Development of A Finite Element Model For The Study of Tendon Repair Techniques

DEVELOPMENT OF A FINITE ELEMENT MODEL FOR THE
STUDY OF TENDON REPAIR TECHNIQUES
A thesis submitted to the University of Manchester for the degree of

Master of Philosophy (MPhil)
in the Faculty of Engineering and Physical Sciences.
2012
SHELLEY DYAN RAWSON
SCHOOL OF MATERIALS
LIST OF CONTENTS
LIST OF CONTENTS 2
LIST OF TABLES 6
LIST OF FIGURES 7
LIST OF ABBREVIATIONS 11
ABSTRACT 12
DECLARATION 13
COPYRIGHT STATEMENT 13
DEDICATION 14
ACKNOWLEDGMENTS 14
CHAPTER 1: INTRODUCTION 15
1.1 Prevalence of Injury and Current Clinical Outcome 15
1.2 Anatomy 16
1.3 Healing 19
1.4 Tendon Forces 21
1.4.1 Friction 21
1.5 Tendon Mechanical Properties 21
1.5.1 Young’s Modulus 22
1.5.2 Strain Rate 23
1.5.3 Variations within the Tissue 23
1.5.4 Mechanical properties of Fibrils and Surrounding Tissue 24
1.5.5 Viscoelasticity 25
1.6 History; Developments which Influenced Tendon Repair 25
1.6.1 Primary Repair 25
1.6.2 Tendon Mobilisation 26
1.7 Suture; Evaluation of Techniques 26
1.7.1 Number of Core Sutures and Anchor Points 29
1.7.2 Non-Grasping, Grasping and Locking 30
1.7.3 Peripheral Circumferential Suture 32
1.7.4 Internal vs External 34
1.8 Methods of Evaluating Tendon Repair 35
1.8.1 Animal Surrogates for Human Tendon 35
1.8.2 Oblique Lacerations, Crush Injuries and Tissue Degradation 36
1.8.3 Drawbacks of Current Evaluation Methods 36
1.9 Mathematical Modelling of Tendon Repair 37
1.9.1 Material Behaviour under Tension 37
1.9.2 Mechanical Characteristics of Polypropylene Suture 38
1.9.3 Mechanical Characteristics of Tendon 39
1.9.4 A Brief History of the Finite Element Method 39
1.10 Considerations for FE Modelling 40
1.10.1 Decide Units 41
2
1.10.2 Initial Assumptions 41
1.10.3 Draw and assemble the parts 41
1.10.4 Describe interactions 41
1.10.5 Define material properties and assigning materials to parts 42
1.10.6 Define boundary conditions and loads. 42
1.10.7 Select element type and coarseness of mesh, and mesh the part 42
1.10.8 Submit model for analysis 43
1.10.9 Validating the model 43
1.11 Use of FE Modelling for Analysis of Tendon 44
1.11.1 1D, 2D and 3D Models 46
1.11.2 Modelled Structure 46
1.11.3 Linear Elastic vs Hyperelastic 47
1.12 Summary 47
Chapter 2: AIMS 48
CHAPTER 3: METHODS 49
3.1 Obtaining Tendon Samples 49
3.2 Sample Preparation and Measurement 50
3.3 Tensile testing; Bose Biodynamic Chamber 54
3.4 Tensile Testing; Instron Tensile Testing Equipment 55
3.4.1 Establishing Compliance 56
3.5 Tensile Testing Data Analysis 57
3.6 Finite Element Modelling; Model of Sample Preparation Method C 58
3.7 Finite Element Modelling; Suture Repaired Tendon, Simple Model 59
3.7.1 Validating the model and considering sensitivity to material properties 62
3.8 Finite Element Modelling; Suture Repaired Tendon, Kessler Model 62
3.8.1 Validating the model and considering sensitivity to material properties 65
3.9 Finite Element Modelling; Obtaining Orthotropic Material Properties of Tendon 66
3.9.1 Model of tendon microstructure 67
3.9.2 Homogenisation 69
3.9.2.1 Calculating E1& E2 70
3.9.2.2 Calculating E3 70
3.9.2.3 Calculating G12 70
3.9.2.4 Calculating G13 and G23 71
3.9.2.5 Calculating ν12, ν13 and ν23 71
CHAPTER 4: RESULTS: TRANSVERSE TENDON PROPERTIES 72
4.1 Anchoring the Tendon 72
4.2 Preliminary Test Using Preparation Method C 74
4.3 Effects of Testing Samples in Air 75
4.4 Epitenon Effects, First Experiment 76
4.5 Epitenon Effects, Second Experiment 77
4.6 Effects of Sample length 78
4.7 Final Anchoring Method; Proximal vs Distal 80
3
4.8 Final Anchoring Method; Effects of Varying Strain Rate 81
4.9 Final Anchoring Method; Determining Transverse Modulus 82
4.10 Calculating matrix modulus 82
4.10.1 Em upper limit 83
4.10.2 Em lower limit 83
4.10.3 Checking Em values 83
CHAPTER 5: RESULTS: FINITE ELEMENT SUTURE REPAIRED TENDON MODEL 84
5.1 Initial Simplified Model 84
5.2 Locking 85
5.3 Modified Geometry 85
5.4 Simplified Suture Repair: Model Validation 88
5.5 Grasping Kessler Suture Repair and Model Validation 89
5.6 Stress and Deformation in the Grasping Kessler Suture Repair 91
CHAPTER 6: RESULTS: HOMOGENISATION 92
6.1 Preliminary validation 92
6.2 Varying material properties of fibrils and matrix 92
6.3 Incrementally decreasing Young’s modulus of matrix 93
6.4 Using Orthotropic Material Description in Simple Suture Repaired Model 94
6.5 Using Orthotropic Material Description in Kessler Suture Repaired Model 95
CHAPTER 7: DISCUSSION AND RECOMMENDATIONS 96
7.1 Development of Transverse Tensile Testing Method 96
7.1.1 Testing Samples in Air 96
7.1.2 Epitenon Effects 97
7.1.3 Method of Anchoring the Tendon Samples 98
7.1.4 Proximal and Distal Samples 99
7.1.5 Strain Rate 99
7.2 Transverse Young’s modulus 99
7.3 Matrix Young’s Modulus 100
7.4 Finite Element Model: Isotropic Linear Elastic Material Description 100
7.4.1 Kessler Deformation and Stress 101
7.5 Finite Element Model: Orthotropic Linear Elastic Material Description 101
7.6 Finite Element and Homogenisation Validation 102
8 CONCLUSIONS 103
9 BIBLIOGRAPHY 104
10 APPENDICES 110
10.1 Photographs of Preparation Methods 110
10.2 Custom adapters and Tissue Grips used with Instron Equipment 113
10.3 Appendix for Preliminary Test Using Preparation Method C 117
10.4 Appendix for Effects of Testing Samples in Air 119
10.5 Appendix for Epitenon Effects, First Experiment 120
10.6 Appendix for Epitenon Effects, Second Experiment 121
10.7 Appendix for Effects of Sample length 122
4
10.8 Appendix for Final Anchoring Method; Proximal vs Distal 126
10.9 Appendix for Final Anchoring Method; Effects of Varying Strain Rate 131
10.10 Appendix for Final Anchoring Method; Determining Transverse Modulus 133
10.11 Appendix for Simplified and Kessler Suture Repair: Model Validation 135
10.12 Orthotropic Material Description, Simple and Kessler Validation 139
WORD COUNT 35,321
5
LIST OF TABLES
CHAPTER 1
1.1 Demographic of common tendon injuries 15
1.2 Forces applied to FDP during various exercises 21
1.3 Reported material properties of tendon 22
1.4 Reported material properties of fibrils and inter-fibrilar material 24
1.5 Ex vivo studies of suturing techniques under axial tensile load 28
1.6 Room temperature mechanical characteristics of polypropylene 38
1.7 Methods of modelling tendon using finite element analysis as described
in existing literature 45
CHAPTER 3
3.1 Description of sample preparation methods showing a schematic of the
prepared sample, notes describing the preparation, and the measurements
which were taken 53
3.2 Summary stating which custom adapters and tissue grips were required for
each sample preparation method 55
3.3 Details of calculations used to determine cross sectional area and initial
sample length 57
3.4 Summary of simplified of model 60
3.5 Summary of Kessler model 64
3.6 Summary of the microstructure model 67
CHAPTER 5
5.1 Brief description of the initial suture repair model 84
CHAPTER 6
6.1 Material constants obtained when fibrils and matrix are both linear elastic
materials with a Young’s modulus of 1700 MPa and a Poisson’s ratio of 0.3 92
6.2 Material properties of the fibrils and matrix and engineering constants
obtained from homogenisation 93
6.3 Combinations of fibril modulus and matrix modulus used in microstructure
model, and resultant engineering constants obtained after homogenisation 93
APPENDICES
10.1 Photographs of preparation methods described in Table 3.2 112
10.2 Measurements of the 18 tendon samples from section 4.6 125
10.3 Results of sensitivity tests of the simplified model 135
10.4 Results of sensitivity tests of the Kessler model 137
10.5 Results from simple suture finite element model using homogenized material
description for tendon tissue 139
10.6 Results from Kessler suture finite element model using homogenised
material description for tendon tissue 140
6
LIST OF FIGURES
CHAPTER 1
1.1 A lacerated tendon and spontaneously ruptured tendon 16
1.2 Hierarchical structure of tendon 17
1.3 Typical stress-strain relationship of tendon under uniaxial tension showing
the toe, heel and linear regions of the curve 18
1.4 Palmar view of bones, tendons and ligaments involved in digit flexion 19
1.5 The four stages of tendon healing 20
1.6 Some of the joining techniques described in literature 27
1.7 General relationship between different suturing techniques and strength,
gapping resistance, complexity, handling and gliding resistance 29
1.8 Four different suture anchoring methods 31
1.9 Circumferential sutures 33
1.10 Force from muscle acting on a suture repaired tendon and tensile force
acting on a small section of the suture 37
1.11 Schematic of stress-strain relationship of polypropylene at room temperature
-1
(20⁰C) and a strain rate of 0.1 sec 38
1.12 Flow diagram of FE modelling process using Abaqus 40
CHAPTER 3
3.1 Palmar view of porcine front trotter 49
3.2 Photographs of tendon dissection 49
3.3 Bose biodynamic chamber and tendon sample E held with serrated grips 54
3.4 Example experimental setup when using Instron tensile testing equipment 56
3.5 Geometry of tendon sample C as modelled in finite element 58
3.6 Boundary conditions applied to the model of tendon sample C 59
3.7 Simplified model: Steps to produce the sweep sketch of the suture and the
dimensions of the section sketch 60
3.8 Simplified model: Tendon geometry 60
3.9 Simplified model: Assembly of tendon and suture and schematic of full suture
repaired tendon which the finite element model represents 60
3.10 Simplified model: Boundary conditions applied to the simplified model and
traction applied to the suture 61
3.11 Kessler model: Geometry of the two suture parts and assembly of the two
Parts 63
3.12 Kessler model: Geometry of tendon 63
3.13 Kessler model: Assembly, showing tendon as transparent to allow full view
of suture and full schematic of grasping Kessler suture which this model
represents 64
3.14 Photographs of Grasping Kessler suture 64
7
3.15 Kessler model: Boundary conditions applied to the model and traction
applied to the suture 65
3.16 Schematic illustrating the relationship between the micro-scale model
of tendon microstructure, the process of homogenisation of this model, the
macro-scale model of a suture repaired tendon, and the laboratory testing
of porcine tendon 66
3.17 Finite element model representing tendon microstructure, showing fibrils
and Matrix 67
3.18 Finite element model showing fibrils alone. 67
3.19 Boundary conditions for calculating E1, E2ν12, ν13 andν23 69
3.20 Boundary conditions for calculating E3 69
3.21 Boundary conditions for calculating G12 69
3.22 Boundary conditions for calculating G13 and G23 69
CHAPTER 4
4.1 Anchor method A demonstrating uneven loading 73
