A new modified Tsuge suture for flexor tendon repairs: the biomechanical analysis and clinical application
© Chen et al.; licensee BioMed Central. 2014
Received: 9 October 2014
Accepted: 8 December 2014
Published: 31 December 2014
This study is to develop a new suturing technique for flexor tendon repair by modifying the extant Tsuge repair techniques and to use biomechanical analysis to compare the new method with four established repair techniques and evaluate its clinical efficacy in the repair of 47 flexor tendons in 22 patients.
The biomechanical analysis relied on 50 flexor digitorum profundus tendons harvested from fresh cadavers. The tendons were randomly divided into five groups, transected, and repaired by use of a 1. double-loop suture, 2. double modified locking Kessler, 3. four-strand Savage, 4. modified six-strand Savage, and 5. the new technique. The tensile force and breaking force of all repaired tendons were measured by static loading trials. For clinical application, 22 patients with acute flexor tendon injuries were treated with the new modified Tsuge suture and follow-up for more than 12 months.
While differences in the tensile force and breaking force in the modified Tsuge sutures and modified six-strand Savage sutures were not statistically significant, static loading trials showed the tensile force, in the form of a 2-mm gap formation, and the breaking force of the new modified Tsuge sutures were, statistically, both higher than the ones characteristic of double-loop sutures, double modified locking Kessler, and four-strand Savage sutures. After 12 months, restored functions were observed in all the patients during the postoperative 12 months. Total active motion (TAM) score demonstrated that more than 90% fingers were estimated as excellent or good.
The new modified Tsuge sutures described here have evident higher tensile and breaking forces compared to other four-strand core suture techniques, suggesting, in turn, that this new technique is a good alternative for flexor tendon repairs in clinical applications.
KeywordsFlexor tendon Repair Modified Tsuge Biomechanics Clinical practice
Flexor tendon lacerations are common injuries treated by hand surgery. Even when such injuries are successfully repaired by specialists, however, postoperative complications, such as repair ruptures, gap formations, and adhesions can and do still arise in many patients ,. Numerous studies have demonstrated the advantages of early active mobilization protocols in after-repair tendon healing processes, leading to a number of repair techniques being developed to increase the strength of repairs so that early active motion protocols can be implemented and functional outcomes of patients greatly improved –.
Suturing techniques for flexor tendon repairs can be briefly categorized by the number of strands used for the core suture, such as two-strands, four-strands, and six-strands. Furthermore, they can be featured by properties, such as single- or double-stranded sutures. Double-stranded sutures (also called looped sutures) have been used in several repair techniques ,. Although, in general, looped sutures have not yet been extensively marketed in many regions of Asia (for instance, China and India) and therefore their application is still obviously limited, among the looped sutures, Tsuge repairs and their modifications are accepted for their simplicity of manipulation in many countries. Notwithstanding this approbation, it has been noted by the authors and others that the strength of double-loop sutures, with four strands, modified from Tsuge repairs, still are, in some cases, inadequate for the high demands of early active rehabilitation .
The purpose of this study was to modify Tsuge sutures and to test their biomechanical properties both in vitro and in vivo applications. Single-stranded rather than double-stranded sutures, without many changes to the Tsuge repair configuration, were used to repair flexor tendons. The 2-mm gap formation tensile and ultimate breaking forces were then compared, in vitro, against the four established traditional repair techniques, followed, in vivo, by clinical evaluations of their efficacy. It was hypothesized that the new suture techniques, modified from Tsuge suturing techniques, would provide enough strength of repair to meet the requirements of early active mobilization protocols and would be a good alternative to Tsuge sutures when looped sutures were unavailable.
Materials and methods
The study was approved by the Committee on Clinical Research, Tongji Medical College, Huazhong University of Science and Technology. The biomechanical test used 50 flexor digitorum profundus tendons within zone III and zone IV, each 8 cm long, harvested from nine adult cadavers (seven males, two females) with an average of 67.4 years (range from 54 to 79 years). The cadavers were frozen for 2 to 9 weeks at −20°.
The biomechanical testing system, Instron Model 5848 MicroTester, purchased from Instron (in Norwood, MA), consisted of four components (Figure 1A):
5848 MicroTester frame,
Specimen was attached to the Instron machine as in Figure 1B. Data was collected using an Instron Bluehill software.
