The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 86, Issue 11

Scientific Articles | November 01, 2004

Effect of Gap Size on Gliding Resistance After Flexor Tendon Repair

Chunfeng Zhao, MD¹; Peter C. Amadio, MD¹; Tatsuro Tanaka, MD¹; Keiji Kutsumi, MD¹; Tetsu Tsubone, MD¹; Mark E. Zobitz, MS¹; Kai-Nan An, PhD¹

¹ Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. E-mail address for P.C. Amadio: pamadio@mayo.edu

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In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from the National Institutes of Health-National Institute of Arthritis and Musculoskeletal and Skin Diseases (Grant AR44391). None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Investigation performed at the Orthopedic Biomechanics Laboratory, Mayo Clinic, Rochester, Minnesota

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2004 Nov 01;86(11):2482-2488

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Abstract

Background: Gap formation is a common complication after flexor tendon repair and is associated with adhesion formation, tendon rupture, and decreased strength. The purpose of this study was to investigate the effect of gap formation on tendon gliding resistance after flexor tendon repair in a human cadaver model.

Methods: Twelve index, middle, and ring fingers from four adult human cadaveric hands were used. Gliding resistance versus excursion between the flexor digitorum profundus tendon and the A2 pulley was first measured in intact tendons. After full laceration, each tendon was repaired with the Pennington suture technique and the gliding resistance was measured again. Then, the repaired tendon (a 0-mm gap) was stretched to form a 1-mm gap, and gliding resistance was remeasured. A magnified video image was used to monitor gap size. This process was repeated to evaluate gap sizes of 2, 3, and 4 mm at the repair site. Peak gliding resistance was determined, and the peak gliding resistance was compared among the groups.

Results: No significant difference in peak gliding resistance was detected between repaired tendons without a gap and tendons with a 1-mm gap. Repaired tendons with a 2-mm gap could pass through the A2 pulley; however, peak gliding resistance was significantly higher than that for tendons with a 0 or a 1-mm gap (p < 0.05). When the gap reached =3 mm, all tendons caught at the A2 pulley edge, causing a dramatically increased peak gliding resistance.

Conclusions: The presence of a 2-mm gap after flexor tendon repair significantly increased tendon peak gliding resistance (p < 0.05), while a gap of =3 mm further increased peak gliding resistance because of catching at the pulley edge.

Clinical Relevance: This study suggests that a large gap (=3 mm) that develops after repair of the flexor digitorum profundus tendon may increase the risk of triggering (catching) at the pulley edge, which may predispose the tendon to rupture, limitation of motion, or adhesion formation during postoperative rehabilitation. Therefore, we believe that minimizing gap formation is an important consideration in flexor tendon repair.

Figures in this Article

Improving the outcome of flexor tendon repair remains a challenge for hand surgeons. Complications still lead to functional disability in many patients^1-3. Although adhesion formation, one of the most severe complications following tendon repair, has been reduced by the use of early postoperative motion rehabilitation programs^4-7, other complications, such as tendon rupture and gap formation, still occur^8-10. The rupture rate has been decreased by the use of higher strength suture techniques^11-13, but gap formation is still a problem^14-16. Clinically, gaps of >3 mm are considered to be important, as they have been shown to affect outcomes, causing complictions such as adhesion formation, tendon rupture, and reduced finger strength after flexor tendon repair^17-20. There is little evidence that gaps of <2 mm are associated with a poor clinical outcome^21-22.

Gliding resistance is another property of repaired tendons that may affect outcome^23,24. Increased gliding resistance between the tendon and pulley system after tendon repair can block tendon motion and lead to adhesion formation²⁵. The gliding characteristics of various suture techniques have been evaluated^26-28. However, in those studies, the effect of gapping, if any, was not studied. Erhard et al. reported that trimming or repairing a 75% partially lacerated tendon could decrease the gliding resistance compared with that of an untreated partial laceration²⁹. However, the gap size was not measured in that study.

We hypothesized that gap formation has a detrimental effect on tendon gliding resistance because of triggering when a tendon with a gap passes through the A2 pulley canal and that this effect is proportional to gap size. The purpose of this study was to investigate, in a human cadaver model, the effect of gap size, ranging from 0 to 4 mm, on tendon gliding resistance.

