1
|
Hoppe ED, Birman V, Kurtaliaj I, Guilliams CM, Pickard BG, Thomopoulos S, Genin GM. A discrete shear lag model of the mechanics of hitchhiker plants, and its prospective application to tendon-to-bone repair. Proc Math Phys Eng Sci 2023. [DOI: 10.1098/rspa.2022.0583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023] Open
Abstract
Tendon-to-bone repairs often fail when sutures pull through tendon, like a wire through cheese. Repair strength is maximized when loads are balanced equally among all sutures, relative to the pullout resistance of the tendon and the strength of the sutures. This problem of balancing loads across multiple, discrete attachment sites has been solved in nature by hitchhiker plants that proliferate by adhering relatively stiff fruit to relatively soft fur and fabrics through arrays of hooks. We, therefore, studied the fruits of such a plant,
Harpagonella palmeri
, and developed a discrete shear lag analysis of the force distributions in
H. palmeri
's linear arrays of long, slender hooks of varied lengths and spacing. Results suggested that strategies were used by the plant to distribute loads, including variations in the spacing and stiffnesses of hooks that serve to equalize forces over attachment sites. When applying these models to suturing schemes for surgical reattachment of tendon to bone, results suggested that strategies exhibited by
H. palmeri
show promise for balancing forces over sutures, potentially doubling repair strength relative to what could be achieved with a uniform suture distribution. Results suggest a potential pathway for strengthening surgical repairs, and more broadly for optimizing fasteners for bi-material attachment.
Collapse
Affiliation(s)
- Ethan D. Hoppe
- NSF Science and Technology Center for Engineering Mechanobiology, Washington University in St. Louis, St. Louis, MO
| | - Victor Birman
- Department of Mechanical and Aerospace Engineering, Missouri University of Science and Technology, Rolla, MO
| | - Iden Kurtaliaj
- Department of Orthopedic Surgery, Columbia University, New York, NY
| | | | - Barbara G. Pickard
- NSF Science and Technology Center for Engineering Mechanobiology, Washington University in St. Louis, St. Louis, MO
| | | | - Guy M. Genin
- NSF Science and Technology Center for Engineering Mechanobiology, Washington University in St. Louis, St. Louis, MO
| |
Collapse
|
2
|
Janes LE, Mioton LM, Fracol ME, Ko JH. An In Vivo Comparison: Novel Mesh Suture Versus Traditional Suture-Based Repair in a Rabbit Tendon Model. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2022; 4:32-39. [PMID: 35415598 PMCID: PMC8991626 DOI: 10.1016/j.jhsg.2021.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 10/13/2021] [Indexed: 11/17/2022] Open
Abstract
Purpose Despite advancements in surgical techniques, suture pull-though and rupture continue to limit the early range of motion and functional rehabilitation after flexor tendon repairs. The aim of this study was to evaluate a suturable mesh compared with a commonly used braided suture in an in vivo rabbit intrasynovial tendon model. Methods Twenty-four New Zealand female rabbits (3–4 kg) were injected with 2 units/kg botulinum toxin evenly distributed into 4 sites in the left calf. After 1 week, the animals underwent surgical tenotomy of the flexor digitorum tendon and were randomized to repair with either 2-0 Duramesh suturable mesh or to 2-0 Fiberwire using a 2-strand modified Kessler and 6-0 polypropylene running epitendinous suture. Rabbits were killed at 2, 4, and 9 weeks after surgery. Results Grouping across time points, 58.3% (7 of 12) of Duramesh repairs were found to be intact for the explant compared with 16.7% (2 of 12) of Fiberwire repairs (P = .09). At 2 weeks, the mean Duramesh repairs were significantly stronger than the Fiberwire repairs with a mean failure load of 50.7 ± 12.7 N compared to 14.8 ± 18.3 N (P = .02). The load supported by the Duramesh repairs at 2 weeks (mean 50.7 ± 12.7 N) was similar to the load supported by both Fiberwire (52.2 ± 13.6 N) and Duramesh (57.6 ± 22.3 N) at 4 weeks. The strength of repair between Fiberwire and Duramesh at 4 weeks and 9 weeks was not significantly different. Conclusions The 2-strand tendon repair with suturable mesh achieved significantly greater strength at 2 weeks than the conventional suture material. Future studies should evaluate the strength of repair prior to 2 weeks to determine the strength curve for this novel suture material. Clinical Relevance This study evaluates the utility of a novel suturable mesh for flexor tendon repair in an in vivo rabbit model compared with conventional suture material.
Collapse
|
3
|
Corrie JL, Duffy DJ, Chang YJ, Moore GE. Effect of knot location on the biomechanical strength and gapping characteristics of ex vivo canine gastrocnemius tenorrhaphy constructs. Am J Vet Res 2021; 82:942-947. [PMID: 34727071 DOI: 10.2460/ajvr.21.03.0038] [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 evaluate the effect of knot location on the biomechanical strength and gapping characteristics of ex vivo canine gastrocnemius tenorrhaphy constructs. SAMPLE 36 cadaveric gastrocnemius tendons from 18 adult dogs. PROCEDURES Tendons were randomly assigned to 3 groups (12 tendons/group) and sharply transected and repaired by means of a core locking-loop suture with the knot at 1 of 3 locations (exposed on the external surface of the tendon, buried just underneath the external surface of the tendon, or buried internally between the apposed tendon ends). All repairs were performed with size-0 polypropylene suture. All constructs underwent a single load-to-failure test. Yield, failure, and peak forces, mode of failure, and forces required for 1- and 3-mm gap formation were compared among the 3 knot-location groups. RESULTS Mean yield, failure, and peak forces and mean forces required for 1- and 3-mm gap formation did not differ significantly among the 3 groups. The mode of failure also did not differ significantly among the 3 groups, and the majority (33/36 [92%]) of constructs failed owing to the suture pulling through the tendinous substance. CONCLUSIONS AND CLINICAL RELEVANCE Final knot location did not significantly affect the biomechanical strength and gapping characteristics of canine gastrocnemius tenorrhaphy constructs. Therefore, all 3 evaluated knot locations may be acceptable for tendon repair in dogs. In vivo studies are necessary to further elucidate the effect of knot location in suture patterns commonly used for tenorrhaphy on tendinous healing and collagenous remodeling at the repair site.
