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Cadaveric Comparison of Knotted Versus Knotless Techniques for Digital Flexor Tendon Repair
Alexander J Kammien, BS
1; Fortunay Diatta, MD, MBE
2; K Lynn Zhao, MD
1; David L Colen, MD
21Yale School of Medicine, New Haven, CT; 2Yale University School of Medicine, New Haven, CT
PurposeThe current cadaveric study compares digital flexor tendon repairs using knotted and knotless techniques.
MethodsTwo knotted techniques (Modified Kessler, M-Tang) and two knotless techniques with barbed suture (one previously published, one novel) for flexor tendon repair were assessed. Each repair was tested in twelve flexor digitorum profundus (FDP) tendons from fresh frozen cadaver hands. Palmar tissue was removed from a thawed hand to expose flexor tendons and pulleys. The hand was mounted vertically on an Instron machine. Each finger was flexed three times to 25mm of FDP excursion at 100mm/min. Work of flexion was recorded for the third cycle. FDP tendons were retracted 1cm distally through the A2 pulley and sharply cut at the distal edge of A2. Flexor tendon repairs were performed with 3-0 braided or 2-0 V-Loc suture. Work of flexion measurements were repeated. FDP tendons were removed from the hand. The proximal end of the tendon was loaded at 50mm/min. Load to 2mm gap formation and load to repair failure were recorded. Mode of failure was also recorded. One-way analysis of variance and t-tests were used for statistical analysis.
ResultsOverall, knotted repairs had smaller increases in work of flexion than knotless repairs (106% vs 117%, p=0.020). There were significant differences in work of flexion among individual techniques (p=0.023). The novel knotless technique, compared to the previously published technique, had lower increase in work of flexion that approached significance (110% vs 123%, p=0.073). Increase in work of flexion with the novel technique was similar to the knotted techniques, while the increase in work of flexion with the previously published knotless technique was significantly greater than the knotted techniques (Figure 1). There was no difference in load to 2mm gap formation between braided and barbed techniques (38N vs 38N, p=0.779). Knotted techniques had greater load to failure (56N vs 46N, p=0.001). All knotless techniques failed by pull-through, while only 46% of knotted techniques failed by pull-through.
ConclusionKnotted repair techniques demonstrated smaller increases in work of flexion than knotless techniques with barbed sutures. One knotless technique had similar work of flexion to knotted techniques, while the other showed greater increases in work of flexion. Compared to knotted techniques, knotless techniques had similar load to 2mm gap formation but lower load to failure.
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