Materials and Methods

Materials and Methods | Results | Discussion | References

Twelve index, middle, and ring fingers were harvested from four fresh-frozen hands from four human cadavera with a mean age of seventy-eight years (range, sixty-two to eighty-four years) at the time of death. A transverse incision was made in the flexor sheath just distal to the A2 pulley, in order to mark the lateral surface of the flexor digitorum profundus tendon with the digit in full extension. The tendon was then pulled proximally until full flexion of the proximal interphalangeal and distal interphalangeal joints was achieved. In this position, the tendon was marked again, through the same incision. The distance between these two marks represented the tendon excursion. In each finger, the proximal and middle phalanges, the flexor digitorum profundus and flexor digitorum superficialis tendons and their insertions, and the A2 pulley were preserved. A 1.5-mm Kirschner wire was inserted through the phalanges parallel to the long axis of the bone, passing through the proximal interphalangeal joint to maintain it in an extended position.

The specimen to be tested was mounted on a custom jig with the palmar side upward. To maintain tension in the flexor digitorum superficialis tendon, a 2-N weight was attached to its proximal end. The measurement system consisted of one mechanical actuator with a linear potentiometer, two tensile load transducers, and a mechanical pulley (Fig. 1). Load transducers were connected to the proximal and distal ends of the flexor digitorum profundus tendon. On the basis of the experience from previous studies, a 4.9-N weight was attached to the distal end of the flexor digitorum profundus tendon to keep tension on the tendon during testing^30,31. The distal transducer (F1) was connected to the weight, and the proximal load transducer (F2) was connected to the mechanical actuator. The actuator was positioned at angle a, defined as the angle (in degrees) between the horizontal plane and the proximal cable extension. The pulley for the weight was positioned at angle ß, defined as the angle (in degrees) between the horizontal plane and the distal cable extension. As shown in previous studies^31,32, a set arc of contact (a = 30°, and ß = 20°) provides adequate measurement of the gliding resistance. This set angle was used for all the measurements in this study.

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Fig. 1: Gliding resistance testing apparatus. Angle a is the angle between the proximal end of the flexor digitorum profundus (FDP) tendon and the horizontal line, which is 30°. Angle ß is the angle between the distal end of the flexor digitorum profundus tendon and the horizontal line, which is 20°. Weight-1 is 2.0 N and connects to the proximal end of the flexor digitorum superficialis (FDS) tendon. Weight-2 is 4.9 N and connects to the distal end of the flexor digitorum profundus tendon.

The tendon was pulled proximally by the actuator against the weight at a rate of 2.0 mm/sec. This movement of the tendon toward the actuator was regarded as flexion. The readings from the load transducers (F1 and F2) and the corresponding excursion were recorded by a computer at a sampling rate of 10 Hz. Excursion was limited to the distance between the two tendon markers. The difference in force between the proximal and distal tendon ends represents the gliding resistance. The peak gliding resistance over the excursion range was calculated. All specimens were kept moist throughout testing by immersion in a bath of saline solution at 37°C (Fig. 1).

The gliding resistance was first conducted on the intact tendon. The flexor digitorum profundus tendon was then divided 10 mm distal to the proximal tendon marker to allow the repair site to travel the full length of the A2 pulley. Each tendon was then repaired (a 0-mm gap condition) with a Pennington³³ locking core suture technique of 2-0 coated, braided polyester suture (Ticron Davis and Geck, Wayne, New Jersey), reinforced with a circumferential epitenon simple running suture of 6-0 monofilament nylon (Ethicon, Somerville, New Jersey). The locking loops of the core suture were placed 20 mm apart (10 mm from loop to the cut tendon end). The running suture loops were approximately 4 mm long (2 mm from bite to the cut tendon end) with a depth of approximately 1 to 1.5 mm (Fig. 2). The tendon was carefully removed from the sheath to perform the repair and then was placed back through the A2 pulley in its original orientation and position. The gliding resistance test was then performed again.

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Fig. 2: Schematic of tendon laceration and repair. Following tendon laceration, a Pennington suture (locking loops of the core suture) was placed 20 mm apart (10 mm from loop to the tendon end). Running sutures were placed approximately 4 mm apart (2 mm from bite to the tendon end).

