Editorial Type:
Surgery

Assessment of skin staples for augmentation of core tenorrhaphy in an ex vivo model of canine superficial digital flexor tendon laceration

Yi-Jen Chang 1Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC 27607.

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 BVetMed, MS
,
Daniel J. Duffy 1Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC 27607.

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 BVM&S, MS, FHEA
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Lewis Gaffney 2Joint Department of Biomedical Engineering, North Carolina State University and University of North Carolina–Chapel Hill, Raleigh, NC 27695.

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Matthew B. Fisher 2Joint Department of Biomedical Engineering, North Carolina State University and University of North Carolina–Chapel Hill, Raleigh, NC 27695.

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 PhD
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George E. Moore 3Department of Veterinary Administration, College of Veterinary Medicine, Purdue University, West Lafayette, IN 47906.

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 DVM, PhD
DOI:
https://doi.org/10.2460/ajvr.81.8.681
Volume/Issue:
Volume 81: Issue 8
Online Publication Date:
01 Aug 2020
Restricted access
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Abstract

OBJECTIVE

To compare the biomechanical strength and incidence of gap formation among canine superficial digital flexor tendon (SDFT) constructs that underwent core tenorrhaphy only and those in which the core tenorrhaphy was augmented with skin staples or a continuous Silfverskiold cross-stitch (SXS) suture pattern.

SAMPLE

42 cadaveric forelimb SDFTs from 21 musculoskeletally normal dogs.

PROCEDURES

Tendons were randomly assigned to 3 groups (14 SDTFs/group), sharply transected, and repaired with a core locking-loop suture alone (group 1) or augmented with circumferential placement of skin staples (group 2) or a continuous SXS suture pattern (group 3) in the epitenon. All constructs underwent a single load-to-failure test. Yield, peak, and failure loads, incidence of gap formation, and mode of failure were compared among the 3 groups.

RESULTS

Mean yield, peak, and failure loads differed significantly among experimental groups and were greatest for group 3 and lowest for group 1 constructs. The incidence of gap formation differed among the tested groups and was lowest for group 3 and highest for group 1. The most common mode of construct failure was the suture pulling through the tendon for group 1, staple deformation for group 2, and epitendinous suture breakage for group 3.

CONCLUSIONS AND CLINICAL RELEVANCE

Results indicated epitendinous placement of skin staples around a core SDFT tenorrhaphy site improved the biomechanical strength and resistance to gap formation for the repair but was inferior to epitendinous placement of SXS sutures. Further research is necessary before skin staples are used for tenorrhaphy augmentation in clinical patients.

Abstract

OBJECTIVE

To compare the biomechanical strength and incidence of gap formation among canine superficial digital flexor tendon (SDFT) constructs that underwent core tenorrhaphy only and those in which the core tenorrhaphy was augmented with skin staples or a continuous Silfverskiold cross-stitch (SXS) suture pattern.

SAMPLE

42 cadaveric forelimb SDFTs from 21 musculoskeletally normal dogs.

PROCEDURES

Tendons were randomly assigned to 3 groups (14 SDTFs/group), sharply transected, and repaired with a core locking-loop suture alone (group 1) or augmented with circumferential placement of skin staples (group 2) or a continuous SXS suture pattern (group 3) in the epitenon. All constructs underwent a single load-to-failure test. Yield, peak, and failure loads, incidence of gap formation, and mode of failure were compared among the 3 groups.

RESULTS

Mean yield, peak, and failure loads differed significantly among experimental groups and were greatest for group 3 and lowest for group 1 constructs. The incidence of gap formation differed among the tested groups and was lowest for group 3 and highest for group 1. The most common mode of construct failure was the suture pulling through the tendon for group 1, staple deformation for group 2, and epitendinous suture breakage for group 3.

CONCLUSIONS AND CLINICAL RELEVANCE

Results indicated epitendinous placement of skin staples around a core SDFT tenorrhaphy site improved the biomechanical strength and resistance to gap formation for the repair but was inferior to epitendinous placement of SXS sutures. Further research is necessary before skin staples are used for tenorrhaphy augmentation in clinical patients.

Contributor Notes

Address correspondence to Dr. Duffy (djduffy@ncsu.edu).
Cover American Journal of Veterinary Research
American Journal of Veterinary Research
Publication Date:
01 Aug 2020

  • 1. Biewener A. Tendons and ligaments: structure, mechanical behavior and biological function. In: Fratzl P, ed. Collagen structure and mechanics. New York: Springer Science+Business Media LLC, 2008;269–284.

    • Search Google Scholar
    • Export Citation

  • 2. Boyer MI, Goldfarb CA, Gelberman RH. Recent progress in flexor tendon healing. The modulation of tendon healing with rehabilitation variables. J Hand Ther 2005;18:80–85.

