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Deep Flexor Tendon Repairs Analysis of Current Concepts Introduction of Improvements Establishment of New Techniques

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Deep Flexor Tendon Repairs Analysis of Current Concepts Introduction of Improvements Establishment of New Techniques Deep Flexor Tendon Repairs Analysis of current concepts Introduction of improvements Establishment of new techniques A Dissertation in Medicine by Tim Sebastian Peltz Submitted in Fulfilment of the Requirements for the Degree of Doctor of Philosophy March 2014 Prince of Wales Hospital University of New South Wales Copyright Statement "I hereby grant to the University of New South Wales or its agents the right to archive and to make available my thesis or dissertation in whole or patt in the University libraries in all f01ms of media, now or hereafter known, subject to the provisions of the Copytight Act 1968. I retain all proptietary tights, such as patent tights. I also retain the right to use in future works (such as atticles and books) all or part of this thesis or dissertation. I also authotise University Microfilms to use the abstract of my thesis in Dissertations Abstract Intemational. I have either used no substantial p01tions of copytight material in my thesis or I have obtained pennission to use copytight matetial; where petmission has not been granted I have applied I will apply for a pattial resttiction of the digital copy of my thesis or dissertation." Date: 18.08.2014 Authenticity Statement "I cettify that the Library deposit digital copy is a direct equivalent of the final officially approved version of my thesis. No emendation of content has occmTed and if there are any minor variations in formatting, they are the result of the conversion to the digital f01mat." Date: 18.08.2014 II Originality Statement "I hereby declare that this submission is my own work and to the best of my knowledge it contains no materials previously published or written by another person, or substantial propm1ions of material which have been accepted for the award of any other degree or diploma at UNSW or any other educational institution, except where due acknowledgment is made in the thesis. Any cont1ibution made to the research by others, with whom I have worked at UNSW or elsewhere, is explicitly acknowledged in the thesis. I also declare that the intellectual content of this thesis is the product of my own work, except to the extent that assistance from others in the project's design and conception or in style, presentation and linguistic expression is acknowledged" Date: 18.08.2014 III THE UNIVERSITY OF NEW SOUTH WALES Thesis/Dissertation Sheet Surname or Familv name: Peltz First name: Tim Other name/s: Sebastian Abbreviation for de~ree as given in the University calendar: PhD School: Prince of Wales Clinical School Faculty: Medicine Title: Deep Flexor Tendon Repairs: Analysis of current concepts, Introduction of improvements, Establishment of new techniques. Abstract The patienfs ability to master everyday living tasks is strongly dependent on the utility of healthy functional hands. Therefore the restoration of hand function after tendon injuries is of utmost importance. Tendon injuties are common, especially lacerations in zone II. In this area flexor tendons follow a complicated anatomy and are difficult to repair. Consequently this thesis focuses on the research of tendon repairs in zone II and aims to improve repair quality and ultimately final functional outcome for the patient. To approach this topic the author of this thesis firstly analysis current concepts of tendon repair research models, secondly investigates common tendon repair techniques and improvements of these techniques and thirdly introduces new techniques for repair of deep flexor tendons in zone II. This thesis consists of ex vivo and in vivo experiments, which all build on another. Main results of these expetiments are as follows: • In regards to comparability to human tendons, sheep tendons are better tendon surrogates as pig tendons if used in ex vivo laboratory experiments. IV • When focusing on gapping resistance, "locking loop" repair configurations for tendon repairs are not substantially different to "grasping loop" configurations, and only "cross-locks", as used in the Adelaide repair technique, deserve the adjective description "locking". • The cun·ent gold standard of tendon repairs, the Adelaide repair, produces better repair stability if performed with larger cross locks. • The author's interlocking modification of the Adelaide repair can further improve the Adelaide repair's stability. • In an ex vivo setting, the author's new tendon repair concept, the knotless 3D barbed suture tendon repair, produces superior repair stability than the Adelaide repair. • The turkey tendon model is the first tendon model that replicates human anatomy and tendon sizes and can be used in ex vivo as well as in vivo tendon repair experiments. • In an in vivo tendon repair scenario, the use of the knotless 3D barbed