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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.
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Affiliation(s)
- Ya Fang Wu
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China.
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Muslu Ü, Alıç T, Demir E, Gölpınar M, Bilici İ, Demirezen MO. Biomechanical comparison of different suture materials with different techniques in tendon repair: An ex-vivo study. HAND SURGERY & REHABILITATION 2023; 42:435-441. [PMID: 37453716 DOI: 10.1016/j.hansur.2023.06.010] [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: 04/26/2023] [Revised: 06/21/2023] [Accepted: 06/22/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVES Sheep Achilles tendons are used as an effective preclinical model of flexor tendon repair in plastic surgery, due to their biomechanical properties, which are similar to humans. The aim of this study was to examine the efficacy and biomechanical outcomes of suture materials and tendon repair techniques in flexor tendon repair. MATERIAL AND METHODS 72 sheep tendons were obtained for a total of 12 different scenarios. Tendons were repaired using 4 different suture types and 3 different suture techniques. After repair, the tendons were fixed at both ends and subjected to biomechanical tests. Ultimate Failure Load (UFL) and 2-mm Gap Load (GL) per scenario were compared statistically within and between groups. RESULTS UFL and GL of all sutures were significantly different between the modified Kessler, Bunnell and Krackow techniques (P < 0.05), and between Monosorb, Ti-Cron and V-loc sutures (P < 0.05). UFL and GL according to repair technique were not significantly different for the Propilen suture (P > 0.05). CONCLUSION When UFL and GL were considered together, our findings indicate that optimal strength scenarios were for the modified Kessler technique using Monosorb or V-loc sutures.
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Affiliation(s)
- Ümran Muslu
- Department of Plastic and Reconstructive Surgery, Hürrem Sultan Hospital, İstanbul, Turkey.
| | - Taner Alıç
- Hitit University, Faculty of Medicine, Department of Orthopaedics and Traumatology, Çorum, Turkey
| | - Emre Demir
- Hitit University, Faculty of Medicine, Department of Biostatistics, Çorum, Turkey
| | - Murat Gölpınar
- Hitit University, Faculty of Medicine, Department of Anatomy, Çorum, Turkey
| | - İbrahim Bilici
- Hitit University, Faculty of Engineering, Department of Chemical Engineering, Çorum, Turkey
| | - Murat Okan Demirezen
- Hitit University, Faculty of Medicine, Department of Orthopaedics and Traumatology, Çorum, Turkey
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Maffulli N, Sammaria G, Ziello S, Migliorini F, Oliva F. Percutaneous cruciate repair of ruptured Achilles tendon. J Orthop Surg Res 2023; 18:677. [PMID: 37700324 PMCID: PMC10496360 DOI: 10.1186/s13018-023-04167-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 09/05/2023] [Indexed: 09/14/2023] Open
Abstract
Percutaneous repair is a safe and reliable method to restore continuity after acute Achilles tendon ruptures, with a lower incidence of wound complications compared to open techniques. We describe a novel percutaneous cruciate suture performed through 5 stab skin incisions, four of which are longitudinal and parallel to the course of the sural nerve to minimize the risk of injury and one transverse incision at the site of rupture, with a total of 16 suture threads and the knot outside the tendon body, increasing the tensile strength of the suture and minimizing the risk of re-rupture. Clinical studies are necessary to ascertain whether the theoretical advantages of the cruciate suture technique translate into better clinical outcomes compared to established percutaneous techniques.
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Affiliation(s)
- Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084, Baronissi, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi d'Aragona, 84131, Salerno, Italy
- Centre for Sports and Exercise Medicine, Barts and the London School of Medicine and Dentistry, Mile End Hospital, Queen Mary University of London, 275 Bancroft Road, London, E1 4DG, UK
- School of Pharmacy and Bioengineering, Faculty of Medicine, Keele University, Thornburrow Drive, Stoke on Trent, ST4 7QB, UK
| | - Giuliano Sammaria
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084, Baronissi, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi d'Aragona, 84131, Salerno, Italy
| | - Salvatore Ziello
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084, Baronissi, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi d'Aragona, 84131, Salerno, Italy
| | - Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Medical Centre, Pauwelsstraße 30, 52074, Aachen, Germany.
- Department of Orthopedics and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), 39100, Bolzano, Italy.
| | - Francesco Oliva
- Department of Human Sciences and Promotion of the Quality of Life, San Raffaele Open University, Rome, Italy
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Nassar M, Sallam A, Sokkar S, Abdelsadek H, Zada M. Comparison of 4 Different 4-Strand Core Suturing Techniques for Flexor Tendon Laceration: An Ex Vivo Biomechanical Study. Hand (N Y) 2023; 18:820-828. [PMID: 35132896 PMCID: PMC10336818 DOI: 10.1177/15589447211073831] [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: 11/16/2022]
Abstract
BACKGROUND Forces applied to the repaired flexor tendon should not exceed its yield force during early postoperative rehabilitation to prevent gapping and rupture. We aimed to biomechanically compare the tensile strengths and the 2-mm gapping of 4 different 4-strand core suturing techniques for flexor tendon repair. METHODS Fifty-six goat deep digital flexor tendons were repaired with the 4-strand double-modified Kessler, the 4-strand augmented Becker, the 4-strand Savage, and the 4-strand modified Tang techniques. All tendons were repaired with 4-0 polyester for core suture and 5-0 polyester for continuous epitendinous running suture. The specimens were subjected to static linear tensile testing by applying a single linear load-to-failure pull. After the linear load testing, the yield load, the ultimate strength of the repaired tendons, and the force exerted to yield a 2-mm gap were measured. RESULTS All peripheral sutures ruptured near the yield point. All core suture techniques were similar regarding the yield force. The augmented Becker 4-strand technique had the greatest ultimate strength (98.7 [82-125.3] N). The modified double Kessler technique was the weakest in resisting a 2-mm gap formation. The 4-strand modified Tang repair had the shortest (11.3 [7-15] minutes), while the 4-strand augmented Becker had the longest operative time (29 [23-33] minutes). CONCLUSIONS All 4 techniques demonstrated similar yield force, with differences in operative time, ultimate strength, and resistance to gapping. Future clinical studies can further elucidate their appropriateness for early active motion protocols.