All repairs were performed by one single hand surgeon using the same type of instruments.
The new modified Tsuge suture was designed for and used in three steps using a single-stranded suture 4-0 monofilament polypropylene (Prolene, Ethicon, Somerville, NJ).
In the first step, the needle was laterally inserted into the proximal tendon end of the volar surface, within 1 cm from the intended repair site. The strand was then run longitudinally across the repair conjuncture and taken out 1 cm away from the repair site at the distal tendon end. With the needle passed transversely in the distal part, the strand was taken across the loop and the suture reinserted into the distal tendon end, crossing the repair site at the dorsal surface and existing from the proximal end dorsally, so that it could be reintroduced transversely to make a loop. A knot made in this site finished the first step.
The double-loop suture, double modified locking Kessler, four-strand Savage, and modified Savage (six-strand) were done using well-established procedures, which have been described by Viinikainen et al., without any modifications and completed by also adding a peripheral running suture .
Biomechanical testing procedures
All tendons were properly fixed on clamps. A customary Hall effect sensor was positioned across the repair conjuncture to measure the tendon displacement. The repaired tendons were preloaded with an initial tension of 0.5 N. They were pulled at a speed of 0.2 mm/s. The 2-mm gap formation tension force and ultimate breaking force were measured and recorded.
Comparisons of tensile force for 2-mm gap formation and ultimate breaking force between the various repair groups were performed using a Tukey one-way analysis of variance with the level of significance set at p < 0.05.
From March to September 2011, 22 patients (17 males and 5 females), aged between 19 and 42 years (mean = 32 years), with 47 flexor tendon injuries were operated on at Wuhan Union Hospital, Wuhan, China. Of all the tendons, 11 had lacerations in zone II, 7 were injured in zone III, with the others injured in zone V. Among them, 7 were caused by sharp cuts, 13 were caused by saws, and 2 were crushing injuries. Nerve injuries in 12 of the patients were repaired at the same time. For postoperative rehabilitation, early active mobilization protocols described by Hung et al. were used . Briefly, within the first two postoperative days, the hand was elevated and bound with compression dressings and a dorsal plaster slab. On the third day, the patients were asked to perform active mobilization of their hands under the supervision of a physical therapist. The fingers were actively but slowly and gently moved through 0°–50°. The number of movements was five times per section with three sections per day. The range of mobilization, the number of movements, and the times of section per day were evaluated by a therapist on a day-by-day basis and with an eye on the progress of the rehabilitation, increased gradually. Seven days after the operations, the patients were discharged and asked to accept physiotherapy, for another 14 days, and routine rehabilitation for 6 weeks.
The recovery of function for all patients was estimated by the use of the total active motion (TAM) scoring system (American Society for Surgery of the Hand). The evaluation was performed at 3, 6, 9, 12, and 24 weeks and 1 year postoperative.
These in vitro results showed the new modified Tsuge to be a higher provider of repair strength during early active mobilization when compared with other four-strand core suture techniques.
TAM scores of all fingers in according to zones of transection
Peritendinous adhesions have often proven to be a major problem for functional recovery of the hands ,. Early active mobilization has been considered as one of important factors for successful functional restoration after flexor tendon injury . In the present study, a new modified Tsuge suture was employed to repair tendon injuries. In vitro biomechanical analysis showed that the new technique could provide enough tensile strength to implement early active mobilization protocols. Furthermore, preliminary clinical trials proved that this suture can lead to satisfied functional outcomes with well-organized postoperative physiotherapy.
