Epitendinous Suture Research Articles

Silfverskiold technique combined with dynamic splinting for treatment of digital extensor tendon rupture in zones III and IV

Objective To investigate the clinical results of Silfverskiold suture combined with dynamic splinting in treating extensor digitorum tendon rupture in zones Ⅲ and Ⅳ. Methods Between March 2010 and October 2013, a total of 67 patients with 85 extensor digitorum tendon lacerations in zones Ⅲ and Ⅳ were included in this study. The tendons were repaired using Silfverskiold technique which was a combination of modified Kessler core suture and running cross-stitch epitendinous suture. The patients began controlled exercise within seven days postoperatively wearing a dynamic extension splint. Active flexion and passive extension of the fingers were repeated ten times per hour. After three weeks, the dynamic splint was removed and the patients began active finger flexion and extension. Protective static splinting was continued with the interphalangeal joints in full extension between exercises and during the night for another 2 weeks. Results Postoperative follow-up period ranged from 3 to 6 months, with an average of 4 months. Forty-two of the 67 patients regained full range of motion within 9 weeks postoperatively. At the final follow-up evaluation, according to Miller′s criteria, the results were graded as excellent in 50 fingers, good in 30 fingers and fair in 5 fingers. The overall satisfactory rate was 94.1%. There was no rupture of the repaired tendons. Conclusion Silfverskiold suture combined with dynamic splinting is an effective treatment method for extensor digitorum tendon lacerations in zones Ⅲ and Ⅳ. It is safe and reliable. Key words: Tendon injuries; Rehabilitation; Silfverskiold technique; Dynamic splinting

Bifid Median Nerve Complete Transection at the Wrist.

A 17-yr-old male patient was admitted with a transverse sharp transection caused by broken glass at the volar aspect of his left wrist. Clinical examination showed loss of sensation at the distribution of the median nerve to the thumb, index, and middle finger and an inability to flex the middle finger. Under regional anesthesia and a high humerus tourniquet, surgical exploration of the wound with binocular loupe magnification showed a bifid median nerve with a persistent thin median artery running between the two nerve trunks. The bifid median nerve was sharply and transversely transected, slightly proximal to the transverse carpal ligament. The palmaris longus tendon and the flexor digitorum superficialis tendon of the middle finger were also cut. The flexor digitorum tendon was sutured with a two-strand technique augmented with a running epitendinous suture. The two trunks of the bifid median nerve were repaired separately using microsurgical technique and 8-0 nylon epineural sutures. Postoperatively, the hand was immobilized in a palmar short-arm splint that was removed at 40 d. A progressive Tinel sign was evident 30 d postoperatively. At 3 mo, the patient experienced light touch sensation at the tip of the index and middle fingers. At the last follow-up, 2.5 yr after his injury, the patient has complete nerve functional recovery without atrophy of the thenar muscles and with strong thumb opposition.

Barbed Suture in Tendon Repair

: Hand tendon lacerations are difficult to treat with over 25% of patients achieving an unsatisfactory clinical outcome as assessed by the clinician, and 7.7% of repairs re-rupture, requiring further surgery. The suture materials, which are available today possess tensile strengths capable of withstanding forces far above what occurs during active treatment. The current suture techniques have some disadvantages of bulky repair, adhesion formation and delayed tendon rupture. With availability of better designs of Barbed sutures like Quill™, Vloc™ and Stratafix™ it has opened up a scope for new research into tendon repair. Various ex vivo studies have shown that a four strand repair using barbed suture has similar strength to conventional repair and adding an epitendinous suture adds on to repair strength. The Barbed suture repair reduces the cross sectional area at repair site, which may translate to reduced gliding resistance. There is need for clinical studies to analyze the effectiveness of Barbed suture in tendon repair in clinical setting and explore the potential advantages. Level of evidence II Keywords: Barbed suture, Vloc, Quill, Stratafix, Tendon repair, Gliding resistance, Breaking strength.

