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Absorbable sutures in tendon repair
THE JOURNAL
3x
addition patients were reviewed on a weekly basis by medical staff. Assessment was performed at six weeks, three months and six months from the time of surgery. The six week assessment consisted of measurement of active range of movement (ROM) only. In addition to active ROM measurement, power grip, pinch grip and maximum finger pressure were also evaluated using a Jamar dynamometer kit at the three 7nontlz and six month assessment. To date, 112 patients have been entered into the study. Results have been evaluated using a combination of Kleinert and Strickland grading (So et al, 1990). Statistical analysis carried out on the first 80 patients using the paired students t test shows no significant difference in outcome. A P value of less than 0.05 was the chosen level of significance.
OF HAND
Intact 71= 30
PDS
N. S. Moiemen, D. Harris, A. .I. Foster
Elliot,
North East Thames Regional Hospital, Billericay, Essex
A. F. S. Flemming, Plastic Surgery
S. B.
Unit, St Andrew’s
A series of 1274 acute partial and complete tendon injuries underwent operation following emergency admission in a period of 3.5 years. These included 203 patients with 317 complete divisions of flexor tendons in 224 fingers in zones I and II and 30 patients with 30 complete divisions of flexor pollicis longus tendon in zones I and II. All of these patients were mobilised post-operatively in a controlled active motion (active flexionactive extension) regimen. 13 (5.8%) fingers and 5 (16.6%) thumbs suffered tendon rupture during the post-operative period. Patients treated during the last year of the study were followed prospectively for a minimum period of 3 months: 10 of the 16 (62.5%) fingers with zone I repairs; 50 of the 63 (79.4%) fingers with zone II repairs; all 3 (100%) FPL divisions in zone I and 3 of 4 (75%) FPL divisions in zone II had good and excellent results on assessment by the original criteria (Strickland criteria; Strickland 1980). These results confirm the safety of this regimen as an alternative to other regimens of post-operative flexor tendon repair mobilisation in zone I and zone II finger injuries. However, in the unmodified form used in this series, this regimen has too high a rupture rate for FPL mobilisation.
Absorbable sutures in tendon repair E. S. O ’Broin, Department Irelaud
M. J. Earley,
of Orthopaedics,
A. C. B. Hooper, St. James’s
H. Smyth
Hospital,
Dublin,
Synthetic absorbable sutures with greatly extended degradation times have been available for a number of years and are used
VOL. 19B SUPPLEMENT
I
extensively. Surgeons have been reluctant to use these materials in tendon repair fearing a significant loss of tensile strength during the early critical phase of tendon healing. Polydioxanone (PDS) is a synthetic absorbable suture with an absorption halflife of five weeks for 0:O gauge. The aim of the study was to compare the strength of tendon repairs using PDS with the commonly used non-absorbable prolene. We performed repairs on transected flexor digitorum longus tendons (FDL) from the left hind legs of 46 rabbits. Half the repairs were with PDS, the others with prolene using a modified Kessler stitch. 50 rabbit cadaver (FDL) tendons were available for tensile strength testing, 10 of which were transected and repaired with PDS, 10 repaired with prolene and the others left intact. Tendons were harvested at 3 days, 2 weeks and 4 weeks post surgery and tensile strengths obtained. Tensile strength (Newtons)
The rupture rate of acute flexor tendon repairs mohilised by the controlled active motion regimen
SURGERY
3 days n= 6
2 weeks n = 20
4 weeks
n = 20
Fresh 22.15
18.78
40.72
165.4
17.0
19.26
35.25
169.0
n = 20
228.8 Prolene
By 4 weeks the repair strengths had increased dramatically due to a strong fibrous bond of healing tendon. At this stage the contribution of the suture material to the overall repair strength was negligible. These results show that PDS repairs are as strong as prolene during the critical first four weeks of tendon healing with the added advantage of complete absorption within 180 days.
The “Chinese Finger” ; is the FDS decussation a trap? E. T. Walbeehm,
D. A. McGrouther
Department of Plastic College, London, UK
& Reconstructive
Surgery,
University
Dehiscence of flexor tendon repair may be the most important cause of failure, particularly following early active motion. Much research has been focussed on longitudinal tensile loading, but lateral forces may be of equal importance. The usual concept of tendon function is that the flexor digitorum sublimis (FDS) forms a perfect tunnel through which the flexor digitorum profundus (FDP) slides effortlessly. The mechanism is more complex in that the FDP does not have a regular cylindrical shape but varies its cross-section at different levels in the pulley system. Studies of dynamic motion have been performed in 6 fixed and 10 freshly amputated cadaveric hands, observing the mechanism of the flexor sublimis decussation as it glides proximally. The FDS exerts a lateral force on the FDP tending to grip the FDP like a “Chinese Finger”. Simultaneously there is an anteroposterior force on the FDP which is squeezed between the annular pulleys (especially A2) and the Chiasm of Camper. The lateral forces combined with the shape of the FDP may tend to “lock” both tendons together. These strong forces may impair intrinsic tendon healing or even disrupt the tendon sutures.
