Peripheral Suture Technique Research Articles

Meniscal Allograft Transplantation: Indications, Techniques, Outcomes

AbstractMeniscal allograft transplantation (MAT) has become an acceptable surgical treatment for select symptomatic and relatively young (<50 years of age) patients with a meniscal deficiency. MAT may also be considered in meniscal-deficient patients undergoing anterior cruciate ligament reconstruction and/or articular cartilage repair procedure in the ipsilateral compartment. Contraindications to MAT include asymptomatic patients, severe osteoarthritis, uncorrectable malalignment or instability, irreparable chondral damage, active infection, or inflammatory arthropathy. Most institutions prefer the use of fresh-frozen allografts, whereas the use of fresh-viable grafts is limited by their availability, and the use of cryopreserved and lyophilized grafts has gone out of favor. Donor allografts are size-matched to the recipient using x-rays or magnetic resonance imaging measurements. To date, no particular surgical technique has demonstrated superiority. Therefore, there are several used approaches (mini-open or arthroscopic), horns-fixation techniques (soft-tissue, bone-plugs, or bone-bridge), and peripheral suture techniques (inside-out or all-inside). Ipsilateral malalignment, instability, and/or chondral defects should be corrected or repaired if MAT is being performed. MAT survival rates are estimated at 73.5% at 10 years and 60.3% at 15 years. Mean time-to-failure is ∼8.2 and ∼7.6 years for a medial and lateral meniscus transplant, respectively. Significant improvement in patient-reported outcomes is expected following MAT, and 90% of patients will attest they will undergo the procedure again. Reoperation rates are estimated at 32%, with the most common complication being a tear of the meniscal allograft. Many studies reporting on outcomes of MAT are flawed because of low-quality, the use of non-fresh-frozen preservation techniques, and heterogeneity of patients and concomitant procedures. As our knowledge regarding patient selection, graft preparation, and techniques continue to develop, we expect MAT outcomes to improve much further.

The impact of different peripheral suture techniques on the biomechanical stability in flexor tendon repair

Flexor tendon repair consists of circumferential peripheral sutures in combination with core sutures to avoid fraying and reduces the exposure of suture material on tendon surface. The peripheral suture adds up to a tenfold increase of the biomechanical stability compared to the core suture alone. The purpose of our study was to determine the most favourable peripheral repair technique for tendon repair. Seventy-two porcine flexor tendons underwent standardized tenotomy and repair using one of the following six methods (n = 12): simple-running (SR), simple-locking (SL), Halsted-mattress (HM), lin-locking (LL), Lembert-mattress (LM), and Silfverskiöld cross-stich (SCS) suture technique. The SL- suture was placed 2mm; the HM, LM, SC, and LL suture were placed 5mm from the tendon gap. The SR suture was placed 1, 2, and 3mm from tendon ends; no additional core suture was applied. For cyclic testing (1000 cycles), elongation was calculated; for load to failure construct stiffness, yield load and maximum load were determined. The mean cyclic elongation for all tested suture techniques was less than 2mm; there was no significant difference between the groups regarding elongation as well as yield load. The HM, LM, SCS, and LL suture techniques presented significantly higher maximum loads compared to the SR- and SL-sutures. The 3mm SR showed significantly higher maximum loads compared to the 2 and 1mm SR. Beside the distance from tendon gap, the type of linkage of the suture material across and beneath the epitendineum is important for biomechanical stability. Simple-running suture is easy to use, even with a slight increase of the distance from tendon gap significantly increases biomechanical strength. For future repairs of flexor tendon injuries, 3mm stitch length is highly recommended for simple peripheral suture, while the Halsted-mattress suture unites the most important qualities: biomechanically strong, most part of suture material placed epitendinous, and not too complicated to perform.

Symmetric Peripheral Running Sutures are Superior to Asymmetric Peripheral Running Sutures for Increasing the Tendon Strength in Flexor Tendon Repair.

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. 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. 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. Symmetric running sutures can enhance the suture strength and appears to be a useful technique for increasing the strength of the peripheral suture.

Flexor tendons repair: Effect of core sutures caliber with increased number of suture strands and peripheral sutures. A sheep model

BackgroundSurgeons have aimed to achieve strong repair so as to begin early active rehabilitation programs for flexor tendon injury. Multi-strand suture techniques were developed to gain improved gap resistance and ultimate force compared with the respective two-strand techniques. In vivo studies indicate that multiple strands may cause ischemia during the intrinsic healing process by decreasing the total cross-sectional area of the injured site, unless the total cross-sectional area of the sutures is not decreased. HypothesisThe hypothesis was to design an in vitro study to understand the biomechanical relationship between suture calibers of core sutures with increased number of suture strands and peripheral suture on final repair strength. Materials and methodsSixty fresh sheep forelimb flexor digitorum profundus tendons were randomly placed into three groups (A, B, and C), each containing 20 specimens, for tendon repair. Two-, four-, and eight-strand suture techniques were respectively used in Groups A, B, and C. A simple running peripheral suture technique was used in Subgroups A2, B2, and C2. For each repaired tendon, the 2-mm gap-formation force, 2-mm gap-formation strength, maximum breaking force and maximum breaking strength were determined. ResultsDifferences in 2-mm gap-formation force and 2-mm gap-formation strength were found between Subgroups A1 and A2, B1 and B2, and C1 and C2. Between Groups A and B, A and C, and B and C, there was no difference as well. ConclusionBoth the number of strands and the ratio between the total suture volume and tendon volume at the repair site are important for ideal repair. If the total cross-sectional area of the sutures is equal in 2-strand, 4-strand, and 8-strand procedure, there is no difference in the strength of the repair. A decrease in caliber size suture requires more passes to achieve the same strength. Instead, it is much better to use peripheral suture techniques to improve the strength of the repair with larger diameter 2-strand core sutures.