Biomechanical Analysis of the Modified Kessler, Lahey, Adelaide, and Becker Sutures for Flexor Tendon Repair

To compare the biomechanical properties of the modified Kessler, Lahey, Adelaide, and Becker repairs, which are marked by either a locking-loop or a cross-lock configuration. Ninety-six lacerated porcine flexor tendons were repaired using the respective core suture and an epitendinous repair. Biomechanical testing was conducted under static and cyclic loads. Parameters of interest were 2-mm gap formation force, displacement during different loads, stiffness, maximum force, and mode of failure. The meaningful gap formation occurred in all 4 repairs at similar tension loads without any significant differences. Maximum force was highest in the Becker repair with a considerable difference compared with the modified Kessler and Lahey sutures. The Adelaide repair showed the highest stiffness. Overall, the displacement during cyclic loading demonstrated similar results with an exception between the Lahey and the Adelaide repairs at 10 Nload. Failure by suture pull-out occurred in 42% in the modified Kessler, in 38% in the Lahey, and in 4% in the Adelaide repairs. The Becker repair failed only by suture rupture. The results of our study suggest that the difference between the 4-strand repairs with a cross-lock or a locking-loop configuration is minor in regard to gap formation. A strong epitendinous suture and the application of core suture pretension might prevent differences in gapping. However, the modified Kessler and Lahey repairs had an inferior maximum tensile strength and were prone to early failure caused by the narrow locking loops with their limited locking power. We suggest that surgeons should use pre-tension in repaired tendons to improve gap resistance and should avoid narrow locking loop anchoring to the tendon.

The Effect of the Epitendinous Suture on Gliding in a Cadaveric Model of Zone II Flexor Tendon Repair

We hypothesized that increasing core sutures (4-6) may be preferable in terms of gliding coefficient (GC) measurements when compared with adding an epitendinous suture to zone II flexor tendon repairs. We hypothesized that the inclusion of epitendinous suture in 2 standard repairs would contribute negatively to the GC of the repaired tendon. Nineteen fresh-frozen cadaveric fingers were used for testing. We compared a control group (dissected digits without repair) and 4-strand or 6-strand core tendon repairs with and without epitendinous suture. Arc of motion was driven by direct loading, and digital images were acquired and analyzed. Outcomes were defined as the difference in GC between the native uninjured and the repaired state at each load. A linear mixed-model analysis was performed with comparisons between repairs to evaluate the statistically relevant differences between groups. The test of fixed effects in the linear model revealed that repair type and the use of epitendinous suture significantly affected the change in GC. The addition of an epitendinous suture produced a significant decrement in gliding regardless of repair type. There was significant improvement in GC with the omission of the epitendinous suture in both repair types (4- or 6-strand). The epitendinous suture used in this model resulted in poorer gliding of the repair, which may correspond with an expected increase in catching or triggering.

Biomechanical Evaluation of 4-Strand Flexor Tendon Repair Techniques, Including a Combined Kessler–Tsuge Approach

To test the ultimate tensile strength and stiffness of 3 flexor tendon repair techniques using looped suture material. Seventeen fresh porcine flexor tendons were randomized to a single-throw, 4-strand Kessler technique with a looped structure, a double-throw, 4-strand Tsuge technique with 2 looped structures, or a single-throw, 4-strand Kessler-Tsuge technique with a looped structure. Thirty additional fresh porcine flexor tendons were randomized to the same techniques but with a running epitendinous repair. We measured ultimate tensile strength to failure and stiffness and recorded the cause of failure. The Tsuge technique had the highest mean ultimate tensile strength at 75 N (SD, 14 N) versus 63 N (SD, 13 N) for the Kessler-Tsuge method and 46 N (SD, 11 N) for the Kessler technique. Differences between the Tsuge and Kessler-Tsuge, the Kessler-Tsuge and Kessler, and the Tsuge and Kessler techniques were significant. Mean suture stiffness was 6.8 N/mm for the Tsuge technique, 5.7 N/mm for the Kessler-Tsuge technique, and 4.6 N/mm for the Kessler technique. The difference between the Tsuge and Kessler techniques was significant. Analyzing the tests with or without an epitendinous suture separately did not affect the significance of the differences. The modified double-throw, 4-strand Tsuge was the strongest suture technique in this study. It may be a clinically acceptable, albeit slightly weaker alternative to the more complicated Tsuge method. A combined Kessler-Tsuge approach might be an option for flexor tendon repair.

A2 pulley integrity and the strength of flexor tendon repair: a biomechanical study in a chicken model.

