• Michael G Galvez, Garet C Comer, Arhana Chattopadhyay, Chao Long, Anthony W Behn, and James Chang.
• Stanford University School of Medicine, Stanford, CA; Division of Plastic & Reconstructive Surgery, Stanford University, Stanford, CA; Division of Plastic & Reconstructive Surgery, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA.
• J Hand Surg Am. 2017 Aug 1; 42 (8): 662.e1-662.e9.

PurposeThe importance of flexor tendon repair with both core and epitendinous suture placement has been well established. The objective of this study was to determine whether suture placement order affects gliding resistance and bunching in flexor digitorum profundus tendons in a human ex vivo model.MethodsThe flexor digitorum profundus tendons of the index, middle, ring, and little fingers of paired cadaver forearms were tested intact for excursion and mean gliding resistance in flexion and extension across the A2 pulley. Tendons were subsequently transected and repaired with either an epitendinous-first (n = 12) or a control (n = 12) repair. Gliding resistance of pair-matched tendons were analyzed at cycle 1 and during the steady state of tendon motion. The tendon repair breaking strength was also measured.ResultsThe mean steady state gliding resistance was less for the epitendinous-first repair than for the control repair in flexion (0.61 N vs 0.72 N) and significantly less in extension (0.68 N vs 0.85 N). Similar results were seen for cycle 1. None of the repairs demonstrated gap formation; however, control repairs exhibited increased bunching. Load to failure was similar for both groups.ConclusionsThe order of suture placement for flexor tendon repair is important. Epitendinous-first repair significantly decreased mean gliding resistance, allowed for easier placement of core sutures, and resulted in decreased bunching.Clinical RelevanceEpitendinous-first flexor tendon repairs may contribute to improved clinical outcomes compared with control repairs by decreasing gliding resistance and bunching.Copyright © 2017 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

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