Using Q Suture to Enhance Resistance to Gap Formation and Tensile Strength of Repaired Flexor Tendons

Podsumowanie

Here, we present a “Q” suture technique that can be performed in tendon repair and its effects on the gap formation and tensile strength of the repaired tendons. Q suture is shown to be efficient in enhancing the tensile resistance and tendon repair strength.

Streszczenie

Peripheral epitendinous sutures are believed to enhance core suture strength in tendon repair and decrease the risk of gapping between tendon ends. Here Q suture, an alternative to peripheral sutures, is presented for the use in tendon repair. Its effects on gap formation and tensile strength of the repaired tendons were compared with conventional running peripheral sutures. Three 2-strand sutures and three 4-strand sutures were used in repairing porcine tendons. The time required for performing 2Q and running sutures were recorded. The repaired tendons were subjected to a cyclic loading test, and the cycle number, during which a 2-mm gap was formed, was determined. After the cyclic loading, the gap size at the tendon ends and the ultimate strength of the repaired tendons were measured. Augmentation with the Q sutures reduced the number of tendons showing 2-mm gaps at tendon ends during cyclic loading. With addition of Q sutures 2-strand sutures significantly increased the ultimate strength of the repaired tendons and 4-strand sutures decreased the gap distance at the repair site of tendons. The time required for performing 2Q sutures was significantly less than that for running sutures. Therefore, we conclude that the Q suture is efficient in enhancing the tensile resistance and tendon repair strength and can be an alternative to conventional peripheral sutures.

Wprowadzenie

Gap formation at tendon repair site affects tendon repair strength and gliding resistance substantially. The consequences of gapping between tendon ends may ultimately impede tendon healing in vivo¹. It has been reported that the presence of a gap larger than 2 mm at the repair site lead to a significant increase in the gliding resistance of repaired intrasynovial tendon in cadaveric hands². A study in a canine model has shown that a gap size larger than 3 mm would impair the tendon healing strength and stiffness³. Therefore, improving resistance and decreasing the risk of gapping between tendon ends are critical for tendon repair.

Addition of peripheral sutures has been shown to reduce the gapping at the tendon repair site thereby improving gliding function of the repaired tendons^4,5,6. During the last few decades, a number of peripheral sutures have been developed, including the interlocking cross stitch (IXS), interlocking horizontal mattress (IHM), and cross-linked Silfverskiöld and Lembert, et al^7,8,9,10. These peripheral sutures have proven to be superior to running peripheral sutures with respect to gapping resistance in tendon repair. However, many of these sutures are complex in structure and difficult to perform, thereby limiting their widespread applications. An ideal suture for tendon repair should aim to prevent gap formation while avoiding the addition of bulk to the repair site after tendon repair. Currently, running peripheral suture remains a popular technique due to its simplicity.

In a recent study, a technique, alternative to peripheral suture, named Q suture, because its shape is similar to the letter “Q”, is presented¹¹. Here, we compared this suturing technique with running peripheral suture to check for the differences in gapping resistance and the tensile strength of repaired tendons. The results showed that Q suture was more efficient in enhancing the gapping resistance and ultimate strength of the repaired tendons in the cyclic loading test. Therefore, this article aims to provide a detailed description of how to perform Q suture technique and the biomechanical settings for testing the effects of Q suture on the properties of the repaired tendons.

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Protokół

All experimental procedures described were approved by the Administration Committee of Experimental Animals of the Nantong University. Thirty porcine tendons were repaired with three 2-strand repairs: 2-strand core suture, 2-strand core suture plus 2Q, and 2-strand core suture plus running peripheral sutures. The other 30 porcine tendons were repaired with three 4 strand repairs: 4-strand core suture, 4-strand core suture plus 2Q, and 4-strand core suture plus running peripheral sutures.