4.2 Anchor method B demonstrating adhesive failure 73
4.3 Mean stress with increasing strain for preliminary test using preparation
method C 74
4.4 Tensile test conducted in air and PBS 75
4.5 Tensile test of two preparation methods (C and D) 76
4.6 Tensile tests of preparation method F (with epitenon) and G (without
epitenon) 77
4.7 Tensile test of 5mm, 10mm and 15mm samples 78
4.8 Finite element models of tendon simulating preparation method C, and
tendon samples prepared by method C during tensile testing in the
laboratory 79
4.9 Mean transverse tensile modulus and standard deviation of initial
experiment (n=6) using the improved anchoring method 80
4.10 Mean transverse tensile modulus and standard deviation of repeated
experiment (n=12) using the improved anchoring method 80
4.11 Mean transverse tensile modulus and standard deviation of proximal tendon
samples when a strain rate of 1%/s and 10%/s is applied 81
4.12 Mean transverse tensile modulus and standard deviation of transverse
tendon samples tested to failure at a strain rate of 1%/s 82
CHAPTER 5
5.1 Initial model of the suture repaired tendon and schematic of the simplified
suture repair which this model represents 84
5.2 Photographs of simplified suture repair performed on porcine tendon
showing a sample prior to load application and a sample subject to initial
load application 86
8
5.3 Finite element model of simplified tendon repair before and after load
Application 86
5.4 Photographs of sample prepared by method J showing the geometry of a
simplified suture repair and tightest bend of Prolene suture without
permanent deformation of the suture 86
5.5 Dimensions of simplified tendon repair determined from photographs of
samples prepared by method J 87
5.6 Finite element model simplified tendon repair with amended dimensions
before and after load application 87
5.7 Finite element and laboratory results from tensile testing the simplified
tendon repair 88
5.8 Finite element and laboratory results from tensile testing the Kessler
tendon repair 90
5.9 Kessler finite element model undergoing a suture displacement of 0.5mm,
showing tendon stresses and cut view, showing internal tendon stresses in
the anchor region of the Kessler repair 91
5.10 Deformation of the Kessler suture repaired tendon during load application
as observed in the laboratory and during finite element analysis 91
CHAPTER 6
6.1 Tensile tests using simplified tendon repair, results from lab and finite
element results using the orthotropic material description for tendon tissue 94
6.2 Tensile tests using Kessler tendon repair, results from lab and finite
element results using the orthotropic material description for tendon tissue 95
APPENDICES
10.1 Top pinned shaft 113
10.2 Bottom pinned shaft with tank 113
10.3 Pin sleeve 114
10.4 Top tissue grip adapter, components 114
10.5 Top tissue grip adapter, assembled 114
10.6 Top serrated grip adapter, components 115
10.7 Bottom serrated grip adapter with tank, components 115
10.8 Bottom serrated grip adapter with tank, assembled 116
10.9 Compliance of system used in section 4.2 117
10.10 Stress strain relationship of all samples in section 4.2 117
10.11 Photographs of sample V5L during tensile testing, alongside the stress-strain
response of this sample 118
10.12 Approximately linear region of stress strain curve, and equation of each line 118
10.13 Stress – strain data of all samples in section 4.3 119
10.14 Mean of samples tested in air from Section 4.3 compared with mean of
samples tested in air in Section 4.2 119
10.15 Compliance for preparation method C 120
10.16 Compliance for preparation method D 120
9
10.17 All preparation method C samples tested in Section 4.4 120
10.18 All preparation method D samples tested in Section 4.4 121
10.19 All preparation method F samples tested in Section 4.5 121
10.20 All preparation method G samples tested in Section 4.5 122
10.21 Comparison of samples tested using the same methods, on different days 123
10.22 Compliance for samples tested in section 4.6 123
10.23 Individual 5mm length samples tested in section 4.6 124
10.26 Individual proximal samples from initial experiment 126
10.27 Portion of sample data used to calculate Young’s modulus of proximal
samples from initial experiment 127
10.28 Individual distal samples from initial experiment 127
10.29 Portion of sample data used to calculate Young’s modulus of distal samples
from initial experiment 128
10.30 Individual proximal samples from second experiment 128
samples from second experiment 129
10.32 Individual distal samples from second experiment 129
10.33 Portion of sample data used to calculate Young’s modulus of distal samples
from second experiment 130
10.34 Individual samples tested at 1%/s strain rate 131
10.35 Portion of sample data used to calculate Young’s modulus of 1%/s strain
rate samples from 131
10.36 Individual samples tested at 10%/s strain rate 132
10.37 Portion of sample data used to calculate Young’s modulus of 10%/s strain
rate samples from 132
10.38 Individual samples tested using the Instron equipment at strain rate of
1%/s. Distal samples 133
10.39 Portion of sample data used to calculate Young’s modulus of distal samples 133
10.40 Individual samples tested using the Instron equipment at strain rate of 1%/s.
proximal samples 134
samples 134
10.42 Tensile testing results of samples prepared by method H 136
10.43 Tensile testing results of samples prepared by method I 138
10
LIST OF ABBREVIATIONS
BC Boundary condition
C3D8 Abaqus code for 3D hexahedron linear elements
C3D20 Abaqus code for 3D hexahedron quadratic elements
C3D20R Abaqus code for 3D hexahedron quadratic elements with reduced integration
E1 Young’s modulus in direction 1
Ef Young’s modulus of the fibrils
Em Young’s modulus of the matrix (inter-fibrillar material)
ECL Composite Young’s modulus in the longitudinal direction
ECT Composite Young’s modulus in the transverse direction
E.11 Strain at each integration point in direction 11
E.max Maximum principal strain at each integration point
ECM Extracellular matrix
FDP Flexor digitorum profundus
FDS Flexor digitorum superficialis
FE Finite element
FEA Finite element analysis
FEM Finite element method
G12 Shear modulus in direction 12
IVOL Integration point volume
PBS Dulbecco’s phosphate buffer solution (without Ca and Mg)
S.12 Stress at each integration point in direction 12
S.13 Stress at each integration point in direction 13
S.mises Mises stress at each integration point
Vf Volume fraction of the fibrils
ε Strain
ε1 Strain in direction 1
σ Stress
ν12 Poisson’s ratio in direction 12
11
ABSTRACT
Over 30,000 people suffer tendon injury in the UK per annum and over two thirds of these are hand
tendon injuries. Hand tendon lacerations are notoriously difficult to treat and 25% of patients achieve
an unsatisfactory clinical outcome as assessed by the clinician. Tendons are commonly repaired
using suture, with many different suture configurations described in the literature for tendon repair.
Despite many in vivo clinical studies and ex vivo tensile tests, many different repair techniques are
employed in the clinical setting, demonstrating that there is not currently a best practice method of
repairing ruptured tendons. Direct comparison between all repair methods, along with detailed
observations of localised high stress and deformation would be valuable in determining a best
practice repair method. This information can be obtained by the use of finite element analysis. The
aim of this work was to produce a finite element model of suture repaired tendon suitable for
comparing different suturing methods. This work has also focussed on describing the mechanical
characteristics of tendon tissue for use in the suture repair finite element model.
Whilst the longitudinal Young’s modulus of tendon is well documented, the transverse tendon
properties have received little attention. Porcine tendon samples were tested in tension transverse to
the fibril direction. Stress and strain were observed during tensile testing to determine the transverse
Young’s modulus. From the transverse Young’s modulus, the Young’s modulus of tendon interfibrillar
material was deduced. This informed a micro-scale finite element model of tendon tissue. In
constructing the micro-scale model, the fibrils and inter-fibrillar material were likened to a continuous
fibre reinforced composite material and a simplified model of tendon microstructure was produced.
Homogenisation was performed on the micro-scale model to obtain a homogeneous material
description which represented tendon microstructure’s mechanical behaviour. Finally, this
homogeneous material description was used to describe tendon in the macro-scale finite element
model of a suture repaired tendon. Force was applied to the suture repair finite element model, and
model deformation was compared with deformation observed in sutured ex vivo porcine tendon
samples.
Tensile testing results yielded that the transverse Young’s modulus of tendon ranges from 0.1035
±0.0454 MPa to 0.2551 ±0.0818 MPa. The Young’s modulus of the interfibrillar material was found to
range from 0.0416 MPa to 0.1021 MPa. Deformation of the suture repair model correlated poorly
with ex vivo laboratory results when using the mechanical properties obtained from the micro-scale
model to describe tendon behaviour. The microstructure model considers tendon fibrils and
surrounding tissue as a fibre reinforced composite material. Our results suggest that a more complex
representation of tendon microstructure is required to sufficiently define tendon mechanical
properties for use in a suture repair model. The description of tendon which provided closest
agreement with experimental results in the macro-scale model was an orthotropic linear elastic
material with a Young’s modulus of 200MPa and a Poisson’s ratio of 0.4. A linear elastic description
of tendon permitted analysis of suture repairs at low forces. To obtain data for forces over 0.1N,
development of a hyperelastic description of tendon is recommended. This will permit greater
localised strain in the finite element model.
12
DECLARATION
No portion of the work referred to in the thesis has been submitted in support of an application for
another degree or qualification of this or any other university or other institute of learning.
COPYRIGHT STATEMENT
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Presentation of Theses.
13
DEDICATION
Dedicated to my mum and closest friend, Diane Rawson, who inspires and motivates me in
everything I do.
ACKNOWLEDGMENTS
Firstly, it is a pleasure to offer my utmost gratitude to my supervisors Dr Sarah Cartmell and Dr

