The document discusses various tendon repair techniques, emphasizing the importance of approximating tendon ends and ensuring minimal gapping during healing. It highlights the significance of using multiple suture strands for strength, optimizing suture materials for tensile strength, and different configurations of suture components to minimize gliding friction. Additionally, it compares historical techniques and modern advancements to assess biomechanical strengths and weaknesses for effective tendon repair.

1. TENDON REPAIR TECHNIQUES
DR GEENA GEORGE

2. AIM
• Approximate the ends of tendon or end of tendon to adjoining tendon or to
bone
• To retain this during the process of healing
• Early active mobilisation

3. IDEAL TENDON REPAIR -STRICKLAND
• Easy placement of sutures in tendon
• Secure suture knots
• Smooth juncture of tendon ends
• Minimal or no gapping at repair site
• Minimal interference with tendon vascularity
• Sufficient strength throughout healing to allow early
motion stress to the tendon

5. • Multiple core suture strands (≥ 4)  stronger repair  able to tolerate
early postoperative active motion rehabilitation
• Repair strength further increased by using higher suture caliber and
stiffer suture materials
• Addition of an epitendinous stitch  improves biomechanical strength,
minimizes gapping, reduces cross-sectional area decreases gliding
friction.

6. • Knots weakest component of the repair
• Pruitt et al - in vivo canine study - internal knots inferior to outside knot
-overall biomechanical strength at day 0
• 6 weeks post operatively , same biomechanical strength
• In terms of gliding friction from external knot placement, Momose et al -
2 lateral sided knots had more friction than 1 volar-sided or 1 lateral-
sided knot

7. SUTURE MATERIAL
• Highest tensile strength – Stainless steel  difficult to handle, pulls through
the tendon , large knot
• Can be used in forearm, not in hand
• Absorbable - Catgut, vicryl – absorbed early before strength
• Synthetic – Nylon, Caprolactam – maintain resistance to disrupting forces
more than Prolene & Polyester
• PDS, Maxon

8. • Monofilament – earlier gap formation
• In biomechanical study , Braided --most suited
• Sufficient resistance, easy handling , good knot (polyester)
• 4-0 suture 66% stronger than 5-0
• 3-0 52% stronger than 4-0

9. • 3-0  forearm, palm, larger digits
• 4-0  smaller digits
• 5-0 or 6-0 monofilament for epitendinous

10. SUTURE CONFIGURATION
• Strongest to allow early active & passive mobilization
• 4/6/8 strand core sutures – strongest
• Reduce gap formation, permit more early active motion
• Tang et al – global survey – multistrand 3-0 or 4-0 core suture with 6-0
epitendinous

11. COMPONENTS OF CORE SUTURE
• 3 components- longitudinal, transverse & link component
• Link component  junction between a longitudinal and a transverse
component or between 2 longitudinal components
• All techniques have the longitudinal and link components and may have the
transverse component
• Longitudinal and transverse components usually placed within the tendon
substance
• Link component lie outside the tendon

13. • The transverse & link components convert the longitudinal pull of the suture
to a transverse compressive force  prevent the longitudinal component
from pulling out
• Longitudinal component allows placement of the transverse and/or link
components away from the divided end of the tendon

14. • Orientation of components can vary
• Transverse component may be placed distal or proximal to the far end of the
longitudinal component
• Transverse component may be placed superior, inferior, or between the
longitudinal
• Link component may be constructed as an arc, a loop, or a knot

15. • Arc  when the 2 suture components forming the link component do not
cross each other (a grasping loop)
• Arc component does not encircle any tendon fibrils
• Loop link  when the suture components cross each other and form a full
circle (a locking loop).
• Holds the tendon fibrils within the loop
• Knot link component Loop is secured with a knot

16. • Variations in link component - result in a sliding or an anchored suture on
each half of the divided tendon
• Sliding suture allows the suture to slide within the tendon substance when
tension is applied to one of the longitudinal components
• Anchored suture does not allow the suture to move independent of the
tendon
• Arc link component  in sliding suture
• Knot link component  anchored suture
• Loop link component  sliding or an anchored suture, depending on the
complexity of the loop

17. • Sliding sutures  tension is equally distributed among the different
longitudinal strands
• Anchored suture - longitudinal strands are fixed –any slack in the suture 
uneven distribution of tension and gapping at tendon ends
• Also associated with less bunching of the tendon ends when the suture knot
is tied

18. EVOLUTION
• Nicoladoni - 1882
• Single strand suture with intratendinous longitudinal and
transverse components connected by an arc link with sliding
suture
• Suture knot outside the tendon
• Kirchmayr - 1917
• Transverse component between the cut end of tendon & far
end of the longitudinal component
• Arc link component - sliding suture
• Single strand of suture and knot tied outside

19. • Bunnell - 1928
• Intratendinous longitudinal & multiple transverse components connected by
arc link components  sliding suture
• Oblique placement of the longitudinal component to form a figure-of-8
pattern that, combined with the transverse components  required grasp of
the tendon
• single strand of suture with 2 needles & knot was placed outside

20. • Mason and Allen -1941.
• Used 4 strands of sutures with intratendinous transverse
and extratendinous longitudinal components
• Each tendon end had 2 parallel transverse components
anchored using a tendon knot
• Extratendinous longitudinal components were sutured
to each
• First anchored suture technique.
• Kessler repair - based on the repair described by Mason
and Allen