This study assesses the influence of A2 pulley integrity on the strength of the repair. Part 1- The flexor digitorum profundus (FDP) tendons of 72 Cobb chicken feet were severed and repaired in the region of the A2 pulley using a modified Kessler core suture and an epitendinous suture. The A2 pulley was either left intact, divided for 50% of its length, or divided in its entirety. The distal interphalangeal joint was fixed at a position of 20°, 40° or 60° of joint flexion. The load to failure, integrity of the A2 pulley and the site of tendon failure were analysed. Part 2- A further 32 chicken feet were used to exclude the effects of freezing and thawing on results and to analyse differences when using a core suture only. No difference in failure load between any of the test groups or subgroups was identified. The integrity of the A2 pulley was preserved in all specimens. The most common cause of failure was distal suture pull-out. This study does not demonstrate that release of the A2 pulley provides an advantage in increasing tendon repair strength. Division of 50% of the A2 pulley does not predispose to pulley rupture. Flexor tendon repair strength did not alter with distal interphalangeal joint flexion between 20° and 60°. The findings of this study do not support division of the A2 pulley to prevent flexor tendon repair failure if repair methods of appropriate strength are utilised.

Biomechanical comparison of double grasping repair versus cross-locked cruciate flexor tendon repair.

This study was conducted to compare the in vitro biomechanical properties of tensile strength and gap resistance of a double grasping loop (DGL) flexor tendon repair with the established four-strand cross-locked cruciate (CLC) flexor tendon repair, both with an interlocking horizontal mattress (IHM) epitendinous suture. The hypothesis is that the DGL-IHM method which utilizes two looped core sutures, grasping and locking loops, and a single intralesional knot will have greater strength and increased gap resistance than the CLC-IHM method. Forty porcine tendons were evenly assigned to either the DGL-IHM or CLC-IHM group. The tendon repair strength, 2-mm gap force and load to failure, was measured under a constant rate of distraction. The stiffness of tendon repair was calculated and the method of repair failure was analyzed. The CLC-IHM group exhibited a statistically significant greater resistance to gapping, a statistically significant higher load to 2-mm gapping (62.0N), and load to failure (99.7N) than the DGL-IHM group (37.1N and 75.1N, respectively). Ninety percent of CLC-IHM failures were a result of knot failure whereas 30% of the DGL-IHM group exhibited knot failure. This study demonstrates that the CLC-IHM flexor tendon repair method better resists gapping and has a greater tensile strength compared to the experimental DGL-IHM method. The authors believe that while the DGL-IHM provides double the number of sutures at the repair site per needle pass, this configuration does not adequately secure the loop suture to the tendon, resulting in a high percentage of suture pullout and inability to tolerate loads as high as those of the CLC-IHM group.

Biomechanical Comparison of Different Suturing Techniques in Rabbit Medial Gastrocnemius Muscle Laceration Repair

Skeletal muscle laceration is a common injury. Repair of disrupted delicate tissue is still a clinical challenge for surgeons. A few different muscle repair techniques have been reported. However, the best muscle repair technique has not been identified. The aim of the present study is to compare the biomechanical features of different repair techniques in muscles to identify the most effective one. New Zealand white rabbits (2.5-3 kg) were euthanized and medial gastrocnemius muscles were isolated. The muscles were completely transected with scalpels and then repaired by 3 different techniques, namely, (1) 2-strand mattress, (2) 4-strand Kessler (with epitendinous suture), and (3) Mason-Allen. To measure suture performance, the repaired specimens were mounted onto a mechanical testing machine Instron 5543. The muscles were loaded to failure at a constant speed of 60 mm/min. Data collected from Merlin v5.31 software were used to compute the biomechanical properties of each specimen. There was no significant difference in the mean maximum load of Kessler group (15.5 N) and Mason-Allen group (13.2 N), whereas the mean maximum load of the control (Mattress) group (4.4 N) was significantly smaller than the other 2 groups. Moreover, Kessler stitches were the stiffest among the 3. It is noteworthy that the mechanisms of failure were different: Kessler stitches were all pulled out longitudinally, whereas Mason-Allen stitches transmitted load across the laceration and ruptures occur at areas adjacent to the stitches, indicating that muscle is the weakest element in the biomechanical testing. Both Kessler and Mason-Allen stitches have shown better biomechanical features compared with the control group. Further study has to be done to compare the effect of these 2 techniques on muscle regeneration and scar formation in an in vivo model.