Following the second gliding resistance test, the repaired tendon was removed from the digit and mounted with custommade clamps to grip the tendon ends in a custom-made apparatus to create the gap at the repair site (Fig. 3). The grip-to-grip distance was approximately 60 mm, with the repair site centrally located. Some damage occurred at the tendon ends due to gripping, although the damage did not affect the gliding resistance test. The tendon was distracted at a rate of 0.1 mm/sec by a motor attached to the proximal end of the tendon. A magnification (10×) video-monitor system (DCRTRV103; Sony, Tokyo, Japan) was used to monitor the gap. The accuracy of the gap measurement was about 0.1 mm in the longitudinal direction. When the gap reached 1 mm, the motor was stopped. After the distraction was maintained at 1 mm for ten seconds, the motor was reversed to release the tendon. This procedure was repeated until the gap was maintained at 1 mm under a load of 4.9 N, which was the tension applied during the gliding resistance test. Following the formation of the 1-mm gap, the tendon was placed back in the digit, and the gliding resistance test was performed again. After the 1-mm gap test, the same procedure was repeated to form a 2, 3, and 4-mm gap at the repair site. The tendon was kept moist by dropping 0.9% saline solution every several seconds through all the testing procedures.

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Fig. 3: Repaired tendon gap formation apparatus. The repaired tendon is mounted with clamps such that the repaired site is centrally located. A computer-controlled actuator is connected to the top clamp, which holds the proximal end of the tendon. A digital camcorder is placed at the level of the repair site. An enlarged image is obtained from the computer.

Statistical Methods

One-factor (gap size) repeated measures analysis of variance was used to compare the gliding resistance among the groups of intact, immediate repair, 1-mm, 2-mm, 3-mm, and 4-mm gaps. In all cases, a level of p < 0.05 was considered to be significant.

Results

Materials and Methods | Results | Discussion | References

During distraction of the repaired tendon to form a gap, the running suture was first stretched, and then it cut through the tendon and finally pulled out from the tendon end. The number of loops for the running suture was sixteen to twenty (average, seventeen), depending on the size of the tendon, with half being on the volar side. When a 1-mm gap was formed, the running suture generally was still intact. With a 2-mm gap, most of the running suture stitches on the volar side had pulled out from the tendon end. When the gap reached 3 mm, all running suture stitches in all tendons had pulled out from the tendon end (Table I). There were no failures of the core suture during gap formation testing.

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TABLE I Running Suture Status During the Gap Formation

Running Suture Pullout Status	Observable Triggering (no. of tendons)	Catching (no. of tendons)
1-mm gap	0	0
4 tendons: intact
3 tendons: 1 stitch pulled out
5 tendons: 2 stitches pulled out
2-mm gap	10	1
11 tendons: all stitches on volar side pulled out
1 tendon: 4 stitches on volar side pulled out
3-mm gap
All stitches in all tendons pulled out	0	12

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TABLE I Running Suture Status During the Gap Formation

Running Suture Pullout Status	Observable Triggering (no. of tendons)	Catching (no. of tendons)
1-mm gap	0	0
4 tendons: intact
3 tendons: 1 stitch pulled out
5 tendons: 2 stitches pulled out
2-mm gap	10	1
11 tendons: all stitches on volar side pulled out
1 tendon: 4 stitches on volar side pulled out
3-mm gap
All stitches in all tendons pulled out	0	12

The mean peak gliding resistance of all repaired tendons (with or without a gap) was significantly higher than that of the intact tendon (p < 0.05) (Table II). No significant difference in peak gliding resistance was detected between repairs without a gap and repairs with a 1-mm gap (p > 0.05). The peak gliding resistance for repairs with a 2-mm gap increased to a mean (and standard deviation) of 4.3 ± 2.8 N, which was significantly higher than the resistance for tendons with a 0 or 1-mm gap (p < 0.05). While all tendons with a 0, 1, or 2-mm gap could pass through the A2 pulley, when the gap reached 3 mm, nine tendons caught on the A2 pulley edge during testing, which caused six tendons to fail because of either suture breakage or suture pullout and three tendons to fail because of gap elongation of as much as 5 mm. Thus, these nine tendons could not be tested with 4-mm gap formation. Figure 4 illustrates the relationship between the gliding resistance and the excursion after repair and after a 1, 2, and 3-mm gap in one tendon.

