Effect of Suture Purchase on Biomechanical Characteristics in Barbed Sutures

Effect of Suture Purchase on Biomechanical Characteristics in Barbed Sutures | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Effect of Suture Purchase on Biomechanical Characteristics in Barbed Sutures yigit umut cirdi, ali eray gunay, mehmet ekici, omer tolga sekerci, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3982828/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract The effects of the purchase length on the maximum tensile strength (MTS) and 2mm gap resistance (2 mmGR) of barbed and polypropylene (PP) sutures were investigated. A total of 24 sheep flexor tendons were divided into four groups. Increasing the suture purchase from 1 cm to 2 cm resulted in 58.3% vs. 157.5% increase in 2mmGR for PP and barbed sutures, respectively. While the repair with a 1cm suture purchase using barbed sutures is weaker than the PP group (8.1N vs. 12.1N)(p=0.445), when the suture purchase is increased to 2 cm, a comparable tensile strength is obtained in terms of 2 mmGR (20.7N vs. 19.9N) (p = 0.971). Compared to PP sutures, the tensile force achieved with barbed sutures grows exponentially as the distance traveled through the tendon increases. Consequently, barbed sutures provide comparable tensile force for flexor tendon repair when suture purchase is increased. Level of evidence: V Health sciences/Health care Health sciences/Medical research Tenorrhaphy strength Modified Kessler Flexor Tendon V-Loc Figures Figure 1 INTRODUCTION The flexor tendon repair technique evolved rapidly to provide more durable repairs to adapt aggressive post-operative rehabilitation protocols. Multi-strand repairs and peripheral sutures are now frequently preferred and became the backbone of the flexor tendon treatment [1,2]. Suture material strongly influences the biomechanical durability of the tendon repair [3]. However, traditional 4 to 6-strand repairs have shown to increase the cross-sectional area (CSA) of the tendon, therefore creating a bulkiness that makes it difficult for tendon to glide through the flexor pulleys and adhesions if the repair site is adjacent to pulleys [4,5] . The use of barbed sutures in flexor tendon repair was introduced in 1967 [6]. Barbed sutures have unidirectional clefts all around. The clefts on this provide resistance by holding onto the tendon in a perpendicular direction against sliding. The number of clefts buried inside the tendon is responsible for the resistance generated. Therefore, providing anti-glide effect by anchoring multiple points making it a valuable alternative for flexor tendon repairs [7].Pull-out strength and final failure force were shown to be similar with conventional 4-strand Adelaide repair [8,9]. The aim of this study is to examine the relation of the length of suture inside the tendon and repair strength and its effect on tensile force. Suture purchase directly influences the strength and reduced the re-rupture rates and makes the more aggressive rehabilitation protocol possible. Furthermore, reducing the overall tendon repair-associated complications [10]. We hypothesize that a longer course of the barbed suture inside the tendon achieves comparable biomechanical repair strength. METHODS This study was performed at biomechanics center in 2023. This study was exempt from instutional review board approval owing to the use of deidentified cadaveric specimens. A pilot study was carried out with an alpha error as 0.05 and 24 samples generated a significant difference of p < 0.05 when power is 0.80. Study Group Total of 24 tendons of sheep flexor digitorum profundus tendons have been dissected and collected for the study. All the tendons were examined for abnormalities or impairments, including degeneration and trauma. Those with any defects were discarded. 10 cm-long tendon sections were spared and prepared. A perpendicular line was drawn on the tendon to prevent rotation of the tendon during the repair. The continuity of the line has been closely monitored during the repair process. Then, the tendon was halved into two parts. All specimens were repaired according to the aforementioned protocols then, divided into 4 subgroups with 6 specimens in each : Group P1: Polypropylene suture (3/0) (PP) with 2-strand modified Kessler method, 1 cm away from the gap. Group P2: Polypropylene suture (3/0) with 2-strand modified Kessler method, 2 cm away from the gap. Group B1: Barbed suture (3/0) with 2-strand modified Kessler method, 1 cm away from the gap. Group B2: Barbed suture (3/0) with 2-strand modified Kessler method, 2 cm away from the gap. Repair Technique Tendons were shortened to eight cm in length after grouping and marked with a longitudinal line to determine rotation. A smooth incision was made in the middle of the tendon with the help of the number 11 scalpel. Tendons in group P1 were repaired with 