MANAGEMENT OF FLEXOR TENDON INJURIES — PART 2: CURRENT PRACTICE IN AUSTRALIA AND GUIDELINES FOR TRAINING YOUNG SURGEONS

This study aims to gain a better understanding of current practice for the surgical management and rehabilitation of flexor tendon injuries in Australia, with the intent of establishing common guidelines for training of young surgeons. A survey was distributed to the membership of the Australian Hand Surgery Society to determine whether a consensus could be obtained for: suture material and gauge; core and epitenon suture techniques; sheath and pulley management; and post-operative protocols for primary flexor tendon repair. The predominant materials used for core suture are Ticron™ Suture (Tyco Healthcare Group LP, Norwalk, Connecticut, USA) (34%) and Ethibond™ Polyester Suture (Ethicon, Somerville, New Jersey, USA) (24%). The two core suture configurations commonly used are the Adelaide (45%) and Kessler (32%) repair. The predominant materials used for epitendinous sutures are 6-0 Prolene™ Polypropylene Suture (Ethicon, Somerville, New Jersey, USA) (56%), 5-0 Prolene™ (21%) and 6-0 Ethilon™ Nylon Suture (Ethicon, Somerville, New Jersey, USA) (13%); and the majority (63%) use a running epitendinous technique. The management of critical pulleys is variable, with 89% prepared to perform some release of A2 and A4 pulleys. Rehabilitation protocols vary widely, with 24% of respondents using the same method for all patients, while 76% tailor their approach to each patient. Some component of active motion was used by most. There exists some consensus on the management of flexor tendon injuries in Australia. However, the management of critical pulleys and methods of post-operative rehabilitation remain varied. For the training of young surgeons, a majority advise a 3-0 gauge braided polyester core suture of four strands, combined with a 6-0 Prolene™ simple running epitendinous suture for increased tendon repair strength and smooth glide. Trainees should attempt to retain the integrity of the A2 and A4 pulleys. Post-operative rehabilitation should include a component of active flexion.

Zone II Flexor Tendon Repair in a 13-Month-Old: Report of a Complication

Despite early cautions against the primary repair of zone II flexor tendon injuries, recent advances in surgical technique and suture materials have allowed such repairs to become commonplace. The 6-strand repair technique is rarely applied to the young pediatric population, however, to our knowledge, no English-language articles have described this method of primary repair in zone II of children less than 2 years old. A 13-month-old male presented flexor digitorum profundus repair after lacerating it in zone II on a sharp aluminum can. The tendon was repaired with a 6-strand technique, using a 4.0 Fiberloop for the core suture and 6.0 Prolene for the epitendinous suture. Approximately four months after surgery, the patient developed a palmar collection at the level of his middle phalanx and a serosanguinous sinus tract at the distal interphalangeal crease. During the revision surgery, the inspection of the repaired tendon revealed a small gap filled with scar tissue. There was no evidence of new fistula formation at his final visit one month after the second procedure. After the revision, the patient could move his digit with minimal loss of range of motion at the distal interphalangeal joints. Unfortunately, he was subsequently lost to follow up. This surgical technique was selected to provide a strong repair that would allow the early postoperative movement. In retrospect, a 6-strand repair with braided suture is not ideal in young children as the bulky suture can cause a foreign-body reaction and possibly extrude through the skin. Additionally, the immobilization with a long-arm cast remains a valuable tool after tendon repair in infants who cannot voluntarily restrict their movements.