22. END TO END SUTURE TECHNIQUES
• Bunnel technique
• Tsuge
• Bevel
• Tajima Kessler
• Kessler
• Indiana 4 strand repair

23. TWO STRAND TENDON REPAIRS

24. FOUR STRAND TENDON REPAIRS

25. SIX STRAND REPAIR
• Savage (with Modifications)
• Lim-Tsai
• Tsuge (Tang Modification)

26. EIGHT STRAND REPAIR
• Winters Gelberman
• Knotless Barbed sutures

27. KESSLER -1969

28. • Suture is anchored to the tendon at all 4 corners with a knot
• This knot prevents the suture from moving within the tendon substance
• Urbaniak et al – compared tensile strengths of 5 different end-to-end tendon-
suturing techniques
• Circumferential interrupted suture , techniques described by Nicoladoni,
Mason and Allen, Bunnell, and Kessler

29. • The strongest end-to-end suture technique - Mason–Allen technique - tensile
strength of 4,030 g
• Kessler grasping technique - tensile strength of 3,970 g
• Strengths of the Bunnell technique and the Kessler grasping technique
compared during healing
• On day 5, Kessler’s technique was 3 times stronger than the Bunnell suture

30. MODIFIED KESSLER

31. BUNNEL STITCH

33. FOUR OR SIX STRAND MODIFIED TSUGE REPAIR-

34. CRUCIATE REPAIR
• One of the most commonly performed repairs in flexor tendon surgery
• Original cruciate repair  McLarney et al - nonlocking repair technique
• Locking configurations - biomechanically superior to nonlocking
configurations
• Croog et al compared the biomechanics of different locking cruciate
configurations: simple lock, circlelock, and cross-lock cruciate repairs
• Cross-lock - most superior with and without an epitendinous stitch
• Smaller increase in work of flexion and a higher ultimate load to failure than
the Strickland repair

36. • Advantages :
• Biomechanical strength compared with other 4-strand repairs
• Single suture to complete the repair
• Overall the cruciate configuration is easier to place than other repairs
• Disadvantages :
• Exposed suture on the surface of the tendon
• Increased tissue handling from placing the cross-locks
• Need to make sure tendon ends are well approximated when the cross-locks
are placed

37. MASSACHUSETTS GENERAL HOSPITAL (MODIFIED
BECKER)
• Running cross-lock loop configuration
• Uses 2 separate sutures secured with 2 separate
knots on the outside of the tendon
• Gliding resistance was significantly higher
• Advantages:
• Biomechanical strength
• Larger suture purchase based on its configuration
biomechanical stability

38. • Disadvantages:
• Exposed suture on the surface & cross-lock configuration  increased work
of flexion due to friction and potential for increased adhesions
• Potential weaknesses with the placement of 2 knots
• Increased tissue handling of the injured tendon

39. STRICKLAND
• Also known as the Indiana Hand method
• 4-core nonlocking (grasping) repair
• Supplemented by a running-locking epitendinous stitch
• Advantages:
• Biomechanical strength compared to 2-core repairs
• Ability to be used for early motion exercises
• Disadvantages
• Poor biomechanical strength compared to other 4 core repairs
• Increased number of knots points of weaknesses in the construct

40. SIX STRAND REPAIR – SAVAGE

41. • Lim-Tsai and Tsuge
• Uses 2 double-stranded
sutures

42. • Advantage:
• Superior biomechanical strength compared to other 2- and 4-core stranded
repairs
• Disadvantage:
• 2 separate sutures increases tissue handling

43. EIGHT STRAND WINTERS-GELBMERMAN REPAIR

44. • Advantage :
• Stout biomechanical strength compared to 4-core and 6-core repairs
• Most useful in larger tendons able to withstand 8-strands
• Disadvantages:
• Potentially increased bulk
• Increased tissue handling with increased suture passes
• Technical difficulty

46. FISH-MOUTH END-TO-END SUTURE (PULVERTAFT)
• Tendon of small diameter can
be sutured to large diameter
tendon
• Used to suture tendons of
unequal size

47. ROLL STITCH
• For suturing extensor tendons over or near the MCP joints
• 4-0 monofilament wire or nylon
• Tendon sutured through skin

48. END TO SIDE TECHNIQUES
• Used in tendon transfers when one motor
must activate several tendons
• Pierce the recipient tendon through the
center with blade  grasp blade end with
a straight hemostat
• Withdraw the blade  carrying the
hemostat inside

49. • Grasp the end of the tendon to
be transferred on the end of
hemostat and bring it through
the slit
• Vertical mattress stitch at each
pass & bury the end of the
transferred

50. CIRCUMFERENTIAL SUTURES
• Lindsay et al,Pruitt and colleagues, Silfverskiod”ld - gapping at the repair site
becomes the weakest part of the tendon unfavorably alters tendon
mechanics adhesions  decreased tendon excursion
• Peripheral circumferential suture at the completion of a tendon repair  Diao
et al,203 Silfverskio¨ld and colleagues
• Provide a 10% to 50% increase in flexor tendon repair strength and a
significant reduction in gapping between the tendon ends

51. • The running lock loop stitch  Lin et al
• Horizontal mattress intrafiber method  Mashadi and Amis
• Halsted continuous horizontal mattress suture
• Cross-stitch technique by Silfverskio¨ld

53. TENDON-TO-BONE ATTACHMENT
• Requires a pull-out technique
• Tendon-to-tendon repair of grafts
preferable in children - avoid physeal
injury
• Core suture techniques - Kessler and
modified Bunnell crisscross suture

56. SUTURE ANCHOR TENDON ATTACHMENT
• Avoids complications with
the fingernail
• Two suture anchors placed in
the distal phalanx
• From distal-volar to proximal-
dorsal
• Gains purchase in the
thickest portion of the distal
phalanx  greatest pull-out
strength

57. Key factors determining the strength of tendon core repair:
Number of suture strands crossing the repair site
caliber of the suture
Tensile strength of the suture material
Hold of the core suture on the tendon fibers (sliding vs anchored)
Other factors
Number of knots
Location of the knots (intratendinous vs
extratendinous)
Addition of a peripheral repair