3 − 0 polypropylene (Doğsan, Türkiye), and tendons in group B1 were repaired with 3 − 0 barbed sutures (Vloc, Covidien, USA) using the modified Kessler method, passing 1 cm forward from the incision. Tendons in group P2 were repaired with 3/0 polypropylene, and tendons in group B2 were repaired with 3/0 barbed sutures using the modified Kessler method, passing 2 cm away from the incision. The 2-strand modified Kessler method was used to maximize the effect of suture materials and transition length (Fig. 1 ). Outcome Measures The reconstructed tendons were subjected to tensile force testing device (Instron, USA) using a compression method at both ends. A 5 cm tendon was left in the middle section. Traction force was applied to open 10 mm per minute. Slow motion video recording was taken while the tendon was distracted. The amount of resistance at which the 2 mm gap formed was recorded in newtons(N) as 2mmGR. The unsustainable peak point of the continuing traction force was determined as the maximum tensile strength(MTS) point of the resistance force where the tendon ends became completely independent from each other. The MTS values as newtons and the pattern of failure in tendon repair at the MTS point was recorded. Statistical analysis After the data were transferred to the computer environment, evaluations were made using the SPSS 22.0 program. The conformity of the data to the normal distribution was analyzed with the Shapiro-Wilk test, the means between the groups with the appropriate distribution were compared with the ANOVA test, pairwise comparisons were made with the Scheffé test, and results with a p value below 0.05 were considered statistically significant. RESULTS Two cm suture purchase increased mean 2mmGR value in polypropylene and barbed sutures by 6.9 N and 12.6N respectively. The increase rate in 2mmGR was 58.3% (group P1 to P2) for polypropylene and 157.5% (group B1 to B2) for barbed sutures. The highest 2mmGR value was obtained in group B2 (20.7N (SD:5.4) Group P2 and group B2 demonstrated significantly higher 2mmGR values than group P1 and B1 (p < 0.05). Additionally, the MTS values were comparable for all groups, with the highest value observed in the group P1 37.0N (SD:7.5) without any significant difference among the groups (p = 0.743). (Table 1 ) The pattern of failure was suture breakage in 92% (22/24) of specimens and knot opening was observed in 8% (2/24) at the maximum tension (one in each Group P2 and B2). DISCUSSION The main finding of this study is to demonstrate (1) longer suture purchase significantly increases repair strength and, (2) longer suture purchase with barbed suture provide comparable MTS and 2mmGR values to conventional PP 2-strand Kessler method. The 2 cm suture purchase resulted in a 58.3% rise in the 2mmGR value for polypropylene, and a 157.5% increase for barbed suture. While 1 cm suture purchase provides lower tensile force in flexor tendon repair, the use of longer course of barbed suture inside the tendon provided similar 2mmGR and MTS values compared to conventional repair. The inadequacy of biomechanical durability remains a crucial drawback for the routine use of the barbed sutures. However, our study demonstrated that this deficit might be compensated by simply increasing suture purchase. Cao et al. demonstrated that increasing the purchase length from 4 mm to 12 mm increased the 2mmGR value by approximately 50% [10].Similar to these findings Tang et al. also demonstrated the increased tensile force as the suture purchase increases and stated the optimal suture purchase to be between 7 to 10 millimeters [11]. In our study, in the repair with barbed sutures, taking the transitions further from the incision line than the routinely used distances increased the tensile force and made it equal to conventional PP repair group. The maximal tensile strength must be sufficient enough to allow the hand to perform active motion following repair. In the current study, tendon repair with barbed suture provided similar MTS results compared to conventional repair (p = 0.743). Likewise, it has been shown that 2-strand barbed and conventional repairs provide similar MTS with advantage of lesser CSA increase [8,12]. Similarly, with 4-strand repair technique, authors highlighted equivalent tensile force with barbed suture [9,13]. Furthermore, in another study, maximum pullout force enhanced by 280% (38N to 145 N) in 4-stranded barbed suture configuration compared to 2-strand, whereas polydioxanone suture increased it by 54% reaching the almost similar maximum tensile force eventually (149.5N vs 145.6N) [14]. It actually supports our hypothesis that increased course inside the tendon generates comparable MTS values for barbed suture. Although routine usage of barbed sutures is not prominently attractive for flexor tendon repair, it is a candidate for the ideal tendon repair with