Fibrin Glue Augmentation for Flexor Tendon Repair Increases Friction Compared With Epitendinous Suture

Purpose To compare the gliding resistance, repair gapping, and ultimate strength of a common suture construct with a modified construct with fibrin glue augmentation. Methods Twelve human cadaveric flexor digitorum profundus tendons were transected and repaired with a 4-strand core suture. Specimens were divided into 2 groups and augmented with epitendinous suture (n = 6) or fibrin glue (n = 6). We compared gliding resistance, 2-mm gapping, and ultimate strength of the repaired tendon between groups. Results The linear stiffness, force to produce a 2-mm gap, and ultimate failure were similar in both repair methods. However, the 4-strand suture repair with fibrin glue augmentation displayed significantly higher gliding resistance compared with the 4-strand suture with a running epitendinous suture. Conclusions The significantly increased gliding resistance associated with fibrin glue raises questions regarding the use of this material for flexor tendon repair augmentation. Clinical relevance In a human cadaveric study, fibrin glue augmentation to zone II flexor tendon repairs significantly increased friction in the tendon sheath compared with an epitendinous suture.

The Effect of Pulley Reconstruction on Maximum Flexion, Bowstringing, and Gliding Coefficient in the Setting of Zone II Repair of FDS and FDP: A Cadaveric Investigation

The purpose of this experiment was to determine the effect of A2 pulley reconstruction on gliding coefficient (GC), bowstringing, and proximal interphalangeal (PIP) joint maximum flexion angle after zone II repair of flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) lacerations. Fresh frozen cadaver forearms were mounted, and the wrist and MCP joints fixed. FDS and FDP tendons were dissected free, and sequential loads were applied while digital images were captured. The dissected digit with intact native A2 pulley, FDS, and FDP tendons was used as the control (group 1). Zone II lacerations followed by four-stranded repair of FDP plus epitendinous suture and repair of FDS were then performed, and the data recorded (group 2). A2 pulley excision and reconstruction with a loop of palmaris longus autograft was then completed and the specimens sequentially loaded and photographed (group 3). Using the digital images, GC, bowstringing, and maximum flexion angle were calculated. No difference in maximum flexion angle was observed across the three testing conditions. Zone II laceration and subsequent FDS and FDP tendon repair significantly increased the GC for group 2 specimens; however, pulley reconstruction alleviated some of this increase for group 3. Bowstringing was significantly greater after pulley reconstruction, with a mean increase of 1.9mm at maximum flexion for group 3 specimens relative to group 1 controls. Strong flexor tendon repairs are needed to prevent gap formation and subsequent triggering; however, the increased bulk from these large repairs can itself produce deleterious triggering, as well as tendon abrasion. Pulley reconstruction, in the setting FDP and FDS repair (group 3), significantly reduced the GC relative to tendon repair alone (group 2). While bowstringing was significantly greater after pulley reconstruction (group 3), it averaged only 1.9mm over group 1 specimens and did not compromise maximum flexion angle compared to the uninjured controls (group 1) or the isolated tendon repair digits (group 2).

The Effect of Core and Epitendinous Suture Modifications on Repair of Intrasynovial Flexor Tendons in an In Vivo Canine Model

To determine in vivo effects of modifications to core and epitendinous suture techniques in a canine intrasynovial flexor tendon repair model using clinically relevant rehabilitation. Our null hypothesis was that gap formation and rupture rates would remain consistent across repair techniques. We evaluated gap formation and rupture in 75 adult mongrel dogs that underwent repair of intrasynovial flexor tendon lacerations followed by standardized postoperative therapy. The current suture technique was a 4-0, 8-strand core suture with a purchase of 1.2 cm and a 5-0, epitendinous suture repair with a 2-mm purchase length and depth. We compared gap and failure by chi-square analysis to a historical group of in vivo repairs (n = 76) from the same canine model using 8-strand core suture repair with purchase of 0.75 cm and 6-0 epitendinous suture with a 1-mm purchase length and depth. A total of 93% of tendons (n = 70) demonstrated gapping of less than 3 mm using the current suture technique. Five percent of tendons (n = 4) had a gap of 3 mm or greater, and there was 1 repair site failure. This was significantly improved over the comparison group of historical 8-strand core repair technique, which resulted in 82% (n = 62) of repairs with a gap of less than 3 mm and 7 failures (9%). In an in vivo model, current modifications to suture techniques for intrasynovial flexor tendon repair demonstrated significant improvements in gap formation and rupture compared with a similar technique using shorter purchase lengths and shallower purchase depth. Suggested repair modifications for the treatment of zone II flexor tendon transections demonstrate improvements in gap formation and tendon rupture in vivo.

