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Bidirectional Barbed Suture Repair in Flexor Tendons: A Novel Technique
Jamie L Engel, MD; Joseph N Gabra, DEng; Andrew Esterle, MD; William Lanzinger, MD; John Elias, PhD
Cleveland Clinic-Akron General Medical Center, Akron, OH

Introduction: Repair of flexor tendon ruptures in Zone II remains a challenging problem. Both the flexor digitorum profundus and flexor digitorum superficialis pass within the same fibro-osseous sheath. A suture construct must be employed that maximizes strength while minimizing increases in bulk and friction. Various configurations of barbed suture have been studied and found to be promising solutions to the issues created by these injuries; such techniques have not taken full advantage of the bidirectional orientation of the barbs in the suture in order to prevent distraction at the tendon repair site. This study proposes a repair technique in which all barbs, throughout the length of the repair, are acting to prevent distraction at the repair site.

Methods: Twenty-four flexor tendons from cadaver specimens were transected to mimic Zone II tendon injuries. Four repair techniques were studied: Amadeo (barbed suture repair), McClellan (barbed suture repair), Kessler (standard, knotted technique), and the experimental configuration (barbed suture repair). The repairs underwent biomechanical testing to examine ultimate load and 2-mm gap force, normalized to cross-sectional area of the tendon.

Results: Prior to normalization to tendon cross-sectional area, the Amadeo technique had a significantly larger force at 2-mm gap than the Kessler (p < 0.01) and McClellan (p < 0.05) techniques. The ultimate load for the Amadeo technique was significantly larger than that of the Kessler (p < 0.05) and McClellan (p < 0.01) techniques. Differences were found among techniques when parameters were normalized to the cross-sectional area of the tendon both before transection and after repair. Specifically, the Amadeo technique had a significantly larger force at 2-mm gap than Kessler (p < 0.05), and a significantly higher ultimate load than McClellan (p < 0.05). There was no statistically significant difference between the novel knotless suture technique and any other repair type.

Conclusion: The suture technique developed in this study was found to have equivalent biomechanical strength to the Amadeo, McClellan, and Kessler techniques. Amadeo did have superior 2mm gap force strength when compared to Kessler and a greater ultimate load than McClellan. The experimental suture technique has sufficient strength of repair in biomechanical testing to be used for flexor tendon injuries, and it eliminates the need for a knot.

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