Jason Wong for their substantial support, advice and guidance throughout the year. I would also like
to give special thanks to Dr Lee Margetts, whose advice, critique and expertise have been
invaluable. Without the support of these people, this work would not have been possible.
My thanks are extended to my colleagues within the Biomaterials group, notably I would like to thank
Dr Sarah Rathbone and Dr Lucy Bosworth for their valuable training, alongside Yusra Haq, Richard
Balint, Dr Araida Hidalgo-Bastida and Dr James Dugan for their friendship and support. I would also
like to thank Stuart Morse for his helpful methalogical input, along with the workshop staff for their
technical help and expertise in producing custom equipment. Furthermore, I extend my gratitude to
Dr William Parnell from the school of Mathematics for his valuable advice and critique. Not forgetting
Anne Markey and Brian Landamore who kindly provided much needed and appreciated equipment.
I would like to acknowledge the support, care and uplifting influence provided by my friends and
family. Finally I would like to give a heartfelt thank you to my husband, Adam, for his unwavering
support, confidence, patience and strength throughout everything this year, without whom I could not
have begun this journey.
14
CHAPTER 1: INTRODUCTION
Poor clinical outcome following tendon repair can affect a patient’s mobility and quality of life. Many
repair techniques have been developed over the years. Rather than converging upon a recognised
method of best practice, repair methods have diversified. Current methods of evaluating tendon
repair can determine strength, healing quality and clinical outcome, however, evaluation is time
consuming, restricting studies to a small selection of repair techniques. Furthermore, existing
techniques are unable to quantify detailed internal stress and deformation. Finite element modelling
offers a method of rapid analysis, allowing direct comparison of all tendon repair techniques. It can
provide detailed stress patterns throughout the tendon which would indicate regions of detrimental
abnormal loading, or acellular regions within the tissue. This information would be a valuable
contribution to current knowledge and would aid in approaching a conclusion of the best practice
method of tendon repair.
1.1 Prevalence of Injury and Current Clinical Outcome
Tendon injuries affect over 30,000 people in the UK per annum and over two thirds of these are hand
tendon injuries. The mean age of patients with flexor tendon lacerations is 29 years, with 71% of
patients being male (Clayton and Court-Brown, 2008) (Table 1.1). Historically, such injuries had poor
prognosis (Bunnell, 1918).
Tendon Mean Age (years) Male (%) Female (%) Common cause
Laceration
Hand Flexor 29 71 29 Sharp 85% Crush 15%
Spontaneous Rupture
Achilles 36 80 20 Sport
Biceps Brachii 63 71 29 Lifting Weight / Age related
Quadriceps 65 89 21 Age related
Rotator Cuff 52 48 52 Age related
Table 1.1 Demographic of common tendon injuries. (Kannus and Jozsa, 1991, Su et al., 2005,
Yamaguchi et al., 2006, Clayton and Court-Brown, 2008)
Assessment by the clinician aims to quantify the range of motion in the digit following six
postoperative months. There are several different methods used to assess clinical outcome, which
include the Strickland and modified Strickland criteria, Verdant Gradings, the American Society for
Surgery of the Hand (ASSH) Total Active Motion (TAM) method and the Kleinert method. At present,
over a quarter of patients achieve an undesirable clinical outcome as assessed by the clinician and,
7.7% of repairs re-rupture before the tendon has healed, requiring further surgery (Su et al., 2005).
Such cases are associated with a poor outcome.
Flexor tendon injuries are the result of a sharp laceration in 85% of cases (Figure 1.1.a), often from
broken glass. Crush injuries account for the remaining 15% (Table 1.1). Crush injuries are
15
associated with poor clinical outcome due to tissue loss, broken bones, or nerve damage. Despite
the relatively low occurrence of crush injuries, improvements in repair of such injuries would be
valuable. In other tendons, spontaneous rupture occurs following degenerative changes in the tissue
and is often age related, or associated with sporting injuries (Table 1.1). The degenerative changes
preceding spontaneous rupture mean the surrounding tendon is weakened (Figure 1.1.b) and a
repair may not provide the expected strength. Establishing the ideal repair techniques for a given
injury would aid in ensuring patients obtain the best possible outcome and improve prognosis for
tendon injury.
a b
Figure 1.1 A lacerated tendon (a) (Guimberteau, 2001) (reproduced with the kind permission of Dr J.
C. GUIMBERTEAU) and spontaneously ruptured tendon (b) (Maffulli, 1999) (reproduced with
permission)
1.2 Anatomy
Tendon is a dense regular connective tissue which transmits force from muscle to bone to facilitate
articulation. Type I collagen dominates tendon extracellular matrix (ECM) and constitutes 68.5-88%
of tendon dry weight (Koob and Vogel, 1987). Other main constituents of the ECM are
proteoglycans, glycoproteins, small amounts of elastin and traces of type III, IV and XII collagen
(Alberts et al., 2002, Aparecida de Aro et al., 2011). Tendon has a hierarchical arrangement;
fibroblasts synthesise collagen molecules, which self assemble into long, super molecular structures
called fibrils in a staggered formation known as D-banding (Fraser et al., 1983). The fibrils are
arranged in compact aligned fibres, which are themselves arranged in fibre bundles which form the
tendon (Figure1.2) (Strickland, 2005, Alberts et al., 2002). Fibres and fibre bundles are encased in
endotenon, which is continuous with the epitenon, a smooth layer of connective tissue which
encases the tendon (Verdan, 1979).
16
Figure 1.2 Hierarchical structure of tendon. Adapted from (Fenwick et al., 2002, Fraser et al., 1983,
Brodsky and Persikov, 2005),
17
The structure of tendon gives rise to its mechanical behaviour when load is applied to the tissue. The
stress-strain curve, obtained from applying an axial load to tendon, shows a ‘toe’ region of low
stiffness at low loads, prior to the ‘heel’ and linear elastic regions (Figure1.3) (Fratzl et al., 1998). The
toe region occurs at strains of up to 3% and is due to periodic kinks in the fibrils known as crimp
(Figure 1.2).Crimp straightens upon load application, and recoils when the load is removed, as
observed using polarised light microscopy (Jarvinen et al., 2004). This mechanism protects the
tendon from damage during the initial stages of loading (Franchi et al., 2007, Franchi et al., 2010).
In the heel region of the stress-strain curve (Figure 1.3), the stiffness increases with increased strain.
It is hypothesised that this may be due to entropic elasticity during straightening of kinks in the
collagen molecules based on results using rat tail tendon and synchrotron X-ray scattering. (Misof et
al., 1997)
In the linear region of the stress-strain curve, the collagen molecules are thought to glide relative to
one another whilst the molecules and cross links stretch. This is reversible and the tendon recovers
once the load is removed (Mosler et al., 1985).
Figure 1.3 Typical stress-strain relationship of tendon under uniaxial tension showing the toe, heel
and linear regions of the curve. Adapted from (Fratzl et al., 1998) (reproduced with permission)
Tendon is approximately 70% water, largely due to proteoglycan content (Dubinskaya et al.,
2007).The glycosaminoglycan (GAG) chains of the proteoglycans are highly hydrophilic, retaining
water and creating osmotic pressure which resists compressive forces (Alberts et al., 2002, Koob
and Vogel, 1987). Tendon adaptation has been observed, whereby the application of compression
resulted in increased localised GAG in an in vivo rabbit model (Gillard et al., 1979).
Repair of the flexor digitorum profundus (FDP) in the hand presents additional challenges due to the
anatomy of the digit. The flexor digitorum superficialis (FDS) inserts at the intermediate phalanx and
articulates the proximal interphalangeal (PIP) joint. The FDP inserts at the distal phalanx and
articulates both the PIP and distal interphalangeal (DIP) joint (Figure1.4). The tendons are encased
in a fibrous sheath comprising of ligaments known as cruciate (C1-3) and annular (A2-5) pulleys. The
pulleys enable the digit to bend when tension is applied to the tendons (Figure1.4) (Strickland, 2005).
18
A smooth parietal layer lines the wall of the fibrous sheath and synovial fluid occupies the space
between the tendon and sheath. This arrangement is the synovial sheath, which facilitates glide.
(Verdan, 1979).
The blood vessels supplying tendon are supported by a loose connective tissue called paratenon. In
the FDP, they insert at the dorsal side of the tendon and extend into the endotenon, however, they
do not penetrate the fibre bundles (Verdan, 1979, Strickland, 2005). Near the epitenon, the tendon is
virtually avascular (Mayer, 1916). Nutrition is primarily delivered to this region via diffusion from the
synovial fluid as opposed to perfusion from the vessels (Peacock, 1959). However, during healing,
cells must ideally infiltrate the tissue from the blood supply, and as such, minimising vascular
interference during surgery is essential (Fenwick et al., 2002).
Figure 1.4 Palmar view of bones, tendons and ligaments involved in digit flexion. FDP = flexor
digitorum profundus. FDS = flexor digitorum superfocialis. DIP joint = distal interphalangeal joint. PIP
joint = proximal interphalangeal joint. A1-5 = annular pulleys. C1-3 = cruciate pulleys. Adapted from
(Strickland, 2005).
1.3 Healing
There are four stages of tendon healing (Figure 1.5). Firstly a clot forms, which releases cytokines to
incite inflammation and recruit cells to the sites of injury. Inflammation occurs at 24 to 48 hours;
Macrophages remove necrotic tissue by phagocytosis and secrete growth factors to promote
revascularisation and the formation of granulation tissue. From day five, fibroblasts proliferate
towards the sites of injury and synthesise collagen. After the third postoperative week the tendon is
remodelled and collagen becomes axially aligned. Remodelling continues for up to a year, after
which the amount of collagen and fibroblasts in the tissue approaches normal levels. (Woo et al.,
1999)
19
a Stage 1: Clot formation b Stage 2:Inflammation
c Stage 3: Fibroblasts synthesise collagen d Stage 4: Remodelling
Figure 1.5 The four stages of tendon healing. Adapted from (Strickland, 2005).
Adhesions are fibrous bands which form during healing and span from the tendon repair site to
surrounding tissue (Figure 1.5.d). When the injury site is the FDP, adhesions bind the tendon to the
flexor sheath and restrict tendon movement. Minimising adhesions is key to the success of an FDP
tendon repair.
It was commonly thought that there were two mechanisms for tendon healing, and the relative
contribution of each method dictated the range of motion obtained in the clinical outcome. Adhesions
were thought to be caused by revascularization which delivered nutrients and cells from the flexor
sheath to the site of injury, resulting in tissue deposits between the tendon and sheath (Potenza,
1964); a mechanism termed extrinsic healing (Strickland, 2005). Migration of nutrients and cells from
the cut ends of the tendon was later observed (Verdan, 1979) and termed intrinsic healing which was
thought to not result in adhesions (Wada et al., 2001). However, recent work observing healing of
tendon and the surrounding tissue, including the sheath and skin, has shed new light on adhesion
formation. Adhesions formed in a murine model where the healing tendon was in close
approximation with surrounding damaged tissue. Whilst cells were observed to migrate into the
tendon from surrounding tissues, adhesions formation was more complex. Ultimately, adhesions
were the result of scarring from both tendon and surrounding tissues rather than a result of nutrient
delivery to the tendon. (Wong et al., 2009) This is in agreement with observations that adhesion
formation requires damage to both the tendon and sheath (Lindsay and Thomson, 1960), and
research demonstrating mobilisation reduces the severity of adhesions (Wada et al., 2001).
20
1.4 Tendon Forces
Early postoperative mobilisation is common practice and the repair must withstand the tension this
exerts. Tendon forces in the FDP reach 0.9kgf (8.9N) and 3.5kgf (34.4N) during passive and active
mobilisation respectively as observed during carpel tunnel surgery of three men and two women
(Table 1.2). These forces were thought to be conservative as the patients were in surgery and
subject to localised anaesthesia. During tip pinch, tendon force reached 12kgf (117.5N). Whilst tip
pinch is not recommended in any mobilisation procedure, accidental over-exertion is commonly
reported as the cause of re-rupture. This study provides an understanding of the minimum tensile
load a repair must withstand (Schuind et al., 1992).
Type of Movement Tendon Force (kgf) Tendon Force (N)