Comparison of modified Kessler and Yotsumoto-Dona suture: A biomechanical study on porcine tendons

There is a need for a strong suture technique that allows early active mobilisation after repair of flexor tendons, but the best method has not yet been found. The aim of this study was to compare the modified Kessler suture biomechanically with a newer, two–strand suture. Eighteen porcine tendons were cut and repaired according to either the grasping modified Kessler suture or the combined side-locking loop technique (Yotsumoto) and interlocking horizontal mattress suture (Dona). The specimens were tested linearly to failure. The 2 mm gap force, yield force, ultimate force, stiffness, energy to yield, and energy to failure were all significantly higher (p value = 0.005, 0.003, <0.001, 0.001, 0.004, and 0.001, respectively) in the Yotsumoto-Dona group (median values (IQR): 30.9 (28.1-39.5) N, 82.7 (64.9-114.1) N, 82.7 (76.6-114.1) N, 12.5 (10-14.5) N/mm, 0.45 (0.2-0.5) J, and 0.45 (0.35-0.5) J) than in the modified Kessler group (25.8 (12.2-28.1) N, 35 (24.6-54.4) N, 50.9 (34.4-55.1) N, 7 (5.8-91) N/mm, 0.09 (0.06-0.18) J, and 0.21 (0.18-0.28) J). All Yotsumoto-Dona specimens had a yield force exceeding 35 N, while in the Kessler group only four did. The early yielding rate was 6/9 and 2/9 in the modified Kessler and the Yotsumoto-Dona groups, respectively (p = 0.15). Most of the core sutures failed by breakage, but three Yotsumoto knots loosened. All the simple running and six of the Dona epitendinous sutures failed predominantly by pulling-out, and by breakage at the intersections in three of the latter. The relatively easy two-strand Yotsumoto-Dona suture is likely to withstand the loads of active finger flexion, whereas the modified Kessler suture is probably not.

A photoactivated nanofiber graft material for augmented Achilles tendon repair

Suture repair of Achilles tendon rupture can cause infection, inflammation and scarring, while prolonged immobilization promotes adhesions to surrounding tissues and joint stiffness. Early mobilization can reduce complications provided the repair is strong enough to resist re-rupture. We have developed a biocompatible, photoactivated tendon wrap from electrospun silk (ES) to provide additional strength to the repair that could permit early mobilization, and act as a barrier to adhesion formation. ES nanofiber mats were prepared by electrospinning. New Zealand white rabbits underwent surgical transection of the Achilles tendon and repair by: (a) SR: standard Kessler suture + epitendinous suture (5-0 vicryl). (b) ES/PTB: a single stay suture and a section of ES mat, stained with 0.1% Rose Bengal (RB), wrapped around the tendon and bonded with 532 nm light (0.3 W/cm(2) , 125 J/cm(2) ). (c) SR + ES/PTB: a combination of (a) and (b). Gross appearance, extent of adhesion formation and biomechanical properties of the repaired tendon were evaluated at Days 7, 14, or 28 post-operatively (n = 8 per group at each time point). Ultimate stress (US) and Young's modulus (E) in the SR group were not significantly different from the ES/PTB group at Days 7 (US, P = 0.85; E, P = 1), 14 (US, P = 0.054; E, P = 1), and 28 (US, P = 0.198; E, P = 0.12) post-operatively. Adhesions were considerably greater in the SR group compared to the ES/PTB group at Days 7 (P = 0.002), 14 (P < 0.0001), and 28 (P < 0.0001). The combination approach of SR + ES/PTB gave the best outcomes in terms of E at 7 (P < 0.016) and 14 days (P < 0.016) and reduced adhesions compared to SR at 7 (P < 0.0001) and 14 days (P < 0.0001), the latter suggesting a barrier function for the photobonded ES wrap. Photochemical sealing of a ES mat around the tendon repair site provides considerable benefit in Achilles tendon repair. Lasers Surg. Med. 44: 645-652, 2012. © 2012 Wiley Periodicals, Inc.