Collapse
Affiliation(s)
- Jessica L Corrie
- From VCA Aurora Animal Hospital, Aurora, IL 60506 (Corrie); Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC 27607 (Duffy, Chang); and Veterinary Administration, College of Veterinary Medicine, Purdue University, West Lafayette, IN 47906 (Moore)
| | - Daniel J Duffy
- From VCA Aurora Animal Hospital, Aurora, IL 60506 (Corrie); Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC 27607 (Duffy, Chang); and Veterinary Administration, College of Veterinary Medicine, Purdue University, West Lafayette, IN 47906 (Moore)
| | - Yi-Jen Chang
- From VCA Aurora Animal Hospital, Aurora, IL 60506 (Corrie); Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC 27607 (Duffy, Chang); and Veterinary Administration, College of Veterinary Medicine, Purdue University, West Lafayette, IN 47906 (Moore)
| | - George E Moore
- From VCA Aurora Animal Hospital, Aurora, IL 60506 (Corrie); Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC 27607 (Duffy, Chang); and Veterinary Administration, College of Veterinary Medicine, Purdue University, West Lafayette, IN 47906 (Moore)
| |
Collapse
|
4
|
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
|
5
|
Duffy DJ, Chang YJ, Fisher MB, Moore GE. Biomechanical evaluation of a novel barbed suture pattern with epitendinous suture augmentation in a canine flexor tendon model. Vet Surg 2021; 50:1128-1136. [PMID: 33959989 DOI: 10.1111/vsu.13653] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 03/16/2021] [Accepted: 04/24/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine the effect of a novel barbed suture pattern (NBSP) compared to a three-loop-pulley (3LP) with and without epitendinous suture (ES) augmentation on the biomechanical strength and gap formation of repaired canine tendons. STUDY DESIGN Ex vivo, cadaveric, randomized, experimental study. SAMPLE POPULATION Forty, adult superficial digital flexor tendons (SDFT). METHODS SDFT were randomly assigned to one of four groups (n = 10/group). Sharp tenotomy was performed and repaired with 3LP, NBSP, 3LP + ES, and NBSP + ES. Constructs were tested to failure while evaluating yield, peak, and failure loads, loads at 1 and 3 mm gap formation, and failure mode. RESULTS Constructs augmented with ES sustained 80% greater yield (p < .001), peak (p < .001), and failure (p < .001) loads, with no difference between 3LP + ES and NBSP + ES constructs regarding peak (p = .614), and failure forces (p = .865). Loads resulting in 1 and 3 mm gap formation were greater when constructs were augmented with an ES (p ≤ .003). Failure mode differed between groups (p < .001), occurring predominantly due to suture pull-through in 3LP and NBSP groups compared to tissue failure distant to the repair site in ES augmented constructs. CONCLUSION Tendons repaired with the NBSP used in this study resisted similar forces as those repaired with 3LP. Augmentation with an ES improved the biomechanical properties of repaired constructs, including resistance to gap formation. CLINICAL RELEVANCE The NBSP repair tested here may be advantageous over monofilament suture repair as it uses a similar-sized barbed core suture but eliminates the requirement for knot tying.
Collapse
Affiliation(s)
- Daniel J Duffy
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
| | - Yi-Jen Chang
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
| | - Matthew B Fisher
- Joint Department of Biomedical Engineering, North Carolina State University and the University of North Carolina, Raleigh, North Carolina, USA
| | - George E Moore
- Department of Veterinary Administration, College of Veterinary Medicine, Purdue University, West Lafayette, Indiana, USA
| |
Collapse
|
6
|
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
|
7
|
Eby AC, Duffy DJ, Chang YJ, Gaffney L, Fisher MB, Moore GE. Influence of barbed epitendinous sutures combined with a core locking-loop suture to repair experimental flexor tendon lacerations. Vet Surg 2020; 49:1590-1599. [PMID: 32830868 DOI: 10.1111/vsu.13496] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 06/03/2020] [Accepted: 07/11/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine the influence of barbed epitendinous sutures (ES) on the biomechanical properties and gap formation of repaired canine tendons. STUDY DESIGN Ex vivo, experimental study. SAMPLE POPULATION Eighty (n = 16/group) canine superficial digital flexor tendons (SDFT). METHODS After transection, SDFT were repaired with a locking-loop (LL) pattern alone (group 1), an LL + smooth ES with monofilament suture (group 2), an LL + V-loc-ES (group 3), an LL + Quill-ES (group 4), or an LL + Stratafix-ES (group 5). All core LL repairs were performed with 0 USP polypropylene, and all ES were placed with 2-0 USP equivalent. Constructs were preloaded and tested to failure. Yield, peak, and failure loads; occurrence of gap formation; and failure modes were compared. RESULTS Yield loads were greater for groups 2 and 5 (P < .0001). Peak and failure loads were greater when an ES was used (P < .005), especially for groups 2 and 5 (P < .0001). Groups with an ES required higher loads to generate 1- and 3-mm gaps compared with specimens without an ES (P < .002). Force to create 1- and 3-mm gaps was greater for group 5 (P < .0001) and groups 2 and 5 (P < .0001), respectively. Failure mechanism did not differ (P = .092) between ES groups, consisting of suture breakage in 51 of 64 constructs compared with pull-through in seven of 16 group 1 constructs. CONCLUSION Epitendinous suture placement improved the biomechanical properties of repaired tendons. Stratafix barbed suture performed better as an ES compared with other barbed sutures and similarly to monofilament suture. CLINICAL SIGNIFICANCE Stratafix barbed suture eliminates the requirement for knot tying and seems to be equivalent to smooth monofilament suture when used as an ES in this pattern.