Passive mobilisation of wrist 0.6 5.9
Passive mobilisation of fingers 0.9 8.9
Unrestricted active mobilisation of wrist 0.4 3.9
Unrestricted active mobilisation of fingers 3.5 34.4
Grasp (FDP) 6.4 62.9
Tip Pinch 12.0 117.5
Table 1.2 Forces applied to FDP during various exercises. Original data from (Wright, 2009) and
(Schuind et al., 1992)
1.4.1 Friction
Friction opposes motion between the tendon and sheath. The coefficient of friction between the FDP
and the A2 pulley in healthy tissues is between 0.022 (±0.040) and 0.063 (±0.014), and a tendon
force of 0.16N (±0.031) is required to permit movement (Uchiyama et al., 1995). Friction is higher in
a repaired tendon, and is dependent on the choice of suture, the suture configuration and the
placement of the knot. Amadio describes a ‘safe zone’ between the force required to permit tendon
glide, and the force at which the repair would rupture (Amadio, 2005). Increasing this safe zone
enables greater mobilisation with a reduced risk of rupture. This can be achieved by decreasing the
resistance to glide or increasing the strength of the repair. Increasing strength is often associated
with increased friction, and a compromise between the two is often necessary.
1.5 Tendon Mechanical Properties
A mathematical model of tendon repair requires a description of the mechanical behaviour of tendon
in response to an applied force. The composition of tendon tissue gives rise to complex mechanical
properties. Establishing tendon properties has been the focus of many studies to further understand
common tendon injuries (Wren et al., 2001, Haraldsson et al., 2005), the effects of gender variance
(Kubo et al., 2003) and ageing on the tissue (Johnson et al., 1994, Lewis and Shaw, 1997, Carroll et
al., 2008), and to aid assessment of repair techniques (Boyer et al., 2001). A wide range of values
have been reported for tendon material properties (Table 1.3).
21
failure tangential
tendon failure Failure Stiffness
stress modulus reference
location strain (%) load (N) (N/mm)
(MPa) (MPa)
ex vivo
86 9.9 5579 822 (Wren et al.,
Achilles ±24 ±1.9 ±1143 ±211 - 2001)
111.5 26.7 847.4* 612.8 (Butler et al.,
Gracillis ±4.0 ±1.4 ±40.6 - 1984)
88.5 33.2 1239* 362.2 (Butler et al.,
Semitendinosus ±5.0 ±1.8 ±21.6 - 1984)
38.0 11.2 2344.6* 462.8 (Schatzmann
Quadriceps ±5.0 ±2.2 ±68.5 - et al., 1998)
#
59 22 3402 375 685 (Lewis and
Achilles (SD±18) (SD±7) (SD±102) (SD±262) Shaw, 1997)
213 2385 (Noguchi et
FDP - - ±12 - ±325 al., 1993)
in vivo
- 2000 2622 (Kongsgaard
Achilles - - (SD±0.4) (SD±534) et al., 2011)
- 1000 2924 (Carroll et al.,
Patellar - - ±100 ±215 2008)
- (Maganaris
1160 150 and Paul,
Gastrocnemius - - ±150 ±28 2002)
Table 1.3 Reported material properties of human tendons. SD = standard deviation. All other error
values are SEM. *Calculated using value for stress, and cross sectional area from the study. [F=σ x
#
A] Mean value calculated.
1.5.1 Young’s Modulus
Young’s modulus relates stress and strain in the approximately linear region of the stress-strain
curve, obtained during uniaxial loading (Explained in detail in section 1.9.2). The modulus reported
from in vivo ultrasonography is between 1,000 and 2,000 MPa, which is substantially greater than
the modulus obtained during ex vivo tensile testing, which ranges from 350 to 850MPa (Table 1.3). It
is likely that the tissue surrounding the tendon is a contributor to the perceived tensile properties
(Peterson et al., 1986). The method of storage of the ex vivo samples may also affect tendon
mechanical properties. Freezing the tissue, for example, has been found to reduce tensile modulus
(Clavert et al., 2001).
22
1.5.2 Strain Rate
During different physical activities, the force is applied to tendon at different rates, resulting in rapid
or gentle movement. When tendon is loaded in the fibre direction, the Young’s modulus and ultimate
tensile stress are strain-rate dependant (Wren et al., 2001, Lewis and Shaw, 1997). Few studies
have considered the strain rate dependence of tendon transverse to the fibre direction. Lynch et al.
investigated strain rate dependence of ovine flexor tendons and found the transverse properties to
be independent of strain rate (Lynch et al., 2003). Typical strain rates experienced in vivo are 1%/s
for quasi-static conditions and 10%/s representing normal daily activity (Wren et al., 2001, Lewis and
Shaw, 1997).Testing potential repair methods over the range of strain rates experienced in vivo, as
opposed to testing at just one rate, would provide a more detailed evaluation of how a repair would
behave in situ.
1.5.3 Variations within the Tissue
Regional variations in tendon material properties exist due to different loading conditions in different
anatomical sites. One example is the FDP tendon, which has a significantly greater Young’s modulus
in the dorsal regions compared with the palmar region, as observed during an in vitro study of human
cadaver samples. It was hypothesised that the regional variation is due to compression from the
pulley system at the palmar side of the tendon (Soejima et al., 2003). This in agreement with
research demonstrating that dorsal FDP suture placement is stronger than medial or palmar
placement (Aoki et al., 1994).
Tendon is anisotropic due to its highly aligned hierarchical composition. The ultimate tensile stress
and Young’s modulus are significantly higher when it is loaded along the long axis of the tendon as
opposed to the transverse direction. Research has commonly focused on tensile properties in the
direction parallel to fibre alignment since this is the primary loading direction, the transverse
properties of tendon have been considered in a limited number of studies. Transverse tensile tests
on the human supraspinatus tendon yielded a Young’s modulus ranging from 1 to 40 MPa
depending on location. Polarised light imaging demonstrated that modulus was significantly
correlated with fibre alignment (Lake et al., 2010). Aligned and transverse tensile tests of ovine flexor
tendons determined Young’s modulus to be 34 ±15.5MPa and 0.157±0.154MPa respectively (Lynch
et al., 2003). The modulus observed by Lynch et al. along the fibre direction is an order of magnitude
lower than typical values quoted in literature (Table 1.3). Furthermore, the transverse modulus
obtained by Lynch et al. disagrees with that concluded by Lake et al., possibly due to differing
species and anatomical locations. Further work is warranted in this area to determine the anisotropic
nature of tendon and consider regional tissue variation.
23
1.5.4 Mechanical properties of Fibrils and Surrounding Tissue
The Young’s modulus of fibrils has been established by several studies using atomic force
microscopy (AFM). Fibril Young’s modulus ranges from 200 to 5000MPa in the literature (Table 1.4),
however, observations by van der Rijt et al. demonstrate that fibrils tested in air have a significantly
greater Young’s modulus than those tested in PBS, suggesting that drying of the tissue affects the
mechanical properties (van der Rijt et al., 2006).
Few studies have quantified the material properties of the interfibrillar material (matrix). Tensile
testing of the Knee Miniscus by Tisakht et al. concluded the Matrix Young’s modulus to be 2.69MPa,
however, this was the modulus of a tissue sample tested transverse to the fibril direction (Tissakht
and Ahmed, 1995). When a composite material is loaded transverse to the fibre direction, the fibres
still contribute to the material properties (Callister, 2010). As such, the matrix Young’s modulus
reported by Tisakht et al. may not be the true value and the fibrils may still be contributing to the
tensile properties in the sample. Computational studies have provided indirect methods of
determining matrix modulus. Work by Herchenhan et al. suggests the fibril Young’s modulus is over
750 times that of the matrix modulus. However, matrix properties were not directly measured in this
study (Herchenhan et al., 2012).
Youngs Modulus (MPa)

Methods Tissue Reference
Fibrils Matrix
Laboratory based results
Tensile tests of circumferential and radial samples human (Tissakht
of miniscus to produce stress-strain graph. Radial cadaver and
508.58 2.69
toe region used for matrix values. Circumferential knee Ahmed,
linear region used for fibres. meniscus 1995)
5,000 ± 2 bovine
in ambient achiles (van der
conditions Tensile tests of individual collagen fibrils using an
- tendon type Rijt et al.,
AFM cantilever.
200 - 500 1 collagen 2006)
in PBS fibril
rat tail
3,750 - Nanoindentation using AFM cantilever. Tests tendon (Wenger et
-
11,500 conducted in air. collagen al., 2007)
fibrils
fresh frozen
Tensile testing using AFM. Tests conducted in human (Svensson
≈3,000
PBS. patellar et al., 2010)
tendon
Computational based results
FE model of fibrils, matrix and cells showed that (Herchenh
Over 750 X
fibrils 750 X stiffer than the matrix produced a FE model of
matrix -
crimp wavelength approaching that observed in tendon
an et al.,
modulus 2012)
tendon.
Table 1.4 Reported material properties of fibrils and inter-fibrilar material. (Note that we use the
engineering meaning of the term “matrix”.)
24
1.5.5 Viscoelasticity
As well as elastic behaviour, characterised by immediate elongation in response to an applied load,