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TABLE II Gliding Resistance with Different Gap Sizes

	Intact	Repair	1-mm Gap	2-mm Gap	3-mm Gap	4-mm Gap
No. of tendons	12	12	12	12	12	3
Gliding resistance^*(N)	0.67 ± 0.15	2.23 ± 0.44	2.23 ± 1.09	4.28 ± 2.75	25.95 ± 17.97	44.85 ± 4.91

The values are given as the mean and the standard deviation

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TABLE II Gliding Resistance with Different Gap Sizes

	Intact	Repair	1-mm Gap	2-mm Gap	3-mm Gap	4-mm Gap
No. of tendons	12	12	12	12	12	3
Gliding resistance^*(N)	0.67 ± 0.15	2.23 ± 0.44	2.23 ± 1.09	4.28 ± 2.75	25.95 ± 17.97	44.85 ± 4.91

The values are given as the mean and the standard deviation

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Fig. 4: The relationship between peak gliding resistance and excursion after repair and after formation of a 1-mm, 2-mm, and 3-mm gap in one tendon.

Only three of the twelve tendons with a 3-mm gap were able to pass through the A2 pulley without rupturing. Thus, only these three tendons could be tested at a 4-mm gap, and all three failed during testing because the tendon at the gap caught on the pulley. The mean peak gliding resistance for the tendons with a 3-mm gap, including ruptured and nonruptured tendons, was significantly higher than that for the tendons with a 2-mm gap (p < 0.05). The mean peak gliding resistance at failure for the three tendons with a 4-mm gap was significantly higher than that for the tendons with a 3-mm gap (p < 0.05) (Table II).

Discussion

Materials and Methods | Results | Discussion | References

Gap formation is one of the most common complications following tendon suture and postoperative rehabilitation^17,18,20,21. Presumably, it is caused by applied tension during either active motion or passive therapy, which exceeds the tolerance of the suture repair. Typically, gap formation occurs during the first few weeks following tendon repair^7,18. In our cadaver model, increased gap size increased the peak gliding resistance. There appeared to be a threshold effect at 2 to 3 mm, beyond which catastrophic failure of the repair was likely if loading was increased to restore tendon gliding. Thus, we believe that gap formation is an important issue for hand surgeons and therapists to consider after tendon repair and during postoperative rehabilitation. If a gap could be detected when it was small, it might be possible to use modifications in the therapy regimen, such as reducing tendon loading by switching from active to passive therapy, that could reduce the chances of the development of a larger gap.

To prevent gap formation, strong suture techniques have been designed and studied^12,18,33. The use of locking loops increases the repair stiffness and enhances the suture-tendon interface, which is the weak point as far as gap formation is concerned. The Pennington suture technique, which was used in this study, uses locking loops.

In our results, although the repaired tendons with a 2-mm gap were able to pass through the A2 pulley, the peak gliding resistance increased markedly, to 4.28 N, nearly a 100% increase over the initial repair or 1-mm gap values, and to more than 600% of the peak gliding resistance of the intact tendon. While a 4.28-N peak gliding resistance for a 2-mm gap is relatively small compared with the force needed to rupture a repaired tendon (=30 N in most studies)^11-13,33, this resistance may be important during passive motion rehabilitation in which the tension applied to the tendon is low, on the order of 2 to 5 N^30,34,35. In addition, it is important to remember that, in the present study, the peak gliding resistance was determined at an arc of contact of 50°. At higher arcs of contact, which would occur with full finger flexion, the forces resisting tendon gliding would be higher. If the applied force does not exceed the peak gliding resistance of the tendon, the tendon may not move and the effect would be equivalent to immobilization of the tendon, with possible adhesion formation.

If the gap is >3 mm and the repair site does pass through the A2 pulley during rehabilitation, our in vitro data suggest that there would be a high risk of tendon failure. This concern is supported clinically, as Seradge²⁰ reported that the prevalence of tenolysis rose sharply when elongation at the repair site was >3 mm, and Pruitt et al.³⁶ showed that tendons with gaps have poorer results in vivo compared with those without gaps.

