In Vitro Comparison of Two Barbed Suture Configurations for Flexor Tendon Repair
14 July 2017
11 August 2017
06 November 2017 (eFirst)
Purpose The current study compares the strength of a previously studied technique for flexor tendon repair with barbed sutures to an experimental approach that aligns all the barbs to oppose distraction.
Methods Twelve flexor tendons from cadaveric specimens were mechanically tested following repair of simulated zone II tendon injuries. Two repair techniques utilizing barbed sutures were studied: the Marrero-Amadeo four-core barbed suture approach and the experimental configuration with all barbs on four cores opposing distraction. Maximum applied load at failure, that is, ultimate load, and 2-mm gap force were compared between the two repair techniques, both as raw values and after normalization to cross-sectional area of the intact tendon. Statistical testing was performed using t-tests and Mann-Whitney U-tests, where appropriate, with a significance level of 0.05.
Results The ultimate loads, raw (58.2 N) and normalized (4.8 N/mm2), were significantly larger for the Marrero-Amadeo repair than the proposed experimental approach (35.6 N and 2.7 N/mm2; p < 0.05). No significant differences were identified for 2-mm gap force.
Conclusion The innovation of suturing to align all barbs to oppose distraction does not improve strength of the repaired tendon. The Marrero-Amadeo technique was found to have superior strength for use in traumatic zone II flexor tendon injuries.
- 1 Bunnell S. Surgery of the Hand. Philadelphia, PA: J.B. Lippincott; 1948
- 2 Newmeyer III WL, Manske PR. No man's land revisited: the primary flexor tendon repair controversy. J Hand Surg Am 2004; 29 (01) 1-5
- 3 Strickland JW. Flexor tendon injuries: I. foundations of treatment. J Am Acad Orthop Surg 1995; 3 (01) 44-54
- 4 Trumble TE, Vedder NB, Seiler III JG, Hanel DP, Diao E, Pettrone S. Zone-II flexor tendon repair: a randomized prospective trial of active place-and-hold therapy compared with passive motion therapy. J Bone Joint Surg Am 2010; 92 (06) 1381-1389
- 5 Beredjiklian PK. Biologic aspects of flexor tendon laceration and repair. J Bone Joint Surg Am 2003; 85-A (03) 539-550
- 6 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 (02) e99-e108
- 7 Thurman RT, Trumble TE, Hanel DP, Tencer AF, Kiser PK. Two-, four-, and six-strand zone II flexor tendon repairs: an in situ biomechanical comparison using a cadaver model. J Hand Surg Am 1998; 23 (02) 261-265
- 8 Osei DA, Stepan JG, Calfee RP. , et al. 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 (02) 262-268
- 9 Taras JS, Raphael JS, Marczyk SC, Bauerle WB. Evaluation of suture caliber in flexor tendon repair. J Hand Surg Am 2001; 26 (06) 1100-1104
- 10 Alavanja G, Dailey E, Mass DP. Repair of zone II flexor digitorum profundus lacerations using varying suture sizes: a comparative biomechanical study. J Hand Surg Am 2005; 30 (03) 448-454
- 11 Aoki M, Manske PR, Pruitt DL, Larson BJ. Work of flexion after tendon repair with various suture methods. A human cadaveric study. J Hand Surg [Br] 1995; 20 (03) 310-313
- 12 Marrero-Amadeo IC, Chauhan A, Warden SJ, Merrell GA. Flexor tendon repair with a knotless barbed suture: a comparative biomechanical study. J Hand Surg Am 2011; 36 (07) 1204-1208
- 13 McClellan WT, Schessler MJ, Ruch DS, Levin LS, Goldner RD. A knotless flexor tendon repair technique using a bidirectional barbed suture: an ex vivo comparison of three methods. Plast Reconstr Surg 2011; 128 (04) 322e-327e
- 14 Parikh PM, Davison SP, Higgins JP. Barbed suture tenorrhaphy: an ex vivo biomechanical analysis. Plast Reconstr Surg 2009; 124 (05) 1551-1558
- 15 Trocchia AM, Aho HN, Sobol G. A re-exploration of the use of barbed sutures in flexor tendon repairs. Orthopedics 2009; 32 (10) DOI: 10.3928/01477447-20090818-12.
- 16 Chauhan A, Schimoler P, Miller MC, Kharlamov A, Merrell GA, Palmer BA. Comparing biomechanical properties, repair times, and value of common core flexor tendon repairs. Hand (N Y) 2017; DOI: 10.1177/1558944717701238.
- 17 Al-Qattan MM, Mirdad AT, Hafiz MO. Suture purchase length: a biomechanical study of flexor tendon repair in newborn lambs. J Hand Surg Am 2013; 38 (01) 62-65
- 18 Moriya T, Larson MC, Zhao C, An KN, Amadio PC. The effect of core suture flexor tendon repair techniques on gliding resistance during static cycle motion and load to failure: a human cadaver study. J Hand Surg Eur Vol 2012; 37 (04) 316-322
- 19 Zeplin PH, Zahn RK, Meffert RH, Schmidt K. Biomechanical evaluation of flexor tendon repair using barbed suture material: a comparative ex vivo study. J Hand Surg Am 2011; 36 (03) 446-449
- 20 Zeplin PH, Henle M, Zahn RK, Meffert RH, Schmidt K. Tensile strength of flexor tendon repair using barbed suture material in a dynamic ex vivo model. J Hand Microsurg 2012; 4 (01) 16-20
- 21 Godinsky RJ, Vrabec GA, Guseila LM, Filipkowski DE, Elias JJ. Biomechanical comparison of locked versus non-locked symphyseal plating of unstable pelvic ring injuries. Eur J Trauma Emerg Surg 2016; DOI: 10.1007/s00068-016-0661-x.
- 22 O'Brien III FP, Parks BG, Tsai MA, Means Jr KR. A knotless bidirectional-barbed tendon repair is inferior to conventional 4-strand repairs in cyclic loading. J Hand Surg Eur Vol 2016; 41 (08) 809-814
- 23 Nayak AN, Nguyen DV, Brabender RC. , et al. A mechanical evaluation of zone II flexor tendon repair using a knotless barbed suture versus a traditional braided suture. J Hand Surg Am 2015; 40 (07) 1355-1362
- 24 Schuind F, Garcia-Elias M, Cooney III WP, An KN. Flexor tendon forces: in vivo measurements. J Hand Surg Am 1992; 17 (02) 291-298