tendon also exhibits a time dependant response to loading, typical of a viscous material
(Schatzmann et al., 1998). Viscoelastic behaviour is attributed to molecular rearrangement in
response to an applied constant load. This rearrangement is reversed over time following removal of
the load and as such the material also behaves elastically. This agrees with studies showing the
straightening of crimp in the toe region of the stress-strain curve (Fratzl et al., 1998) and the
molecular rearrangement during the toe and linear regions (Figure 1.3) which fully recovers upon
removal of the load (Mosler et al., 1985, Misof et al., 1997).
During tests of joining methods, preconditioning is commonly performed which involves cyclical
application of a low load. This reduces the viscoelastic effects of creep and hysteresis and allows
reproducibility of the experiment (Schatzmann et al., 1998).
1.6 History; Developments which Influenced Tendon Repair
Primary repair is now successfully performed by suturing the severed tendon ends, followed by early
active mobilisation to promote healing and maintain digit mobility. However, advances have been
slow, owing to the complexity of variables affecting healing. In early years, rejoining severed tendons
and preserving digital mobility was a great challenge.
1.6.1 Primary Repair
In 1918, Bunnell described his experiences in attempting primary repair of severed flexor tendons in
zone 2 of the finger. Adhesions formed as the repair healed, resulting in total loss of movement in
the digit. Primary repair was deemed unsuitable and Bunnell recommended performing an autograft,
followed by tenolysis at six weeks, a secondary procedure to remove adhesions, and reported that
partial function of the finger was regained. (Bunnell, 1918)
Autograft was the common treatment of zone 2 tendon laceration until the 1960s. However, the
procedure was regarded as difficult and time consuming, yielding unpredictable results prompting
reconsideration of primary repair for zone 2 severed tendons. Verdan reported comparable results
from a new method of primary repair, viable for cases with minimal crush damage. Stainless steel
transfixion pins immobilised the tendon and the tendon ends were approximated using a
circumferential suture. After three weeks the pins were removed to allow passive mobilisation.
Tenolysis was recommended after three months if results were poor. (Verdan, 1960). Primary tendon
repair using suture became, and remains, the method of choice for repair of zone 2 severed tendons.
Tendon allograft is now only performed in cases where severe skin and tissue loss, nerve damage or
broken bones must heal before tendon repair can be considered.
25
1.6.2 Tendon Mobilisation
It was well recognised that tissue healing may benefit from immobilisation based on experience with
skin and bone grafts. However, restrictive adhesions form when a tendon repair is immobile. This
resulted in conflicting views over the ideal method of rehabilitation for tendon repair. (Mason and
Shearon, 1932)
Since the work of Bunnell adhesions had been recognised as a hindrance to motion in the repaired
digit. However, adhesions were thought to be unavoidable following longitudinal histological
observations of canine autografts which suggested that adhesions were the result of nutrient and cell
delivery to the repair site from the surrounding tissue (Potenza, 1964).
The notion that adhesions were necessary was challenged with the observation of nutrient and cells
delivery to the site of injury via the cut ends of the tendon (Verdan, 1979). Clinical studies involving
early active mobilisation yielded improved range of motion in follow up observations of patients
(Baktir et al., 1996). Improved repair strength, and reduced adhesions result from early active
mobilisation compared with immobilising the tendon as observed in a canine FDP in vivo study.
Immobilised tendons exhibited a dramatic loss in strength by day seven, however, no significant
reduction in strength occurred in the mobilised tendons (Wada et al., 2001).
Early active mobilisation is now regarded best practice in the interest of improved clinical outcome,
following studies reporting improved strength and gapping resistance (Aoki et al., 1994, Wada et al.,
2001) and reduced adhesion formation (Halikis et al., 1997). However, in parallel with the many
suturing techniques, there have been a diversity of recommended rehabilitation protocols and a clear
ideal method is yet to be concluded. This has been reviewed in detail (Pettengill, 2005).
1.7 Suture; Evaluation of Techniques
The objective of a tendon repair is to rejoin the tendon ends and provide sufficient mechanical
strength until the tendon has healed. Close approximation is necessary as the tendon does not heal
if an excessive gap exists (Ejeskar and Irstam, 1981). Geleberman et al. presented convincing
evidence that 3mm is the maximum permissible gap to allow tendon repair (Gelberman et al., 1999).
Poor range of motion following healing is due to fibrous adhesions. In the interest of reducing
adhesions, handling and vascular interference must be minimized. Early active mobilisation is
employed to minimize adhesions, inflicting greater force on the site of repair. Finally, the tendon must
glide within the sheath, and gliding resistance must be minimised.
Suturing has dominated the history of tendon repair as a means of joining the severed tendon
stumps. An abundance of different suturing techniques are described in the literature, with many
possible variations of each technique (Figure 1.6). Studies comparing the relative merits of several
techniques have been well documented (Table 1.5). Due to a lack of consistency in the methods of
investigation, these studies are not easily comparable. Despite this, there are some techniques
which are clearly superior to others, as demonstrated by mechanical testing and clinical studies.
26
a. Bunnell, 2 strand, non- b. Grasping Kessler, 2 strands, c. Tajima 2 strands, grasping
grasping anchor. grasping anchor. (two knots on anchor. (similar to grasping
external loops) (See figure 10B Kessler, with knots between
for anchor method) tendon ends on both core
sutures) (See figure 10B for
anchor method)
d. Modified locking Kessler e. Four strand double modified f. Modified Pennington, 2

(aka. Pennington) 2 strand, Kessler, 4 strands, locking strand, locking anchor. (see
locking anchor. (See figure 10C anchor. figure 10D for locking method)
for anchor method)
g. Becker. h. Grasping Cruciate, 4 strand, i. Locking Cruciate, 4 strand,

grasping anchor. locking anchor.
j. Savage, 6 strand, x-stitch k. Locking Lee, 2 strand, l. Tsuge, 2 strand, anchor