the convenience it provides. Repaired tendon must remain intact when force is applied to endure post-operative mobilization protocols. It has been shown that 24N force is generated during the flexion of the flexor digitorum profundus in an intact tendon [15].Furthermore, durability of at least 35N is required to perform unresisted active finger movement [16] . Gap resistance force is the keystone for early rehabilitation and our findings stated that, the increase of the 2mmGR in barbed suture was higher compared to conventional method (57.1% vs 155.5%). In addition, the ultimate gap resistance gets equal when suture purchase was increased. Consistent with our findings, similar to superior gap resistance forces were obtained when similar strand counts were used [8,13,17]. On the other hand, authors concluded that these differences do not provide significant advantage over the conventional method and even increased work of flexion may result in increased incidence of failure [13,14,17]. Likewise, a recent meta-analysis postulated that barbed sutures generate comparable tensile force but are not superior to conventional method [18]. There are several limitations due to the nature of biomechanical study. First, further research and clinical trials are needed to validate the effectiveness and safety of barbed sutures. Additionally, long-term follow-up studies are necessary to assess the durability and potential complications associated with the use of barbed sutures in flexor tendon injuries. Second, in daily practice, more dissection may be required to move 2 cm away from the incision line of the tendon. Third, Since this study aimed to investigate the effect of the amount of barbed suture thread left in the tendon on the strength, to reduce the effect of other variables 4-strand Kessler method was used in tendon repair, and the threads were knotted in the both groups. Although 1 cm suture purchases do not reach sufficient durability for repair, it can be achieved by increasing the distance traveled within the tendon. Comparable tensile force is reached with 2 cm suture purchase in terms of 2mmGR and MTS. Consequently, barbed suture might be considered as a valuable alternative as it provides the necessary tensile force for flexor tendon repair if suture purchase is increased. In vivo studies are required to validate the finding and to expose potential advantages and drawbacks of the routine use of barbed sutures in flexor tendon repair. Declarations Data Accessibility The data that support the findings of this study are available from Ali Eray Günay but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of Ali Eray Günay. Author Contribution Y.U.C, A.E.G and M.E wrote the main manuscript text and O.T.S. , R.I.O prepared figures and tables. S.G made statistical analysis and language review. All authors reviewed the manuscript. References Pearce, O., Brown, M. T., Fraser, K. & Lancerotto, L. Flexor tendon injuries: Repair & Rehabilitation. Injury 52, 2053–2067 (2021). Savage, R. & Tang, J. B. History and Nomenclature of Multistrand Repairs in Digital Flexor Tendons. J Hand Surg Am 41, 291–293 (2016). Lawrence, T. M. & Davis, T. R. C. A biomechanical analysis of suture materials and their influence on a four-strand flexor tendon repair. J Hand Surg Am 30, 836–841 (2005). Amadio, P. C. Gliding resistance and modifications of gliding surface of tendon: clinical perspectives. Hand Clin 29, 159–166 (2013). Momose, T., Amadio, P. C., Zhao, C., Zobitz, M. E. & An, K. N. The effect of knot location, suture material, and suture size on the gliding resistance of flexor tendons. J Biomed Mater Res 53, 806–811 (2000). McKenzie, A. R. An experimental multiple barbed suture for the long flexor tendons of the palm and fingers. Preliminary report. J Bone Joint Surg Br 49, 440–447 (1967). Ingle, N. P., King, M. W. & Zikry, M. A. Finite element analysis of barbed sutures in skin and tendon tissues. J Biomech 43, 879–886 (2010). Joyce, C. W. et al. A barbed suture repair for flexor tendons: a novel technique with no exposed barbs. Plast Reconstr Surg Glob Open 2, e237 (2014). Peltz, T. S. et al. Performance of a knotless four-strand flexor tendon repair with a unidirectional barbed suture device: a dynamic ex vivo comparison. J Hand Surg Eur Vol 39, 30–39 (2014). Cao, Y., Zhu, B., Xie, R. G. & Tang, J. B. Influence of core suture purchase length on strength of four-strand tendon repairs. J Hand Surg Am 31, 107–112 (2006). Tang, J. B., Zhang, Y., Cao, Y. & Xie, R. G. Core suture purchase affects strength of tendon repairs. J Hand Surg Am 30, 1262–1266 (2005). McClellan, W. T., Schessler, M. J., Ruch, D. S., Levin, L. S. & Goldner, R. D. A knotless flexor tendon repair technique using a bidirectional barbed suture: an ex vivo comparison of three methods. Plast Reconstr Surg 128, 322e–327e (2011). Ben-Amotz, O., Kargel, J., Mailey, B. & Sammer, D. M. The