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Comparing Biomechanical Properties, Repair Times, and Costs of Common Flexor Tendon Repairs
Aakash Chauhan, MD, MBA1 Patrick Schimoler, BSE2; Mark C. Miller, PhD2; Edward Birdsong, MD1; Matthew J. Schessler, MD1; Bradley A. Palmer, MD1
1Department of Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, PA; 2Orthopaedic Research, Allegheny General Hospital, Pittsburgh, PA

Introduction: Zone II flexor tendon injuries have numerous repair configurations, simple and complex, that range from 2 to 8 stranded repairs. Higher stranded repair configurations can be technically difficult but have been shown to be stronger. However there is significant variability across studies comparing the same constructs/suture with few studies presenting comprehensive biomechanical data across multiple configurations. The purpose of our study was to determine what the best repair configuration was in terms of biomechanical strength, repair time, and total repair value for popular Zone II flexor tendon repairs.

Methods: A total of 75 fresh-frozen FDS/FDP human cadaveric tendons were harvested from the index through small finger. They were randomized into one of five groups: 4-0 Polyester and 4-0 Braided Cross-Stitch Cruciate, 2-0 Bi-Directional Polypropylene Barbed Knotless Double Pennington (Modified Kessler), 4-0 Double-Stranded Braided Pennington (Modified Kessler), and 4-0 Braided Modified Lim-Tsai. All repairs had 1 cm of suture purchase and no epitendinous stitch was placed in order to assess the true core repair strength. Tendons were linearly loaded to failure at 30 mm/min. The 2 mm gapping load, max failure load, stiffness, and energy to cause 2 mm gapping were measured. In situ repairs were also performed on 6 FDP tendons and repair time was measured. The total repair value was calculated based on operating room costs, repair times, and suture costs. ANOVA and Tukey post-hoc analysis following any significant ANOVAs were used to statistically compare all data points.

Results: The braided cross-stitch cruciate was the strongest repair (p< 0.05) compared to all other repair groups in terms of max load to failure. (Figure 1) The braided cross-stitch cruciate required the most time for completion compared to all other repair times (p<0.05), although average repair time differed at most by 2 minutes. (Figure 2) The total repair dollar value was highest for barbed cross-stitch cruciate (p<0.05) compared to all other repairs.

Conclusions: The braided cross-stitch cruciate repair was the strongest in a series of commonly performed repair configurations, including a 6-stranded repair (modified Lim-Tsai). The 2 mm gapping and max load to failure approached similar historical strength of other 6 and 8 stranded repairs. All repairs performed are adequate enough to start light active range of motion. This can be augmented with an epitendinous stitch. Suture cost was negligible in the overall repair cost, and should not be a determining factor in choosing a repair.

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