anchor locking anchor with large buried within tendon
purchase.
Figure 1.6 Some of the joining techniques described in literature. Light Grey = Tendon. White =
Suture internal of tendon. Black = suture external of tendon. Dark Grey = Suture external of tendon,
dorsally placed (Only shown on figures f and k). * = placement of knot (only shown on figures b and
c). Adapted from (Pennington, 1979, Wada et al., 2001, Hatanaka et al., 2000, Lee, 1990a)
27
was an epitenon
Force at load to
Name Suture suture also Test Tissue Reference
fail (N) 2mm gap
applied?
Bunnell 4.0 Ethibond no pig 22.563 15.696 (Savage, 1985)
≈1.6kg
Grasping 4.0 Ethibond no pig 19.62 3.924 (Savage, 1985)
Kessler ≈0.4kg
human
4-0 Dracon no 22.09212 (Lee, 1990a)
cadaver
(Noguchi et al.,
4-0 nylon 6-0 nylon running Human 23.8
1993)
nonabsorbable cadaver finger
(SEM1.6)
(Noguchi et al.,
4-0 nylon 6-0 nylon running Canine flexor 26
1993)
nonabsorbable digitorum
(SEM2.4)
(Tanaka et al.,
4-0 looped 6-0 nylon (ethicon) human 33.7 30.3
2004)
(supramid) running suture cadaver finger
(SD4.7) (SD8.6)
6-0 Ethilon human (Barrie et al.,
4.0 Ethibond 31
circumferential cadaver 2001)
locking suture (SD7)
(Noguchi et al.,
Tajima 4-0 nylon 6-0 nylon running human 30.5
1993)
nonabsorbable cadaver finger
(SEM1.9)
Modified 4/0 (Dogramaci et al.,
no sheep 34.44 22.56
Kessler polypropylene 2008)
monofilament
Locking (SD2.33) (SD3.44)
core suture
AKA 6-0 Ethilon human (Barrie et al.,
4.0 Ethibond 32
Pennington circumferential cadaver 2001)
locking suture (SD9)
(Tanaka et al.,
4-0 looped 6-0 nylon (ethicon) human 38.7 32.5
2004)
(SD5.1) (SD5.3)
Four- (Dogramaci et al.,
4/0 no sheep 53.38 30.85
strand 2008)
polypropylene
double-
monofilament
modified (SD8.09) (SD1.90)
core suture
Kessler
(Tanaka et al.,
Modified 4-0 looped 6-0 nylon (ethicon) human 48 40.5
2004)
Pennington (SD3.9) (SD5.5)
no gap up
Becker 6.0 Prolene no pig 12.753 to ≈1.3kg, (Savage, 1985)
then failure
Grasping 4.0 Ethibond 46
Cruciate locking suture (SD12)
Locking 4.0 Ethibond 49
Cruciate locking suture (SD13)
Savage 4.0 Ethibond no pig 67.1985 44.145 (Savage, 1985)
≈4.5kg
Locking human
4-0 Dracon no 43.164 (Lee, 1990a)
Lee cadaver
(Noguchi et al.,
4-0 polyester 6-0 nylon running human 37.6
1993)
fiber suture cadaver finger
(SEM1.5)
(Tanaka et al.,
4-0 looped 6-0 nylon (ethicon) human 41 37.4
2004)
(SD3.5) (SD9)
(Noguchi et al.,
Tsuge 4-0 polyester 6-0 nylon running human 27.3
1993)
fiber suture cadaver finger
(SEM1.4)
Table 1.5 Ex vivo studies of suturing techniques under axial tensile load.
28
1.7.1 Number of Core Sutures and Anchor Points
Initial repairs employed two core sutures, however, Savage (Savage, 1985) described a technique
using six core sutures reporting superior strength. The suture knot is well known as an area of
weakness, along with the sites at which the suture anchors to the tendon. The Savage method
(Figure 9J) was designed to share the load over six core suture, thus reducing the load on the knot.
Similarly, the load is shared and thus reduced at each of the six anchor sites. Tensile testing of
porcine samples concluded the failure strength of the Savage technique to be 6.85kg (SD 1.346)
which was significantly greater than repairs employing two core sutures. Dogramaci et al.
demonstrated that doubling the anchor points of a Kessler repair made no significant difference.
However, by doubling the number of both anchor points and core sutures, the failure strength and
gap strength were significantly improved during this ex vivo study of ovine tendon. (Dogramaci et al.,
2008)
Whilst increasing the number of core sutures increases strength, it also increases friction by adding
bulk to the repair site. The same is true for increasing the number of anchor points. This was
observed by Zhao et al. who investigated the gliding resistance of six suturing techniques using
canine tendon. Techniques with increased number of core sutures and externally exposed anchor
points demonstrated increased gliding resistance. (Zhao et al., 2001) This is in agreement with
subsequent work (Tanaka et al., 2004). A compromise is often necessary between failure strength
and gliding resistance (Figure 1.7).
Repairs which possess more anchor points and suture strands are more complex, requiring more
handling which can cause increased trauma to the tissue. In the early years of tendon repair, Bunnell
(Bunnell, 1918) observed that the repair technique must inflict minimal trauma on the tendon to
prevent excessive adhesion formation. This has been supported by subsequent research (Lindsay
and Thomson, 1960). A compromise must be made between the level of complexity of a repair and
the strength it provides (Figure 1.7).
Figure 1.7 General relationship between different suturing techniques and strength, gapping
resistance, complexity, handling and gliding resistance.
29
1.7.2 Non-Grasping, Grasping and Locking
The anchoring method of a suture technique significantly impacts on the repair strength. Tendon’s
high tensile strength is attributed to its hierarchical arrangement of long parallel collagen fibres. This
is encased in a tough smooth layer, known as the epitenon, whose incredibly low friction surface
allows the tendon to glide (Uchiyama et al., 1995). Repairs have been developed which better exploit
the aligned structure of the tendon and the high strength of the fibres and epitenon.
Understanding the formation of different anchoring methods aids assessment of their merits and
downfalls. The strength of a given method is attributed to how effectively it transmits the axial tension
of an applied load into grip onto the tendon fibre bundles. Initial configurations employed a non-
grasping anchor aligned perpendicular to the fibre bundles, looped around a small portion of the
epitenon (Figure 1.8.a) such as the Bunnell technique (Figure 1.6.a). When the applied force
approaches failure, the suture cuts between the fibres, thus the strength of the fibres is not exploited.
The grasping method of anchoring, used in the grasping Kessler (Figure 1.6.b), Tajima (Figure 1.6.c)
and Savage (Figure 1.6.j) techniques, takes advantage of the strength of the tendon fibres as the
suture is looped around the epitenon and fibres. The loop tightens as the load is increased, which
pinches onto the fibres (Figure1.8.b). However, the loop is not closed around the fibres, so it does
not fully transmit the tensile load to compression around the fibres in the loop. The locking suture
improves on this method of grasping the fibres, by creating a closed loop (Figure 1.8.c). The loop
acts like a noose and tightens around the enclosed portion of fibres, thus resulting in a much more
effective anchor (Pennington, 1979). Locking Kessler (Figure 1.6.d) and Locking Lee (Figure 1.6.k)
are examples which employ this method of anchoring.
30
Figure 1.8 Four different suture anchoring methods. The portion of tendon fibres that the suture
anchors around is shown in grey. The tendon outline is shown as a dashed in the cross sectional
views. Dark grey represents suture which passes outside the tendon on the dorsal side.
The locking Kessler has superior strength and gapping resistance when compared with the grasping
Kessler. The differing anchor method does not affect gliding because the amount of external suture
is equal in the two given anchor methods. Tanaka et al. found no significant difference in gliding
resistance between the modified Kessler, Pennington, and Modified Pennington, during
investigations using the cadaveric human FDP tendon and pulley system (Tanaka et al., 2004). This
provides a solution to the sacrifice of glide when strength is increased by adding core sutures or
anchor points. Instead, the anchor arrangement can be improved.
31
Repeatability is a key problem associated with the locking anchor. In contrast to findings by Tanaka
et al. which show improved strength by use of a locking loop, Barrie et al. found no significant
difference when comparing the fatigue strength of locking and grasping anchoring techniques using
human cadaver tendon (Barrie et al., 2001). This may be due to the difficulty in executing a locking
loop. Since tendon is opaque, it is not possible to see whether the suture passes have been correctly
placed. Grasping loops may have been performed in error when attempting to make a locking loop.
The modified Pennington suture was developed to address this issue. Part of the core suture passes
external of the tendon, making correct placement of the transverse suture pass more straightforward
(Figure 1.8.d) (Hatanaka et al., 2000). Whilst this improves repeatability, it introduces additional
puncturing of the tendon. Trauma caused by application of suture encourages adhesion formation
(Lindsay and Thomson, 1960) and thus, whilst improving repeatability, this technique may pose a
detriment to the range of motion in the clinical outcome.
The requirement for increased strength inspired the Locking Lee suture (Figure 1.6.k) which locks
around a large portion of the fibre bundles to exploit their strength. During tensile testing of human
cadaveric tissue, the join withstood double the load of the grasping Kessler (Lee, 1990a). Lee et al.
concluded that it facilitated early active mobilisation with use of a splint following clinical studies (Lee,
1990b). However, it ruptured in one of the 11 cases which could be regarded as an unacceptably
high failure rate. Furthermore, the Locking Lee presents inferior resistance to gapping compared with
grasping and locking Kessler techniques due to an increased amount of suture present in the repair
(Tanaka et al., 2004).
Despite the increased strength attainable by improved anchor methods, the repair technique is only
as strong as its weakest feature. If the repair continues to possess two core strands, the force must
be withstood by a relatively small amount of material bridging the join.
1.7.3 Peripheral Circumferential Suture
The use of a peripheral circumferential suture in addition to a core suture was first recommended by
Mason and Shearon to ensure the ends meet laterally (Mason and Shearon, 1932). Work by Wade
et al. clearly demonstrates the gapping resistance benefits of a circumferential suture in a study
using cadaver leg and hand tendon. Without the circumferential suture, gapping occurred in a
modified Kessler repair at loads of up to 0.9kg, whereas with the addition of a circumferential suture
the join withstood 2 to 3 kg before a gap was detected (Wade et al., 1986). Circumferential sutures
are now commonplace in the repair of tendon and have been shown to enhance both mechanical
strength and gapping resistance (Dona et al., 2004).
Six circumferential suture techniques were comprehensively tested by Kubota et al., which were, in
ascending order of strength; Simple locking, Simple, Lembert, Halstead, Cross-stitch and Lin-locking
(Figure 1.9) (Kubota et al., 1996). This human cadaver study was in agreement with previous work
(Wade et al., 1986, Lin et al., 1988). Gapping resistance and tensile strength increased with
increasing number of suture strands across the join (Kubota et al., 1996). In parallel with core
32
sutures, it is apparent that the more complex circumferential sutures possess greater mechanical
integrity. The study by Kubota et al., also quantified the impact on glide of the various circumferential
sutures. The strongest technique, 18 strand Lin Locking, possessed almost twice the strength of the
next strongest, however, it also presented a 33.5% ±10.1 to 36.8% ± 13.6 increased gliding
resistance compared with healthy tendon, significantly greater than all other methods. It was
hypothesized that the locking loops, which are external to the tendon in the Lin-locking technique,
accounted for this high gliding resistance (Kubota et al., 1996). Whilst the use of circumferential
suture is now commonplace, the method of choice is not standardised, owing to the compromise
between strength and gapping resistance against glide and complexity.
Figure 1.9 Circumferential sutures. Light grey = tendon. Dark grey = Suture, external of tendon.
White = Suture, internal of tendon. (adapted from (Kubota et al., 1996, Dona et al., 2004)).
33
1.7.4 Internal vs External
An abundance of external suture increases gliding resistance of a repair, as demonstrated by