effect of barbed suture tendon repair on work of flexion. J Hand Surg Am 40, 969–974 (2015). Zeplin, P. H., Zahn, R. K., Meffert, R. H. & Schmidt, K. Biomechanical evaluation of flexor tendon repair using barbed suture material: a comparative ex vivo study. J Hand Surg Am 36, 446–449 (2011). Edsfeldt, S., Rempel, D., Kursa, K., Diao, E. & Lattanza, L. In vivo flexor tendon forces generated during different rehabilitation exercises. J Hand Surg Eur Vol 40, 705–710 (2015). Schuind, F., Garcia-Elias, M., Cooney, W. P. & An, K. N. Flexor tendon forces: in vivo measurements. J Hand Surg Am 17, 291–298 (1992). Nayak, A. N. et al. A Mechanical Evaluation of Zone II Flexor Tendon Repair Using a Knotless Barbed Suture Versus a Traditional Braided Suture. J Hand Surg Am 40, 1355–1362 (2015). Shin, J. Y., Kim, J. S., Roh, S.-G., Lee, N.-H. & Yang, K.-M. Biomechanical Analysis of Barbed Suture in Flexor Tendon Repair versus Conventional Method: Systematic Review and Meta-Analysis. Plast Reconstr Surg 138, 666e–674e (2016). Table Table 1. Comparison of the 2mm GR and MTS averages between the groups. If groups have different superscript letters (e.g., Group P1 has ' x ' and Group P2 has ' y '), it implies that there is a statistically significant difference between those groups (p<0.05). n 2mmGR (Newton) Mean (SD) MTS (Newton ) Mean (SD) Group P1 6 12,1 (1,4) x 37,0 (7,5) Group P2 6 19,0 (6,1) y 32,0 (11,6) Group B1 6 8,1 (0,9) x 32,6 (3,9) Group B2 6 20,7 (5,4) y 32,8 (9,6) p-value <0.001 0,743 x Significantly different from Group P2 and Group B2 (p<0.05) y Significantly different from Group P1 and Group B1 (p<0.05) Additional Declarations No competing interests reported. Supplementary Files 2mmGapresistance.mov Video.mp4 Barbedandnonbarbedgroups2mmGRvisualabstractmaterial.png Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3982828","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":285643253,"identity":"ded78782-9412-4f3b-b468-08797cfaec02","order_by":0,"name":"yigit umut cirdi","email":"","orcid":"","institution":"Acıbadem University Atakent Hospital","correspondingAuthor":false,"prefix":"","firstName":"yigit","middleName":"umut","lastName":"cirdi","suffix":""},{"id":285643254,"identity":"ece79349-1643-4f23-b21d-050620746e0f","order_by":1,"name":"ali eray gunay","email":"","orcid":"","institution":"Kayseri City 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Multi-strand repairs and peripheral sutures are now frequently preferred and became the backbone of the flexor tendon treatment [1,2]. Suture material strongly influences the biomechanical durability of the tendon repair [3]. However, traditional 4 to 6-strand repairs have shown to increase the cross-sectional area (CSA) of the tendon, therefore creating a bulkiness that makes it difficult for tendon to glide through the flexor pulleys and adhesions if the repair site is adjacent to pulleys [4,5] .\u003c/p\u003e \u003cp\u003eThe use of barbed sutures in flexor tendon repair was introduced in 1967 [6]. Barbed sutures have unidirectional clefts all around. The clefts on this provide resistance by holding onto the tendon in a perpendicular direction against sliding. The number of clefts buried inside the tendon is responsible for the resistance generated. Therefore, providing anti-glide effect by anchoring multiple points making it a valuable alternative for flexor tendon repairs [7].Pull-out strength and final failure force were shown to be similar with conventional 4-strand Adelaide repair [8,9].\u003c/p\u003e \u003cp\u003eThe aim of this study is to examine the relation of the length of suture inside the tendon and repair strength and its effect on tensile force. Suture purchase directly influences the strength and reduced the re-rupture rates and makes the more aggressive rehabilitation protocol possible. Furthermore, reducing the overall tendon repair-associated complications [10]. We hypothesize that a longer course of the barbed suture inside the tendon achieves comparable biomechanical repair strength.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eThis study was performed at biomechanics center in 2023. This study was exempt from instutional review board approval owing to the use of deidentified cadaveric specimens. A pilot study was carried out with an alpha error as 0.05 and 24 samples generated a significant difference of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 when power is 0.80.\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy Group\u003c/h2\u003e \u003cp\u003eTotal of 24 tendons of sheep flexor digitorum profundus tendons have been dissected and collected for the study. All the tendons were examined for abnormalities or impairments, including degeneration and trauma. Those with any defects were discarded. 