This article is found in the Journal of Plastic and Reconstructive Surgery Oct. 2011 issue. It is original bench-top research that demonstrates that a flexor tendon can be repaired without knots while remaining as strong as some traditional repairs.
In an effort to increase the immediate strength of a rotator cuff repair and to simulate the standard open reconstruction with its effective suture fixation, we have developed a novel technique for suture anchor reconstruction of the rotator cuff. The technique, termed mattress double anchor (MDA), is simple and adaptable. It makes use of 2 suture anchors that are placed independently and then connected by a suture loop. The technique produces a repair construct that distributes the stress across 2 anchors. The method also restores a large surface area for healing between the rotator cuff and the tuberosity.
In an effort to increase the immediate strength of a rotator cuff repair and to simulate the standard open reconstruction with its effective suture fixation, we have developed a novel technique for suture anchor reconstruction of the rotator cuff. The technique, termed mattress double anchor (MDA), is simple and adaptable. It makes use of 2 suture anchors that are placed independently and then connected by a suture loop. The technique produces a repair construct that distributes the stress across 2 anchors. The method also restores a large surface area for healing between the rotator cuff and the tuberosity.
Arthroscopic Single Row Versus Double-Row Suture Anchor Rotator Cuff Repair |...Peter Millett MD
Twenty fresh-frozen cadaveric shoulders were randomly assigned to 4 arthroscopic repair techniques. The repair was performed as either a single-row suture anchor rotator cuff repair technique or 1 of 3 double-row techniques: diamond, mattress double anchor, or modified mattress double anchor. Angle of loading, anchor type, bone mineral density, anchor distribution, angle of anchor insertion, arthroscopic technique, and suture type and size were all controlled. Footprint length and width were quantified before and after repair. Displacement with cyclic loading and load to failure were determined. For more shoulder surgery and rotator cuff studies, visit Peter Millett, MD, The Steadman Clinic, Vail Colorado http://drmillett.com/shoulder-studies
Effect of Suture Tubularization on Quadruple Stranded Hamstring ACL Grafts wi...CrimsonPublishersOPROJ
Effect of Suture Tubularization on Quadruple Stranded Hamstring ACL Grafts with Femoral Suspensory Fixation: A Biomechanical Study by Matthew Richard Moralle* in Crimson Publishers: Orthopedic Research and Reviews Journal
The “Bony Bankart Bridge” Procedure Shoulder Instability | Shoudler Surgery |...Peter Millett MD
Arthroscopic treatment of bony Bankart lesions can be challenging. We present a new easy and reproducible technique for arthroscopic reduction and suture anchor fixation of bony Bankart fragments. A suture anchor is placed medially to the fracture on the glenoid neck, and its sutures are passed around the bony fragment through the soft tissue including the inferior glenohumeral ligament complex. The sutures of this anchor are loaded in a second anchor that is placed on the glenoid face. This creates a nontilting 2-point fixation that compresses the fragment into its bed. By use of the standard technique, additional suture anchors are used superiorly and inferiorly to the bony Bankart piece to repair the labrum and shift the joint capsule. We call this the “bony Bankart bridge” procedure. Key Words: Arthroscopy—Bony Bankart lesion—Suture bridge—Instability—Shoulder. For more shoulder surgery and shoulder instability studies, visit Dr. Millett, The Steadman Clinic, Greater Denver Area http://drmillett.com/shoulder-studies
Arthroscopic Single Row Versus Double-Row Suture Anchor Rotator Cuff Repair |...Peter Millett MD
Twenty fresh-frozen cadaveric shoulders were randomly assigned to 4 arthroscopic repair techniques. The repair was performed as either a single-row suture anchor rotator cuff repair technique or 1 of 3 double-row techniques: diamond, mattress double anchor, or modified mattress double anchor. Angle of loading, anchor type, bone mineral density, anchor distribution, angle of anchor insertion, arthroscopic technique, and suture type and size were all controlled. Footprint length and width were quantified before and after repair. Displacement with cyclic loading and load to failure were determined. For more shoulder surgery and rotator cuff studies, visit Peter Millett, MD, The Steadman Clinic, Vail Colorado http://drmillett.com/shoulder-studies
