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A Biomechanical Analysis of Barbed Suture Use in Flexor Tendons
Michael J. Terry, MD; Michael Matthew, MD
Plastic Surgery, Yale University , New Haven , CT

Background: Outcomes in flexor tendon repair have steadily improved since the 1960’s along with advances in suture materials and technique.  However, conventional flexor tendon repair continues to face multiple challenges, such as gapping, adhesions, strangulation of tissue, and knot failure.  Flexor tendon repair using barbed suture has the theoretical advantage of allowing repair without knots at the repair site or along gliding surfaces, thereby minimizing the amount of suture material in the repair site, as well as potential adhesion formation.  It also theoretically allows for a more even distribution of load throughout the repair, and the prevention of gapping.  We present here the initial data in a comprehensive biomechanical analysis of the properties of barbed suture material relating to use in flexor tendons. 

Methods: Flexor digitorum profundi tendons were harvested from 2 cadaveric hands and divided into 4cm segments.  These segments were randomly assigned to 8 different groups in which a different pattern of barbed polyglyconate suture (Vloc, Covidien) was passed into the transected end of the flexor tendon.  The groups included simple longitudinal passes of 1cm, 2cm, and 3cm into the tendon substance; 2 patterns based on the modified Kessler flexor tendon repair, and 3 patterns based on the MGH “zig-zag” design.  Each segment was placed in a tensiometer (Instrom), and the maximum load to failure was measured.

Results: The data demonstrates that the barbed suture generates a resistive force of 4.2N per centimeter of suture.  This result was found to be additive, consistent, and reproducible.  The MGH patterns generated resistant forces exceeding that which would be predicted based purely on the length of suture in the tendon substance.  The modified Kessler patterns demonstrated the strongest resistance to pull-out, with forces that exceeded the upper limit of the experimental setup, but were at minimum 20+N greater than what would be expected based on length of suture in the tendon substance.

Conclusions: Based on these results, we conclude that design of a knotless flexor tendon repair technique using barbed suture is feasible, and we propose 2 such designs.  The next phase of this project will consist of further experiments in the cadaveric model to compare these designs to conventional repair techniques with regard to load to failure, gapping, and work of flexion.

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