10 cm-long tendon sections were spared and prepared. A perpendicular line was drawn on the tendon to prevent rotation of the tendon during the repair. The continuity of the line has been closely monitored during the repair process. Then, the tendon was halved into two parts.\u003c/p\u003e \u003cp\u003eAll specimens were repaired according to the aforementioned protocols then, divided into 4 subgroups with 6 specimens in each :\u003c/p\u003e \u003cp\u003eGroup P1: Polypropylene suture (3/0) (PP) with 2-strand modified Kessler method, 1 cm away from the gap.\u003c/p\u003e \u003cp\u003eGroup P2: Polypropylene suture (3/0) with 2-strand modified Kessler method, 2 cm away from the gap.\u003c/p\u003e \u003cp\u003eGroup B1: Barbed suture (3/0) with 2-strand modified Kessler method, 1 cm away from the gap.\u003c/p\u003e \u003cp\u003eGroup B2: Barbed suture (3/0) with 2-strand modified Kessler method, 2 cm away from the gap.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eRepair Technique\u003c/h2\u003e \u003cp\u003eTendons were shortened to eight cm in length after grouping and marked with a longitudinal line to determine rotation. A smooth incision was made in the middle of the tendon with the help of the number 11 scalpel. Tendons in group P1 were repaired with 3\u0026thinsp;\u0026minus;\u0026thinsp;0 polypropylene (Doğsan, T\u0026uuml;rkiye), and tendons in group B1 were repaired with 3\u0026thinsp;\u0026minus;\u0026thinsp;0 barbed sutures (Vloc, Covidien, USA) using the modified Kessler method, passing 1 cm forward from the incision. Tendons in group P2 were repaired with 3/0 polypropylene, and tendons in group B2 were repaired with 3/0 barbed sutures using the modified Kessler method, passing 2 cm away from the incision. The 2-strand modified Kessler method was used to maximize the effect of suture materials and transition length (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eOutcome Measures\u003c/h2\u003e \u003cp\u003eThe reconstructed tendons were subjected to tensile force testing device (Instron, USA) using a compression method at both ends. A 5 cm tendon was left in the middle section. Traction force was applied to open 10 mm per minute. Slow motion video recording was taken while the tendon was distracted. The amount of resistance at which the 2 mm gap formed was recorded in newtons(N) as 2mmGR. The unsustainable peak point of the continuing traction force was determined as the maximum tensile strength(MTS) point of the resistance force where the tendon ends became completely independent from each other. The MTS values as newtons and the pattern of failure in tendon repair at the MTS point was recorded.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eAfter the data were transferred to the computer environment, evaluations were made using the SPSS 22.0 program. The conformity of the data to the normal distribution was analyzed with the Shapiro-Wilk test, the means between the groups with the appropriate distribution were compared with the ANOVA test, pairwise comparisons were made with the Scheff\u0026eacute; test, and results with a p value below 0.05 were considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eTwo cm suture purchase increased mean 2mmGR value in polypropylene and barbed sutures by 6.9 N and 12.6N respectively. The increase rate in 2mmGR was 58.3% (group P1 to P2) for polypropylene and 157.5% (group B1 to B2) for barbed sutures. The highest 2mmGR value was obtained in group B2 (20.7N (SD:5.4) Group P2 and group B2 demonstrated significantly higher 2mmGR values than group P1 and B1 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Additionally, the MTS values were comparable for all groups, with the highest value observed in the group P1 37.0N (SD:7.5) without any significant difference among the groups (p\u0026thinsp;=\u0026thinsp;0.743). (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe pattern of failure was suture breakage in 92% (22/24) of specimens and knot opening was observed in 8% (2/24) at the maximum tension (one in each Group P2 and B2).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe main finding of this study is to demonstrate (1) longer suture purchase \u0026nbsp;significantly increases repair strength and, (2) longer suture purchase with barbed suture provide comparable MTS and 2mmGR values to conventional PP 2-strand Kessler method.\u003c/p\u003e\n\u003cp\u003eThe 2 cm suture purchase resulted in a 58.3% rise in the 2mmGR value for polypropylene, and a 157.5% increase for barbed suture. While 1 cm suture purchase provides lower tensile force in flexor tendon repair, the use of longer course of barbed suture inside the tendon provided similar 2mmGR and MTS values compared to conventional repair.