1. Preparation of porcine tendons

1. Purchase fresh adult pig hind-leg trotters from a slaughtering house. Remove the skin and subcutaneous tissues to expose the pulley and tendon sheath (Figure 1A).
   NOTE: The pulley and tendon sheath are dense in texture, which form an obvious fibro-osseous tunnel for the gliding tendons. The subcutaneous tissues are relatively loose in texture and very easy to be removed.
2. Incise the pulley and tendon sheath longitudinally along the central line to expose the flexor tendons (Figure 1B).
3. Dissect the flexor digitorum superficialis (FDS) tendon to expose the branches of the flexor digitorum profundus (FDP) tendons (Figure 1C).
4. Harvest the FDP tendons by cutting proximally at about 5 cm to the bifurcation of the FDP tendon and distally at the tendon insertion to the distal phalanx. (Figure 1D).
5. Wash the tendon samples with clean water and remove the paratenon using surgical scissors.
6. Cut the tendon along the midline from the end that was proximal to the bifurcation (Figure 1E).
7. Cut the FDP tendon transversely into 2 stumps at the level that structurally corresponds to the middle part of human zone 2 flexor tendons. The resulting 2 tendon stumps are ready to be repaired (Figure 1F).

2. Tendon repair

1. Mark the anterior surface of one of the tendon stumps with 2 points that are 10 mm from the cut tendon end, with each point locating one-fourth of the way from the left (point 1) and the right (point 2), respectively, in the medial-lateral direction (Figure 2A).
2. Mark each of the left (point 3) and right (point 4) lateral surfaces of the tendon with one point that is 8 mm from the cut tendon end and locate in the middle in the anterior-posterior direction (Figure 2A). Determine all lengths with a Vernier caliper (rated accuracy of 0.02 mm).
3. Repair the tendon with 4-0 suture. Insert the needle into the cut surface of one tendon stump from the point that is in the middle in the anterior-posterior direction and one-fourth of the way from the left in the medial-lateral direction (Figure 2B). Pass the needle longitudinally through the tendon and withdraw the needle on the anterior surface of the tendon, exiting from point 1 (Figure 2B).
4. Re-insert the needle obliquely from point 3 and pass it transversely toward point 4, creating a small loop at the lateral surface of the tendon (Figure 2C). Pull out the suture and re-insert the needle obliquely from point 2 and pass it longitudinally toward the cut end (Figure 2D,E).
5. Insert the needle into the cut end of the other tendon stump and repair it with the same construct, forming a symmetrical repair (Figure 2F).
6. Tighten the suture with 10% shortening of the tendon segment within the core suture. Tie the tendon ends together with 3 to 4 knots and complete the 2-strand core suture (Figure 2G).
7. Repeat the operation once to complete the 4-strand core suture. Do not cut off the first core suture when performing the second core suture.
8. Insert the same needle into the tendon anterior surface 2 mm away from the joined tendon end and pass through the full thickness of the tendon stump (Figure 3A).
9. Withdraw the needle on the posterior surface of the tendon and re-insert the needle into the posterior surface of the tendon 2 mm away from the other side of the joined tendon end (Figure 3B).
10. Pull out the suture from the anterior surface of the tendon and tie 3 knots to complete 1 Q suture (Figure 3C). Repeat the procedure to complete the second Q suture (Figure 3D).
11. In the 2-strand and 4-strand core suture plus running group, add a running epitendinous suture of 9 to 10 stitches to the tendon ends using 6-0 suture. Keep a similar purchase of 1.5 mm and depth of 1 mm (Figure 3E,F,G).
12. Keep the repaired tendon moist by wet gauzes before biomechanical testing.