Effect of Suture Tubularization on Quadruple Stranded Hamstring ACL Grafts wi...CrimsonPublishersOPROJ
Effect of Suture Tubularization on Quadruple Stranded Hamstring ACL Grafts with Femoral Suspensory Fixation: A Biomechanical Study by Matthew Richard Moralle* in Crimson Publishers: Orthopedic Research and Reviews Journal
The “Bony Bankart Bridge” Procedure Shoulder Instability | Shoudler Surgery |...Peter Millett MD
Arthroscopic treatment of bony Bankart lesions can be challenging. We present a new easy and reproducible technique for arthroscopic reduction and suture anchor fixation of bony Bankart fragments. A suture anchor is placed medially to the fracture on the glenoid neck, and its sutures are passed around the bony fragment through the soft tissue including the inferior glenohumeral ligament complex. The sutures of this anchor are loaded in a second anchor that is placed on the glenoid face. This creates a nontilting 2-point fixation that compresses the fragment into its bed. By use of the standard technique, additional suture anchors are used superiorly and inferiorly to the bony Bankart piece to repair the labrum and shift the joint capsule. We call this the “bony Bankart bridge” procedure. Key Words: Arthroscopy—Bony Bankart lesion—Suture bridge—Instability—Shoulder. For more shoulder surgery and shoulder instability studies, visit Dr. Millett, The Steadman Clinic, Greater Denver Area http://drmillett.com/shoulder-studies
The temporal branch of the facial nerve is a commonly injured nerve during facial trauma due to its superficial course over the zygomatic arch, and is a commonly damaged nerve during facial surgery.1 We report a case of trauma to the left temporal fossa, and subsequent unilateral forehead paralysis. Early exploration revealed external suture compression as the origin of his paralysis. Removal of the suture led to complete resolution of the neurological deficit. The differential diagnosis did not include the possibility of the compression of the nerve by a suture, however the decision for early exploration led to a full recovery.
We report a case of acquired anterior thoracic lung herniation in a 63-year-old female. This painful herniation developed four years after uncomplicated video-assisted thoracic surgery for lung cancer resection and adjuvant radiation for concomitant breast cancer. The herniation site was remote from all prior incisions, and demonstrated intercostal muscle denervation and radiation fibrosis. The 8 cm x 10 cm chest wall defect was reconstructed with inlay PROCEED mesh and reinforced with a pedicled latissimus dorsi flap. Five months postoperatively the patient had complete resolution of symptoms, no evidence of herniation, and a stable wound.
This is initial data from the Figure 8 FlatWire Sternal Closure System. FlatWire is a simple, strong, and cost effective replacement for traditional steel wire for sternal cerclage.
This is a CME article that appears in Plastic and Reconstructive Surgery, the gold standard of publications within the field. Reconstructing the eyelid can be difficult and complicated. This article discusses the various approaches to defects caused by cancer.
This is a pilot study which examines the use of the fistbump instead of a traditional handshake in the hospital setting. In the hospital we use automatic doors, automatic sinks, and alcohol based hand sanitizer. However the rise of antibiotic resistant bacteria continues to increase. We propose ceasing handshaking within the hospital and opting instead for the fun fistbump will reduce the transmission of bacteria.
This is a paper that Dr. W. Thomas McClellan co-authored on the anatomy and reconstruction of the inframammary fold. This critical structure is often injured during breast augmentation and understanding of the anatomy is crucial to a good outcome in breast augmentation.
This is a powerpoint presentaiton given by W. Thomas McClellan, MD FACS, a Board Certified Plastic Surgeon who specializes in breast augmentation. This presentation is unique and critical because it gives patients detailed information about what is important regarding breast augmentation. For example: How to choose a surgeon, what is important in the operating room, postoperative care, how to pick a size, type of breast implant.