\u003c/p\u003e\n\u003cp\u003eThe inadequacy of biomechanical durability remains a crucial drawback for the routine use of the barbed sutures. However, our study demonstrated that this deficit might be compensated by simply increasing suture purchase. Cao et al. demonstrated that increasing the purchase length from 4 mm to 12 mm increased the 2mmGR value by approximately 50% [10].Similar to these findings Tang et al. also demonstrated the increased tensile force as the suture \u0026nbsp;purchase increases and stated the optimal suture purchase to be between 7 to 10 millimeters [11]. In our study, in the repair with barbed sutures, taking the transitions further from the incision line than the routinely used distances \u0026nbsp;increased the tensile force and made it equal to conventional PP repair group.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe maximal tensile strength must be sufficient enough to allow the hand to perform active motion following repair. In the current study, tendon repair with barbed suture \u0026nbsp; provided similar MTS results compared to conventional repair (p = 0.743). Likewise, it has been shown that 2-strand barbed and conventional repairs provide similar MTS with advantage of lesser CSA increase\u0026nbsp;[8,12]. Similarly, with 4-strand repair technique, authors highlighted equivalent tensile force with barbed suture\u0026nbsp;[9,13]. Furthermore, in another study, maximum pullout force enhanced by 280% (38N to 145 N) in 4-stranded barbed suture configuration compared to 2-strand, whereas polydioxanone suture increased it by 54% reaching the almost similar maximum tensile force eventually (149.5N vs 145.6N)\u0026nbsp;[14]. It actually supports our hypothesis that increased course inside the tendon generates comparable MTS values for barbed suture. Although routine usage of barbed sutures is not prominently attractive for flexor tendon repair, it is a candidate for the ideal tendon repair with the convenience it provides.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRepaired tendon must remain intact when force is applied to endure post-operative mobilization protocols. \u0026nbsp;It has been shown that 24N force is generated during the flexion of the flexor digitorum profundus in an intact tendon\u0026nbsp;[15].Furthermore, durability of at least 35N is required to perform unresisted active finger movement\u0026nbsp;\u003ca href=\"https://www.zotero.org/google-docs/?a3D393\"\u003e[16]\u003c/a\u003e. Gap resistance force is the keystone for early rehabilitation and our findings stated that, the increase \u0026nbsp;of the 2mmGR in barbed suture was \u0026nbsp;higher compared to conventional method (57.1% vs 155.5%). In addition, \u0026nbsp;the ultimate gap resistance gets equal when suture purchase was increased. Consistent with our findings, similar to superior gap resistance forces were obtained when similar strand counts were used\u0026nbsp;[8,13,17]. On the other hand, authors concluded that these differences do not provide significant advantage over the conventional method and even increased work of flexion may result in increased incidence of failure\u0026nbsp;[13,14,17]. Likewise, a recent meta-analysis postulated that barbed sutures generate comparable tensile force but are not superior to conventional method\u0026nbsp;[18].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere are several limitations due to the nature of biomechanical study. First, further research and clinical trials are needed to validate the effectiveness and safety of barbed sutures. Additionally, long-term follow-up studies are necessary to assess the durability and potential complications associated with the use of barbed sutures in flexor tendon injuries. Second, in daily practice, more dissection may be required to move 2 cm away from the incision line of the tendon. Third, Since this study aimed to investigate the effect of the amount of barbed suture thread left in the tendon on the strength, to reduce the effect of other variables 4-strand Kessler method was used in tendon repair, and the threads were knotted in the both groups.\u003c/p\u003e\n\u003cp\u003eAlthough 1 cm suture purchases do not reach sufficient durability for repair, it can be achieved by increasing the distance traveled within the tendon. Comparable tensile force is reached with 2 cm suture purchase in terms of 2mmGR and MTS. \u0026nbsp; Consequently, barbed suture might be considered as a valuable alternative as it provides the necessary tensile force for flexor tendon repair if suture purchase is increased. In vivo studies are required to validate the finding and to expose potential advantages and drawbacks of the routine use of barbed sutures in flexor tendon repair.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData Accessibility\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from Ali Eray G\u0026uuml;nay but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of Ali Eray G\u0026uuml;nay.