3. Software setting

1. Open the testing software and go to the Home screen. Click Method to create a test method. Click New to open the Create a New Test Method dialog box. Select the test type Tension-TestProfile Method and click Create. Click Save As to name and save the test method file.
2. Open the Control-Pre-Test screen in the Method tab by clicking Control | Pre-Test in the navigation bar. Click Preload. Set the control mode as Tensile Extension, the rate as 25 mm/min, the channel as load, and the value as 0.5 N. Enable Auto balance. Add the Available Channels of Tensile strain and Load to the Selected Channels.
3. Open the Control-Test screen in the Method tab and click Edit Profile of the cyclic loading. Insert 4 blocks.
   1. In the first block, set the Mode as Tensile extension, Shape as Triangle, Maximum load as 8 N in the 2-strand repairs and 15 N in the 4-strand repairs, Minimum load as 0 N, Rate as 25 mm/min, and Cycle as 10.
   2. In the second block, set the Mode as Tensile extension, Shape as Absolute Ramp, Rate as 25 mm/min, and Endpoint as 8N in the 2-strand repairs and 15 N in the 4-strand repairs.
   3. In the third block, set the Mode as Tensile extension, Shape as Hold, Criteria as Duration, and Duration as 8 s.
   4. In the fourth block, set the Mode as Tensile extension, Shape as Absolute Ramp, Rate as 25 mm/min, and Endpoint as 100 N. Click Save and Close.
4. Open the Control-End of Test screen in the Method tab. Set Criteria 1 as Rate of Load, and Sensitivity as 40%.
5. Open the Calculation-Setup screen in the Method tab. Select Absolute peak and add to the Selected calculations. Select Load in the drop-down list of Channel. Apply to the 4. Absolute Ramp.
6. Open the Results 1-Columns screen in the Method tab. Select Maximum Load and add Load to the selected results. Click Save and Close.

4. Biomechanical test

1. Turn on the testing machine and the computer that runs the software (Figure 4A). Open the testing software and go to the Home screen (Figure 4A). Set the initial distance between the upper and lower clamps of the testing machine to 5 cm (Figure 4B).
2. Wrap the tendon with dry gauzes 2–3 cm away from the cut end. Mount the tendon segments wrapped with gauzes into the upper and lower clamps and keep the tendon vertical as much as possible (Figure 4C).
3. Click Test on the Home screen. Choose the test method file saved in step 3.6 above. Click Next.
4. Enter a name and choose a location for the sample data file. Click Next. The Test tab displays. Open Load Cell Setup dialog and click Calibrate to remove load from load cell.
5. Open Control Panel Setup Dialog and select Balance Load in the drop-down list of Key 1 and Reset Gauge Length of Key 2. Click Balance Load and Reset Gauge Length. Click Start to run a test for each specimen in the sample. Record the number of tendon when a 2-mm gap is formed between the 2 ends during the cyclic loading.
6. Measure the gap distance between tendon ends during a pause of 8 s at the maximum load of the 10th cycle (Figure 4D).
7. Pull the tendon upwards until the repair ruptures and record the ultimate breaking strength (Figure 4E).
8. Click Stop, Return, and Finish to save the results.

5. Statistical Analysis

1. Present data as mean and standard deviation (SD).
2. Analyze data on gap distance and ultimate strength of tendons repaired by different methods using a one-way analysis of variance (ANOVA).
3. Perform multiple comparisons using LSD tests. Set the level of significance at P < 0.05.

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Wyniki

Table 1 shows that addition of Q suture reduced the number of tendons with 2-mm gapping during cyclic loading in both 2-strand and 4-strand repairs. All tendons repaired with 2-strand and 4-strand core sutures formed a 2-mm gap, whereas none of the tendons repaired with 2-strand plus 2Q and only half of those repaired with 4-strand plus 2Q had a 2-mm gapping after 10 cycles. More tendons repaired with 2-strand plus running or 4-strand plus running sutures showed a 2-mm gap than those augmented with Q sut...

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Dyskusje

The results of the current study showed that Q suture not only reduced the gapping and improves tensile strength of the repaired tendons but was also timesaving and labor-saving. Nonetheless, some key points regarding tendon repair in the current study should be noted.

First, we tried to select tendon samples that were similar in shape and size because we were not sure whether tendon size would have a notable impact on tensile strength after repair. In addition, tendon samples can be preserved...

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Materiały

Name	Company	Catalog Number	Comments
4-0 suture	Ethicon, Somerville, NJ	Ethilon 1667
6-0 suture	Ethicon, Somerville, NJ	Ethilon 689
biomechanical testing machine	Instron Corp, Norwood, MA	Instron 3365
biomechanical testing software	Instron Corp, Norwood, MA	Bluehill 2