Collapse
Affiliation(s)
- Adam C Eby
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
| | - Daniel J Duffy
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
| | - Yi-Jen Chang
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
| | - Lewis Gaffney
- Joint Department of Biomedical Engineering, North Carolina State University and the University of North Carolina-Chapel Hill, Raleigh, North Carolina, USA
| | - Matthew B Fisher
- Joint Department of Biomedical Engineering, North Carolina State University and the University of North Carolina-Chapel Hill, Raleigh, North Carolina, USA
| | - George E Moore
- Department of Veterinary Administration, College of Veterinary Medicine, Purdue University, West Lafayette, Indiana, USA
| |
Collapse
|
8
|
Duffy DJ, Chang YJ, Fisher MB, Moore GE. Effect of partial vs complete circumferential epitendinous suture placement on the biomechanical properties and gap formation of canine cadaveric tendons. Vet Surg 2020; 49:1571-1579. [PMID: 32812666 DOI: 10.1111/vsu.13494] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/21/2020] [Accepted: 07/11/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine the effect of partial vs complete circumferential epitendinous suture (ES) placement in addition to a core suture on the biomechanical strength and gapping characteristics of repaired canine tendinous constructs. STUDY DESIGN Ex vivo, biomechanical study. SAMPLE POPULATION Thirty-six canine superficial digital flexor tendons. METHODS Superficial digital flexor tendons were randomly assigned to three groups (n = 12), sharply transected and repaired with a core locking-loop suture with Group 1 a partial circumferential ES, 180° on the palmar side; Group 2 a complete circumferential ES, 360° and double knotting technique; or Group 3 a complete circumferential ES, 360° and single knotting technique. After preloading, constructs were distracted to monotonic failure. Failure mode, gap formation, yield, peak, and failure forces were analyzed. RESULTS Mean yield (group 1 = 68.6 N, group 2 = 106.5 N, group 3 = 114 N, P < .013), peak (group 1 = 92.8 N, group 2 = 134.6 N, group 3 = 147.3 N; P < .001), and failure (group 1 = 88.7 N, group 2 = 133.0 N, group 3 = 145.5 N, P < .001) loads differed between groups. No difference in yield (P = .874), peak (P = .434), or failure load (P = .434) was detected between complete circumferential ES groups. Force to create 1-mm (P < .001) and 3-mm (P < .038) gap formation was greater in specimens with complete vs partial circumferential ES placement. Complete circumferential ES repairs failed primarily by suture pull-through compared with suture breakage in most partial circumferential ES constructs. CONCLUSION Addition of a complete circumferential ES with a single or double knotting technique increased the biomechanical strength of normal tendon repairs while reducing gap formation compared with partial ES placement alone. CLINICAL SIGNIFICANCE Complete circumferential ES is recommended over partial ES placement.
Collapse
Affiliation(s)
- Daniel J Duffy
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina
| | - Yi-Jen Chang
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina
| | - Matthew B Fisher
- Joint Department of Biomedical Engineering, North Carolina State University and the University of North Carolina-Chapel Hill, Raleigh, North Carolina
| | - George E Moore
- Department of Veterinary Administration, College of Veterinary Medicine, Purdue University, West Lafayette, Indiana
| |
Collapse
|
9
|
Chang YJ, Duffy DJ, Gaffney L, Fisher MB, Moore GE. Assessment of skin staples for augmentation of core tenorrhaphy in an ex vivo model of canine superficial digital flexor tendon laceration. Am J Vet Res 2020; 81:681-688. [PMID: 32700993 DOI: 10.2460/ajvr.81.8.681] [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 compare the biomechanical strength and incidence of gap formation among canine superficial digital flexor tendon (SDFT) constructs that underwent core tenorrhaphy only and those in which the core tenorrhaphy was augmented with skin staples or a continuous Silfverskiold cross-stitch (SXS) suture pattern. SAMPLE 42 cadaveric forelimb SDFTs from 21 musculoskeletally normal dogs. PROCEDURES Tendons were randomly assigned to 3 groups (14 SDTFs/group), sharply transected, and repaired with a core locking-loop suture alone (group 1) or augmented with circumferential placement of skin staples (group 2) or a continuous SXS suture pattern (group 3) in the epitenon. All constructs underwent a single load-to-failure test. Yield, peak, and failure loads, incidence of gap formation, and mode of failure were compared among the 3 groups. RESULTS Mean yield, peak, and failure loads differed significantly among experimental groups and were greatest for group 3 and lowest for group 1 constructs. The incidence of gap formation differed among the tested groups and was lowest for group 3 and highest for group 1. The most common mode of construct failure was the suture pulling through the tendon for group 1, staple deformation for group 2, and epitendinous suture breakage for group 3. CONCLUSIONS AND CLINICAL RELEVANCE Results indicated epitendinous placement of skin staples around a core SDFT tenorrhaphy site improved the biomechanical strength and resistance to gap formation for the repair but was inferior to epitendinous placement of SXS sutures. Further research is necessary before skin staples are used for tenorrhaphy augmentation in clinical patients.