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Affiliation(s)
| | - Asser Sallam
- Suez Canal University Hospitals, Ismailia, Egypt
| | | | | | - Mohamed Zada
- Suez Canal University Hospitals, Ismailia, Egypt
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Huan KWSJ, Lim RQR, Wong YR. A Biomechanical Comparison of Gliding Resistance between Modified Lim Tsai and Asymmetric Tendon Repair Techniques in Zone II Flexor Tendon Repairs. J Hand Surg Asian Pac Vol 2022; 27:499-505. [PMID: 35674265 DOI: 10.1142/s2424835522500515] [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: 11/18/2022]
Abstract
Background: Early active motion protocols have shown better functional outcomes in zone II flexor tendon lacerations. Different techniques of tendon repair have different effects on gliding resistance, which can impact tendon excursion and adhesion formation. For successful initiation of early active mobilisation, the repair technique should have high breaking strength and low gliding resistance. Previous studies have shown the Modified Lim-Tsai technique demonstrates these characteristics. The Asymmetric repair has also shown superior ultimate tensile strength. This study aims to compare the gliding resistance between the two techniques. Methods: FDP tendons from ten fresh frozen cadaveric fingers were randomly divided into two groups, transected completely distal to the sheath of the A2 pulley and repaired using either the Modified Lim-Tsai or Asymmetric technique. The core repair was performed with Supramid 4-0 looped sutures and circumferential epitendinous sutures were done with nylon monofilament Prolene 6-0 sutures. The gliding resistance and ultimate tensile strength were then tested. Results: The gliding resistance of the Asymmetric and Modified Lim-Tsai repair techniques were 0.2 and 0.95 N respectively. This difference was significant (p = 0.008). The Modified Lim-Tsai technique had a higher ultimate tensile strength and load to 2 mm gap formation, though this was not significant. Conclusions: Gliding resistance of the Asymmetric repair is significantly less than that of Modified Lim-Tsai. Ultimate tensile strength and load to 2 mm gap formation are comparable.
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Affiliation(s)
| | - Rebecca Qian Ru Lim
- Department of Hand and Reconstructive Microsurgery, Singapore General Hospital, Singapore
| | - Yoke Rung Wong
- Biomechanics Laboratory, Singapore General Hospital, Singapore
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Corduneanu‑Luca A, Pasca S, Tamas C, Moraru D, Ciuntu B, Stanescu C, Hreniuc‑Jemnoschi I, Tecuceanu A, Stamate T. Improving flexor tendon gliding by using the combination of carboxymethylcellulose‑polyethylene oxide on murine model. Exp Ther Med 2021; 23:105. [PMID: 34976147 PMCID: PMC8674966 DOI: 10.3892/etm.2021.11028] [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: 09/14/2021] [Accepted: 10/14/2021] [Indexed: 11/08/2022] Open
Abstract
The current approach to flexor tendon injuries is complex and is no longer limited to suturing techniques. Strategies for improving hand function currently include rehabilitation protocols, appropriate suturing materials and techniques, changing the gliding surface by using lubricants and providing growth factors. One product, originally used in spinal surgery, has been shown to be effective in preventing postoperative adhesions. It is a combination of carboxymethylcellulose and polyethylene oxide-Dynavisc® (FzioMed, Inc.). The aim of the present study was to test the effect of Dynavisc® on acute injuries of the intrasynovial flexor tendons in the prevention of postoperative adhesions and the improvement of functional results. The study was performed on 20 Wistar rats distributed in two groups. The control group, represented by 10 rats, in which after the reconstruction of the flexor tendon, the peritendinous area was injected with saline solution and the study group, in which the peritendinous area was injected with a single administration of the lubricating gel, Dynavisc® (carboxymethylcellulose and polyethylene oxide). At 4 and 12 weeks, the rats were sacrificed and tissue biopsy consisted of tendon fragments and adjacent tissue. The evaluation of the results was performed by measuring the adhesion score and observing histological parameters. The presence of important adhesions was found in the control group compared with the group treated with Dynavisc®, where a supple and smooth tendon, with significantly fewer adhesions were found. The differences between the two groups were significant, thus indicating the efficiency of the lubricant in preventing adhesions. This study supported the important role of Dynavisc® in the regeneration of the tendon and the peritendinous structures, by limiting aberrant fibrous proliferation in the regeneration process and helping to build a peritendinous space.
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Affiliation(s)
| | - Sorin Pasca
- Department of Veterinary Pathology, Faculty of Veterinary Medicine, ‘Ion Ionescu de la Brad’ University of Agricultural Sciences and Veterinary Medicine, 700490 Iasi, Romania
| | - Camelia Tamas
- Department of Plastic Surgery, Faculty of Medicine, ‘Grigore T. Popa’ University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Dan Moraru
- Department of Plastic Surgery, Faculty of Medicine, ‘Grigore T. Popa’ University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Bogdan Ciuntu
- Department of General Surgery, Faculty of Medicine, ‘Grigore T. Popa’ University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Cristina Stanescu
- Department of Morphological and Functional Sciences, Faculty of Medicine and Pharmacy, ‘Dunarea de Jos’ University, 800216 Galati, Romania
| | - Irina Hreniuc‑Jemnoschi
- Department of Plastic Surgery, Faculty of Medicine, ‘Grigore T. Popa’ University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Angela Tecuceanu
- Department of Plastic Surgery, Faculty of Medicine, ‘Grigore T. Popa’ University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Teodor Stamate
- Department of Plastic Surgery, Faculty of Medicine, ‘Grigore T. Popa’ University of Medicine and Pharmacy, 700115 Iasi, Romania
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Biomechanical analysis of a new 8-strand technique for flexor tendon repair. HAND SURGERY & REHABILITATION 2020; 39:442-447. [PMID: 32450161 DOI: 10.1016/j.hansur.2020.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 04/25/2020] [Accepted: 05/14/2020] [Indexed: 11/23/2022]
Abstract
We sought to compare the strength and rupture sites of a new 8-strand suture technique with those of an established 6-strand flexor tendon repair through biomechanical analysis. This new 8-strand suture pattern places minimal suture material in the remodeling zone and focuses on protecting the knot, a well-known weak point of the suture construct. The knot was buried within the tendon so as to not interfere with tendon gliding. In a biomechanical simulation, strength and rupture sites were compared with those of the 6-strand repair. We repaired a total of 54 porcine flexor tendons using one of the two techniques (n=27 each). Tensile strength at 2-mm gap formation and ultimate failure load were determined. Afterwards, we dissected the tendons to identify the rupture site of the suture material. The new 8-strand suture had a significant higher ultimate load to failure (87.7N) and 2-mm gap load (71.6N) compared to the 6-strand technique (57.7N and 45.9N) (P<0.001). Whereas the rupture site of the core suture in the 6-strand technique was mainly located next to the knot (81.5%), the suture seemed to fail independently from this weak spot in the 8-strand technique (11.1%). This new 8-strand technique achieves a strong flexor tendon repair in a biomechanical model. Additional cross-locking on either side of the knot seems to contribute to the repair's strength. The resulting higher ultimate failure load and 2-mm gap load may allow more aggressive active motion-based postoperative rehabilitation.
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Liu H, Thoreson A, Kadar A, Moran S, Zhao C. Evaluation of hollow mesh augmentation on the biomechanical properties of the flexor tendon repaired with modified Kessler technique. J Orthop Translat 2020; 20:80-85. [PMID: 31908937 PMCID: PMC6939116 DOI: 10.1016/j.jot.2019.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 08/07/2019] [Accepted: 08/12/2019] [Indexed: 11/13/2022] Open
Abstract
Purpose The aim of the study was to test flexor tendon repair with a novel hollow mesh suture augmentation served as a centre core cable [Triple-C (Tri-C)] in an in vitro study using a turkey model. Methods Forty long digits from white turkey feet were divided into the following four groups based on repair techniques: Group 0, intact tendon without repair; Group 1, modified Kessler (MK) repair only (MKo); Group 2, MK repair plus Tri-C (MK + Tri-C); and Group 3, MK repair plus an additional outside knot plus Tri-C (MK-2knots + Tri-C). Mechanical evaluations were performed for all groups. Results The frictions of the two groups with Tri-C were not significantly different than those of the MKo group. The ultimate tensile strength of the MK + Tri-C group was not significantly different from that of the MKo group or the MK-2knots + Tri-C group. In contrast, the MK-2knots + Tri-C group had a significantly greater ultimate tensile strength compared with that of the MKo group. Forces at 2-mm gap formation in the groups with Tri-C were significantly stronger than that of MK alone. Conclusion Our data have demonstrated that MK repair augmented with the centre hollow mesh suture increased failure strength without inducing increased friction. The translational potential of this article Our study elucidates that a Tri-C augmentation designed in this study can achieve mechanical enhancements without increasing the repaired tendon friction. Hence, this novel technique has potential biological validity and clinical application.