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eY.U.C, A.E.G and M.E wrote the main manuscript text and O.T.S. , R.I.O prepared figures and tables. S.G made statistical analysis and language review. All authors reviewed the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePearce, O., Brown, M. T., Fraser, K. \u0026amp; Lancerotto, L. Flexor tendon injuries: Repair \u0026amp; Rehabilitation. \u003cem\u003eInjury\u003c/em\u003e 52, 2053\u0026ndash;2067 (2021).\u003c/li\u003e\n\u003cli\u003eSavage, R. \u0026amp; Tang, J. B. History and Nomenclature of Multistrand Repairs in Digital Flexor Tendons. \u003cem\u003eJ Hand Surg Am\u003c/em\u003e 41, 291\u0026ndash;293 (2016).\u003c/li\u003e\n\u003cli\u003eLawrence, T. M. \u0026amp; Davis, T. R. C. A biomechanical analysis of suture materials and their influence on a four-strand flexor tendon repair. \u003cem\u003eJ Hand Surg Am\u003c/em\u003e 30, 836\u0026ndash;841 (2005).\u003c/li\u003e\n\u003cli\u003eAmadio, P. C. Gliding resistance and modifications of gliding surface of tendon: clinical perspectives. \u003cem\u003eHand Clin\u003c/em\u003e 29, 159\u0026ndash;166 (2013).\u003c/li\u003e\n\u003cli\u003eMomose, T., Amadio, P. C., Zhao, C., Zobitz, M. E. \u0026amp; An, K. N. The effect of knot location, suture material, and suture size on the gliding resistance of flexor tendons. \u003cem\u003eJ Biomed Mater Res\u003c/em\u003e 53, 806\u0026ndash;811 (2000).\u003c/li\u003e\n\u003cli\u003eMcKenzie, A. R. An experimental multiple barbed suture for the long flexor tendons of the palm and fingers. Preliminary report. \u003cem\u003eJ Bone Joint Surg Br\u003c/em\u003e 49, 440\u0026ndash;447 (1967).\u003c/li\u003e\n\u003cli\u003eIngle, N. P., King, M. W. \u0026amp; Zikry, M. A. Finite element analysis of barbed sutures in skin and tendon tissues. \u003cem\u003eJ Biomech\u003c/em\u003e 43, 879\u0026ndash;886 (2010).\u003c/li\u003e\n\u003cli\u003eJoyce, C. W. \u003cem\u003eet al.\u003c/em\u003e A barbed suture repair for flexor tendons: a novel technique with no exposed barbs. \u003cem\u003ePlast Reconstr Surg Glob Open\u003c/em\u003e 2, e237 (2014).\u003c/li\u003e\n\u003cli\u003ePeltz, T. S. \u003cem\u003eet al.\u003c/em\u003e Performance of a knotless four-strand flexor tendon repair with a unidirectional barbed suture device: a dynamic ex vivo comparison. \u003cem\u003eJ Hand Surg Eur Vol\u003c/em\u003e 39, 30\u0026ndash;39 (2014).\u003c/li\u003e\n\u003cli\u003eCao, Y., Zhu, B., Xie, R. G. \u0026amp; Tang, J. B. Influence of core suture purchase length on strength of four-strand tendon repairs. \u003cem\u003eJ Hand Surg Am\u003c/em\u003e 31, 107\u0026ndash;112 (2006).\u003c/li\u003e\n\u003cli\u003eTang, J. B., Zhang, Y., Cao, Y. \u0026amp; Xie, R. G. Core suture purchase affects strength of tendon repairs. \u003cem\u003eJ Hand Surg Am\u003c/em\u003e 30, 1262\u0026ndash;1266 (2005).\u003c/li\u003e\n\u003cli\u003eMcClellan, W. T., Schessler, M. J., Ruch, D. S., Levin, L. S. \u0026amp; Goldner, R. D. A knotless flexor tendon repair technique using a bidirectional barbed suture: an ex vivo comparison of three methods. \u003cem\u003ePlast Reconstr Surg\u003c/em\u003e 128, 322e\u0026ndash;327e (2011).\u003c/li\u003e\n\u003cli\u003eBen-Amotz, O., Kargel, J., Mailey, B. \u0026amp; Sammer, D. M. The effect of barbed suture tendon repair on work of flexion. \u003cem\u003eJ Hand Surg Am\u003c/em\u003e 40, 969\u0026ndash;974 (2015).\u003c/li\u003e\n\u003cli\u003eZeplin, P. H., Zahn, R. K., Meffert, R. H. \u0026amp; Schmidt, K. Biomechanical evaluation of flexor tendon repair using barbed suture material: a comparative ex vivo study. \u003cem\u003eJ Hand Surg Am\u003c/em\u003e 36, 446\u0026ndash;449 (2011).\u003c/li\u003e\n\u003cli\u003eEdsfeldt, S., Rempel, D., Kursa, K., Diao, E. \u0026amp; Lattanza, L. In vivo flexor tendon forces generated during different rehabilitation exercises. \u003cem\u003eJ Hand Surg Eur Vol\u003c/em\u003e 40, 705\u0026ndash;710 (2015).\u003c/li\u003e\n\u003cli\u003eSchuind, F., Garcia-Elias, M., Cooney, W. P. \u0026amp; An, K. N. Flexor tendon forces: in vivo measurements. \u003cem\u003eJ Hand Surg Am\u003c/em\u003e 17, 291\u0026ndash;298 (1992).\u003c/li\u003e\n\u003cli\u003eNayak, A. N. \u003cem\u003eet al.\u003c/em\u003e A Mechanical Evaluation of Zone II Flexor Tendon Repair Using a Knotless Barbed Suture Versus a Traditional Braided Suture. \u003cem\u003eJ Hand Surg Am\u003c/em\u003e 40, 1355\u0026ndash;1362 (2015).\u003c/li\u003e\n\u003cli\u003eShin, J. Y., Kim, J. S., Roh, S.-G., Lee, N.-H. \u0026amp; Yang, K.-M. Biomechanical Analysis of Barbed Suture in Flexor Tendon Repair versus Conventional Method: Systematic Review and Meta-Analysis. \u003cem\u003ePlast Reconstr Surg\u003c/em\u003e 138, 666e\u0026ndash;674e (2016).\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Comparison of the 2mm GR and MTS averages between the groups. If groups have different superscript letters (e.g., Group P1 has \u0026apos;\u003csup\u003ex\u003c/sup\u003e\u0026apos; and Group P2 has \u0026apos;\u003csup\u003ey\u003c/sup\u003e\u0026apos;), it implies that there is a statistically significant difference between those groups (p\u0026lt;0.05).