Barbed sutures

Early Outcomes of Tendon Repair and Reconstruction in the Hand using Barbed Sutures

1. Early Outcomes of Tendon Repair and Reconstruction in the Hand using Barbed Sutures Daniel Hap, R Vaikunthan Department of Orthopaedic Surgery Khoo Teck Puat Hospital

2. Introduction Tendon repair and reconstruction an integral part of Hand Surgery Advancements in suture material, suture techniques 1 Conventional sutures pose problems of 2 Knot rupture, unravelling Bulky knot material  inhibit tendon gliding Barbed sutures may be the solution Knotless 1 Thurman RT, Trumble TE, Hanel DP, Tencer AF, Kiser PK. Two-, four-, and six-strand zone II flexor tendon repairs: an in situ biomechanical comparison using a cadaver model. J Hand Surg. 1998;23: 261–5. 2 A Shah, M Rowlands . Barbed Sutures and Tendon Repair—a Review; HAND (2015) 10:6–15

3. Objectives To examine the early outcomes of tendon repair and reconstruction in the hand using barbed sutures Identify potential complications

4. Methods Retrospective study Conducted in KTPH from August 2015 to July 2016 ‘OT Sys’ used as search tool All patients who underwent tendon repair and reconstruction of the hand using barbed sutures included Case-notes reviewed for Patient demographics Diagnosis Surgery performed Surgical technique Type of suture used

5. Methods Clinic notes and records from Hand Occupational Therapist reviewed Range of motion Complications Revision surgery

6. Results 16 patients underwent repair or reconstruction of tendon of hand using barbed sutures. 1 patient with repaired EPL laceration lost to follow-up 15 patients with of 18 operated hand tendons 3 patients with concomitant injuries to 2 tendons on the same hand 9 females and 6 males Age ranged from 23 to 80 years old, Follow-up duration ranged from 3 to 8 months

7. Results – Surgical technique All repairs performed using V-LOC 3-0 non-absorbable sutures Standard tendon repair techniques employed Post-op care: Standard flexor / extensor tendon repair protocol by Hand OT.

8. Results

9. Results – Nature of surgery Pt No. Surgery Type Complications Adhesions Rupture 1 Trapeziectomy and APL suspensioplasty Tendon transfer Nil Nil 2 PL to APB Camitz Transfer Tendon Transfer Nil Nil 3 FDS repair (MF) Flexor repair Nil Nil FDP repair (MF) Flexor repair Nil Nil 4 EPL repair Extensor repair Nil Nil 5 Trapeziectomy and APL suspensioplasty Tendon transfer Nil Nil 6 PL to APB Camitz Transfer Tendon transfer Nil Nil 7 APB to EPL graft Tendon transfer Nil Nil 8 Trapeziectomy and APL suspensioplasty Tendon transfer Nil Nil

10. Results – Nature of surgery Pt No. Surgery Type Complications Adhesions Rupture 9 FPL repair Flexor repair Nil Nil 10 FDP repair (MF) Flexor repair Nil Nil FDP repair (LF) Flexor repair Nil Nil 11 EIP to EPL tendon graft Tendon transfer 12 EPL repair Extensor repair Nil Nil 13 EPL repair Extensor repair Nil Nil 14 FDP repair Flexor repair Nil Nil 15 FDP repair (LF) Flexor repair Nil Nil FDS repair (LF) Flexor repair Nil Nil

11. Results – Pt #10 LF FDP rupture LF FDP Post-repair MF FDP rupture MF FDP post-repair

12. Results

13. Results

14. Discussion Barbed suture repair described since 1960s 1 Advantages: Barbs provide multiple anchoring points, uniform distribution of tissue-holding forces Knotless suturing 1 McKenzie AR. An experimental multiple barbed suture for the long flexor tendons of the palm and fingers. Preliminary report. J Bone Joint Surg 1967;49B:440–447. Source: http://mms.businesswire.com/bwapps/mediaserver/ViewMedia?mgid=229832&vid=5

15. Discussion 24 studies identified in MEDLINE, EMBASE, Google Scholar 2 meta-analysis, 21 biomechanical studies, 1 in-vivo study (chickens) No in-vivo study with human subjects.

16. Discussion Studies showing biomechanically comparable, if not superior results in barbed sutures. Greater or equivalent load to failure 1,2 Smaller cross-sectional area 3 Friction between exposed barbs and flexor tendon sheath 4 . Adhesions 1 Joyce CW, Whately KE, Chan JC, Murphy M, O’Brien FJ, Carroll SM. Flexor tendon repair: a comparative study between a knotless barbed suture repair and a traditional four-strand monofilament suture repair. J Hand Surg Eur Vol. 2014;39:40–5 2 Parikh PM, Davison SP, Higgins JP. Barbed suture tenorrhaphy : an ex vivo biomechanical analysis. Plast Reconstr Surg. 2009;124: 1551–8. 3 McClellan WT, Schessler MJ, Ruch DS, Levin LS, Goldner RD. A 　 knotless flexor tendon repair technique using a bidirectional barbed 　 suture: an ex vivo comparison of three methods. Plast Reconstr Surg. 　 2011;128:322e–7e 4 Oded BA, J Kargel , B Mailey . The Effect of Barbed Suture Tendon Repair on Work of Flexion. J Hand Surg Am. 2015;40(5):969-974

17. Limitations Retrospective study Small sample size No comparison between barbed suture and traditional sutures in our study

18. Conclusion Early outcomes of using barbed sutures for tendon repair and reconstruction in the hand favourable . Viable alternative to traditional sutures Advantages – less suture material and faster repair. Further studies required to ascertain long term results Prospective study to compare barbed sutures and traditional sutures.

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