    • Crossref
    • Search Google Scholar
    • Export Citation

  • 3. Gelberman RH, Boyer MI, Brodt MD, et al. The effect of gap formation at the repair site on the strength and excursion of intrasynovial flexor tendons. An experimental study on the early stages of tendon healing in dogs. J Bone Joint Surg Am 1999;81:975–982.

    • Crossref
    • Search Google Scholar
    • Export Citation

  • 4. Stuart C, William GM. Muscle and tendon disorders. In: Johnson SA, Tobias KM, eds. Veterinary surgery: small animal. Vol 2. 2nd ed. St Louis: Elsevier, 2018;1316–1323.

    • Search Google Scholar
    • Export Citation

  • 5. Johnson JA, Austin CC, Breur GJ. Incidence of canine appendicular musculoskeletal disorders in 16 veterinary teaching hospitals from 1980 through 1989. Vet Comp Orthop Traumatol 1994;34:93–98.

    • Search Google Scholar
    • Export Citation

  • 6. Zhao C, Amadio PC, Momose T, et al. The effect of suture technique on adhesion formation after flexor tendon repair for partial lacerations in a canine model. J Trauma 2001;51:917–921.

    • Crossref
    • Search Google Scholar
    • Export Citation

  • 7. Zhao C, Amadio PC, Zobitz ME, et al. Gliding resistance after repair of partially lacerated human flexor digitorum profundus tendon in vitro. Clin Biomech (Bristol, Avon) 2001;16:696–701.

    • Crossref
    • Search Google Scholar
    • Export Citation

  • 8. Aoki M, Manske PR, Pruitt DL, et al. Work of flexion after tendon repair with various suture methods: a human cadaveric study. J Hand Surg Br 1995;20:310–313.

    • Crossref
    • Search Google Scholar
    • Export Citation

  • 9. Moores AP, Comerford EJ, Tarlton JF, et al. Biomechanical and clinical evaluation of a modified 3-loop pulley suture pattern for reattachment of canine tendons to bone. Vet Surg 2004;33:391–397.

    • Crossref
    • Search Google Scholar
    • Export Citation

  • 10. Krackow KA, Thomas SC, Jones LC. A new stitch for ligament-tendon fixation. Brief note. J Bone Joint Surg Am 1986;68:764–766.

  • 11. Wilson L, Banks T, Luckman P, et al. Biomechanical evaluation of double Krackow sutures versus the three-loop pulley suture in a canine gastrocnemius tendon avulsion model. Aust Vet J 2014;92:427–432.

    • Crossref
    • Search Google Scholar
    • Export Citation

  • 12. Duffy DJ, Main RP, Moore GE, et al. Ex vivo biomechanical comparison of barbed suture and standard polypropylene suture for acute tendon laceration in a canine model. Vet Comp Orthop Traumatol 2015;28:263–269.

    • Crossref
    • Search Google Scholar
    • Export Citation

  • 13. Moores AP, Owen MR, Tarlton JF. The three-loop pulley suture versus two locking-loop sutures for the repair of canine achilles tendons. Vet Surg 2004;33:131–137.

    • Crossref
    • Search Google Scholar
    • Export Citation

  • 14. Gall TT, Santoni BG, Egger EL, et al. In vitro biomechanical comparison of polypropylene mesh, modified three-loop pulley suture pattern, and a combination for repair of distal canine achilles' tendon injuries. Vet Surg 2009;38:845–851.

    • Crossref
    • Search Google Scholar
    • Export Citation

  • 15. Putterman AB, Duffy DJ, Kersh ME, et al. Effect of a continuous epitendinous suture as adjunct to three-loop pulley and locking-loop patterns for flexor tendon repair in a canine model. Vet Surg 2019;48:1229–1236.

    • Crossref
    • Search Google Scholar
    • Export Citation

  • 16. Cocca CJ, Duffy DJ, Kersh ME, et al. Biomechanical comparison of three epitendinous suture patterns as adjuncts to a core locking loop suture for repair of canine flexor tendon injuries. Vet Surg 2019;48:1245–1252.

    • Crossref
    • Search Google Scholar
    • Export Citation

  • 17. Lister GD, Kleinert HE, Kutz JE, et al. Primary flexor tendon repair followed by immediate controlled mobilization. J Hand Surg Am 1977;2:441–451.

    • Crossref
    • Search Google Scholar
    • Export Citation

  • 18. Silfverskiöld KL, Andersson CH. Two new methods of tendon repair: an in vitro evaluation of tensile strength and gap formation. J Hand Surg Am 1993;18:58–65.

    • Crossref
    • Search Google Scholar
    • Export Citation

  • 19. Dona E, Turner AW, Gianoutsos MP, et al. Biomechanical properties of four circumferential flexor tendon suture techniques. J Hand Surg Am 2003;28:824–831.

    • Crossref
    • Search Google Scholar
    • Export Citation

  • 20. Strickland JW. Development of flexor tendon surgery: twenty-five years of progress. J Hand Surg Am 2000;25:214–235.