Collapse
|
10
|
Farinas A, Stephanides M, Schneeberger S, Pollins A, Cardwell N, Thayer WP. Improving Strength and Quality of Epitendinous Repairs. Hand (N Y) 2020; 15:495-501. [PMID: 30518263 PMCID: PMC7370385 DOI: 10.1177/1558944718813608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Epitendinous sutures not only join the 2 severed tendon edges but also supply strength and support to the repair. Multiple techniques have been described, but none of them include another thread of suture. This could potentially increase the strength of the repair without affecting gliding. Methods: Caprine tendons were harvested, transected, and sutured with 6-0 Prolene. Four groups were created: single thread running (SR), single thread locking (SL), double thread running (DR), and double thread locking (DL). An Instron 5542 was used to pull the repaired tendons apart, and the energy at the break was calculated (gf/mm). For gliding resistance, we harvested a human A2 pulley. A pre- and postrepair value was obtained, and a ratio was elaborated. A single-factor analysis of variance and independent sample t tests were performed. Results: The SR group had a mean energy at break of 9339.71 ± 1630.212 gf/mm; the SL group, 9629.96 ± 1476.45 gf/mm; and the DR group, 9600.221 ± 976.087 gf/mm, with no statistical significance. The DL group was significantly higher at 14 740.664 ± 2596.586 gf/mm (P < .05). When comparing SR with DL for gliding, SR had less than half of the resistance than DL (0.018 ± 0.004 and 0.049 ± 0.015 N/mm, respectively), with statistical significance (P < .05). Conclusion: Using a single suture thread for running epitendinous repair is no different than locking with a single thread or using an extra thread in a running fashion. Performing a double suture thread with a locking technique is significantly stronger than the previously mentioned repairs, with the disadvantage of more resistance at the pulley.
Collapse
Affiliation(s)
| | | | | | | | | | - Wesley P. Thayer
- Vanderbilt University, Nashville, TN, USA,Wesley P. Thayer, Department of Plastic Surgery, Vanderbilt University Medical Center, Vanderbilt University, 1161 21st Avenue South, MCN D4207, Nashville, TN 37232-2345, USA.
| |
Collapse
|
11
|
Duffy DJ, Cocca CJ, Kersh ME, Kim W, Moore GE. Effect of bite distance of an epitendinous suture from the repair site on the tensile strength of canine tendon constructs. Am J Vet Res 2020; 80:1034-1042. [PMID: 31644343 DOI: 10.2460/ajvr.80.11.1034] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate effects of bite distance of an interlocking horizontal mattress epitendinous suture (IHMES) from the repair site on tensile strength of canine tendon repairs. SAMPLE 72 canine cadaveric superficial digital flexor tendons (SDFTs). PROCEDURES Transverse tenotomy was performed, and SDFTs were repaired with a locking-loop construct (LL construct) or 3 LL constructs with IHMES suture bites placed 5 (LL + 5ES construct), 10 (LL + 10ES construct), or 15 (LL + 15ES construct) mm from the transection site (18 SDFTs/group). Constructs were loaded to failure. Load at 1- and 3-mm gapping, yield force, failure load, and failure mode were evaluated. RESULTS Mean ± SD yield force and failure load for LL constructs were significantly lower than for IHMES constructs. Load at 1- and 3-mm gapping was significantly higher for IHMES constructs. Increasing the bite distance significantly increased construct strength (134.4 ± 26.1 N, 151.0 ± 16.8 N, and 182.1 ± 23.6 N for LL + 5ES, LL + 10ES, and LL + 15ES constructs, respectively), compared with strength for the LL construct. Failure mode differed significantly among constructs when an IHMES was used. CONCLUSIONS AND CLINICAL RELEVANCE Addition of an IHMES to an LL construct led to increased ultimate tensile strength by 2.5 times and significantly reduced gap formation. Increasing the IHMES bite distance increased yield force by 2.1, 2.3, and 2.7 times for bites placed 5, 10, and 15 mm from the tenotomy, respectively. Positioning an IHMES at a greater distance from the repair site provided superior biomechanical strength for tendon repairs in dogs.
Collapse
|
12
|
Duffy DJ, Chang YJ, Gaffney LS, Fisher MB, Moore GE. Effect of bite depth of an epitendinous suture on the biomechanical strength of repaired canine flexor tendons. Am J Vet Res 2020; 80:1043-1049. [PMID: 31644344 DOI: 10.2460/ajvr.80.11.1043] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine effects of bite depth for placement of an epitendinous suture on the biomechanical strength and gap formation of repaired canine tendons. SAMPLE 48 superficial digital flexor tendons (SDFTs) obtained from 24 canine cadavers. PROCEDURES Tendons were assigned to 3 groups (16 tendons/group). Each SDFT was transected and then repaired with a continuous epitendinous suture placed with a bite depth of 1, 2, or 3 mm for groups 1, 2, and 3, respectively. Specimens were loaded to failure. Failure mode, gap formation, yield force, peak force, and failure force were analyzed. RESULTS Yield, peak, and failure forces differed significantly between groups 1 and 3 and groups 2 and 3 but not between groups 1 and 2. Comparison of the force resisted at 1 and 3 mm of gapping revealed a significant difference between groups 1 and 3 and groups 2 and 3 but not between groups 1 and 2. Failure mode did not differ among groups; suture pull-through occurred in 43 of 48 (89.6%) specimens. CONCLUSIONS AND CLINICAL RELEVANCE Increasing bite depth of an epitendinous suture toward the center of the tendon substance increased repair site strength and decreased the incidence of gap formation. Repair of tendon injuries in dogs by use of an epitendinous suture with bites made deep into the tendon should result in a stronger repair, which potentially would allow loading and rehabilitation to begin sooner after surgery. Suture techniques should be investigated in vivo to determine effects on tendinous healing and blood supply before clinical implementation.
