Technical and Biological Modifications for Enhanced Flexor Tendon Repair

doi:10.1016/j.jhsa.2009.12.044

The Journal of Hand Surgery

Volume 35, Issue 6, June 2010, Pages 1031-1037

https://doi.org/10.1016/j.jhsa.2009.12.044 Get rights and content

Clinical outcomes after intrasynovial flexor tendon repair have been substantially improved over the past 2 decades through advances in tendon suture techniques and postoperative rehabilitation methods. Nevertheless, complications such as repair site elongation (i.e., gap formation) and rupture continue to occur frequently. Experimental studies have shown that repair site strength fails to increase in the first 3 weeks after tendon suture. After 3 weeks, the strength and rigidity of the repair site improve significantly, a process that continues for several months. Formation of a repair site gap during the early rehabilitation period has been shown to considerably delay the accrual of repair site strength over time. Thus, it is of prime importance that the method of tendon suture achieves and maintains a stiff and strong repair site during the early healing interval by maintaining close approximation of the tendon stumps and by stimulating, where possible, the intrinsic repair response. In this review, we describe recent efforts to enhance the integrity of the immature repair site. We focus on 2 major areas of advancement: surgical technique modifications and manipulation of the biologic and biochemical environment.

Section snippets

Number of core suture strands

Increasing the number of suture strands crossing the repair site increases strength, stiffness, and resistance to gap formation.1, 2 Early methods of repair with 2 core suture strands (e.g., Kessler, Bunnell, Tajima methods, etc.) coupled with postoperative immobilization led to a decrease in ultimate strength during the first 3 weeks after tendon suture.³ Although subsequent studies showed that the decrease in strength could be partially obviated by early motion exercise, the strength of the

Biologic Modifications for Enhanced Flexor Tendon Repair

Although surgeons have achieved substantial gains in tendon repair outcomes by modifying surgical technique, a considerable rate of complications still remains (e.g., repair-site gapping, suture pullout, tendon rupture, and adhesion formation). Flexor tendon healing relies on intrinsic tendon fibroblast activity arising from the epitenon and the endotenon and on an extrinsic inflammatory response originating from the tendon sheath. This intrinsic and extrinsic cellular response, while assisting

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Cited by (45)