  • 21. Dy CJ, Hernandez-Soria A, Ma Y, et al. Complications after flexor tendon repair: a systematic review and meta-analysis. J Hand Surg Am 2012;37:543.e1–551.e1.

    • Crossref
    • Search Google Scholar
    • Export Citation

  • 22. Tobias KM. Surgical stapling devices in veterinary medicine: a review. Vet Surg 2007;36:341–349.

  • 23. Schwartz A. Historical and veterinary perspectives of surgical stapling. Vet Clin North Am Small Anim Pract 1994;24:225–246.

  • 24. Pavletic MM, Schwartz A. Stapling instrumentation. Vet Clin North Am Small Anim Pract 1994;24:247–278.

  • 25. Coolman BR, Ehrhart N, Marretta SM. Use of skin staples for rapid closure of gastrointestinal incisions in the treatment of canine linear foreign bodies. J Am Anim Hosp Assoc 2000;36:542–547.

    • Crossref
    • Search Google Scholar
    • Export Citation

  • 26. Coupland RM. Sutures versus staples in skin flap operations. Ann R Coll Surg Engl 1986;68:2–4.

  • 27. Ng WT, Yiu MK, Wong MK, et al. Use of skin staples for fixation of T tubes and drains. Surg Gynecol Obstet 1993;177:93–95.

  • 28. Morris DM. The use of skin staples to secure skin towels in areas difficult to drape. Surg Gynecol Obstet 1984;159:387.

  • 29. Mills IW, McDermott IM, Ratliff DA. Prospective randomized controlled trial to compare skin staples and polypropylene for securing the mesh in inguinal hernia repair. Br J Surg 1998;85:790–792.

    • Search Google Scholar
    • Export Citation

  • 30. Edwards DP, Galbraith KA. Colonic anastomosis in the presence of fecal peritonitis using a disposable skin stapler. J Invest Surg 1998;11:267–274.

    • Crossref
    • Search Google Scholar
    • Export Citation

  • 31. Coolman BR, Ehrhart N, Pijanowski G, et al. Comparison of skin staples with sutures for anastomosis of the small intestine in dogs. Vet Surg 2000;29:293–302.

    • Crossref
    • Search Google Scholar
    • Export Citation

  • 32. Hirpara KM, Sullivan PJ, O'Sullivan ME. The effects of freezing on the tensile properties of repaired porcine flexor tendon. J Hand Surg Am 2008;33:353–358.

    • Crossref
    • Search Google Scholar
    • Export Citation

  • 33. Tomlinson J, Moore R. Locking loop tendon suture use in repair of five calcanean tendons. Vet Surg 1982;11:105–109.

  • 34. Silfverskiöld KL, May EJ. Gap formation after flexor tendon repair in zone II. Results with a new controlled motion programme. Scand J Plast Reconstr Surg Hand Surg 1993;27:263–268.

    • Crossref
    • Search Google Scholar
    • Export Citation

  • 35. Silfverskiöld KL, May EJ, Törnvall AH. Gap formation during controlled motion after flexor tendon repair in zone II: a prospective clinical study. J Hand Surg Am 1992;17:539–546.

    • Crossref
    • Search Google Scholar
    • Export Citation

  • 36. Diao E, Hariharan JS, Soejima O, et al. Effect of peripheral suture depth on strength of tendon repairs. J Hand Surg Am 1996;21:234–239.

    • Crossref
    • Search Google Scholar
    • Export Citation

  • 37. Lotz JC, Hariharan JS, Diao E. Analytic model to predict the strength of tendon repairs. J Orthop Res 1998;16:399–405.

  • 38. Duffy DJ, Cocca CJ, Kersh ME, et al. Effect of bite distance of an epitendinous suture from the repair site on the tensile strength of canine tendon constructs. Am J Vet Res 2019;80:1034–1042.

    • Crossref
    • Search Google Scholar
    • Export Citation

  • 39. Fufa DT, Osei DA, Calfee RP, et al. The effect of core and epitendinous suture modifications on repair of intrasynovial flexor tendons in an in vivo canine model. J Hand Surg Am 2012;37:2526–2531.

    • Crossref
    • Search Google Scholar
    • Export Citation

  • 40. Duffy DJ, Chang YJ, Gaffney LS, et al. Effect of bite depth of an epitendinous suture on the biomechanical strength of repaired canine flexor tendons. Am J Vet Res 2019;80:1043–1049.

    • Crossref
    • Search Google Scholar
    • Export Citation

  • 41. Zaruby J, Gingras K, Taylor J, et al. An in vivo comparison of barbed suture devices and conventional monofilament sutures for cosmetic skin closure: biomechanical wound strength and histology. Aesthet Surg J 2011;31:232–240.

    • Crossref
    • Search Google Scholar
    • Export Citation

  • 42. Pruitt DL, Manske PR, Fink B. Cyclic stress analysis of flexor tendon repair. J Hand Surg Am 1991;16:701–707.

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