- See:
discussion flexor tendon repair: theory and modes of failure
- Discussion:
- consider use of the
tenofix device;
- ref:
Device for Zone-II Flexor Tendon Repair. A Multicenter, Randomized, Blinded, Clinical Trial.
-
Bury the Knot:
- which ever technique is used, a knot should never be left on the outer surface of the flexor tendon;
- to bury the knot, use a knife to make a small longitudinal slit in the flexor tendon and bring the suture arms out through this slit;
- the knot is then thrown, and it will remain buried underneath the tendon surface;
-
Kessler Repair:
- Kessler grasping stitch or similar core suture methods of flexor tendon repair are popular types of flexor tendon repair;
-
Tajima Modification:
- in which suture knots are tied w/ in repair site, is convenient since sutures are placed in tendon ends & ends are then used to pass
tendon thru flexor tendon sheath and run into position for repair w/o need to further damage tendon by instrumentation;
-
4 strand cruciate repair:
- technique:
- a small 2 mm slit is made on the side of the tedon, 1 cm from the tendon edge;
- suture needle is inserted into the side of the tendon (thru the slit), 1 cm from the severed tendon edge, and is passed longitudinally out of the tendon edge;
- needle is then passed into the corresponding severed tendon edge and is passed longitudinally 1 cm out of the side of the tendon;
- suture is then reinserted a few mm distal to its exit point (no locking), and is directed in a cross-wise fashion to exit in the middle of the tendon laceration site;
- suture is reintroduced into the opposite tendon segment and continues across in crossing direction, and is brought out on the
opposite tendon side (1 cm from the laceration site);
- suture is introduced a few mm distal (no locking) and is directed longitudinally across the laceration site;
- suture is then passed back crossing the middle of the laceration site to exit next to the free tendon edge;
- make sure the slack is removed with each pass of the suture;
- because the core suture is non-locking, additional tightening is possible before the knot is tied;
- after the knot is tied, it is buring inside of the slit;
- outcomes:
- in the study by E. McLarney MD et al 1999, this repair technique was faster than the other major repair techniques and was significantly
stronger than other 4 strand core suture techniques (including the MGH criss crossing locking stitch);
-
Running Locking Stitch:
- consider placing the lock-running suture along the back half of the tendon, prior to placing the core suture;
- this facilitates the "no touch" technique of tendon repair;
- after the core suture has been placed, the running-lock stitch can be completed;
-
Augmented Becker Technique / MGH / Savage:
- in the study by Singer et al 1998, the core suture technique was the most important element in establishing both strength
and stiffness of the repair;
- the Becker technique involves 4 strand repair with two knots out side of the repair site;
- repair consists of criss-crossing running suture using a double armed needle;
- sutures should be placed 0.75 cm from the cut edge of the tendon;
- volar epitenon suture is used to augment the repair;
- as noted in the report by Howard and Greenwald 1997, the MGH tendon repair technique (crossing running suture repair) was signficantly more resistant
to gap formation than the Bunnel or the Krackow technique;
- MGH tendon repair has superior suture purchase which is probably related to superior resistance to gap formation;
- as noted by T. Stein MD et al 1998, there were no increases in dorsal versus volar grasping strength with the Beck Technique (where as dorsally
placed sutures were found to be stronger with the Kessler technique);
- hence sutures can be placed on the volar tendon surface without disrupting the dorsal blood supply;
-
The effect of suture technique on adhesion formation after flexor tendon repair for partial lacerations in a canine model.
Biomechanical and clinical evaluation of the epitenon-first technique of flexor tendon repair.
Flexor tendon repair using a "six strand" method of repair and early active mobilisation..
Effect of suture knot location on tensile strength after flexor tendon repair.
Year Book: Double Loop Locking Suture: A Technique of Tendon Repair for Early Active Mobilization. Part I: Evolution of Technique and Experimental Study.
Lee-H. J Hand Surg. 1990. 15-A. pp 945-952.
Year Book: Double Loop Locking Suture: A Technique of Tendon Repair for Early Active Mobilization. Part II: Clinical Experience.
Lee-H. J Hand Surg. 10. 15-A. pp 953-958.
Two, Four, and Six Strand Zone II Flexor Tendon Repairs: An in situ Biomechanical comparison using Cadaver Model.
RT Thurman MD. J. Hand Surg. 1998. Vol 23-A. No 2. March. p 261.
Use of the Taguchi method for biomechanical comparison of flexor tendon repair techniques to allow immediate active flexion; A new method of analyis and optimization of technique to improve the quality of the repair.
G. Singer MD et al. JBJS Vol 80-A. No 10. Oct 1998. p 1498.
Effect of peripheral suture depth on strength of tendon repairs.
Diao, E. et al. J. Hand Surg. Vol 21-A. 1996. p 234-239.
Biomechanical analysis of four strand extensor tendon repair techniques.
RF Howard et al. J. Hand Surg. Vol 22-A. 1997. p 838-842.
A randomized biomechanical study of zone II human flexor tendon repairs analyzed in an in vitro model.
T. Stein MD et al. J. Hand Surg. Vol 23-A. 1998. p 1046-1051.
Effect of the cross sectional area of locking loops in flexor tendon repair.
H. Hatanaka and PR Manske. J. Hand Surgery. Vol 24-A. No 4. July 1999.
The effects of multiple-strand suture methods on the strength and excursion of repaired intrasynovial flexor tendons: a biomechanical study in dogs.
Winters SC, Gelberman RH, Woo SL-Y, Chan SS, Grewal R, Seiler JG III. J Hand Surg 1998;23A:97-104.
Biomechanical properties of four circumferential flexor tendon suture techniques
A Biomechanical Analysis of Suture Materials and Their Influence on a Four-Strand Flexor Tendon Repair.
