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Side-to-side vs. Pulvertaft Extensor Tendon Repair; Biomechanical Study
Michael Rivlin, Amir Reza Kachooei, MD, Ali Hosseini, PhD, Kyle Eberlin, MD, Nikola Zivaljevic, MD, Guoan Li, PhD and Chaitanya S. Mudgal, MD
Department of Orthopaedics, Massachusetts General Hospital, Harvard University, Boston, MA

Introduction: Extensor tendons can be coapted using a weave suture technique to provide tensile strength and repair surface overlap. Pulvertaft (PT) weave is the standard method of extensor tendon repair. However, recently, Brown and colleagues described a side-to-side (STS) tendon repair technique (one weave). This method may compare in speed of repair, while simpler, potentially less bulky and without the need specialized equipment while not compromising repair strengths and tensile properties. We hypothesize that STS is more practical than PT with matching biomechanical characteristics.

Materials and Methods: In a biomechanical study on 6 cadaver arms, we harvested 30 extensor tendons including four extensor digitorum communis (EDC) and one extensor indicis proprius (EIP). Three hand surgical fellows with similar backgrounds of training under the same conditions and precise standardized technique performed timed repairs (5 PT and 5 STS per surgeon). Following the repairs, the tendons were passed through a custom made graft sizing guide to determine bulk and the results were expressed as a repaired vs. native diameter ratio. The specimens were then tested for ultimate strength and fatigue properties (Instron Inc., Norwood, MA). Failure type and mechanical properties were recorded and compared to the native tendon portion.

Results: The STS technique demonstrated comparable time to repair (average tendon repair STS: 8.16 min vs. PT: 7.38 min ; P=0.14). The average peak force to failure was 93 N for the STS and 51 N for PT group (P<0.001). Relative strength ratio (repair strength compared to native tendon strength) was 35.2% for the STS and 22.1% for the PT group (P=0.19). In the side-to-side group all failures occurred due to tissue failure; however, in the Pulvertaft technique suture failures occurred in 3 tendons prior to tissue failure. The mean bulk ratio of the repaired site vs. native tendon was +31% and +34% more for the STS and PT groups respectively (P=0.78). Furthermore, the bulk of the repaired site for the STS and PT groups was 4.2 and 4.9 mm respectively (P=0.098).

Conclusion: Side-to-side repair technique showed superior biomechanical properties while demonstrating comparable repair bulk and speed of tendon coaptation compared to the Pulvertaft weave.


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