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Affiliation(s)
- Haoyu Liu
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA.,Department of Hand Surgery, China-Japan Union Hospital of Jilin University, China
| | - Andrew Thoreson
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Assaf Kadar
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Steven Moran
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Chunfeng Zhao
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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Dawood AA. Repair of flexor tendon injuries by four strands cruciate technique versus two strands kessler technique. J Clin Orthop Trauma 2020; 11:646-649. [PMID: 32684704 PMCID: PMC7355087 DOI: 10.1016/j.jcot.2020.05.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 05/27/2020] [Accepted: 05/28/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Flexor tendon injuries are commonly encountered and the surgical repair still represents a challenging problem. Many repair techniques are present but there is still no ideal one that achieves the best functional outcome. This study was undertaken to compare four-strand locked cruciate repair technique and modified Kessler technique in forty eight patients by assessing the functional outcome. METHODS Forty eight patients (114 digits) with flexor tendon injury were assigned into two groups based on suture repair technique; Group A: 24 cases by Modified Kessler repair (50%). Group B: 24cases by 4-strand cruciate repair (50%). Adults in Both groups were rehabilitated by combined Duran protocol and early active mobilization while no specific rehabilitation program was used for pediatric age group. Follow up was from 6 to 36 months (mean 21.5). Functional outcome was assessed by White criteria to all patients after 6 months. RESULTS Functional outcome was better in 4 strand cruciate repair with excellent result in 66.6%, good in 29.1% and fair in 4.1%, as compared to modified Kessler technique in which excellent results were found in 45.8%, good in 37.5%, fair in 12.5% and poor in 4.1% of cases. A better functional result was achieved in 4 strand cruciate repair especially in zone II, with excellent results in 33.3%, good in 50% and fair in 16.6% of cases, as compared to modified Kessler repair with no excellent results, 33.3% good, 50% fair and 16.6% poor results. In zone III, 4 strand cruciate technique showed a better functional outcome with 77.7% excellent and 22.2% good results, as compared to 55.5% excellent and 44.4% good results found in Modified Kessler repair. Zone V showed almost comparable results between the two types of repairs. CONCLUSION The 4-strand cruciate repair technique had better functional outcome compared to modified Kessler repair technique, especially in zone II and III.
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Linnanmäki L, Göransson H, Havulinna J, Karjalainen T, Leppänen OV. Factors Accounting for Variation in the Biomechanical Properties of Flexor Tendon Repairs. J Hand Surg Am 2018; 43:1073-1080.e2. [PMID: 30292714 DOI: 10.1016/j.jhsa.2018.08.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 06/26/2018] [Accepted: 08/20/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To investigate factors that cause variation in the mechanical properties of flexor tendon repairs. METHODS One surgeon repaired 50 homogeneous absorbent sticks and 40 porcine flexor tendons with a simple loop, an Adelaide repair, a peripheral over-and-over repair, or a combination of the latter 2 repairs. Ten hand surgeons repaired 1 porcine flexor tendon with the combined Adelaide core and over-and-over peripheral repair. We loaded the samples statically until failure and calculated the variations caused by the testing process, tendon substance, and surgical performance in terms of yield and ultimate load. RESULTS Tendon material and surgical performance both caused about half of the variation in the yield load of the combined repair. Surgical performance caused all variations observed in the ultimate load of the combined, peripheral-only, and core repairs. The effect of the tendon material was negligible in ultimate load. The intersurgeon variation was present only in yield load, and it represented one-tenth of the total variation. CONCLUSIONS The effect of tendon substance on variation of the ultimate load is minimal. In yield load, both tendon and surgical performance are responsible for the variation. CLINICAL RELEVANCE In clinical realm, variation caused by testing is not present, but intersurgeon variation may cause additional variation in yield load. A hand surgeon cannot change the variation due to tendon properties, but with a more meticulous surgical technique, the variation related to the surgical performance can probably be diminished.
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Affiliation(s)
- Lasse Linnanmäki
- Department of Hand and Microsurgery, University of Tampere, Faculty of Medicine and Life Sciences and Tampere University Hospital, Tampere, Finland
| | - Harry Göransson
- Department of Hand and Microsurgery, University of Tampere, Faculty of Medicine and Life Sciences and Tampere University Hospital, Tampere, Finland
| | | | - Teemu Karjalainen
- Department of Surgery, Central Finland Central Hospital, Jyväskylä, Finland
| | - Olli V Leppänen
- Department of Hand and Microsurgery, University of Tampere, Faculty of Medicine and Life Sciences and Tampere University Hospital, Tampere, Finland.
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11
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Yang QQ, Zhou YL. Comparison of the strength of two multi-strand tendon repair configurations in a chicken model. HAND SURGERY & REHABILITATION 2018; 38:67-70. [PMID: 30448036 DOI: 10.1016/j.hansur.2018.10.239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 09/20/2018] [Accepted: 10/08/2018] [Indexed: 11/26/2022]
Abstract
We sought to investigate the strength of two multi-strand tendon repair configurations in a chicken model. Fifty-six chicken flexor tendons were repaired with one to two different four-strand configurations: 1) a four-strand repair consisting of a two-strand core modified Kessler suture with a circle loop repair and 2) a four-strand core Kessler suture repair with three separate peripheral suture points. The strength of the repaired tendons were measured 2, 3 and 4 weeks after the surgical repair and were analyzed statistically. The strength of the two repair methods was not statistically different 2 weeks after surgery. The tendons repaired with the four-strand core Kessler suture repair and three separate peripheral suture points were significantly stronger than those repaired with a two-strand core modified Kessler suture and a circle loop repair at 3 weeks (P = 0.033) and 4 weeks (P = 0.039). The four-strand repair with three separate peripheral suture points had greater strength than a two-strand repair with one circle loop suture based on an in vivo chicken flexor tendon model.
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Affiliation(s)
- Q Q Yang
- The Hand Surgery Research Center, Department of Hand Surgery, Affiliated Hospital of Nantong University, Nantong 226001, PR China
| | - Y L Zhou
- The Hand Surgery Research Center, Department of Hand Surgery, Affiliated Hospital of Nantong University, Nantong 226001, PR China.