Collapse
|
13
|
Abstract
The purpose of this study was to explore the difference in clinical outcome of 2-strand and 4-strand flexor tendon repairs in a single unit in adult population. A total of 109 complete divisions of a single flexor tendon were analyzed from 2016 to 2018 retrospectively. Thirty flexor tendons were repaired with 2-strand and 79 tendons were repaired with 4-strand technique. There was no significant difference in the complication rate including rupture, infection, and adhesions. These results support that 4-strand is not superior than 2-strand and that lower volume type of repair would be preferable.
Collapse
|
14
|
Lee JS, Wong YR, Tay SC. Asymmetric 6-Strand Flexor Tendon Repair - Biomechanical Analysis Using Barbed Suture. J Hand Surg Asian Pac Vol 2019; 24:297-302. [PMID: 31438796 DOI: 10.1142/s2424835519500371] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: This study investigates the biomechanical performance of the Asymmetric flexor tendon repair technique using barbed suture. The Asymmetric repair technique using monofilament nylon suture was previously reported to have a higher tensile strength than the modified Lim-Tsai repair technique, but its repair stiffness and load to gap force were significantly lower. There is hence an unmet need to improve this technique and the substitution of nylon suture with barbed sutures may be the solution. Methods: Two groups consisting of 10 porcine tendons each were repaired with the six-strand Asymmetric repair technique using V-Loc® 3-0 and Supramid® 4-0 respectively. The repairs were subjected to a mechanical tester for static testing. The ultimate tensile strength, load to 2 mm gap force, repair stiffness, time taken to complete a repair and failure mechanism of the repairs were recorded and analyzed. Results: All the repairs using V-Loc® 3-0 sutures had significantly higher median values of ultimate tensile strength (64.1 N; 56.9 N), load to 2 mm gap force (39.2 N; 19.7 N), repair stiffness (6.4 N/mm; 4.7 N/mm) and time taken to complete a repair (9.4 mins; 7.7 mins). All the repairs using V-Loc® sutures failed by suture breakage while 80% of repairs using Supramid® sutures failed by suture pullout. Conclusions: The use of the barbed sutures in the Asymmetric repair technique, whilst more time consuming, has shown promising improvement to its biomechanical performance (i.e. better ultimate tensile strength, stiffness and resistance to 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
| |
Collapse
|
15
|
Putterman AB, Duffy DJ, Kersh ME, Rahman H, Moore GE. Effect of a continuous epitendinous suture as adjunct to three-loop pulley and locking-loop patterns for flexor tendon repair in a canine model. Vet Surg 2019; 48:1229-1236. [PMID: 31222767 DOI: 10.1111/vsu.13268] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 04/29/2019] [Accepted: 05/26/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To evaluate the effect of combining a continuous epitendinous suture with three-loop pulley (3LP) and locking-loop (LL) core patterns for flexor tendon repair. STUDY DESIGN Ex vivo biomechanical study. SAMPLE POPULATION Seventy-two cadaveric superficial digital flexor musculotendon (SDFT) units. METHODS Tendons were divided into four groups (n = 18/group). After sharp transection, SDFT were repaired with 3LP, LL, 3LP + epitendinous (E), or LL + E suture patterns. After preloading, repaired constructs were tested to failure. Video data acquisition allowed evaluation of failure mode and quantitation of gap formation. Yield, peak, and failure force were measured from force-displacement data. Significance was set at P < .05. RESULTS Mode of failure did not differ between repairs with or without an epitendinous suture (P = .255). Gap formation was best prevented with 3LP compared with LL when used alone (P = .001). Mean yield force for 3LP, LL, 3LP + E, and LL + E were 91.4 N ± 25.4, 61.3 N ± 18.4, 195.2 N ± 66.0, 165.3 N ± 46.8, respectively. Tenorrhaphies combined with an epitendinous suture achieved higher yield (P < .0001), peak (P < .0001), and failure forces (P < .0001), without gapping between tendon ends. CONCLUSION Addition of an epitendinous suture eliminated gapping between tendon ends until failure and increased resistance to loads tolerated at the repair site. CLINICAL SIGNIFICANCE The addition of an epitendinous suture may increase the strength of tendon repairs and resistance to gap formation over core suture use alone. The influence of epitendinous suture placement on tendinous healing and blood supply warrants in-vivo testing.