Postoperative repair strength for tendon injuries are mainly determined by the repair techniques employed, including material properties, knot security, and suture configuration . Commonly, the suture techniques used for flexor tendon repair are composed of two parts, core sutures, and peripheral sutures. While peripheral sutures are similar among different repairs, the number of strands for the core suture differs with different techniques. Applications of two-strand repairs, widespread in clinical practice, are strong enough to exert early passive motion . However, several studies have reported increased rupture rates for two-strand repairs after using early active mobilization protocols ,. Therefore, it is not surprising that many multiple-strand sutures have been designed to meet clinical demands. Savage et al., for example, first described a six-strand core suture, while modified Kessler, modified Becker, and the triple-loop suture, etc. were reported as having been used to repair flexor tendon injuries with six- or eight-strand core sutures –. Nevertheless, while these techniques have proven to improve tensile force for gap formation and ultimate breaking force, their complex properties lead to several limitations in clinical practice. For instance, it took injured tendons markedly increase operating times due to the complicated configuration of six- or eight-strand core sutures. Higher gliding resistance also resulted from these repair methods. Balancing of loads has proven difficult to control using these techniques. Difficulties in the learning process may also have discouraged widespread acceptance of these repairs –. Not unexpectedly, many hand surgeons would like to see more well-balanced techniques in their practice.
In conclusion, the new modified Tsuge technique is a simpler suture, providing stronger tensile force and breaking force. It is a good alternative when looped sutures are unavailable.
Written informed consent was obtained from the patient for the publication of this report and any accompanying images.
- Ejeskar A: Flexor tendon repair in no man’s land: results of primary repair with controlled mobilization. J Hand Surg Am. 1984, 9 (2): 171-177. 10.1016/S0363-5023(84)80135-5.View ArticlePubMedGoogle Scholar
- Schenck RR, Lenhart DE: Results of zone II flexor tendon lacerations in civilians treated by the Washington regimen. J Hand Surg Am. 1996, 21 (6): 984-987. 10.1016/S0363-5023(96)80304-2.View ArticlePubMedGoogle Scholar
- Becker H, Orak F, Duponselle E: Early active motion following a beveled technique of flexor tendon repair: report on fifty cases. J Hand Surg Am. 1979, 4 (5): 454-460. 10.1016/S0363-5023(79)80043-X.View ArticlePubMedGoogle Scholar
- Harris SB, Harris D, Foster AJ, Elliot D: The aetiology of acute rupture of flexor tendon repairs in zones 1 and 2 of the fingers during early mobilization. J Hand Surg Br. 1999, 24 (3): 275-280. 10.1054/jhsb.1998.0212.View ArticlePubMedGoogle Scholar
- Wada A, Kubota H, Miyanishi K, Hatanaka H, Miura H, Iwamoto Y: Comparison of postoperative early active mobilization and immobilization in vivo utilising four-strand flexor tendon repair. J Hand Surg Br. 2001, 26 (4): 301-306. 10.1054/jhsb.2000.0547.View ArticlePubMedGoogle Scholar
- Lim BH, Tsai TM: The six-strand technique for flexor tendon repair. Atlas Hand Clin. 1996, 1: 65-76.Google Scholar
- Kusano N, Yoshizu T, Maki Y: Experimental study of two new flexor tendon suture techniques for postoperative early active flexion exercises. J Hand Surg Br. 1999, 24 (2): 152-156. 10.1054/jhsb.1998.0174.View ArticlePubMedGoogle Scholar
- Gill RS, Lim BH, Shatford RA, Toth E, Voor MJ, Tsai TM: A comparative analysis of the six-strand double-loop flexor tendon repair and three other techniques: a human cadaveric study. J Hand Surg Am. 1999, 24 (6): 1315-1322. 10.1053/jhsu.1999.1315.View ArticlePubMedGoogle Scholar
- Viinikainen A, Göransson H, Ryhänen J: Primary flexor tendon repair techniques. Scand J Surg. 2008, 97 (4): 333-340.PubMedGoogle Scholar