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12
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Wong YR, Jais ISM, Chang MK, Lim BH, Tay SC. An Exploratory Study Using Semi-Tabular Plate in Zone II Flexor Tendon Repair. J Hand Surg Asian Pac Vol 2018; 23:547-553. [DOI: 10.1142/s242483551850056x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: This study evaluated the feasibility of using a low-profile titanium (Ti) plate implant, also known as the Ti-button, for Zone II flexor tendon repair. We hypothesize that the use of the Ti-button can distribute the tensile force on the digital flexor tendons to achieve better biomechanical performance. Methods: Twenty lacerated porcine flexor tendons were randomly divided into two groups and repaired using Ti-button or 6-strand modified Lim-Tsai technique. Ultimate tensile strength, load to 2 mm gap force, and mode of failure were recorded during a single cycle loading test. We also harvested twelve fingers with lacerated flexor digitorum profundus tendons from six fresh-frozen cadaver hands and repaired the tendons using either Ti-button method or modified Lim-Tsai technique. A custom-made bio-friction measurement jig was used to measure the gliding resistance and coefficient of friction of the tendon sheath interface at the A2 pulley. Results: The ultimate tensile strength, load to 2 mm gap force, stiffness, and gliding resistance of the Ti-button repairs were 101.5 N, 25.7 N, 7.8 N/mm, and 2.2 N respectively. Ti-button repairs had significantly higher ultimate tensile strength and stiffness than the modified Lim-Tsai repair. However, Ti-button also increased the gliding resistance and coefficient of friction but there was no significant difference between the two repair techniques. Conclusions: Ti-button repair displayed comparable mechanical properties to the traditional repair in terms of 2-mm gap formation and gliding resistance, but with a stronger repair construct. Thus, this deepened our interest to further investigate the potential of using Ti-button implant in Zone II flexor tendon repair by studying both the mechanical and biochemical (tendon healing) properties in more in-depth.
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Affiliation(s)
- Yoke-Rung Wong
- Biomechanics Laboratory, Singapore General Hospital, Singapore
| | | | - Min-Kai Chang
- Duke-NUS Medical School, Singapore General Hospital, Singapore
| | - Beng-Hai Lim
- Centre for Hand And Reconstructive MicroSurgery, Singapore General Hospital, Singapore
| | - Shian-Chao Tay
- Biomechanics Laboratory, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore General Hospital, Singapore
- Department of Hand Surgery, Singapore General Hospital, Singapore
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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.
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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.
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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.
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15
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Pillukat T, Fuhrmann R, Windolf J, van Schoonhoven J. [Suture techniques and material in surgery of flexor tendons]. Chirurg 2018; 88:259-270. [PMID: 28224209 DOI: 10.1007/s00104-017-0383-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Adhesions and scar formation between flexor tendons and the surrounding tissue are only contemporarily avoidable by movement of flexor tendons. Concepts with active follow-up protocols are more favorable than passive mobilization. The main risks of flexor tendon repair are rupture of the tendon suture, insidious gap formation and resistance to tendon gliding within the tendon sheath. Currently, there is no consensus with respect to the optimal suture technique or suture material. Nevertheless, there are some principles worth paying attention to, such as using stronger suture material, blocking stitches, suture techniques with four or more strands as well as circular running sutures. A technically acceptable compromise, even for the less experienced, is currently the four-strand suture combined with a circular running suture. It maintains sufficient stability for active motion follow-up protocols without resistance.
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Affiliation(s)
- T Pillukat
- Klinik für Handchirurgie, Salzburger Leite 1, Bad Neustadt an der Saale, Deutschland.
| | - R Fuhrmann
- Klinik für Fußchirurgie, Bad Neustadt an der Saale, Deutschland
| | - J Windolf
- Klinik für Unfall- und Handchirurgie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - J van Schoonhoven
- Klinik für Handchirurgie, Salzburger Leite 1, Bad Neustadt an der Saale, Deutschland
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16
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Abstract
The protocol for primary flexor tendon repair in zones 1 and 2 of the hand is changing. This article discusses recent changes. Immediate repair within 48 hours is performed whenever possible. A 6-strand core suture is performed using the M modification of Tang's technique. The pulleys are divided to allow free excursion of the repaired tendon within the tendon sheath. To avoid repaired structures within the sheath being too bulky, the authors generally repair only half of the flexor digitorum superficialis. In some cases, the flexor digitorum superficialis is excised completely. Rehabilitation remains based on controlled active motion.
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Affiliation(s)
- Thomas Giesen
- Plastic Surgery and Hand Surgery Division, University Hospital Zurich, Raemistrasse 100, Zurich 8091, Switzerland.
| | - Maurizio Calcagni
- Plastic Surgery and Hand Surgery Division, University Hospital Zurich, Raemistrasse 100, Zurich 8091, Switzerland
| | - David Elliot
- St. Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Court Road, Broomfield CM1, UK
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17
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Strong Digital Flexor Tendon Repair, Extension-Flexion Test, and Early Active Flexion: Experience in 300 Tendons. Hand Clin 2017; 33:455-463. [PMID: 28673622 DOI: 10.1016/j.hcl.2017.04.012] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Over the past 2 decades, repair and rehabilitation methods of primary repair of the digital flexor tendon have changed. In this article, we outline interim results from ongoing investigations in several units. Surgeons in these units now perform digital flexor tendon repairs according to a treatment protocol. Before adopting the protocol, they had no history of tendon-related research; they had not used any of the repair and rehabilitation methods described in the protocol. The surgeons involved are junior or midlevel attending surgeons. At the end of this article, we outline current practice of digital flexor tendon repair in Asian countries.
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18
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Takeuchi N, Okada T, Kozono N, Shimoto T, Higaki H, Iwamoto Y. Symmetric Peripheral Running Sutures are Superior to Asymmetric Peripheral Running Sutures for Increasing the Tendon Strength in Flexor Tendon Repair. J Hand Surg Asian Pac Vol 2017; 22:208-213. [PMID: 28506161 DOI: 10.1142/s0218810417500265] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND The fatigue strength of three peripheral suture techniques for flexor tendon repair was compared by cyclic loading of the repairs in the porcine flexor digitorum tendon. METHODS Thirty-six tendons were sutured using only peripheral sutures with 6-0 Nylon. An initial cyclic load of 10 N for 500 cycles was applied and increased by 10 N for an additional 500 cycles at each new load until rupture. RESULTS The fatigue strength of the symmetric running peripheral suture was 85.0% and 144.8% greater than that of the two kinds of the asymmetric running peripheral sutures. CONCLUSIONS Symmetric running sutures can enhance the suture strength and appears to be a useful technique for increasing the strength of the peripheral suture.
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Affiliation(s)
- N Takeuchi
- * Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Japan
| | - T Okada
- * Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Japan
| | - N Kozono
- * Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Japan
| | - T Shimoto
- † Department of Information and System Engineering, Faculty of Information Engineering, Fukuoka Institute of Technology, Japan
| | - H Higaki
- ‡ Department of Biorobotics, Faculty of Engineering, Kyushu Sangyo University, Fukuoka, Japan
| | - Y Iwamoto
- * Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Japan
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19
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Watanabe K, Ota H, Sasaki H. Eight-strand Cross-locked Cruciate Flexor Tendon Repair Using Double-stranded Suture: A Description of the Surgical Technique. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2016; 4:e1048. [PMID: 27975005 PMCID: PMC5142471 DOI: 10.1097/gox.0000000000001048] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 08/02/2016] [Indexed: 11/25/2022]
Abstract
This article describes a technique for improved repair of digital flexor tendon laceration. Eight-strand cross-locked cruciate repair using 4-0 caliber double-stranded suture is not bulky and has a smooth configuration for tendon gliding. Additionally, it has sufficient strength for early postoperative active motion exercise.