Collapse
Affiliation(s)
- Allison B Putterman
- Department of Veterinary Clinical Medicine, College of Veterinary Medicine, University of Illinois, Urbana, Illinois
| | - Daniel J Duffy
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina
| | - Mariana E Kersh
- Department of Mechanical Science and Engineering, University of Illinois, Urbana, Illinois
| | - Hafizur Rahman
- Department of Mechanical Science and Engineering, University of Illinois, Urbana, Illinois
| | - George E Moore
- Veterinary Administration, College of Veterinary Medicine, Purdue University, West Lafayette, Indiana
| |
Collapse
|
16
|
|
17
|
Gibson PD, Sobol GL, Ahmed IH. Zone II Flexor Tendon Repairs in the United States: Trends in Current Management. J Hand Surg Am 2017; 42:e99-e108. [PMID: 27964900 DOI: 10.1016/j.jhsa.2016.11.022] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 10/29/2016] [Accepted: 11/10/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE The repair of zone II flexor tendon injuries is an evolving topic in hand surgery with current literature suggesting the use of a 4-strand repair; 3-0 or 4-0 braided, nonabsorbable sutures; and an epitendinous repair. It was hypothesized that variability would exist within the hand surgeon community in treatment of zone II flexor tendon repairs in surgical material used, surgical technique, and postoperative rehabilitation protocol. METHODS An online single-answer multiple-choice survey was distributed to the American Society for Surgery of the Hand members' database. Surgeons were asked questions about demographics, surgical technique, suture type, common complications, postoperative management, and the factor that plays the largest role in guiding their surgical preferences. Responses were compared with current medical evidence. RESULTS A total of 410 individuals responded to the survey. In regards to technique, the majority of surgeons reported using a 4-strand repair; with 3-0 or 4-0 core braided, nonabsorbable sutures; and performing an epitendinous repair. Only 20% of surgeons surveyed reported ever using wide-awake local anesthesia, no tourniquet and postoperative protocols were split between early active and early passive rehabilitation. Senior surgeons (≥ 15 years in practice) were more likely than their colleagues to use a 2-strand repair and a passive rehabilitation protocol. CONCLUSIONS This study demonstrates that the majority of respondents are performing zone II flexor tendon repairs in accordance with the best currently available evidence, although there is variability with respect to suture material, surgical technique, and rehabilitation protocols. CLINICAL RELEVANCE There is still a need for high-quality studies on surgical technique and rehabilitation protocols.
Collapse
Affiliation(s)
- Peter D Gibson
- Department of Orthopaedic Surgery, Rutgers-New Jersey Medical School, Newark, NJ.
| | - Garret L Sobol
- Department of Orthopaedic Surgery, Rutgers-New Jersey Medical School, Newark, NJ
| | - Irfan H Ahmed
- Department of Orthopaedic Surgery, Rutgers-New Jersey Medical School, Newark, NJ
| |
Collapse
|
18
|
Linderman SW, Gelberman RH, Thomopoulos S, Shen H. Cell and Biologic-Based Treatment of Flexor Tendon Injuries. ACTA ACUST UNITED AC 2016; 26:206-215. [PMID: 28042226 DOI: 10.1053/j.oto.2016.06.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The two primary factors leading to poor clinical results after intrasynovial tendon repair are adhesion formation within the digital sheath and repair-site elongation and rupture. As the outcomes following modern tendon multi-strand repair and controlled rehabilitation techniques are often unsatisfactory, alternative approaches, such as the application of growth factors and mesenchymal stem cells (MSCs), have become increasingly attractive treatment options. Successful biological therapies require carefully controlled spatiotemporal delivery of cells, growth factors, and biocompatible scaffold matrices in order to simultaneously (1) promote matrix synthesis at the tendon repair site leading to increased biomechanical strength and stiffness and (2) suppress matrix synthesis along the tendon surface and synovial sheath preventing adhesion formation. This review summarizes recent cell and biologic-based experimental treatments for flexor tendon injury, with an emphasis on large animal translational studies.
Collapse
Affiliation(s)
- Stephen W Linderman
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO, United States; Department of Biomedical Engineering, Washington University, St. Louis, MO, United States
| | - Richard H Gelberman
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO, United States
| | - Stavros Thomopoulos
- Department of Orthopaedic Surgery, Columbia University, New York, NY, United States; Department of Biomedical Engineering, Columbia University, New York, NY, United States
| | - Hua Shen
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO, United States
| |
Collapse
|
19
|
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
|
20
|
Linderman SW, Kormpakis I, Gelberman RH, Birman V, Wegst UGK, Genin GM, Thomopoulos S. Shear lag sutures: Improved suture repair through the use of adhesives. Acta Biomater 2015; 23:229-239. [PMID: 26022966 PMCID: PMC4522236 DOI: 10.1016/j.actbio.2015.05.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 03/27/2015] [Accepted: 05/07/2015] [Indexed: 10/23/2022]
Abstract
Suture materials and surgical knot tying techniques have improved dramatically since their first use over five millennia ago. However, the approach remains limited by the ability of the suture to transfer load to tissue at suture anchor points. Here, we predict that adhesive-coated sutures can improve mechanical load transfer beyond the range of performance of existing suture methods, thereby strengthening repairs and decreasing the risk of failure. The mechanical properties of suitable adhesives were identified using a shear lag model. Examination of the design space for an optimal adhesive demonstrated requirements for strong adhesion and low stiffness to maximize the strength of the adhesive-coated suture repair construct. To experimentally assess the model, we evaluated single strands of sutures coated with highly flexible cyanoacrylates (Loctite 4903 and 4902), cyanoacrylate (Loctite QuickTite Instant Adhesive Gel), rubber cement, rubber/gasket adhesive (1300 Scotch-Weld Neoprene High Performance Rubber & Gasket Adhesive), an albumin-glutaraldehyde adhesive (BioGlue), or poly(dopamine). As a clinically relevant proof-of-concept, cyanoacrylate-coated sutures were then used to perform a clinically relevant flexor digitorum tendon repair in cadaver tissue. The repair performed with adhesive-coated suture had significantly higher strength compared to the standard repair without adhesive. Notably, cyanoacrylate provides strong adhesion with high stiffness and brittle behavior, and is therefore not an ideal adhesive for enhancing suture repair. Nevertheless, the improvement in repair properties in a clinically relevant setting, even using a non-ideal adhesive, demonstrates the potential for the proposed approach to improve outcomes for treatments requiring suture fixation. Further study is necessary to develop a strongly adherent, compliant adhesive within the optimal design space described by the model.