Angeles et al. who evaluated the relative merits of six different suturing techniques using cadaver
hands. The joining method with the greatest resistance to flexion also possessed the greatest
amount of external suture. Conversely the method which has no external suture, demonstrated the
least resistance to flexion (Angeles et al., 2002).
A suture knot which is buried within the tendon poses less gliding resistance than one which is
external of the tendon. This is illustrated in a study which observed several repairs including the
Kessler and Tajima methods, which are identical with the exception of knot placement; external in
the Kessler (Figure 1.6.b), and internally placed between the cut ends in the Tajima (Figure 1.6.c).
The Tajima repair exhibited significantly lower gliding resistance than Kessler, demonstrating the
benefits to glide of an internally placed knot (Noguchi et al., 1993). This is in agreement with similar
work (Zhao et al., 2001) but contradicts the belief that knot placement between the cut ends should
be avoided to allow maximum contact to permit intrinsic healing (Mason and Shearon, 1932,
Papandrea et al., 1995).
Large amounts of external suture material have been associated with increased formation of
adhesions; however, observations by Aoki et al. contradict this belief. Savage and Dorsal Splint
repairs, which both have large amounts of external material, were placed in canine tendons along
with Kessler which has relatively little external suture. Active mobilisation followed. Excessive
adhesions were not observed in the Savage repairs despite the large amount of external material. It
was hypothesized that active mobilisation prevented the formation of adhesions regardless of the
presence of a relatively large amount of external suture (Aoki et al., 1994). However, three Dorsal
Splint failures were recorded due to excessive adhesions, which could be regarded as an
unacceptably high failure rate.
Typically, repairs with greater strength tend to pose greater gliding resist (Figure 1.7), with the
exception of the Tsuge repair which is entirely internal. A modification of the Tsuge repair was
reported to withstand 60.3 ±15.3 N during ex vivo tensile testing of cadaver FDP tendons, and posed
the least resistance to glide of the six repairs tested (Angeles et al., 2002). Since this repair provides
high strength with little detriment to glide it displays clear benefits, however, trauma to the tissue
during internal placement of the suture may impact on healing.
Whilst externally placed suture poses concerns over gliding resistance and adhesions, internally
placed suture has been associated with ischemia. Vascularity is located in the central portion of the
tendon and minimizing vascular interference is important to ensure healing is not impaired (Fenwick
et al., 2002). The Bunnell repair is no longer used as the concertina-like arrangement caused
ischemia within the tendon.
34
In recent years, novel techniques have emerged using both entirely internal and entirely externally
placed material. An external synthetic mesh sleeve has been considered and mechanically
evaluated for flexor tendon repair. The load to failure was 103N in a cadaver study (Silfverskiold and
Andersson, 1993), however, widespread uptake of this method has not been apparent. The Teno Fix
device, which is a stainless steel repair, fully embedded within the tendon, received greater interest.
During clinical evaluation, none of the 34 Teno Fix repairs ruptured during active mobilisation (Su et
al., 2005). However, the device is only suited to tendons of adequate size, where adequate surgical
exposure is possible, transection of the tendon is clean and where there is minimal fraying and
damage to the tissue (Rocchi et al., 2008). The cost of the device is also thought to be a
disadvantage (Lee and Dubey, 2007).
1.8 Methods of Evaluating Tendon Repair
Tendon repair techniques are assessed by ex vivo tensile testing, or in vivo clinical or animal studies.
Tensile testing can provide the strength and gapping resistance of a repair. Animal in vivo studies
are commonly employed for histological analysis of the repair site following several postoperative
weeks. Clinical studies assess the recovered range of motion following healing. Whilst these
methods of evaluation provide valuable information regarding the relative merits of different repair
techniques, there are also limitations to the relevance of data obtained by these methods.
1.8.1 Animal Surrogates for Human Tendon
Due to tissue availability many studies use animal tendon as a surrogate for human tissue.
Mechanical properties of human tendon exhibit regional variation (Havulinna et al., 2011). Suitable
surrogate tissue must possess similar mechanical properties to human tendon in the area of interest.
Few studies have assessed animal models as a surrogate for human tendon. Further work in this
area, directly comparing histology, mechanical properties and anatomy of different animal surrogates
with human tissue would be valuable in aiding surrogate selection.
The FDP of the second toe in the porcine fore-trotter, and the proximal region of the extensor digiti
quarti proprius in the porcine hind-trotter have both been found to be suitable surrogates for the
study of human FDP tendon repairs in zones 1 to 3. However, only ex vivo similarities were
considered in this study, healing and in vivo characteristics were not observed. (Havulinna et al.,
2011)
Data collected by Noguchi et al. (Noguchi et al., 1993) suggested that, despite differences between
mechanical properties of tissues, canine and human tendon repairs behave similarly under tension.
During axial loading, human tendon withstood 213N (±12.0) prior to failure, whereas canine tendon
withstood 334N (±22.0) yet results for the failure load of five suturing techniques were similar in the
canine and human models (Noguchi et al., 1993)
35
1.8.2 Oblique Lacerations, Crush Injuries and Tissue Degradation
Whilst tendon injuries often present oblique lacerations, crush damage, or tissue degradation, the
evaluation of repair techniques seldom consider such circumstances.
The effect of oblique transection on repair strength has not been widely studied. However, obliquely
transected tendons (cut at a 45⁰ angle) repaired by modified Kessler and Cruciate sutures had
reduced failure strength of 26% and 23% respectively and reduced 2mm gapping resistance of 24%
and 19% respectively compared with tendons transacted tangentially (Tang et al., 2003). Similarly,
crush damage, or degenerative changes to tissue which precedes spontaneous rupture would
weaken the tendon, resulting in failure at a reduced force than expected. These circumstances
warrant further research to ensure the repair will still withstand the forces arising during mobilisation.
1.8.3 Drawbacks of Current Evaluation Methods
Whilst there is a wealth of publications which directly compare techniques, due to the time
consuming nature of experimental methods, only a small number of techniques are compared in
each study. Direct comparison between studies should be made with caution due to variability
between methods. Despite numerous tensile test studies and clinical evaluations there is no
definitive conclusion as to which tendon repair technique is ideal. An analysis method enabling direct
comparison of all the commonly described repair techniques would be valuable in approaching a
conclusion of the most advantageous repair.
36
1.9 Mathematical Modelling of Tendon Repair
Mathematical modelling is a novel approach enabling analysis and comparison of many methods.
Furthermore, a mathematical approach provides an avenue for investigating internal tissue
deformation, which is difficult to observe experimentally. Inroads have been made to produce a
mathematical model to simulate tendon repair (Sawadkar et al., 2012) demonstrating a requirement
for such work, however, current models are highly simplified and would not be suited to analysis of
complex suture repairs.
1.9.1 Material Behaviour under Tension
Failure and gapping of a repair are due to stress and strain in the tendon and suture when the repair
is subject to tensile loading. Figure 1.10.a illustrates muscle contraction applying a tensile load to a
repaired tendon. To define stress and strain we will consider a small portion of the suture (Figure
1.10.b). Stress is a measure of the internal force within a material due to an applied load, and is
found by dividing the applied force acting on the suture by its cross sectional area (Equation 1). The
tensile force results in elongation of the suture (Figure 1.10.b). Strain is a ratio between the change
in length of the suture and its original length (Figure 1.10.b, Equation 2). Stress and strain are easily
calculated for simple geometries, however, the arrangement of sutured tendon repairs require more
complex analysis to determine stress and strain.
Figure 1.10 Force from muscle acting on a suture repaired tendon (a) and tensile force acting on a
small section of the suture (b).
[1]
[2]
Where: σ = Stress, F = Force, A = Cross sectional area, ε = Strain, ΔL = change in length, L0 = initial
length.
(Callister, 2010)
37
1.9.2 Mechanical Characteristics of Polypropylene Suture
Tendons are commonly repaired using Prolene, which is a monofilament suture made from
polypropylene. Figure 1.11 illustrates the stress-strain relationship for a sample of polypropylene
undergoing an increasing tensile force until failure. The Young’s modulus relates the stress and
strain in the approximately linear region of the graph and is obtained by calculating the gradient of
the linear region (Equation 3). At strains within this region, the material behaves elastically. At strains
above the yield point, deformation is permanent as the material approaches its ultimate tensile
strength, at which failure occurs. To describe this behaviour, we require the Young’s modulus, stress
at the yield point (yield strength), stress at failure (tensile strength), and strain at failure. To fully
describe polypropylene we also require its Poisson’s ratio, which is the relationship between
elongation and contraction (Equation 4) and describes the material’s ability to maintain volume
during loading. Table 1.6 details typical room temperature characteristics of polypropylene.
Figure 1.11 Schematic of stress-strain relationship of polypropylene at room temperature (20⁰C) and
-1
a strain rate of 0.1 sec .
[3]
[4]
Where: E = Young’s modulus, σ = Stress, ε = strain, ν = Poisson’s ratio, ε x = strain in x direction, εy

= strain in y direction
(Callister, 2010)
Polypropylene
Tensile Modulus Yield Strength Tensile Strength Strain at Failure Poisson’s Ratio
(MPa) (MPa) (MPa) (%)
1140-1550 31-37.2 31-41.5 100-600 0.4
Table 1.6 Room temperature mechanical characteristics of polypropylene (Callister, 2010)
38
1.9.3 Mechanical Characteristics of Tendon
In contrast to polypropylene, tendon exhibits complex mechanical behaviour. Tendon is anisotropic,

and displays both elastic and time-dependant viscous behaviour (Lake et al., 2010, Schatzmann et
al., 1998).Owing to the complexity of tendon, simplifications are required when mathematically
modelling its behaviour. Selected characteristics are chosen rather than modelling all aspects of the
material’s behaviour, based on the focus of the study. For example, several methods have been
investigated to describe the longitudinal behaviour of tendon; focusing on mathematically
representing the time dependant viscoelastic behaviour (Tang et al., 2011, Machiraju et al., 2006)
or the characteristic toe, heel and linear curve (Maceri et al., 2010).
Biological structures are typically complex, making stress and strain analysis difficult. Finite element
method (FEM) is commonly employed to analyse stress and strain in complex structures. FEM is a
numerical technique whereby a complex geometry is divided into a finite number of simple shapes,
known as elements. Whilst calculating the deformation and stresses in the complex shape would be
difficult, the deformation in the simple shapes can be found easily. This allows calculation of an
approximate solution for deformation, from which stress and strain is calculated in the complex
geometry.
1.9.4 A Brief History of the Finite Element Method
FEM can be traced back to the 1940s when Courant described a method of dividing a region into
triangular elements in order to approximate a solution for vibration and equilibrium problems
(Courant, 1943). The method was developed throughout the 1950s for structural, civil and
aeronautical applications. Computers permitted practical use of FEM by providing rapid means of
computing the required calculations. FEM has since become a widely used engineering tool, with a
number of software packages commercially available for finite element (FE) modelling.
The first use of FEM for biomechanics was in the 1970s to investigate stresses in bone (Brekelmans
et al., 1972). FE modelling has received increasing attention for biomechanical applications
throughout the years. A search of PubMed using the keyword “finite element” retrieves 32 papers in
1980, 134 in 1990, 478 in 2000 and 1818 in 2010. The method is suited to analysing stresses in the
complex materials, loading environment and geometry of biological structures; the analysis of which
could not be approached by simple methods. Detailed maps can be produced, illustrating
deformation and stress concentrations throughout the tissue.
39
1.10 Considerations for FE Modelling
We will briefly discuss the process of FE modelling and best practice techniques using modern FE
analysis (FEA) software. Many software packages are available to perform FEA, however, we will
focus on the commercial package Abaqus (version 6.9; Simula, Providence, RI, USA). The
applications for FEA are vast as the technique can be applied to a variety of situations; investigating
mechanical stress, fluid flow, conduction, acoustics and heat expansion to name a few (Logan and
Chaudhry, 2011). However, for simplicity we shall focus on its use for deformation and stress
analysis which is relevant to suture repair investigation.
When using Abaqus, the user must build a model to describe the problem they wish to analyse. This
is then submitted for analysis and the FE calculations are computed. Once this is complete, results
are viewed as a map of deformation and stresses on the model and reports can be printed to provide
detailed information. Figure 1.12 shows a flow chart detailing the steps required to perform an
analysis. We will explore considerations and best practice at each step in order to create a robust
and meaningful model.
Figure 1.12 Flow diagram of FE modelling process using Abaqus.
40
1.10.1 Decide Units
Abaqus has no set unit convention that must be used. However, it is imperative that units are kept
consistent throughout. Inconsistency in the input figures propagates to incorrect results.
1.10.2 Initial Assumptions
With all but the simplest of models, assumptions will be necessary in performing an analysis.
Assumptions are used to simplify the model and reduce the computational cost of analysis, however,
any assumption can affect the accuracy of the results. Obtaining a balance between accuracy and
simplicity is central to ensuring the model is not so complex that it becomes impractical or so over-
simplified that it becomes meaningless.
At this stage the user must decide if a 3D model is necessary, or whether a 2D or 1D model would
be sufficient. 1D analyses require the least computing expense, followed by 2D. This decision will
depend on the geometry of the model, and the information required from the analysis. It is best
practice to begin with a very simple model to ensure a rapid analysis step, allowing any initial errors
to be identified and resolved rapidly.
1.10.3 Draw and assemble the parts
The parts are created using simple geometric commands. They must then be arranged into an
assembly. It may only be necessary to model part of the structure; with biomechanical analyses the
surrounding tissues are often omitted. Care must be taken at this stage to ensure that complications
do not arise with singularities (whereby the stress at one point becomes infinite, causing problems at
the analysis stage) which can occur with features such as sharp corners.
If a part possesses any lines of symmetry it is best practice to only draw a section of the part. For
example, if the left and right side of the geometry are identical, and the loading conditions are also
identical, it is convention that only one side is modelled. A boundary condition is later employed to
define the part as symmetric in a given direction. The strains in the side that is not modelled will be
an identical mirror image of those found from the analysis. Neglecting to take advantage of symmetry
results in unnecessary computing expense.
1.10.4 Describe interactions
For models with two or more parts in contact with each other it is necessary to define the interaction
properties between the parts. For example, this may be defining contact as frictionless, rigid or
assigning friction between the surfaces.
41
1.10.5 Define material properties and assigning materials to parts
The material properties are defined mathematically. For a simple elastic material this can be
described using the elastic modulus and Poisson’s ratio alone. However, with more complex material
behaviour, more information must be supplied to describe the material. There is a diverse catalogue
available within Abaqus for the definition of material behaviour. Biomechanical materials are often
simplified at this stage. For example, many studies have described tendon as an isotopic, linear
elastic material defining only the elastic modulus and Poisson’s ratio (Ingle et al., 2010,
Wakabayashi et al., 2003, Garcia-Gonzalez et al., 2009, Fessel and Snedeker, 2011). Once the
materials are defined, they are assigned to the relevant parts in the assembly.
A Poisson’s ration which is too high may cause a problem in the model known as locking. A
Poisson’s ratio of 0.5 describes a material which is incompressible. Abaqus limits the value of
Poisson’s ratio at a maximum value of 0.5, however, incompressible, and near-incompressible
materials (0.475 < ν < 0.5) can result in the model becoming over-constrained. A conservative
Poisson’s ratio should be used to prevent locking. This usually has negligible impact on the accuracy
of results in models where change in volume is not likely to be significant.
1.10.6 Define boundary conditions and loads.
A boundary condition is a constraint which dictates or prevents movement or rotation of selected