Effect of Platelet-Rich Plasma With Fibrin Matrix on Healing of Intrasynovial Flexor Tendons

To investigate the effects of platelet-rich plasma (PRP) with fibrin matrix on the healing of intrasynovial flexor tendons in a rabbit model in vivo. We transected and repaired 156 toe flexors of 73 rabbits using the technique of Tsuge et al and a simple running epitendinous suture. We randomly assigned Repaired tendons to groups that recieved no additional treatment (control) or to which we applied PRP, fibrin (F), or PRP with fibrin matrix (PRP-F) at the repair site. We scored edema and adhesion at 2, 3, and 6 weeks after surgery, and linearly tested repaired tendons for load to failure. We also histologically evaluated tendons at 2 and 3 weeks. Edema scores and adhesion scores did not significantly differ among the 4 groups at any time point. Mean load to failure in the PRP-F group (14.7 N) was the highest among the 4 groups at 2 weeks after surgery, and was significantly higher than in the control group (10.0 N). Median histological scores in the PRP-F group (3.3 points) were significantly higher than in the control group (1.0 point). Mean load to failure in the PRP-F group (16.1 N) was highest, and median histological scores in the PRP-F group (3.5 points) were higher than in the control group (2.4 points) at 3 weeks, although there were no significant differences at 3 or 6 weeks. In a rabbit model of cut flexor tendons, PRP with fibrin matrix significantly increased healing strength within 2 weeks after surgery. Side effects such as increases in toe edema or adhesions around the tendons did not arise. Platelet-rich plasma with fibrin matrix might help reduce the risk of repeated rupture after flexor tendon surgery, and lead to early rehabilitation.

Dynamic Splinting With Early Motion Following Zone IV/V and TI to TIII Extensor Tendon Repairs

To investigate the influence of a dynamic splinting protocol on outcomes of extensor tendon repairs. All patients in a prospectively collected database underwent extensor tendon repair by a single surgeon between 2004 and 2008. The inclusion criterion was simple extensor tendon repairs in zone IV and V in the fingers and zones TI to TIII in the thumb. The tendon repairs used a 4-strand core technique and running epitendinous suture. Within 7 days, each subject began using a dynamic extension splint during the day and a static extension splint at night. The extension splint allowed the patient to passively extend and actively flex the digits. After 3 weeks, the dynamic splint was discontinued and the patients were started on active digital motion. Static night splinting was continued for the next 3 weeks, after which time splinting was discontinued and strengthening was instituted. A total of 17 patients with 19 tendon lacerations met the inclusion criterion. There were 5 patients with lacerations of the thumb extensors and 12 patients with zone IV/V finger extensor tendon lacerations. The average time from injury to surgery was 11 days (range, 2-39 d). The follow-up was 43 to 215 days, with an average of 96 days. A total of 16 patients achieved good or excellent results by 6 weeks according to our grading system. One patient had a fair result. There were no ruptures and no tenolysis surgeries performed. Dynamic splinting resulted in generally good functional outcomes for extensor tendon laceration repairs in zone IV/V and TI to TIII, without complications. Therapeutic IV.

Complications After Flexor Tendon Repair: A Systematic Review and Meta-Analysis

Although outcomes after flexor tendon repair have reportedly improved with modern treatment, complications are common. The purpose of this study was to determine the incidence of these complications and the potential contributory factors within the published literature. We performed a systematic review of the available literature to identify publications in which patients with flexor tendon ruptures were surgically treated. We extracted demographics, zone of injury, core suture technique (only modified Kessler or a combination of techniques), use of epitendinous suture, and date of publication (before or after January 1, 2000). We excluded articles if they did not report information on reoperation, rupture, or adhesions. We used unadjusted pooled meta-analysis to report the incidence of complications, and meta-regression to describe the potential contributory factors for each complication while controlling for age, gender, and zone of injury. Unadjusted meta-analysis revealed rates of re-operation of 6%, rupture of 4%, and adhesions of 4%. Meta-regression analysis of 29 studies showed that core suture technique or use of an epitendinous suture does not influence rupture. However, the presence of an epitendinous suture decreases re-operation by 84%. Adhesion development is 57% lower when the modified Kessler technique is used. The incidence of complications did not vary with publication date. The published literature supports use of the modified Kessler repair technique with an epitendinous suture to minimize complications. Although complication rates are low, our data suggest that there has been no definitive improvement in reported complications before and after 2000.