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Affiliation(s)
- Kentaro Watanabe
- Department of Orthopaedic Surgery, Nagoya Ekisaikai Hospital, Nagoya, Japan
| | - Hideyuki Ota
- Department of Orthopaedic Surgery, Nagoya Ekisaikai Hospital, Nagoya, Japan
| | - Hiroshi Sasaki
- Department of Orthopaedic Surgery, Nagoya Ekisaikai Hospital, Nagoya, Japan
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20
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Leppänen OV, Linnanmäki L, Havulinna J, Göransson H. Suture configurations and biomechanical properties of flexor tendon repairs by 16 hand surgeons in Finland. J Hand Surg Eur Vol 2016; 41:831-7. [PMID: 27066998 DOI: 10.1177/1753193416641624] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Accepted: 02/24/2016] [Indexed: 02/03/2023]
Abstract
The aim of this study was to find out how common it is to modify standard core suture configurations in flexor tendon repair and whether the use of standard core suture configurations gives a stronger repair. A total of 16 hand surgeons or residents participated in a workshop, in which they were asked to draw the suture configurations they used and to repair a porcine tendon. The properties of the repaired tendons were measured. Seven participants used a standard core suture configuration, and nine used a modified core suture. The biomechanical properties of the repairs were not affected by modifications to the core suture. However, they were affected by the number and lengths of peripheral suture bites, type of peripheral suture and the location of the core suture knot.
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Affiliation(s)
- O V Leppänen
- Department of Hand- and Microsurgery, Tampere University Hospital, Tampere, Finland Medical School, University of Tampere, Tampere, Finland
| | - L Linnanmäki
- Medical School, University of Tampere, Tampere, Finland
| | - J Havulinna
- Department of Hand- and Microsurgery, Tampere University Hospital, Tampere, Finland
| | - H Göransson
- Department of Hand- and Microsurgery, Tampere University Hospital, Tampere, Finland
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Mistry R, McCleave MJ, Codrington J. Causes of Flexor Tendon Repair Failures in Two Common Repair Techniques: A Cadaver Study. J Hand Surg Asian Pac Vol 2016; 21:333-8. [PMID: 27595950 DOI: 10.1142/s2424835516500302] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Flexor tendon repair failures have primarily been attributed to either core suture rupture or core suture pull out. Recent studies have suggested that knot unravelling may also cause failure of a tendon repair. The aim of this study was to investigate the causes of core suture failure in two types of common flexor tendon repairs. METHODS Twenty four cadaver tendons were divided into three groups of eight. Each group tested a specific flexor tendon repair. The repairs tested included an Adelaide repair using 4/0 Ethibond (Ethicon), an Adelaide repair using 4/0 Fiberwire (Arthrex) and the Tsai repair with 4/0 Fiberloop (Arthrex). The repaired tendons were pull-tested to failure. The mechanism of failure, maximum tensile strength and 2 mm gap force were recorded. RESULTS The predominant mode of failure was by the knot unravelling. This occurred in 50-88% of the tendon repairs. The sequence of failure was initiated with gapping at the repair site followed by failure of the epitendinous suture. Next the core suture knot unravels. Once the knot unravels, the suture thread slips out of the tendon resulting in the repair failure. Failures due to knot slippage occurred at a lower maximum tensile strength in Ethibond and Fiberloop sutures than failure due to core rupture or pull out. However, given the small number of tendons tested, this result was not significant. CONCLUSIONS This study has clearly demonstrated one of the main causes of flexor tendon repair failure in two common repair techniques is knot unravelling.
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Affiliation(s)
- Raakhi Mistry
- * Department of Plastic & Reconstructive Surgery, The University of Adelaide, The Royal Adelaide Hospital, Adelaide, Australia
| | - Michael John McCleave
- * Department of Plastic & Reconstructive Surgery, The University of Adelaide, The Royal Adelaide Hospital, Adelaide, Australia
| | - John Codrington
- † Department of Mechanical Engineering, The University of Adelaide, Adelaide, Australia
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22
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Al-Thunayan TA, Al-Zahrani MT, Hakeem AA, Al-Zahrani FM, Al-Qattan MM. A biomechanical study of pediatric flexor profundus tendon repair. Comparing the tensile strengths of 3 suture techniques. Saudi Med J 2016; 37:957-62. [PMID: 27570850 PMCID: PMC5039614 DOI: 10.15537/smj.2016.9.15069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Objectives: To investigate the tensile strength of repaired flexor profundus tendons in young lambs, which would be equivalent to repairs in children older than 2 years of age. Methods: A comparative in-vitro experimental study conducted at King Saud University, Riyadh, Kingdom of Saudi Arabia from October 2014 to December 2015. We utilized 30 flexor profundus tendons of young lambs with a width of 4 mm. All tendons were repaired with a 4-strand repair technique using 4/0 polypropylene core sutures. In group I (n=10 tendons), 2 separate figure-of-eight sutures were applied. In group II (n=10 tendons), simple locking sutures were added to the corners of 2 separate figure-of-eight sutures. In group III (n=10 tendons), the locked cruciate repair was used. All tendon repairs were tested to single-cycle tensile failure. Results: There was no significant difference between groups II and III with regards to gap and breaking forces; and all forces of these 2 groups were significantly higher than the forces in group I. Conclusion: It was concluded that 4 mm-wide pediatric flexor tendons allow a 4-strand repair and the use of 4/0 sutures. The use of locking sutures increases the tensile strength to values that may allow protective mobilization in children.
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Affiliation(s)
- Turki A Al-Thunayan
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia. E-mail.
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23
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Peltz TS, Haddad R, Scougall PJ, Nicklin S, Gianoutsos MP, Oliver R, Walsh WR. Structural Failure Mechanisms of Common Flexor Tendon Repairs. ACTA ACUST UNITED AC 2016; 20:369-79. [PMID: 26387996 DOI: 10.1142/s0218810415400092] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND This study investigated the exact failure mechanisms of the most commonly used conventional tendon repair techniques. A new method, radiographing repair constructs in antero-posterior and lateral projections before and after tensioning was used. This allowed to precisely analyse failure mechanisms in regards to geometrical changes in all three dimensions. Additionally the biomechanical stability focusing on gapping was tested. METHODS Sheep fore limb deep flexor tendons were harvested and divided in eight groups of ten tendons. Three common variants of the Kessler repair method and four common 4-strand repair techniques were tested. Additionally a new modification of the Adelaide repair was tested. RESULTS Biomechanical testing showed no significant differences in gapping for the three tested 2-strand Kessler repair groups. Once a double Kessler or 4-strand Kessler repair was performed the stability of the repair improved significantly. Further significant improvements in biomechanical stability could be achieved by using cross locks in the repair like in the Adelaide repair method. Qualitative analysis using radiographs showed that all Kessler repair variants unfolded via rotations around the transverse suturing component, no matter which variant was used. CONCLUSIONS Additional to the commonly described constriction of the repair construct, the rotating deformation is the main reason for repair site gapping in Kessler tendon repair methods. The term "locking" in a Kessler repair is misleading. The cruciate repairs tended to loose grip and drag (cheese-wire) through the tendon and therefore lead to gapping. The most stable repair constructs in all three dimensions were the Adelaide repair and its interlocking modification. This is due to the superior anchoring qualities of its cross locks and three dimensional stability.