This is a paper which describes an innovative approach for skin sparing mastectomy. This incision tends to distract the eye and be less noticeable. Additionally it allows excellent access to the axilla for lymph node sampling and reduces the excessive retraction on the skin flaps.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
2. Volume 128, Number 4 • Knotless Flexor Tendon Repair
eral studies indicate that friction created by Table 1. Brief Description of Tendon Repair Methods
tendons gliding against pulleys during active finger Group
flexion increases load.5,8,9 In addition, increased su-
ture caliber and number of knots increases tendon Group A B C
cross-sectional area, causing increased gliding No. of
resistance.4,10 This increased load endangers the nas- tendons 22 22 22
Repair Modified Modified
cent repair during active rehabilitation. Clearly, one technique Kessler Savage Knotless
must balance repair strength with the increased ten- No. of
don cross-sectional area within the tendon sheath. strands 2 4 4
Suture 3-0 Ethibond 3-0 Ethibond 0 barbed
We hypothesized that a four-strand knotless tendon
repair using a bidirectional barbed suture has com-
parable strength and reduced repair-site cross-sec-
tional area when compared with traditional flexor nonabsorbable, 3-0 braided polyester suture (Ethi-
tendon repairs. bond Excel; Ethicon, Inc., Somerville, N.J.), whereas
the knotless repair was performed using barbed,
nonabsorbable, 0-diameter monofilament polypro-
MATERIALS AND METHODS pylene suture (Quill SRS; Angiotech, Inc., Vancou-
Sixty-six fresh flexor digitorum profundus ten- ver, British Columbia, Canada). The 0-diameter su-
dons were obtained from adult pigs. These tendons ture was selected because of its similar strength to 3-0
have been used frequently in prior studies because polyester.17,18 A core suture purchase of 1 cm was
they are similar in structure and strength to a human used on all repairs.11,14
middle finger flexor tendon.11–15 The tendons were
examined for abnormalities such as synovitis and Knotless Repair Technique
degeneration, and were rejected if an abnormality
was present. Although a novel repair method, the knotless
technique incorporates elements of both the mod-
ified Kessler and the Savage methods. The knotless
Cross-Sectional Area Measurements method uses four strands and a locking grasp of the
Each tendon’s height and width were measured epitenon. A diagram of our technique is shown in
at the repair site and 1 cm proximal and distal to the Figure 1. The barbed repair first incorporates a
repair site using a Brown & Sharpe IP67 digital cal- straight pass through the tendon until the barbs
iper (part no. 00530300; Hexagon Metrology, Inc., catch the opposite side of the tendon. Then, the
North Kingstown, R.I.). The measurements were an- double-armed suture is passed back through the cen-
alyzed to ensure all tendons were a similar size. The tral core of the tendon to the transection site. The
cross-sectional area at each site was calculated using central core limbs of the barbed repair are then
the formula for area of an ellipse (area ab, where passed diagonally across the tendon twice and an
a equals one-half tendon height and b equals one- external bite of the epitenon is performed. The di-
half tendon width). Measurements were taken at all agonal passes serve two purposes. First, they increase
three sites before tendon transection and after re- the number of barbs within the tendon substance.
pair to determine prerepair and postrepair cross- Second, the diagonal passes allow for multiple grasps
sectional area. Blinded intrarater analysis was con- of the epitenon. Finally, the external bite locks the
ducted both before transection and after repair to suture onto itself and then a mirror stitch is applied to
ensure measurement consistency. the initial tendon. A running epitendinous suture was
not performed so that only the core suture strength was
Repair analyzed.
The tendons were divided randomly into three
repair groups (A, B, and C), transected, and then Biomechanical Testing
repaired as described in Table 1. After repair and surface area measurement,
All knots in groups A and B received six throws each tendon was secured into the clamps of a
to maximize effectiveness.1,16 The modified Kessler tensiometer (model 4411; Instron Corp., Canton,
technique was chosen to represent a two-strand Mass.) with a load cell of 500 N. The clamps have
grasping technique and the modified Savage tech- a broad surface that prevented tendon slippage
nique was chosen to represent a four-strand locking during testing. The upper clamp had a preload of
technique. One surgeon (W.T.M.) performed all 1.5 N and was advanced at a rate of 20 mm/minute
repairs under 3.5 loupe magnification. The mod- The preload and rate were selected because they
ified Kessler and Savage repairs were performed with best simulate forces acting on an immobilized ten-
323e
3. Plastic and Reconstructive Surgery • October 2011
Fig. 1. Diagram of the four-strand knotless flexor tendon repair technique.