The Use of Ultrasound in Evaluating Flexor Tendons following Surgical Repair

Sir:FigureZone 1 and 2 flexor tendon repairs are associated with difficult repairs and poor outcomes. Clinical scores cannot differentiate between repair rupture and tendon adhesions in a poorly scoring digit. Ultrasound is not used routinely postoperatively but is used when concern regarding the integrity of the repair exists. High-resolution transducers can be used to assess repair integrity, tendon excursion, and adhesions.1,2 This study aimed to assess whether ultrasound can accurately evaluate zone 1 and 2 flexor tendon repairs and whether imaging provided useful clinical information. A series of patients attended postoperatively for ultrasound of their injured digit. Inclusion criteria were zone 1 and 2 complete flexor tendon lacerations. Concomitant neurovascular injuries were included, but patients with additional injuries were excluded. Patients underwent tendon repair with a four-strand core tendon repair using a 3-0 polypropylene suture and a 6-0 polypropylene epitendinous suture. Subjects were splinted dorsally for 6 weeks, and early active mobilization was commenced. Between postoperative weeks 6 and 8, the injured digit(s) and the uninjured contralateral digit were scanned. High-frequency (12-MHz) linear array ultrasound including color flow Doppler was performed at rest and during active flexion and extension. For each tendon repair site, repair integrity, tendon thickness, tendon glide, presence of adhesions, and vascularity were recorded. Corresponding values were obtained from the contralateral uninjured digit. Tendon glide was graded as unimpaired or mildly, moderately, or severely impaired. Vascularity was noted as equal, increased, or decreased compared with normal. A Strickland score was calculated for each injured digit.3 Paired samples t tests were carried out. A value of p ≤ 0.05 was considered significant. Ultrasonic data of the tendon repair were compared with the scanned uninjured tendon and the Strickland score. Fifteen patients participated with a total of 17 injured digits and 23 injured tendons. Nine had neurovascular injuries. Ultrasound scans were obtained at a mean of 50 days postoperatively. The majority of Strickland scores were good/excellent (eight) or fair (six). Three had poor scores. All repairs were imaged intact. Vascularity was increased in two patients. High-quality images of flexor tendons, repair sites, neurovascular bundles, and annular pulleys were obtained consistently (Figs. 1 and 2). When adhesions were present, the distinction between tendon and scar tissue was difficult but possible. On dynamic scanning, tendon glide was easily visualized.Fig. 1: Transverse color Doppler image of a digit in which the radial digital artery but not the ulnar digital artery has been repaired. The flexor tendons are visible in the center of the image, with the two flexor digitorum superficialis slips inferior to the flexor digitorum profundus tendon.Fig. 2: Transverse view of zone 2 flexor digitorum profundus repair close to the proximal interphalangeal joint. The two white spots at the center top part of the image are end-on views of the suture material. The flexor digitorum superficialis slips are directly underneath the repaired flexor digitorum profundus tendon.On average, flexor tendon repair sites were 50 percent thicker in the anteroposterior diameter and 25 percent wider in the radioulnar diameter compared with unrepaired tendons (p = 0.001). Two digits had unimpaired tendon glide, six had mild impairment, six had moderate impairment, and three had severe impairment of glide. Sixty percent of those with good/excellent Strickland scores had good tendon mobility compared with 25 percent of those with fair scores. Ultrasound provided tangible, clinically relevant information about surgical repairs and clinical progress of patients. High-frequency linear array probes of a small size are ideal for hand imaging, providing clear images with excellent resolution of anatomical structures and dynamic images of tendon glide.4,5 Our study confirmed the feasibility of using ultrasound in this patient cohort. Ultrasound is useful in identifying tendon rupture or excessive adhesions, and could be used as a method of stratifying patients with poor outcomes to the appropriate rehabilitation program. Nora Nugent, F.R.C.S.I.(Plast.) Department of Plastic and Reconstructive Surgery Joseph Coyle, M.B., B.Ch. Josephine Barry, M.R.C.P., F.R.C.R. Department of Radiology Michael O'Shaughnessy, F.R.C.S.(Plast.) Department of Plastic and Reconstructive Surgery, Cork University Hospital, Wilton, Cork, Ireland DISCLOSURE No financial support was received for this study and none of the authors has any financial interests to declare.