3x
addition patients were reviewed on a weekly basis by medical staff. Assessment was performed at six weeks, three months and six months from the time of surgery. The six week assessment consisted of measurement of active range of movement (ROM) only. In addition to active ROM measurement, power grip, pinch grip and maximum finger pressure were also evaluated using a Jamar dynamometer kit at the three 7nontlz and six month assessment. To date, 112 patients have been entered into the study. Results have been evaluated using a combination of Kleinert and Strickland grading (So et al, 1990). Statistical analysis carried out on the first 80 patients using the paired students t test shows no significant difference in outcome. A P value of less than 0.05 was the chosen level of significance.
OF HAND
Intact 71= 30
PDS
N. S. Moiemen, D. Harris, A. .I. Foster
Elliot,
North East Thames Regional Hospital, Billericay, Essex
A. F. S. Flemming, Plastic Surgery
S. B.
Unit, St Andrew’s
A series of 1274 acute partial and complete tendon injuries underwent operation following emergency admission in a period of 3.5 years. These included 203 patients with 317 complete divisions of flexor tendons in 224 fingers in zones I and II and 30 patients with 30 complete divisions of flexor pollicis longus tendon in zones I and II. All of these patients were mobilised post-operatively in a controlled active motion (active flexionactive extension) regimen. 13 (5.8%) fingers and 5 (16.6%) thumbs suffered tendon rupture during the post-operative period. Patients treated during the last year of the study were followed prospectively for a minimum period of 3 months: 10 of the 16 (62.5%) fingers with zone I repairs; 50 of the 63 (79.4%) fingers with zone II repairs; all 3 (100%) FPL divisions in zone I and 3 of 4 (75%) FPL divisions in zone II had good and excellent results on assessment by the original criteria (Strickland criteria; Strickland 1980). These results confirm the safety of this regimen as an alternative to other regimens of post-operative flexor tendon repair mobilisation in zone I and zone II finger injuries. However, in the unmodified form used in this series, this regimen has too high a rupture rate for FPL mobilisation.
Absorbable sutures in tendon repair E. S. O ’Broin, Department Irelaud
M. J. Earley,
of Orthopaedics,
A. C. B. Hooper, St. James’s
H. Smyth
Hospital,
Dublin,
Synthetic absorbable sutures with greatly extended degradation times have been available for a number of years and are used
VOL. 19B SUPPLEMENT
I
extensively. Surgeons have been reluctant to use these materials in tendon repair fearing a significant loss of tensile strength during the early critical phase of tendon healing. Polydioxanone (PDS) is a synthetic absorbable suture with an absorption halflife of five weeks for 0:O gauge. The aim of the study was to compare the strength of tendon repairs using PDS with the commonly used non-absorbable prolene. We performed repairs on transected flexor digitorum longus tendons (FDL) from the left hind legs of 46 rabbits. Half the repairs were with PDS, the others with prolene using a modified Kessler stitch. 50 rabbit cadaver (FDL) tendons were available for tensile strength testing, 10 of which were transected and repaired with PDS, 10 repaired with prolene and the others left intact. Tendons were harvested at 3 days, 2 weeks and 4 weeks post surgery and tensile strengths obtained. Tensile strength (Newtons)
The rupture rate of acute flexor tendon repairs mohilised by the controlled active motion regimen
SURGERY
3 days n= 6
2 weeks n = 20
4 weeks
n = 20
Fresh 22.15
18.78
40.72
165.4
17.0
19.26
35.25
169.0
n = 20
228.8 Prolene
By 4 weeks the repair strengths had increased dramatically due to a strong fibrous bond of healing tendon. At this stage the contribution of the suture material to the overall repair strength was negligible. These results show that PDS repairs are as strong as prolene during the critical first four weeks of tendon healing with the added advantage of complete absorption within 180 days.
The “Chinese Finger” ; is the FDS decussation a trap? E. T. Walbeehm,
D. A. McGrouther
Department of Plastic College, London, UK
& Reconstructive
Surgery,
University
Dehiscence of flexor tendon repair may be the most important cause of failure, particularly following early active motion. Much research has been focussed on longitudinal tensile loading, but lateral forces may be of equal importance. The usual concept of tendon function is that the flexor digitorum sublimis (FDS) forms a perfect tunnel through which the flexor digitorum profundus (FDP) slides effortlessly. The mechanism is more complex in that the FDP does not have a regular cylindrical shape but varies its cross-section at different levels in the pulley system. Studies of dynamic motion have been performed in 6 fixed and 10 freshly amputated cadaveric hands, observing the mechanism of the flexor sublimis decussation as it glides proximally. The FDS exerts a lateral force on the FDP tending to grip the FDP like a “Chinese Finger”. Simultaneously there is an anteroposterior force on the FDP which is squeezed between the annular pulleys (especially A2) and the Chiasm of Camper. The lateral forces combined with the shape of the FDP may tend to “lock” both tendons together. These strong forces may impair intrinsic tendon healing or even disrupt the tendon sutures.