suture tendon repair with resorbable barbed sutures produces inferior repair stability compared to the Adelaide repair, but improves functional outcomes. This thesis presents new insights into tendon repair research from a surgical and biomechanical point of view. The use of the novel unknotted barbed suture repair method did show superior results in ex vivo experiments but barb resorbtion in the in vivo experiments caused high failure rates. Nevertheless, there is a probability that with the development of more stable small barbed suturing materials in the near future it will be possible to fUJther improve deep flexor tendon repairs using this novel repair technique. Declaration relating to disposition of project thesis/dissertation I hereby grant to the University of New South Wales or its agents the right to archive and to make available my thesis or dissertation in whole or in part in the University libraries in all forms of media, now or here after known, subject to the provisions of the Copyright Act 1968. I retain all property rights, such as patent rights. I also retain the right to use in future works (such as articles fr ~ ks all or part of this thesis or dissertation. I also authorise Unive i i r se the 350 word abstract of my thesis in Dissertation Abstracts International (this is applicable( fioc< S S/01 )/ "7 0 ~ / ,'- ................. .................. ~ .. /.~ ............... .~:.0.!:.19 ·············~ . l;~;~ If··· W1tness Date The University rec~gnis~Ht'iere may be exceptional circumstances requiring restrictions on copying or conditions on use. Requests for restriction for a period of up to 2 years must be made in writing. Requests for a longer period of restriction may be considered in exceptional circumstances and require the approval of the Dean of Graduate Research. FOR OFFICE USE ONLY v ACKNOWLEDGEMENTS Acknowledgements and my honest thanks go out to all staff of the Surgical and Orthopaedic Research Laboratories (SORL) at the University of New South Wales (UNSW), staff of Prince of Wales Hospital (POW), St. Lukes Hospital, Sydney Hospital and staff of St. George Hospital Biological Research Centre (BRC). Primarily to my bosses, Prof. William R Walsh (or Bill), A/Prof Mark P Gianoutsos (or Mark) and my supervisor Dr Rema Oliver (or Rema). But also everybody else whom I met, annoyed, learned of and laughed with at SORL, BRC, POW, St Lukes and Sydney Hospital. Of course all would not have been possible without my amazing family and my dear friends over here and back home in Munich, who always gave me the biggest support no matter how impossible the task seemed. And I want to thank the ocean, for providing these beautiful waves for surfing, no matter what times, always energizing me with the power of nature and guiding me through life. Dedicated to the coolest family on earth, the Peltz Family! VI LIST OF PUBLICATIONS Journal Articles 1. In reply to "Letter regarding performance of a knotless four-strand flexor tendon repair with a unidirectional barbed suture device: a dynamic ex vivo comparison. Peltz TS, Walsh WR. J Hand Surg Eur Vol. 2014 Jan;39(1):116- 7. 2. Performance of a knotless four-strand flexor tendon repair with a unidirectional barbed suture device: a dynamic ex vivo comparison. Peltz TS, Haddad R, Scougall PJ, Gianoutsos MP, Bertollo N, Walsh WR. J Hand Surg Eur Vol. 2014 Jan;39(1):30-9. 3. In reply to “Letter regarding influence of locking stitch size in a four-strand cross- locked cruciate flexor tendon repair”. Peltz TS, Walsh WR. J Hand Surg Am. 2012 Jan;37(1):188-9. 4. Biomechanical evaluation of flexor tendon repair using barbed suture material: a comparative ex vivo study. Haddad R, Peltz TS, Walsh WR. J Hand Surg Am. 2011 Sep;36(9):1565-6. VII 5. Influence of locking stitch size in a four-strand cross-locked cruciate flexor tendon repair. Peltz TS, Haddad R, Scougall PJ, Nicklin S, Gianoutsos MP, Walsh WR. J Hand Surg Am. 2011 Mar;36(3):450-5. Epub 2011 Feb 17. 6. The change in three-dimensional geometry of the Kessler flexor tendon repair under tension: a qualitative assessment using radiographs. Peltz TS, Haddad R, Walsh WR. J Hand Surg Eur Vol. 2010 Oct;35(8):676-7. 7. The relationship between gap formation and grip-to-grip displacement during cyclic testing of repaired flexor tendons. Haddad R, Peltz TS, Lau A, Bertollo N, Nicklin S, Walsh WR. J Biomech. 2010 Oct 19;43(14):2835-8. 8. A biomechanical assessment of repair versus nonrepair of sheep flexor tendons lacerated to 75 percent. Haddad R, Scherman P, Peltz TS, Nicklin S, Walsh WR. J Hand Surg Am. 2010 Apr;35(4):546-51. VIII Conference Presentations 1. Mar 2010 Australian Hand Surgery Society Annual Conference (Canberra/ACT). Podium presentation: A biomechanical comparison of human, porcine and ovine deep flexor tendons. What is the ideal Model for in vitro studies? 2. Mar 2010 Orthopaedic Research Society ORS Annual Meeting (New Orleans/USA). Poster Presentation: Changes in Core Suture Geometry within repaired Flexor Tendons: an X-ray Evaluation.
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