Collapse
Affiliation(s)
- Stephen W Linderman
- Department of Orthopaedic Surgery, Washington University, St Louis, MO 63110, United States; Department of Biomedical Engineering, Washington University, St Louis, MO 63130, United States
| | - Ioannis Kormpakis
- Department of Orthopaedic Surgery, Washington University, St Louis, MO 63110, United States
| | - Richard H Gelberman
- Department of Orthopaedic Surgery, Washington University, St Louis, MO 63110, United States
| | - Victor Birman
- Engineering Education Center, Missouri University of Science and Technology, St Louis, MO 63131, United States
| | - Ulrike G K Wegst
- Thayer School of Engineering, Dartmouth College, Hanover, NH 03755, United States
| | - Guy M Genin
- Department of Mechanical Engineering and Materials Science, Washington University, St Louis, MO 63130, United States.
| | - Stavros Thomopoulos
- Department of Orthopaedic Surgery, Washington University, St Louis, MO 63110, United States; Department of Biomedical Engineering, Washington University, St Louis, MO 63130, United States; Department of Mechanical Engineering and Materials Science, Washington University, St Louis, MO 63130, United States.
| |
Collapse
|
21
|
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
|
22
|
Thompson MJ, Owen JR, McDowell CL, Wayne JS. Proximal tendon-prosthesis junction for active tendon implants of the hand: a biomechanical comparison of 2 techniques. J Hand Surg Am 2015; 40:109-14. [PMID: 25534839 DOI: 10.1016/j.jhsa.2014.10.034] [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: 06/02/2014] [Revised: 10/17/2014] [Accepted: 10/20/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To study the biomechanical characteristics (percent stretch, stiffness, and ultimate load) of 2 tendon-prosthesis techniques used to connect the proximal tendon stump to silicone active tendon implants used in reconstruction of flexor tendons. METHODS We evaluated percent stretch following cyclic loading and at failure, stiffness during load to failure, and ultimate load of 16 tendon-prosthesis junctions using cadaveric canine flexor digitorum profundus tendons to re-create 2 junction techniques: the tendon loop (TL) and the polyester weave (PW). RESULTS The TL junction showed greater percent stretch at a static load of 2 N, following 500 cycles of loading between 2 N and 50 N, and at peak load. The PW junction displayed greater stiffness from 50 to 150 N during load to failure. Both junctions failed at a mean ultimate load greater than 220 N. CONCLUSIONS The described proximal junction techniques for active tendon implants were strong enough to resist early active motion in the immediate postoperative period without significant elongation. The PW technique displayed greater stiffness and ultimate load compared with the TL. CLINICAL RELEVANCE Data on tendon-prosthesis characteristics of these 2 methods may aid the surgeon in choosing which junction technique to use, during surgical tensioning decisions, and in considering activity protocols after surgery. These data may also serve as a baseline for further investigations regarding active tendon implants.
Collapse
Affiliation(s)
- Matthew J Thompson
- Orthopaedic Research Laboratory, Departments of Orthopaedic Surgery & Biomedical Engineering, Virginia Commonwealth University, Richmond, VA
| | - John R Owen
- Orthopaedic Research Laboratory, Departments of Orthopaedic Surgery & Biomedical Engineering, Virginia Commonwealth University, Richmond, VA
| | - Charles L McDowell
- Orthopaedic Research Laboratory, Departments of Orthopaedic Surgery & Biomedical Engineering, Virginia Commonwealth University, Richmond, VA
| | - Jennifer S Wayne
- Orthopaedic Research Laboratory, Departments of Orthopaedic Surgery & Biomedical Engineering, Virginia Commonwealth University, Richmond, VA.
| |
Collapse
|
23
|
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
|
24
|
Abstract
Tendinopathy is a debilitating musculoskeletal
condition which can cause significant pain and lead to complete rupture
of the tendon, which often requires surgical repair. Due in part
to the large spectrum of tendon pathologies, these disorders continue
to be a clinical challenge. Animal models are often used in this
field of research as they offer an attractive framework to examine
the cascade of processes that occur throughout both tendon pathology and
repair. This review discusses the structural, mechanical, and biological
changes that occur throughout tendon pathology in animal models,
as well as strategies for the improvement of tendon healing. Cite this article: Bone Joint Res 2014;3:193–202.