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Affiliation(s)
- Tim Sebastian Peltz
- * Surgical & Orthopaedic Research Laboratories, University of New South Wales, Australia.,† Department for Plastic and Reconstructive Surgery, Prince of Wales Hospital, Australia.,‡ Department for Hand Surgery, Sydney and St Lukes Hospital, Sydney, Australia
| | - Roger Haddad
- * Surgical & Orthopaedic Research Laboratories, University of New South Wales, Australia
| | - Peter James Scougall
- * Surgical & Orthopaedic Research Laboratories, University of New South Wales, Australia.,‡ Department for Hand Surgery, Sydney and St Lukes Hospital, Sydney, Australia
| | - Sean Nicklin
- * Surgical & Orthopaedic Research Laboratories, University of New South Wales, Australia.,† Department for Plastic and Reconstructive Surgery, Prince of Wales Hospital, Australia.,‡ Department for Hand Surgery, Sydney and St Lukes Hospital, Sydney, Australia
| | - Mark Peter Gianoutsos
- * Surgical & Orthopaedic Research Laboratories, University of New South Wales, Australia.,† Department for Plastic and Reconstructive Surgery, Prince of Wales Hospital, Australia
| | - Rema Oliver
- * Surgical & Orthopaedic Research Laboratories, University of New South Wales, Australia
| | - William Robert Walsh
- * Surgical & Orthopaedic Research Laboratories, University of New South Wales, Australia
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24
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Gil JA, Skjong C, Katarincic JA, Got C. Flexor Tendon Repair With Looped Suture: 1 Versus 2 Knots. J Hand Surg Am 2016; 41:422-6. [PMID: 26787411 DOI: 10.1016/j.jhsa.2015.12.011] [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] [Received: 09/04/2015] [Revised: 12/07/2015] [Accepted: 12/08/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess the strength of flexor tendon repair with looped suture. We hypothesized that, after passing the intact looped suture in the desired repair configuration, splitting the loop and tying 2 independent knots would increase the strength of flexor tendon repair. METHODS Thirty-two flexor tendons were harvested and were sharply transected in zone II. The tendons were repaired with a 4-strand core suture repair using 3-0 looped nonabsorbable nylon suture. The harvested tendons were randomly assigned and repaired with either a 1- or a 2-knot construct. The repaired flexor tendons were fixed in a servohydraulic material testing system and were loaded to failure either with uniaxial tension or cyclically. RESULTS The average force at failure was 43 N for the 1-knot repair and 28 N for the 2-knot repair. The mode of failure of 15 of the flexor tendon repairs that were cyclically loaded to failure was suture pull-out. The average number of cycles and force in cyclic testing that caused failure of flexor tendon repairs was 134 cycles and 31 N for tendons repaired with looped 3-0 suture tied with 1 knot and 94 cycles and 33 N for tendons repaired with looped 3-0 suture tied with 2 knots. CONCLUSIONS Our hypothesis was disproved by the results of this study. CLINICAL RELEVANCE This study suggests that, when using looped suture, tying 2 independent knots instead of tying a single knot does not increase the strength of the flexor tendon repair.
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Affiliation(s)
- Joseph A Gil
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI.
| | - Christian Skjong
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI
| | - Julia A Katarincic
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI
| | - Christopher Got
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI
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25
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Tang JB, Zhou YL, Wu YF, Liu PY, Wang XT. Gene therapy strategies to improve strength and quality of flexor tendon healing. Expert Opin Biol Ther 2016; 16:291-301. [PMID: 26853840 DOI: 10.1517/14712598.2016.1134479] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Rupture of the repair and adhesion around a tendon are two major problems after tendon surgery. Novel biological therapies which enhance healing and reduce adhesions are goals of many investigations. Gene therapy offers a new and promising approach to tackle these difficult problems. In the past decade, we sought to develop methods to augment tendon healing and reduce tendon adhesion through gene therapy. AREAS COVERED This review discusses the methods and results of adeno-associated viral (AAV) type 2 vector gene therapy to increase tendon healing strength and reduce adhesions in a chicken model. Micro-RNA related gene therapy is also discussed. We also developed a controlled release system, which incorporates nanoparticles to deliver micro-RNAs to regulate tendon healing. EXPERT OPINION We obtained promising results of enhancement of tendon healing strength in a chicken model using AAV2-mediated gene transfer. AAV2-mediated micro-RNA transfer also limited adhesions around the tendon. Controlled release systems incorporating nanoparticles have ideally delivered genes to the healing tendons and resulted in a moderate (but incomplete) reduction of adhesions. It remains to be determined what the best doses are and what other factors are in play in adhesion formation. These are two targets in our future investigations.
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Affiliation(s)
- Jin Bo Tang
- a Department of Hand Surgery , The Hand Surgery Research Center, Affiliated Hospital of Nantong University , Nantong , Jiangsu , China
| | - You Lang Zhou
- a Department of Hand Surgery , The Hand Surgery Research Center, Affiliated Hospital of Nantong University , Nantong , Jiangsu , China
| | - Ya Fang Wu
- a Department of Hand Surgery , The Hand Surgery Research Center, Affiliated Hospital of Nantong University , Nantong , Jiangsu , China
| | - Paul Y Liu
- b Department of Plastic Surgery, Rhode Island Hospital , The Alpert Medical School of Brown University , Providence , RI , USA
| | - Xiao Tian Wang
- b Department of Plastic Surgery, Rhode Island Hospital , The Alpert Medical School of Brown University , Providence , RI , USA
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26
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Wu YF, Mao WF, Zhou YL, Wang XT, Liu PY, Tang JB. Adeno-associated virus-2-mediated TGF-β1 microRNA transfection inhibits adhesion formation after digital flexor tendon injury. Gene Ther 2015; 23:167-75. [PMID: 26381218 DOI: 10.1038/gt.2015.97] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 09/08/2015] [Accepted: 09/11/2015] [Indexed: 01/12/2023]
Abstract
Adhesion formation after digital flexor tendon injury greatly affects gliding function of the tendon, which is a major clinical complication after hand surgery. Transforming growth factor beta 1 (TGF-β1) has a critical role in adhesion formation during tendon healing. Persistent regulation of TGF-β1 through application of microRNA (miRNA) specifically inhibiting the function of TGF-β1 (TGF-β1-miRNA) holds promise for treatment of such a complication. Adeno-associated virus (AAV) was used to transfer TGF-β1-miRNA to the chicken digital flexor tendons, which had been injured and surgically repaired. Four doses of AAV2-TGF-β1-miRNA (2 × 10¹¹, 2 × 10¹⁰, 2 × 10⁹ and 2 × 10⁸ vector genomes (vg)) were used to determine the transfection efficiency. At postoperative 3 weeks, we found a positive correlation between the administered AAV2-TGF-β1-miRNA doses and transfection efficiency. The transfection rate ranged from 10% to 77% as the doses increased. Production of TGF-β1 protein in the tendons decreased on increasing vector dosage. When 2 × 10¹¹ and 2 × 10¹⁰) vg were injected into the tendon, gliding excursion of the repaired tendon and work of flexion of chicken toes were significantly increased and adhesion score decreased 6 and 8 weeks later, indicating the improvement of tendon gliding and decreases in adhesion formations. However, the ultimate strength of the tendons transfected at the dose of 2 × 10¹⁰ vg was 12-24% lower than that of the control tendons. The results of this study demonstrate that application of TGF-β1-miRNA had a mixed impact on tendon healing: adhesion around the tendon is reduced but strength of the tendon healing is adversely affected. Future studies should aim at maintaining the beneficial effects of reducing tendon adhesions, while eliminating the adverse effects of decreasing the healing strength.