The biomechanical assessment of gap formation after flexor tendon repair using partial interlocking cross-stitch peripheral sutures

The gap formation of five core plus peripheral suture techniques for flexor tendon repair was evaluated by cyclic load testing. Fifty pairs of dental roll tendon models were sutured using six-strand Pennington modified Kessler core suture with 4-0 Polypropylene. One-half or three-fourths circumferential interlocking cross-stitch, or three complete circumferential peripheral suture techniques were performed using 6-0 Polypropylene. An initial cyclic load of 10 N for 500 cycles was applied and increased by 5 N for an additional 500 cycles at each new load until rupture. The complete circumferential interlocking cross-stitch had the greatest fatigue strength. The partial circumferential cross-stitches resulted in significantly larger gap formations at both the repaired and unrepaired sides than the complete circumferential sutures, and were also associated with early rupture. The full circumference of the cut tendon must be sutured using an interlocking cross-stitch peripheral suture to improve strength and avoid gap formation.

Biomechanical Properties of a New Multilocking Loop Peripheral Suture Technique for the Repair of Flexor Tendons: A Comparative Experimental Study

Biomechanical Properties of a New Multilocking Loop Peripheral Suture Technique for the Repair of Flexor Tendons: A Comparative Experimental Study

Biomechanical Properties of a New Multilocking Loop Peripheral Suture Technique for the Repair of Flexor Tendons: A Comparative Experimental Study

Biomechanical Properties of a New Multilocking Loop Peripheral Suture Technique for the Repair of Flexor Tendons: A Comparative Experimental Study

Biomechanical Properties of a New Multilocking Loop Peripheral Suture Technique for the Repair of Flexor Tendons

We aimed to evaluate the biomechanical properties of a new multilocking loop peripheral suture technique. For this aim, 40-deep digital flexor tendons of adult male sheep front limb were divided and then repaired using one of the following methods: simple peripheral suture plus 2- or 4-strand Kessler core suture or a new multilocking loop peripheral suture combined with either 2- or 4-strand Kessler core suture. Intact tendons were used as controls. The following biomechanical parameters were tested: ultimate tensile strength, energy to failure, 2-mm gap formation force, stiffness, and mechanism of failure. Regardless of the number of core suture strands, the new technique resulted in greater ultimate tensile strength, energy to failure, 2-mm gap formation force, and stiffness values, compared with simple running peripheral suture. In conclusion, the new multilocking loop peripheral suture technique represents a biomechanically strong and technically suitable method for flexor tendon repair.

Strength enhancement of the interlocking mechanism in cross-stitch peripheral sutures for flexor tendon repair: biomechanical comparisons by cyclic loading

The fatigue strength of three peripheral suture techniques for flexor tendon repair was compared by cyclic loading of repairs in a cotton dental roll tendon model. Thirty pairs of dental roll were sutured using only peripheral sutures with 6-0 polypropylene. An initial cyclic load of 5 N for 500 cycles was applied and increased by 5 N for an additional 500 cycles at each new load until rupture. The fatigue strength of an interlocking cross-stitch suture was 113% greater than a running suture and 36% greater than a standard cross-stitch suture. Interlocking the cross-stitch prevented shortening of the transverse portions under load and appears to be a useful technique for increasing the strength of the peripheral suture.

A-0389 The effect of repair width on the strength of the silferskiold peripheral suture technique

A-0389 The effect of repair width on the strength of the silferskiold peripheral suture technique

Optimizing biomechanical performance of the 4-strand cruciate flexor tendon repair

Purpose The purpose of this study was to determine whether increasing the size of the locking loop increased the repair strength of the cruciate 4-strand suture technique and to quantify the biomechanical properties that various peripheral suture techniques provide in the cruciate 4-strand suture technique. Methods Fifty-six deep flexor tendons harvested from adult sheep hind limbs were divided randomly into 7 groups of 8. Four groups were repaired using the cruciate core technique without a peripheral suture. The locking loops were set using 10%, 25%, 33%, or 50% of the tendon width and loaded to failure using a distraction rate of 20 mm/min. The 3 groups of tendons then were repaired by using the established optimal locking loop size. These 3 groups were combined with a simple running, cross-stitch, or the interlocking horizontal mattress (IHM) peripheral suture. Repairs were tested to failure and the load at a 2-mm gap, load at failure, and stiffness were determined for all samples. Results Repairs with locking loops of 25% had the greatest biomechanical properties with load to 2-mm gap formation, load to failure, and stiffness of 10 N, 46.3 N, and 3.9 N/mm, respectively. Those with 33%, 50%, and 10% locking loops followed. Repairs with 10% locking loops failed owing to the suture cut out of the tendon. All other groups failed because of suture breakage. By using the cruciate core technique with a 25% locking loop the IHM/cruciate combination was markedly better than both the cross-stitch/cruciate and simple running/cruciate combinations. Conclusions The ideal-sized bite of the locking loops for the cruciate repair is 25% of the tendon’s width. Peripheral sutures are vital to the biomechanical properties of the repair. The IHM peripheral suture technique provided the greatest improvement in biomechanical properties.