- Hung LK, Pang KW, Yeung PL, Cheung L, Wong JM, Chan P: Active mobilisation after flexor tendon repair: comparison of results following injuries in zone 2 and other zones. J Orthop Surg (Hong Kong). 2005, 13 (2): 158-163.Google Scholar
- Khanna A, Gougoulias N, Maffulli N: Modalities in prevention of flexor tendon adhesion in the hand: what have we achieved so far?. Acta Orthop Belg. 2009, 75 (4): 433-444.PubMedGoogle Scholar
- Khanna A, Friel M, Gougoulias N, Longo UG, Maffulli N: Prevention of adhesions in surgery of the flexor tendons of the hand: what is the evidence?. Br Med Bull. 2009, 90: 85-109. 10.1093/bmb/ldp013.View ArticlePubMedGoogle Scholar
- Starr HM, Snoddy M, Hammond KE, Seiler JG: Flexor tendon repair rehabilitation protocols: a systematic review. J Hand Surg Am. 2013, 38 (9): 1712-1717. 10.1016/j.jhsa.2013.06.025.View ArticlePubMedGoogle Scholar
- Pennington D: The locking loop tendon suture. Plast Reconstr Surg. 1979, 63: 648-652. 10.1097/00006534-197905000-00007.View ArticlePubMedGoogle Scholar
- Bainbridge LC, Robertson C, Gillies D, Elliot D: A comparison of post-operative mobilization of flexor tendon repairs with “passive flexion-active extension” and “controlled active motion” techniques. J Hand Surg Br. 1994, 19 (4): 517-521. 10.1016/0266-7681(94)90219-4.View ArticlePubMedGoogle Scholar
- Barrie KA, Tomak SL, Cholewicki J, Merrell GA, Wolfe SW: Effect of suture locking and suture caliber on fatigue strength of flexor tendon repairs. J Hand Surg Am. 2001, 26 (2): 340-346. 10.1053/jhsu.2001.22926.View ArticlePubMedGoogle Scholar
- Savage R, Risitano G: Flexor tendon repair using a “six strand” method of repair and early active mobilisation. J Hand Surg Br. 1989, 14 (4): 396-399. 10.1016/0266-7681(89)90154-X.View ArticlePubMedGoogle Scholar
- Viinikainen A, Göransson H, Huovinen K, Kellomäki M, Törmälä P, Rokkanen P: The strength of the 6-strand modified Kessler repair performed with triple-stranded or triple-stranded bound suture in a porcine extensor tendon model: an ex vivo study. J Hand Surg Am. 2007, 32 (4): 510-517. 10.1016/j.jhsa.2007.01.010.View ArticlePubMedGoogle Scholar
- Miller B, Dodds SD, deMars A, Zagoreas N, Waitayawinyu T, Trumble TE: Flexor tendon repairs: the impact of fiberwire on grasping and locking core sutures. J Hand Surg Am. 2007, 32 (5): 591-596. 10.1016/j.jhsa.2007.03.003.View ArticlePubMedGoogle Scholar
- Tang JB: Release of the A4 pulley to facilitate zone II flexor tendon repair. J Hand Surg Am. 2014, 39 (11): 2300-2307. 10.1016/j.jhsa.2014.08.025.View ArticlePubMedGoogle Scholar
- Joyce CW, Sugrue CM, Carroll SM, Kelly JL: A quick and simple four-strand barbed suture repair technique for flexor tendons: a comparison to a traditional four-strand monofilament repair. Plast Reconstr Surg. 2014, 134 (4 Suppl 1): 40-10.1097/01.prs.0000455371.90659.32.View ArticleGoogle Scholar
- Moriya K, Yoshizu T, Maki Y, Tsubokawa N, Narisawa H, Endo N: Clinical outcomes of early active mobilization following flexor tendon repair using the six-strand technique: short- and long-term evaluations.J Hand Surg Eur 2014. doi:10.1177/1753193414551682.,Google Scholar
- Dovan TT, Ditsios KT, Boyer MI: Eight-strand core suture technique for repair of intrasynovial flexor tendon lacerations. Tech Hand Up Extrem Surg. 2003, 7 (2): 70-74. 10.1097/00130911-200306000-00005.View ArticlePubMedGoogle Scholar
- Wagner WF, Carroll C, Strickland JW, Heck DA, Toombs JP: A biomechanical comparison of techniques of flexor tendon repair. J Hand Surg Am. 1994, 19 (6): 979-983. 10.1016/0363-5023(94)90101-5.View ArticlePubMedGoogle Scholar
- Strickland JW: Flexor tendon injuries: I. Foundations of treatment. J Am Acad Orthop Surg. 1995, 3: 44-54.PubMedGoogle Scholar
- Sandvall BK, Kuhlman-Wood K, Recor C, Friedrich JB: Flexor tendon repair, rehabilitation, and reconstruction. Plast Reconstr Surg. 2013, 132 (6): 1493-1503. 10.1097/01.prs.0000434411.78335.63.View ArticlePubMedGoogle Scholar
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