This is a podium presentation given at the American Society of Plastic Surgeons on tendon repair without knots.

1. Knotless flexor tendon repair using a barbed suture: An ex vivo comparison. W. Thomas McClellan Matt Schessler David Ruch L. Scott Levin Richard Goldner Kauai HI 2010

2. Disclosures No disclosures

3. Hypothesis Knotless flexor tendon repair is as strong as a traditional knot based repair with reduced cross sectional area at the repair site.

4. Methods 66 fresh adult pig FDP tendons 3 points established – cross-sectional area 1cm proximal, transection site, 1cm distal

5. Methods Divided into 3 groups, transected, repaired Group A (n=22) – 2 strand modified Kessler 3-0 ethibond Group B (n=22) – 4 strand modified Savage 3.0 ethibond Group C (n=22) – 4 strand Knotless Repair 0 barbed

6. Knotless Technique

7. Measured the x-sectional area at all 3 sites after repair and before insitron testing Results – X-Sectional Area(mm2) (p<0.0001)

9. Results - Strength (p<0.0001)

10. Summary A 4 strand Knotless repair is as strong as a 4 strand Savage and stronger than a 2 strand Kessler Must maximize # of barbs within the tendon Must incorporate grasps of the epitenon for increased repair strength

11. Summary Knotless repair has significantly reduced cross sectional area, at the repair site, compared to the Savage and Kessler This may reduce resistance within the pulley system.

12. Summary however Knotless repair is technically difficult and time consuming Increased handling of the tendon required must place limbs upstream Manipulation of larger core suture is more cumbersome Difficult to remove suture if needed Additional research should be performed to address shortcomings and limitations

13. Thank you