don during active flexion.7,11,12,19,20 The linear dis- Table 2. Data from Mechanical Strength Testing of
traction was monitored with a video camera and Tendon Repairs Including 2-mm-Gap Formation
the digital caliper (previously noted) was placed Force, Ultimate Strength, and Mode of Failure
near the repaired tendon. The force and tendon
Tensile Strength (N) Failure Mode
displacement were recorded by Instron Series 9
software. The force that produced a 2-mm gap Repair 2-mm-Gap
between tendon halves at the repair site was re- Method Formation Ultimate Rupture Pullout
corded as the 2-mm-gap formation force. Linear Knotless 62.84 17.30 72.39 15.16 18 4
distraction continued until the sutures were pulled Savage 59.22 15.12 69.18 8.96 22 0
Kessler 23.45 5.32 32.03 5.36 17 5
out or ruptured. In all cases, the greatest force oc-
curring immediately before repair failure was re-
corded as the ultimate strength. The mode of repair Table 3. Comparison of Postrepair
failure was reported as pullout or rupture. An ob- Cross-Sectional Area*
server blinded to the tendon repair technique per-
Repair Site
formed all mechanical strength testing. Cross-Sectional Area (mm2)
RESULTS Repair Absolute Change
Technique Size (vs. native tendon)
Power analysis was performed to ensure a large
Knotless 24.4 7.10 4.58
enough sample size. For 0.80 power, seven tendons Savage 31.9 13.6 3.35
were needed in each group. The 2-mm-gap forma- Kessler 32.3 14.3 5.55
tion force, ultimate strength, and cross-sectional *The knotless technique had a significantly smaller tendon size and
area data were analyzed with one-way analysis of vari- change in cross-sectional area compared with the Kessler and Savage
techniques.
ance. A log transformation of the 2-mm-gap force
and ultimate strength data were taken before anal-
ysis of variance. Intergroup reliability was checked. 2-mm-gap formation force for tendons repaired by
Values of p 0.05 were considered significant. the Savage method was 59.22 N. Tendons repaired
The 2-mm-gap formation force results, ulti- with the modified Kessler method required 23.45
mate strength results, and mode of failure are N to form a 2-mm gap. The knotless and Savage
listed in Table 2, and changes in tendon dimen- methods demonstrated a significantly greater
sions are listed in Table 3. All values are reported 2-mm-gap formation force than the Kessler
as mean SD. Results are depicted graphically in method (p 0.05). However, no significant dif-
Figures 2 and 3. Mode of failure is reported as ference in 2-mm-gap formation force existed be-
either suture rupture or suture pullout. Rupture tween the knotless technique and the Savage
failure means the strands or knots broke. Pullout method.
failure means that the strands tore from the ten-
don without breaking. Ultimate Strength
The force causing ultimate failure is reported
2-mm-Gap Formation Force in Figure 2 and Table 2. Tendons repaired by the
Forces necessary to produce a 2-mm gap at the knotless method withstood 72.39 N before failing.
repair site are reported in Figure 2 and Table 2. The ultimate failure force for tendons repaired by
Tendons repaired by the knotless method pos- the Savage method was 69.18 N. Tendons repaired
sessed a 2-mm-gap formation force of 62.84 N. The by the modified Kessler method ultimately failed
324e
4. Volume 128, Number 4 • Knotless Flexor Tendon Repair
Fig. 2. Comparison of tensile strength among tendon repair techniques. Average
2-mm-gap formation force (yellow bars) and ultimate strength (blue bars) are
shown for each tendon repair technique. Knotless and Savage repairs were signif-
icantly stronger than the Kessler repairs (p 0.05). Knotless and Savage methods
were not significantly different in strength.
DISCUSSION
McKenzie first reported using a unidirectional
barbed steel wire to repair flexor tendons in
1967.21 His repair showed theoretical advantages
compared with traditional repair techniques, but
the use of a barbed suture repair was lost to the
literature until recently.22,23 Current barbed suture
technology has advanced radically. Barbed sutures
are bidirectional, with barbs spiraling around the
central core suture. Barbed suture can now be
Fig. 3. Comparison of postsurgical cross-sectional area among created using absorbable and nonabsorbable ma-
tendon repair techniques. Average cross-sectional area at the re- terials, unlike the original steel wire description.
pair site is shown for each repair technique. The knotless method Using these types of materials is advantageous for
had a significantly smaller cross-sectional area than the Savage or tendon repair.