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Affiliation(s)
- Y F Wu
- Hand Surgery Research Center, Department of Hand Surgery, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China
| | - W F Mao
- Department of Anatomy, Medical School of Nantong University, Nantong, Jiangsu, China
| | - Y L Zhou
- Hand Surgery Research Center, Department of Hand Surgery, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China
| | - X T Wang
- Department of Plastic Surgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - P Y Liu
- Department of Plastic Surgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - J B Tang
- Hand Surgery Research Center, Department of Hand Surgery, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China
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27
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Rodger MP, Theobald P, Giddins G. Vein grafts to augment flexor tendon repairs: a biomechanical study on strength and gap resistance. J Hand Surg Eur Vol 2015; 40:695-9. [PMID: 25541551 DOI: 10.1177/1753193414564902] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 11/22/2014] [Indexed: 02/03/2023]
Abstract
The ultimate tensile repair strength and gap formation of the pig extensor tendons repaired with a standard 4-strand Savage with epitendinous suture repair, was compared with a new technique of adding a vein sleeve. Force and displacement data were recorded, and video images during linear cyclic loading up to failure. At 35 N, video-graphic observation detected significantly smaller gap lengths in the standard and vein repair specimens compared with standard repair specimens (p = 0.047). The incidence of 3 mm gaps between the repaired tendon ends in the standard repair group was 20 %, but no 3 mm gaps were seen in the standard and vein specimens. The addition of a vein sleeve increased the ultimate tensile strength of the standard repair from 50.4 N (4.5) to 55.4 N (4.5); this was statistically significant (p = 0.03). This study demonstrated that the addition of a vein graft prevented gap formation and increased ultimate tensile strength of tendon repair.
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Affiliation(s)
- M P Rodger
- School of Engineering, Cardiff University, Cardiff, UK
| | - P Theobald
- School of Engineering, Cardiff University, Cardiff, UK
| | - G Giddins
- Department of Mechanical Engineering, University of Bath, Bath, UK
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28
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Jordan MC, Schmitt V, Dannigkeit S, Schmidt K, Meffert RH, Hoelscher-Doht S. Surgical adhesive BioGlue™ does not benefit tendon repair strength: an ex vivo study. J Hand Surg Eur Vol 2015; 40:700-4. [PMID: 25588666 DOI: 10.1177/1753193414566566] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 11/19/2014] [Indexed: 02/03/2023]
Abstract
UNLABELLED Surgical adhesives are useful supplements in surgery, but their benefit in tendon repair is uncertain. The purpose of this study was to evaluate the effect of BioGlue™ on strength of flexor tendon repair. A total of 60 porcine flexor tendons were divided into three groups. In group one, a conventional core and peripheral suture repair was used. In group two, a core suture and BioGlue™ were used. In group three, a conventional core and peripheral suture repair and BioGlue™ were used. We performed static and cyclic axial load testing and measured diameter of the repair site. We found that BioGlue™ did not improve the tensile strength when added to a core and peripheral suture and that there was an increase in bulk at the repair site. We conclude that BioGlue™ application cannot replace a peripheral suture as tensile strength significantly decreases without a peripheral suture, and it does not benefit a tendon already repaired with a core and peripheral suture. LEVEL OF EVIDENCE n/a.
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Affiliation(s)
- M C Jordan
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Clinics of Wuerzburg, Wuerzburg, Germany
| | - V Schmitt
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Clinics of Wuerzburg, Wuerzburg, Germany
| | - S Dannigkeit
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Clinics of Wuerzburg, Wuerzburg, Germany
| | - K Schmidt
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Clinics of Wuerzburg, Wuerzburg, Germany
| | - R H Meffert
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Clinics of Wuerzburg, Wuerzburg, Germany
| | - S Hoelscher-Doht
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Clinics of Wuerzburg, Wuerzburg, Germany
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Lee HI, Lee JS, Kim TH, Chang SH, Park MJ, Lee GJ. Comparison of Flexor Tendon Suture Techniques Including 1 Using 10 Strands. J Hand Surg Am 2015; 40:1369-76. [PMID: 26050206 DOI: 10.1016/j.jhsa.2015.03.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 03/11/2015] [Accepted: 03/12/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare mechanical properties of a multistrand suture technique for flexor tendon repair with those of conventional suture methods through biomechanical and clinical studies. METHODS We describe a multistrand suture technique that is readily expandable from 6 to 10 strands of core suture. For biomechanical evaluation, 60 porcine flexor tendons were repaired using 1 of the following 6 suture techniques: Kessler (2-strand), locking cruciate (4-strand), Lim/Tsai's 6-strand, and our modified techniques (6-, 8-, or 10-strand). Structural properties of each tenorrhaphy were determined through tensile testing (ultimate failure load and force at 2-mm gap formation). Clinically we repaired 25 flexor tendons using the described 10-strand technique in zones I and II. Final follow-up results were evaluated according to the criteria of Strickland and Glogovac. RESULTS In the biomechanical study, tensile properties were strongly affected by repair technique; tendons in the 10-strand group had approximately 106%, 66%, and 39% increased ultimate load to failure (average, 87 N) compared with those in the 4-, 6-, and 8-strand groups, respectively. Tendons in the 10-strand group withstood higher 2-mm gap formation forces (average, 41 N) than those with other suture methods (4-strand, 26 N; 6-strand, 27 N; and 8-strand, 33 N). Clinically, we obtained 21 excellent, 2 good, and 2 fair outcomes after a mean of 16 months (range, 6-53 mo) of follow-up. No patients experienced poor results or rupture. CONCLUSIONS The 10-strand suture repair technique not only increased ultimate strength and force at the 2-mm gap formation compared with conventional suture methods, it also showed good clinical outcomes. This multistrand suture technique can greatly increase the gap resistance of surgical repair, facilitating early mobilization of the affected digit. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Hyun Il Lee
- Department of Orthopaedic Surgery, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Jae Sung Lee
- Department of Orthopedic Surgery, College of Medicine, Chung-Ang University, Seoul, Korea
| | - Tae Hyuk Kim
- Department of Orthopaedic Surgery, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Seung-Hwan Chang
- School of Mechanical Engineering, Chung-Ang University, Seoul, Korea
| | - Min Jong Park
- Department of Orthopedic Surgery, Samsung Medical Center, SungKyunKwan University School of Medicine, Seoul, Korea
| | - Gi Jun Lee
- Department of Orthopaedic Surgery, MS Jaegeon Hospital, Daegu, Korea.