Use of Silicone Tubes as Antiadhesion Devices in a Modified Two-Stage Flexor Tendon Reconstruction in Zone II: A Retrospective Study
2023, Journal of Hand Surgery
This study aimed to assess the outcome of a modified two-stage flexor tendon reconstruction using silicone tubes as antiadhesion devices while performing simultaneous tendon grafting.
From April 2008 to October 2019, 16 patients (21 fingers) with zone II flexor tendon injuries, who sustained failed tendon repair or neglected tendon laceration, were treated by a modified two-stage flexor tendon reconstruction. The first stage of treatment comprised flexor tendon reconstruction with interposition of silicone tubes to minimize fibrosis and adhesion around the tendon graft; the second stage of treatment comprised silicone tube removal under local anesthesia.
The patient median age was 38 (range, 22–65) years. After a median follow-up period of 14 (range, 12–84) months, the median total active motion (TAM) of fingers was 220° (range, 150–250°). Excellent and good TAM ratings were identified in 71.4%, 76.2%, and 76.2% according to the Strickland, modified Strickland, and American Society for Surgery of the Hand (ASSH) evaluation systems, respectively. At follow-up, complications included superficial infections in two fingers of one patient whose silicone tube was removed 4 weeks postoperatively. The most common complication was a flexion deformity of the proximal interphalangeal joint (four fingers) and/or distal interphalangeal joint (nine fingers). The rate of failed reconstruction was higher in patients with preoperative stiffness and infection.
Silicone tubes are suitable antiadhesion devices, and the modified two-stage flexor tendon reconstruction technique is an alternative procedure with a shorter rehabilitation period for complicated flexor tendon injury, compared with current popular reconstructions. Preoperative stiffness and postoperative infection may compromise the final clinical outcome.
Therapeutic IV.
Potent anti-adhesion agent using a drug-eluting visible-light curable hyaluronic acid derivative
2019, Journal of Industrial and Engineering Chemistry
Post-operative adhesion is a very serious complication in the clinical field, frequently occurring after surgery. In severe cases, reoperation may be required. In this study, a visible light-curable furfuryl hyaluronic acid derivative was prepared and combined with ibuprofen for anti-adhesion and anti-inflammatory applications. A furfuryl isocyanate moiety was introduced in hyaluronic acid affording furfuryl hyaluronic acid (F-HA). The anti-adhesion and anti-inflammatory effects of F-HA were examined in chickens at 2, 4, and 8 weeks postoperation. It was concluded that F-HA combined with ibuprofen is a suitable anti-adhesion and anti-inflammation agent.
Biological augmentation of flexor tendon repair: A challenging cellular landscape
2016, Journal of Hand Surgery
Citation Excerpt :
Thus, the mechanism of injury, especially in dealing with zone II injuries, can influence outcomes and mechanisms and strategy for repair. Whereas recent improvements in surgical technique, suture patterns, and rehabilitation have dramatically improved outcomes of primary flexor tendon repairs,5,6 unsatisfactory outcomes are still often observed; up to 30% to 40% of primary flexor tendon repairs result in adhesion formation sufficient to limit digital range of motion.7 As such, there is an unmet need to minimize adhesions and promote tendon gliding, with biological intervention representing a potentially practical approach.
Advances in surgical technique and rehabilitation have transformed zone II flexor tendon injuries from an inoperable no-man’s land to a standard surgical procedure. Despite these advances, many patients develop substantial range of motion–limiting adhesions after primary flexor tendon repair. These suboptimal outcomes may benefit from biologic augmentation or intervention during the flexor tendon healing process. However, there is no consensus biological approach to promote satisfactory flexor tendon healing; we propose that insufficient understanding of the complex cellular milieu in the healing tendon has hindered the development of successful therapies. This article reviews recent advances in our understanding of the cellular components of flexor tendon healing and adhesion formation, including resident tendon cells, synovial sheath, macrophages, and bone marrow–derived cells. In addition, it examines molecular approaches that have been used in translational animal models to improve flexor tendon healing and gliding function, with a specific focus on progress made using murine models of healing. This information highlights the importance of understanding and potentially exploiting the heterogeneity of the cellular environment during flexor tendon healing, to define rational therapeutic approaches to improve healing outcomes.
Shear lag sutures: Improved suture repair through the use of adhesives
2015, Acta Biomaterialia
Suture materials and surgical knot tying techniques have improved dramatically since their first use over five millennia ago. However, the approach remains limited by the ability of the suture to transfer load to tissue at suture anchor points. Here, we predict that adhesive-coated sutures can improve mechanical load transfer beyond the range of performance of existing suture methods, thereby strengthening repairs and decreasing the risk of failure. The mechanical properties of suitable adhesives were identified using a shear lag model. Examination of the design space for an optimal adhesive demonstrated requirements for strong adhesion and low stiffness to maximize the strength of the adhesive-coated suture repair construct. To experimentally assess the model, we evaluated single strands of sutures coated with highly flexible cyanoacrylates (Loctite 4903 and 4902), cyanoacrylate (Loctite QuickTite Instant Adhesive Gel), rubber cement, rubber/gasket adhesive (1300 Scotch-Weld Neoprene High Performance Rubber & Gasket Adhesive), an albumin-glutaraldehyde adhesive (BioGlue), or poly(dopamine). As a clinically relevant proof-of-concept, cyanoacrylate-coated sutures were then used to perform a clinically relevant flexor digitorum tendon repair in cadaver tissue. The repair performed with adhesive-coated suture had significantly higher strength compared to the standard repair without adhesive. Notably, cyanoacrylate provides strong adhesion with high stiffness and brittle behavior, and is therefore not an ideal adhesive for enhancing suture repair. Nevertheless, the improvement in repair properties in a clinically relevant setting, even using a non-ideal adhesive, demonstrates the potential for the proposed approach to improve outcomes for treatments requiring suture fixation. Further study is necessary to develop a strongly adherent, compliant adhesive within the optimal design space described by the model.
Flexor Tendon Injury, Repair and Rehabilitation
2015, Orthopedic Clinics of North America
Evaluation of the ability of xanthan gum/gellan gum/hyaluronan hydrogel membranes to prevent the adhesion of postrepaired tendons
2014, Carbohydrate Polymers
Citation Excerpt :
By performing a sharp dissection, the Achilles tendon was exposed and transected at its midpoint. The transected tendon was repaired using a modified Kessler technique (Kim et al., 2010) in which we used 5-0 Prolene sutures (Ethicon, Somerville, NJ, USA), and then the tendon was wrapped with Seprafilm or XGH hydrogel membranes prepared using Formulations A, B, C, or D (Fig. 1). The 36 hind legs of the 18 rats were assigned randomly to six groups containing six legs each: the control group, Seprafilm group, and Groups A, B, C, and D.
After tendon-repair surgery, adhesion between the surgical tendon and the synovial sheath is often presented resulting in poor functional repair of the tendon. This may be prevented using a commercially available mechanical barrier implant, Seprafilm, which is composed of hyaluronan (HA) and carboxymethyl cellulose hydrogels. In a rat model, prepared membranes of various compositions of gellan gum (GG), xanthan gum (XG) and HA as well as Seprafilm were wrapped around repaired tendons and the adhesion of the tendons was examined grossly and histologically after 3 weeks of healing. Certain formulations of the XG/GG/HA hydrogel membranes reduced tendon adhesion with equal efficacy but without reducing the tendon strength compared to Seprafilm. The designed membranes swelled rapidly and blanketed onto the tendon tissue more readily and closely than Seprafilm. Also they degraded slowly, which allowed the membranes to function as barriers for extended periods.

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: This study was supported by grants from the National Institutes of Health (AR033097 to R.H.G. and EB004347 to S.T.).

: No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.

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Current conceptTechnical and Biological Modifications for Enhanced Flexor Tendon Repair

Section snippets

Number of core suture strands

Biologic Modifications for Enhanced Flexor Tendon Repair

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

J Orthop Res

J Hand Surg

J Control Release

Current concept
Technical and Biological Modifications for Enhanced Flexor Tendon Repair