage of suture pullout and inability to tolerate loads as high as those of the CLC-IHM group.
Collapse
Affiliation(s)
- C. Liam Dwyer
- Department of Orthopaedics, UPMC Hamot, Erie, PA USA
| | - D. Dean Dominy
- Houston Methodist Orthopedics and Sports Medicine, Houston, TX USA
| | | | | | | | - John D. Lubahn
- Department of Orthopaedics, UPMC Hamot, Erie, PA USA ,Hand, Microsurgery, and Reconstructive Orthopaedics LLP, 300 State Street, Suite 205, Erie, PA 16507 USA
| |
Collapse
|
45
|
Haddad R, Peltz T, Bertollo N, Walsh WR, Nicklin S. Looped suture properties: implications for multistranded flexor tendon repair. J Hand Surg Eur Vol 2015; 40:234-8. [PMID: 25698798 DOI: 10.1177/1753193413516245] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Multiple-strand repair techniques are commonly used to repair cut flexor tendons to achieve initial biomechanical strength. Looped sutures achieve multiple strands with fewer passes and less technical complexity. Their biomechanical performance in comparison with an equivalent repair using a single-stranded suture is uncertain. This study examined the mechanical properties of double-stranded loops of 3-0 and 4-0 braided polyester (Ticron) and polypropylene monofilament (Prolene). Double loops were generally less than twice the strength of a single loop. Ticron and Prolene had the same strengths, but Ticron was stiffer. The 4-0 double loops had significantly higher stiffness than 3-0 single loops. Increasing the size of sutures had a larger relative effect on strength than using a double-stranded suture. However, a double-strand loop had a larger effect on increasing stiffness than using a single suture of a larger equivalent size. Looped suture repairs should be compared with standard techniques using a thicker single suture.
Collapse
Affiliation(s)
- R Haddad
- Surgical & Orthopaedic Research Laboratories, University of New South Wales, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - T Peltz
- Surgical & Orthopaedic Research Laboratories, University of New South Wales, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - N Bertollo
- Surgical & Orthopaedic Research Laboratories, University of New South Wales, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - W R Walsh
- Surgical & Orthopaedic Research Laboratories, University of New South Wales, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - S Nicklin
- St Luke's & Sydney Hospital Hand Units, Sydney, New South Wales, Australia
| |
Collapse
|
46
|
Okubo H, Kusano N, Kinjo M, Kanaya F. Influence of different length of core suture purchase among suture row on the strength of 6-strand tendon repairs. HAND SURGERY : AN INTERNATIONAL JOURNAL DEVOTED TO HAND AND UPPER LIMB SURGERY AND RELATED RESEARCH : JOURNAL OF THE ASIA-PACIFIC FEDERATION OF SOCIETIES FOR SURGERY OF THE HAND 2015; 20:19-24. [PMID: 25609270 DOI: 10.1142/s0218810415500021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
In multi-strand suture methods consisting of several suture rows, the different length of core suture purchase between each suture row may affect the strength of repairs. We evaluated the influence of the different length of core suture purchase between each suture row on the strength of 6-strand tendon repairs. Rabbit flexor tendons were repaired by using a triple-looped suture technique in which the suture purchase length in each suture row was modified. Group 1, all lengths are 8-mm. Group 2, all lengths are 10-mm. Group 3, two are 10-mm and one is 8-mm. Group 4, one is 10-mm and two are 8-mm. The repaired tendons were subjected to load-to-failure test. The gap strength was significantly greater in Group 1 and Group 2 than in Group 3 and Group 4. This study demonstrates that maintaining equal core suture purchase lengths of each suture row increases the gap resistance.
Collapse
Affiliation(s)
- Hirotaka Okubo
- Department of Orthopedic Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | | | | | | |
Collapse
|
47
|
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.
Collapse
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.
| |
Collapse
|
48
|
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.
Collapse
|
49
|
Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: (1) Describe and apply the current evidence-based treatment of acute flexor tendon injuries. (2) Compare and contrast the current postoperative therapy regimens following repair of flexor tendons. (3) Apply an evidence-based decision-making process for suture techniques of flexor tendon injuries. SUMMARY Flexor tendon repair remains a challenge for hand surgeons to reliably obtain excellent results. Surgical decisions should rely on the surgeon's experience, outcome studies, and direct evidence. This review is a compilation of the evidence from the literature on optimizing outcomes for flexor tendon repair.
Collapse
|
50
|
The effect of asymmetric core suture purchase on gap resistance of tendon repair in linear cyclic loading. J Hand Surg Am 2014; 39:910-8. [PMID: 24630942 DOI: 10.1016/j.jhsa.2014.01.037] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Revised: 01/17/2014] [Accepted: 01/21/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the biomechanical properties of an asymmetric core suture for tendon repair. METHODS Sixty porcine flexor tendons were repaired with 3 different 4-strand sutures using different core suture purchases: 2 sets of identical purchases of 10 mm, 2 sets of asymmetric purchases (8 mm proximal/distal stump and 12 mm distal/proximal stump), and 2 sets of identical purchases of 12 mm. The tendons were subjected to the cyclic loading for 20 cycles. The number of tendons with gaps at each cycle, elongation of gap area between tendon ends and tendon segment, gap formation forces, and ultimate strengths were recorded. RESULTS Tendons repaired with the asymmetric core suture purchases had the smallest gaps during cyclic loading. The elongation of gaps and tendon segments were significantly smaller than those with symmetric suture purchase of 10 or 12 mm. The asymmetric core suture repair had significant higher gap resistance forces than the symmetric suture repair at the final loading cycle. CONCLUSIONS A 4-strand core suture repair with asymmetric purchases on the tendon stumps generated greater gapping resistance than that with an equal length of suture purchase. CLINICAL RELEVANCE The asymmetric core suture purchase may be a practical measure to improve gapping resistance and fatigue strength when the suture purchase meets essential length requirements.
Collapse
|