Collapse
Affiliation(s)
- M W Hast
- University of Pennsylvania, McKay Orthopaedic Research Laboratory, 424 Stemmler Hall 36th Street and Hamilton Walk, Philadelphia, 19104-6081, USA
| | - A Zuskov
- University of Pennsylvania, McKay Orthopaedic Research Laboratory, 424 Stemmler Hall 36th Street and Hamilton Walk, Philadelphia, 19104-6081, USA
| | - L J Soslowsky
- University of Pennsylvania, McKay Orthopaedic Research Laboratory, 424 Stemmler Hall 36th Street and Hamilton Walk, Philadelphia, 19104-6081, USA
| |
Collapse
|
25
|
Osei DA, Stepan JG, Calfee RP, Thomopoulos S, Boyer MI, Potter R, Gelberman RH. The effect of suture caliber and number of core suture strands on zone II flexor tendon repair: a study in human cadavers. J Hand Surg Am 2014; 39:262-8. [PMID: 24342261 PMCID: PMC3927965 DOI: 10.1016/j.jhsa.2013.11.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Revised: 11/06/2013] [Accepted: 11/06/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the tensile properties of a 3-0, 4-strand flexor tendon repair with a 4-0, 4-strand repair and a 4-0, 8-strand repair. METHODS Following evaluation of the intrinsic material properties of the 2 core suture calibers most commonly used in tendon repair (3-0 and 4-0), we tested the mechanical properties of 40 cadaver flexor digitorum profundus tendons after zone II repair with 1 of 3 techniques: a 3-0, 4-strand core repair, a 4-0, 8-strand repair, or a 4-0, 4-strand repair. We compared results across suture caliber for the 2 sutures and across tendon repair methods. RESULTS Maximum load to failure of 3-0 polyfilament caprolactam suture was 49% greater than that of 4-0 polyfilament caprolactam suture. The cross-sectional area of 3-0 polyfilament caprolactam was 42% greater than that of 4-0 polyfilament caprolactam. The 4-0, 8-strand repair produced greater maximum load to failure when compared with the 2 4-strand techniques. Load at 2-mm gap, stiffness, and work to yield were significantly greater in the 4-0, 8-strand repair than in the 3-0, 4-strand repair. CONCLUSIONS In an ex vivo model, an 8-strand repair using 4-0 suture was 43% stronger than a 4-strand repair using 3-0 suture, despite the finding that 3-0 polyfilament caprolactam was 49% stronger than 4-0 polyfilament caprolactam. These results suggest that, although larger-caliber suture has superior tensile properties, the number of core suture strands across a repair site has an important effect on time zero, ex vivo flexor tendon repair strength. CLINICAL RELEVANCE Surgeons should consider using techniques that prioritize multistrand core suture repair over an increase in suture caliber.
Collapse
Affiliation(s)
- Daniel A. Osei
- Washington University School of Medicine, Department of Orthopedic Surgery,Washington University Institute of Clinical and Translational Sciences
| | - Jeffrey G. Stepan
- Washington University School of Medicine,Washington University Institute of Clinical and Translational Sciences
| | - Ryan P. Calfee
- Washington University School of Medicine, Department of Orthopedic Surgery,Washington University Institute of Clinical and Translational Sciences
| | | | - Martin I. Boyer
- Washington University School of Medicine, Department of Orthopedic Surgery
| | - Ryan Potter
- Washington University School of Medicine, Department of Orthopedic Surgery
| | | |
Collapse
|
26
|
Abstract
BACKGROUND Flexor tendon injury is a common problem that plastic surgeons are called on to treat. Despite their common nature, they present a challenge, not necessarily in the surgical treatment per se but in the ability to achieve a "normal" finger as the end result. Because of the difficulty in attaining good outcomes, much continues to be studied and written about flexor tendon injury. METHODS The current literature on flexor tendon repair, rehabilitation, and reconstruction is reviewed. RESULTS Aspects reviewed include type of anesthesia, suture material and configuration, repairs in the different flexor tendon zones, types of tendon rehabilitation, complications of flexor tendon surgery, and flexor tendon reconstruction. CONCLUSION This review provides an update on the current standards in the treatment of flexor tendon injury.
Collapse
|
27
|
Joyce CW, Whately KE, Chan JC, Murphy M, O'Brien FJ, Carroll SM. Flexor tendon repair: a comparative study between a knotless barbed suture repair and a traditional four-strand monofilament suture repair. J Hand Surg Eur Vol 2014; 39:40-5. [PMID: 23695149 DOI: 10.1177/1753193413487470] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We compared the tensile strength of a novel knotless barbed suture method with a traditional four-strand Adelaide technique for flexor tendon repairs. Forty fresh porcine flexor tendons were transected and randomly assigned to one of the repair groups before repair. Biomechanical testing demonstrated that the tensile strengths between both tendon groups were very similar. However, less force was required to create a 2 mm gap in the four-strand repair method compared with the knotless barbed technique. There was a significant reduction in the cross-sectional area in the barbed suture group after repair compared with the Adelaide group. This would create better gliding within the pulley system in vivo and could decrease gapping and tendon rupture.
Collapse
Affiliation(s)
- C W Joyce
- 1Department of Plastic and Reconstructive Surgery, St. Vincent's University Hospital, Elm Park, Dublin, Ireland
| | | | | | | | | | | |
Collapse
|
28
|
Abstract
This article reviews recent reports of outcomes of flexor tendon repair and discusses the problems associated with such surgeries. Reports of no repair rupture in individual case series have emerged recently. Their results move toward the clinical goal of primary repair without repair rupture. The Strickland method remains the most common to record the outcomes. Outcomes should be provided by subzones of the tendon injuries, and the level of expertise of the surgeons expertise should be reported to allow comparisons of the results.
Collapse
Affiliation(s)
- Jin Bo Tang
- Department of Hand Surgery, The Hand Surgery Research Center, Affiliated Hospital of Nantong University, 20 West Temple Road, Nantong 226001, Jiangsu, China.
| |
Collapse
|