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30
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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.
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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.
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31
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Roushdi I, Cumberworth J, Harry LE, Rogers BA. Power tool injuries to the hand and wrist. Br J Hosp Med (Lond) 2015; 76:148-53. [PMID: 25761804 DOI: 10.12968/hmed.2015.76.3.148] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Power tool injuries to the hand and wrist are complex injuries which can have a profound impact on the function of the patient. This article gives an overview of the principles, and provides a systematic approach, to the management and rehabilitation of the injured limb and patient required to minimize future disability.
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Affiliation(s)
- I Roushdi
- ST8 in Trauma and Orthopaedics in the Department of Trauma and Orthopaedics, Brighton and Sussex University Hospital, Brighton BN2 5BE
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32
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Hassan S, Eisma R, Malhas A, Soames R, Harry L. Surgical simulation flexor tendon repair using Thiel cadavers: a comparison with formalin embalmed cadavers and porcine models. J Hand Surg Eur Vol 2015; 40:246-9. [PMID: 24436356 DOI: 10.1177/1753193413520281] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
UNLABELLED The aim of this study was to compare Thiel-embalmed cadavers with formalin-embalmed cadavers and porcine models in the surgical simulation repair of a Zone II flexor tendon division. Nine participants were recruited to the study. The models were assessed using a five-point scale. Assessment was divided into tissue quality, surgical approach and identification of structures. Thiel cadavers rated consistently higher compared with the formalin and porcine models (mean 37 SD 2, 22 SD 6 and 23 SD 5, respectively). Thiel cadavers recorded an average tendon glide of 21 mm SD 5, formalin cadavers 2 mm SD 2 and the porcine model 6 mm SD 2. We have demonstrated the benefit of Thiel embalming, with flexibility of tissues allowing testing of the repair of a flexor tendon in a realistic anatomical model. LEVEL OF EVIDENCE Level V.
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Affiliation(s)
- S Hassan
- Department for Plastic and Reconstructive Surgery, Ninewells Hospital and Medical School, Dundee, UK
| | - R Eisma
- Centre for Anatomy and Human Identification, University of Dundee, Dundee, UK
| | - A Malhas
- Department of Orthopaedics and Trauma Surgery, Ninewells Hospital and Medical School, Dundee, UK
| | - R Soames
- Centre for Anatomy and Human Identification, University of Dundee, Dundee, UK
| | - L Harry
- Department for Plastic and Reconstructive Surgery, Ninewells Hospital and Medical School, Dundee, UK
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33
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Jordan MC, Schmidt K, Meffert RH, Hoelscher-Doht S. Biomechanical analysis of flexor tendon repair using knotted Kessler and Bunnell techniques and the knotless Bunnell technique. J Hand Surg Am 2015; 40:115-20. [PMID: 25446999 DOI: 10.1016/j.jhsa.2014.09.015] [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] [Received: 04/15/2014] [Revised: 09/11/2014] [Accepted: 09/15/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate a knotless Bunnell suture in flexor tendon repair. METHODS Eighty porcine flexor digitorum tendons were assigned to 4 different suture techniques. Group 1 was repaired using a modified 4-strand knotted Kessler suture and served as a control group. Group 2 was repaired using a 4-strand knotted Bunnell suture. Group 3 used a 4-strand knotless Bunnell suture. Group 4 used a 4-strand knotless Bunnell and knotless peripheral suture. Under static and cyclic testing we studied mode of failure, 2-mm gap formation force, displacement, and maximum load. RESULTS The 4-strand knotless Bunnell suture did not show a notable difference with regard to 2-mm gap formation force, displacement, or maximum load in comparison to the modified 4-strand knotted Kessler suture. Adding a knotless peripheral suture improved the repair by a significant reduction of gap formation and displacement and an increase in maximum load. The 4-strand knotted Bunnell showed the highest maximum load but also a considerable lower resistance to gap formation and major displacement. CONCLUSIONS Flexor tendon repair using a 4-strand knotless Bunnell suture showed similar tensile strength to a modified 4-strand knotted Kessler suture. Adding a knotless peripheral suture further improved the repair. CLINICAL RELEVANCE A complete knotless 4-strand Bunnell suture including a barbed core- and peripheral suture might be an option for flexor tendon reconstruction.
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Affiliation(s)
- Martin C Jordan
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital, Würzburg, Germany
| | - Karsten Schmidt
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital, Würzburg, Germany
| | - Rainer H Meffert
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital, Würzburg, Germany
| | - Stefanie Hoelscher-Doht
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital, Würzburg, Germany.
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34
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Bellemère P, Ardouin L. [Primary flexor tendons repair in zone 2]. ACTA ACUST UNITED AC 2014; 33 Suppl:S28-43. [PMID: 25442406 DOI: 10.1016/j.main.2014.07.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Revised: 07/13/2014] [Accepted: 07/19/2014] [Indexed: 11/29/2022]
Abstract
Primary flexor tendon repair is still challenging even in the most experienced hands. With atraumatic surgery, the goal is to suture the tendon in a way that it will be strong enough to allow for tendon gliding without the risk of rupture or adhesions during the 12 weeks needed for the tendon to heal. After reviewing the zone 2 anatomy, the authors describe the state of art for flexor tendon repair along with their personal preferences. Although suture methods and postoperative rehabilitation programs are not universal, most specialized teams now use multistrand suturing techniques with at least 4 stands along with protected and controlled early active mobilization. Although the published rates of failure of the repair or postoperative adhesions with stiffness have decreased, these complications are still a concern. They will continue to pose a challenge for scientists performing research into the mechanics and biology of flexor tendon repairs, especially in zone 2.
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Galvez MG, Crowe C, Farnebo S, Chang J. Tissue engineering in flexor tendon surgery: current state and future advances. J Hand Surg Eur Vol 2014; 39:71-8. [PMID: 24262584 DOI: 10.1177/1753193413512432] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Tissue engineering of flexor tendons addresses a challenge often faced by hand surgeons: the restoration of function and improvement of healing with a limited supply of donor tendons. Creating an engineered tendon construct is dependent upon understanding the normal healing mechanisms of the tendon and tendon sheath. The production of a tendon construct includes: creating a three-dimensional scaffold; seeding cells within the scaffold; encouraging cellular growth within the scaffold while maintaining a gliding surface; and finally ensuring mechanical strength. An effective construct incorporates these factors in its design, with the ultimate goal of creating tendon substitutes that are readily available to the reconstructive hand surgeon.
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Affiliation(s)
- M G Galvez
- Division of Plastic & Reconstructive Surgery, Stanford University Medical Center, Stanford, CA, USA
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