\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"411\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.73722627737226%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.75912408759124%\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.630170316301705%\"\u003e\n \u003cp\u003e\u003cstrong\u003e2mmGR (Newton)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.873479318734795%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMTS\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Newton )\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.73722627737226%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup P1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.75912408759124%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.630170316301705%\"\u003e\n \u003cp\u003e12,1 (1,4)\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.873479318734795%\"\u003e\n \u003cp\u003e37,0 (7,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.73722627737226%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup P2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.75912408759124%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.630170316301705%\"\u003e\n \u003cp\u003e19,0 (6,1)\u003csup\u003ey\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.873479318734795%\"\u003e\n \u003cp\u003e32,0 (11,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.73722627737226%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup B1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.75912408759124%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.630170316301705%\"\u003e\n \u003cp\u003e8,1 (0,9)\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.873479318734795%\"\u003e\n \u003cp\u003e32,6 (3,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.73722627737226%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup B2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.75912408759124%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.630170316301705%\"\u003e\n \u003cp\u003e20,7 (5,4)\u003csup\u003ey\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.873479318734795%\"\u003e\n \u003cp\u003e32,8 (9,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.73722627737226%\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.75912408759124%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.630170316301705%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.873479318734795%\"\u003e\n \u003cp\u003e0,743\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003ex\u003c/sup\u003e Significantly different from Group P2 and Group B2 (p\u0026lt;0.05)\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ey\u003c/sup\u003e Significantly different from Group P1 and Group B1 (p\u0026lt;0.05)\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Tenorrhaphy strength, Modified Kessler, Flexor Tendon , V-Loc","lastPublishedDoi":"10.21203/rs.3.rs-3982828/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3982828/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe effects of the purchase length on the maximum tensile strength (MTS) and 2mm gap resistance (2 mmGR) of barbed and polypropylene (PP) sutures were investigated. A total of 24 sheep flexor tendons were divided into four groups. Increasing the suture purchase from 1 cm to 2 cm resulted in 58.3% vs. 157.5% increase in 2mmGR for PP and barbed sutures, respectively. While the repair with a 1cm suture purchase using barbed sutures is weaker than the PP group (8.1N vs. 12.1N)(p=0.445), when the suture purchase is increased to 2 cm, a comparable tensile strength is obtained in terms of 2 mmGR (20.7N vs. 19.9N) (p = 0.971). Compared to PP sutures, the tensile force achieved with barbed sutures grows exponentially as the distance traveled through the tendon increases. Consequently, barbed sutures provide comparable tensile force for flexor tendon repair when suture purchase is increased.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLevel of evidence: \u003c/strong\u003eV\u003c/p\u003e","manuscriptTitle":"Effect of Suture Purchase on Biomechanical Characteristics in Barbed Sutures","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-01 16:56:15","doi":"10.21203/rs.3.rs-3982828/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"82bbbfff-1242-4d2e-861d-b186f00fffbd","owner":[],"postedDate":"April 1st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":30097356,"name":"Health sciences/Health care"},{"id":30097357,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2024-07-15T08:59:28+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-01 16:56:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3982828","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3982828","identity":"rs-3982828","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}