Whether the gapped repaired tendon is blocked by the A2-pulley edge depends on the integrity of the running suture, especially on the volar side, which is directly opposed to the pulley. If the running suture fails, the repaired tendon can easily catch on the pulley edge, as noted by Coert et al.³⁷. For a 1-mm gap, the running suture generally remained intact. Consequently, there was no catching or triggering as the repair site passed beneath the A2 pulley. With a 2-mm gap, the volar loops of most of the tendons pulled out, causing observable triggering in ten tendons and catching in one tendon. With a gap of >3 mm, the running suture completely failed and the core suture elongated, causing all tendons to catch on the pulley edge. These observations reinforce those of Coert et al.³⁷, who found that the running suture is essential for smooth tendon gliding.

The importance of the effect of gap formation on tendon healing is controversial^18,38,39. In a canine model, Gelberman et al.¹⁸ found that gaps of <3 mm did not affect the mechanical strength of the healing tendon and had no effect on adhesion formation. Tendons with gaps of >3 mm did, however, have a 35% lower ultimate force, 53% less rigidity, and 37% higher strain at failure than did tendons with no gap or a gap of <3 mm^17,18. In a clinical series of thirty-four digits with repairs in zone II, Silfverskiold et al.²² reported that gaps of =10 mm were quite compatible with good results clinically and that there was no significant correlation between gap size and tendon excursion. In contrast, Seradge²⁰ and Lindsay et al.⁴⁰ reported that there is a strong correlation between gap size and poor clinical outcome. Ketchum et al.¹⁹ recommended that a gap between tendon ends should be as small as possible. Some of the differences in the conclusions of these studies may be a result of the way in which they were performed. The studies showing no effect of gap on the final result^18,22 examined only the final result. Such studies risk a selection bias because of the survivor effect. Gapped tendons may have been more likely to rupture, and thus may have been excluded from the final analysis, compared with tendons without a gap, so that the subset of gapped tendons that remained may have been different from the initial cohort of all gapped tendons.

The strength of the current study was that it isolated and analyzed one condition, namely gapping, and its effect on outcome, in terms of peak gliding resistance. This study also had several limitations. We used a model that only assessed tendon gliding against the A2 pulley and at only one arc of contact. Previous work has shown, however, that testing gliding resistance against the whole sheath increases the overall friction value but does not change the relative findings when compared with testing against the A2 pulley alone⁴¹. Moreover, when the tendon is lacerated and repaired clinically, often the flexor sheath is opened extensively, preserving little more than the A2 and A4 pulleys^5,30,42. Finally, the A2 pulley is the most important pulley^43-45, and thus it is the most clinically relevant one to test. A second limitation was that the testing angles were fixed at 30° proximally and 20° distally. Although those angles may change with finger motion in situ, the angles chosen represent the actual angles of a finger in midflexion⁴⁶. Greater angles, associated with higher degrees of finger flexion, would only increase the risk of tendon blockage at the distal pulley edge. A third limitation was that the running suture we used was a simple running suture, with a 4-mm distance between bites. Using a locking epitenon suture technique, such as the one described by Lin et al., may have increased the suture strength⁴⁷. Increasing the distance between bites may have also decreased the risk of a gapped tendon catching at the pulley edge. However, a simple running suture is the most common technique used clinically^4,11,16,38. Finally, of course, our study was in vitro and the observations need to be validated in vivo. We suggest that such a validation include a method to track gap formation over time, and not just at final healing. We believe that it is likely that many ruptured tendon repairs begin as gapped tendons, which then fail later. The results of our study suggest that if these gapped tendons are excluded from analysis, the effect of gapping may be understated.

In summary, in the present in vitro study, gap size affected the ease with which a repaired tendon passed through the A2 pulley. When the gap was 1 mm, there was no significant difference in the peak gliding resistance compared with the repaired (no-gap) condition. When the gap was =3 mm, the repaired tendons had a high risk of catching at the distal A2 pulley edge. Clinically, such repairs may be at greater risk of rupture than those with a smaller gap. We believe that minimizing gap formation and the risk of blocking at the pulley edge is an important consideration in flexor tendon repair. ?

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Topics

adhesions ; rupture ; suture techniques ; sutures ; tendon ; running sutures ; flexor tendon repair

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Chunfeng Zhao, Peter C. Amadio, Tatsuro Tanaka, Keiji Kutsumi, Tetsu Tsubone, Mark E. Zobitz, Kai-Nan An; Effect of Gap Size on Gliding Resistance After Flexor Tendon Repair. The Journal of Bone & Joint Surgery. 2004 Nov;86(11):2482-2488.

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