Biomechanical study on a new peripheral suture method for flexor tendon repair

目的 通过比较连续周边缝合( Running)、 Cross-stitch、 Halsted及一种新型肌腱周边缝合方法的生物力学特性,为该方法的临床应用提供理论依据.方法将 36根新鲜成年猪后蹄Ⅱ区屈肌腱随机分成 4组,分别用连续周边缝合( Running)、 Cross-stitch、 Halsted及一种新型肌腱周边缝合方法进行修复.将缝合好的肌腱等速拉伸至完全断裂,并用材料力学测定仪( Instron 4411)测定 2-mm间隙形成负荷、最大负荷,计算断裂功耗. 结果新型肌腱周边缝合法的 2-mm间隙形成负荷为 (53.2± 6.0)N、最大负荷为 (68.8± 6.9)N、刚度为 (6.6± 0.7)N/mm,为各组中最高;断裂功耗为 (0.784± 0.075)J与 Halsted法相近 ,高于 Cross-stitch及 Running法. 结论该新型肌腱周边缝合法的生物力学强度高于目前临床应用的 Running、 Cross-stitch、 Halsted法,能提供较大的抗张强度、有效抵御间隙形成、操作简便,有利于肌腱早期主被动功能锻炼.

Effect of peripheral suture depth on strength of tendon repairs

The peripheral suture in flexor tendon repairs was originally introduced to "tidy up" the repair site and to improve gliding after core suture placement. More recently, it has been proposed that the peripheral suture can be an important structural component of tendon repair; yet, the effect of peripheral suture technique as an independent factor on the strength of the tendon repair has had little attention. We proceeded to determine whether differing levels of penetration of the tendon by the peripheral suture significantly affect the strength of the repair. We performed tensile tests on two groups of fresh frozen cadaver flexor digitorum superficialis tendons that had lacerations repaired by modified Kessler core sutures: one group had supplemental superficial peripheral sutures while the other group had supplemental deep (half the depth to the center of the tendon) peripheral sutures. The mean failure load of the deep peripheral suture group (38.96 N) was almost 80% greater than that of the superficial suture group (21.68 N). This increased strength may be due to an improved tendon-suture interface, with the deep peripheral suture acting as an auxiliary core suture. Our results with deep peripheral sutures, a simple technique based on a modification of commonly employed suture patterns, demonstrate substantially improved repair strength. This suture has the potential to be used in conjunction with early active finger motion rehabilitation program after flexor tendon repair.

Strength of the suture in the epitenon and within the tendon fibres: Development of stronger peripheral suture technique

In tendon repair, the peripheral stitches are usually placed in the epitenon, but it has not yet been defined whether the grasping strength of the sutures in the epitenon and within the tendon fibres are different. The first stage of this work investigated this difference and found that peripheral stitches within cadaveric tendon fibres were 83% stronger than those in the epitenon layer. A new peripheral stitch, based on this finding, has been designed. Mechanical tests of a range of peripheral suture types in vitro found that the new technique gave a resistance to gap formation twice that of the peripheral stitches commonly in use at present and a rupture strength more than three times, while still avoiding eversion problems.

Flexor tendon repair: Significant gain in strength from the halsted peripheral suture technique

A biomechanical study in vitro has evaluated a new modification of the core and peripheral suture technique for flexor tendon repair. Groups of repairs were conducted in cadaver tendons, using a core suture alone, a core suture with a simple running surface suture and a new modification involving a 'Halsted' horizontal mattress technique for the peripheral stitch. The Halsted modification increased the load at which a visible gap formed by 93%, the load at which a 2 mm gap formed by 77%, and the maximum strength by 89%. This increase was due to the technique; it did not depend on the suture material used. The bulk of the tendon repair was not significantly greater with the Halsted modification.

Flexor tendon repair: significant gain in strength from the Halsted peripheral suture technique.

A biomechanical study in vitro has evaluated a new modification of the core and peripheral suture technique for flexor tendon repair. Groups of repairs were conducted in cadaver tendons, using a core suture alone, a core suture with a simple running surface suture and a new modification involving a 'Halsted' horizontal mattress technique for the peripheral stitch. The Halsted modification increased the load at which a visible gap formed by 93%, the load at which a 2 mm gap formed by 77%, and the maximum strength by 89%. This increase was due to the technique; it did not depend on the suture material used. The bulk of the tendon repair was not significantly greater with the Halsted modification.

A contribution to peripheral nerve suture technique.

A contribution to peripheral nerve suture technique.