Kessler method. According to Strickland, the ideal character-
istics of a primary flexor tendon repair include
secure and easily placed sutures to allow for early
at 32.03 N. The knotless and Savage methods dem- postsurgical mobilization, smooth apposition of
onstrated a significantly greater ultimate strength
the tendon sections, minimum gapping forces,
than the Kessler method (p 0.05). However, no
and minimal tendon vasculature disturbance.24,25
significant difference in ultimate strength was ob-
Trail et al. listed the ideal suture characteristics as
served between the knotless technique and the
having high tensile strength and being inexten-
Savage method.
sible, absorbable, and, most importantly, easy to
use.1,2 No current technique or suture meets all of
Cross-Sectional Area the criteria of Strickland and Trail et al.
The postrepair cross-sectional area for each Traditional flexor tendon repair techniques
tendon repair technique is reported in Figure 3. rely on knots either within the tendon or posi-
The change in tendon size with the knotless tech- tioned externally. When the knots lie within the
nique was significantly less than with the Savage tendon, they may also impede the tendon’s ulti-
and Kessler techniques (p 0.01). No significant mate healing potential because of interposition of
difference was observed in cross-sectional area the knot between the tendon halves.3,26 When us-
proximal or distal to the repair site among the ing a nonabsorbable suture, a permanent obstruc-
techniques (Fig. 4). tion is placed between the tendon ends. With a
325e
5. Plastic and Reconstructive Surgery • October 2011
Fig. 4. An unrepaired tendon (below) and a tendon repaired with the
knotless technique (above).
knotless repair, there is no knot interposition be- The knotless method does not decrease the
tween the tendon ends, so the potential exists for difficulty of flexor tendon repair or change its
better healing and increased long-term strength. indications. Further study of this four-stranded
Knots within the repair site do not affect the knotless technique should include cyclical loading
repair’s overall strength unless they are greater and angular tensile strength. Cyclical loading stud-
than 26 percent of the tendon’s cross-sectional ies would be important to determine the risk of
surface area.3 Although larger suture calibers im- barbed sutures slicing through the freshly re-
part greater strength to the tendon repair, they are paired tendon during early, active rehabilitation.
harder to manipulate and create larger knots.6,26 Angular tensile strength studies would more
Some authors have even recommended at least closely resemble forces acting on the tendon dur-
five throws to create a secure knot.1,16 In addition, ing rehabilitation.
increased foreign material within a repair site has Another weakness of our study is the lack of
been shown to decrease wound healing by stim- clinical data and outcomes from application in
ulating an inflammatory response.26 Although patients. In vivo studies should certainly be per-
large knots impart greater repair strength, they formed to assess repair healing and its environ-
are less than ideal because of their deleterious mental interactions in an animal model. Success-
effect on healing and increased tendon profile. ful application and outcomes in patients would
Bulky knots increase the tendon’s cross-sec- allow the knotless four-stranded technique to be
tional area, thus increasing gliding resistance dur- incorporated into clinical practice.
ing active flexion.4,10,27–29 Furthermore, this in-
creased load at the repair site can cause gap CONCLUSIONS
formation and failure.7,9,30
This report shows that our four-stranded knot-
Furthermore, knots have been shown to im- less technique yields a repair as strong as a con-
pede vasculature.29,31–33 This deprives the ten- temporary four-stranded method but with a
don of vital nourishment necessary to heal, caus- smaller cross-sectional area. Because our repair is
ing extrinsic neovascularization and adhesion as strong as current techniques and has a lower
formation.34 tendon profile, further ex vivo and in vivo studies
One way to prevent the problems caused by are warranted. Our knotless technique may im-
knots is to completely eliminate them. We report prove outcomes in patients with zone II flexor
a four-strand knotless flexor tendon repair tendon lacerations by allowing for more aggressive
method using a bidirectional barbed suture. Our rehabilitation with reduced risk of repair failure.
results show no significant difference in repair
strength between the four-strand knotless tech- W. Thomas McClellan, M.D.
nique and the criterion standard four-strand Sav- Morgantown Plastic Surgery Associates
age technique. Most importantly, the four-strand 1085 Van Voorhis Road, Suite 350
Morgantown, W.Va. 26505
knotless method creates a lower tendon profile at wtmcclellan@yahoo.com
the repair site. It is plausible that decreasing the
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