parts of the model. A load is a force which acts on the model, such as pressure, gravity, or a tensile
or compressive force. Too few boundary conditions can make static equilibrium impossible, resulting
in “rigid body motion” whereby the model simply moves in space, as opposed to deforming. Too
many, and the model will be over-constrained and will not be able to deform. If symmetry has been
used when drawing the parts (Section 1.10.3), a symmetric boundary condition is defined at this
stage.
Caution is advised when using point loads. The improper use of a point load can result in a force
being applied at an infinitely small point. This leads to errors in the analysis and ultimately
meaningless results. Use of traction as opposed to a point load can eliminate this problem since
traction is applied across a selected area of the model as opposed to a point.
1.10.7 Select element type and coarseness of mesh, and mesh the part
Elements are created by creating a mesh on each part. A mesh splits the geometry into tetrahedral
or hexahedral (brick) elements for 3D parts. A coarse mesh will have few elements, whereas a fine
mesh will have many, smaller elements. The coarseness of the mesh is defined by seeding the part.
Once the part is seeded, the element type is selected and the mesh is created. Selection of the
element type will depend on the analysis that is being performed.
42
The academic licence of Abaqus limits the user to a maximum of 20,000 nodes. Nodes are the
integration points in the elements, and the number of nodes in an element is dependent on the type
of elements used. For example, a 3D linear brick element (C3D8) has 8 nodes and a 3D quadratic
brick element (C3D20) has 20 nodes. Analyses with a very fine mesh, and many elements, may be
limited by the limit to the maximum permissible number of nodes.
Locking can arise with the use of linear elements such as C3D8. This is because their edges permit
limited deformation. This can be overcome by the use of quadratic elements such as C3D20 whose
edges are able to flex more. When using C3D20 elements, the increased number of integration
points (and thus increased calculations) can substantially increase computing cost. Using 3D
quadratic brick elements with reduced integration (C3D20R) significantly reduced the computing cost
and time to perform the analysis compared with C3D20 elements.
It is important that the elements possess good quality shape. Ideally, brick elements would be cubic,
or near-cubic. Locking may arise in cases where elements are significantly elongated. To resolve
this, elements of good quality should be used. Higher order elements (e.g. C3D20 as opposed to
C3D8) can also be employed to resolve locking problems associated with element shape.
1.10.8 Submit model for analysis
Depending on the complexity of the model and the processing power of the computer, analysis of the
model may be time consuming. Producing a model which is as simple as possible ensures that
analysis time is not excessive. By doing this, any problems can be resolved quickly before refining
the model to improve results.
1.10.9 Validating the model
It is best practice to begin with a coarse mesh as this permits rapid analysis. Once a working model
has been developed and any errors have been eliminated, the model should be validated. Without
validation the user may be relying on unacceptably inaccurate results. (Henninger et al., 2010)
The first step in validating the model is to perform simple hand calculations to verify results. This will
highlight any errors existing in the model which may have been overlooked.
The next step is to refine the mesh. As we have previously noted, results obtained using the FEM
are an approximation of the true solution for the geometry. This is because we have a finite number
of elements. To obtain the true solution we would need an infinite number of elements which would
require infinite calculations, making such analysis impossible. However, it follows that as you
increase the number of elements used, you converge towards the true solution. To validate the
model, a number of analyses should be completed using the same model, each with a finer mesh
than the last. The solution will approach the true solution and this convergence will be apparent.
Initially the solution will change substantially, however, as the accurate solution is approached, mesh
43
refinement will have less impact on the solution. It is at the user’s discretion to decide when the level
of error in the model has been reduced to acceptable levels.
A balance between computational expense and accuracy of results must be sought. When refining
the mesh, areas with relatively uniform deformation will not alter as dramatically as those where
deformation changes rapidly across a short distance. For this reason it is useful to use localised
mesh refinement, whereby a coarse mesh is maintained in areas of relatively uniform deformation
and a finer mesh is specified in areas which require more refinement. This is a commonly employed
best practice technique allowing convergence of the solution, whilst minimising computational
expense.
It is also important that a sensitivity analysis is completed whereby material properties are varied to
identify the sensitivity of the results to variation of properties. Where results vary largely with the
variation of a material property, the experimental data or assumptions used when specifying the
material properties should be checked to ensure levels of error are not unacceptably high.
(Henninger et al., 2010)
1.11 Use of FE Modelling for Analysis of Tendon
A range of biomechanical studies using FEA have required the modelling of tendon (Table 1.7),
however, few have investigated sutured tendon repairs. The objectives of these publications are
broad, ranging from development of composite materials, to the study of for musculoskeletal injury.
Similarly, the material properties of tendon have been described by a variety of methods. In this
section we shall explore the various ways in which tendon has been descried using FEA.
44
Young’s
2D or modeled Poisson's
Reference Focus of Study material model modulus
3D structure ratio
(MPa)
(Wakabayashi Mechanical environment of

et al., 2003) the supraspinatus tendon isotropic linear
2D tendon 168 0.497
(Funakoshi et Comparison between elastic
al., 2008) rotator cuff repair methods
(Ingle et al., Barbed suture for tendon isotropic linear
2D tendon 648 0.488
2010) repair elastic
full
model
(Garcia-
3D; isotropic linear
Gonzalez et Treatment of claw-toe tendon 450 0.3
tendons elastic
al., 2009)
modelle
d as 1D
isotropic
(Lavagnino et Mechanism for jumper's
2D tendon hyperelastic (neo- ≈ 1,000 0.49
al., 2008) knee injury
hookean)
nonlinear near-
(Sharafi et al., Failure of the
2D endomysium hyperelastic nonlinear incompres
2011) myotendinous junction
orthotropic sible
(Pena et al., Anterior cruciate ligament hypereleastic fibred defined using strain
3D tendon
2005) reconstruction material energy method.
isotropic linear 50 to
Fibrils 0.3
Tapered ends of collagen elastic 10,000
(Goh et al.,
fibrils & composite 3D
2004)
materials isotropic linear
Matrix* 1 0.49
elastic
isotropic linear
fibrils 1,000 not noted
elastic
(Fessel and Tendon stiffness following
Snedeker, glycosaminoglycan 3D
2011) depletion interconnecti
bilinear spring defined using spring
ng PG-GAG
elements stiffness
complexes
isotropic
fibrils hyperelastic (neo- ≈ 1,000 0.3
hookean)
Does tendon
(Reese et al.,
microstructure cause high 3D
2010)
Poisson’s ratio?
isotropic
Matrix* hyperelastic (neo- ≈1 0.3
hookean)
isotropic
Fibrils hyperelastic (neo- varied 0.4
hookean)
(Herchenhan Crimp formation in

2D
et al., 2012) embryonic tendon isotropic
Matrix* hyperelastic (neo- ≈ 0.8 0.49
hookean)
Cells not defined - -
(Bendjaballah fibrils 1D truss not noted not noted

Knee joint in compression
et al., 1995)
3D Matrix* 3D solid not noted not noted
Table 1.7 Methods of modelling tendon using finite element analysis as described in existing
literature. (* refers to the engineering use of the term "matrix" as opposed to the biological use of the
term. PG-GAG = proteoglycan-glycosaminoglycan)
45
1.11.1 1D, 2D and 3D Models
As we have previously discussed, assumptions and simplifications are necessary in order to

construct the FE model. In the first stages of model construction, the user must define whether the
model is to be 1D, 2D or 3D. A 1D model demands substantially less computational cost. This
method has been employed by Garcia-gonzalez et al.. The bones of the human foot were modelled
in 3D and the tendons were represented by 1D elements. The primary interest of this model was the
displacement of the bones and associated stresses. The simplification of the tendons in this study
had minimal impact on the area of interest and was therefore appropriate in this circumstance
(Garcia-Gonzalez et al., 2009). Several studies have modelled tendon in 2D. One such example is
the 2D model of the human shoulder, developed by Wakabayashi et al. This dramatically simplified
the complicated arrangement of the shoulder, substantially reducing computational cost
(Wakabayashi et al., 2003). 2D analysis is also commonly used as an initial modelling stage prior to
3D analysis.
1.11.2 Modelled Structure
Literature describes two distinct methods of modelling tendon using FE. The first method is to model
tendon as a uniform structure. Alternatively, fibres and their surrounding matrix have been modelled
to construct tendon as a structure similar to a fibre-reinforced composite material. (Note that in this
context we are using the engineering meaning of the term ‘matrix’.) The chosen method is largely
dependent on the dimensions of the architecture of interest. For large-scale models it is not practical
to model all the fibrils in the tendon since this level of detail would result in excessive computational
cost. For this reason, the model of the shoulder built by Wakabayashi et al., for example, does not
include detail of tendon fibrils (Wakabayashi et al., 2003). However, on a small-scale it is often
necessary to model the fibril to ensure the model is representative of the true arrangement,
particularly for studies closely related to tendon microstructure such as the work by Herchenhan et
al. investigating crimp formation (Herchenhan et al., 2012).
Models on a large scale can compensate for the lack of fibrils by modelling the material as
anisotropic. This was employed by Pena et al. in the modelling of the human knee (Pena et al.,
2005). Describing a material as anisotropic involves assigning different material behaviour in
different directions. The highly linear fibrous formation of tendon lends itself to being described in this
manner as its composition is similar to that of a fibre reinforced composite engineering material
(Maceri et al., 2010).
46
1.11.3 Linear Elastic vs Hyperelastic
Whilst many FE studies have represented tendon as a linear elastic material (Garcia-Gonzalez et al.,
2009, Ingle et al., 2010, Wakabayashi et al., 2003), tendon does not exhibit linear elastic behaviour.
Instead, several studies have employed a hyperelastic, often neo-hookean model, which is a stress-
strain curve provided by the Abaqus material library and (Lavagnino et al., 2008, Sharafi et al., 2011,
Pena et al., 2005). Similarly, this neo-hookean model has been employed when describing tendon
fibrils, and matrix (Reese et al., 2010, Herchenhan et al., 2012). These higher order approximations
provide a closer representation at high strains that can arise during application of load to tendon.
1.12 Summary
There is a vast array of techniques described in literature for tendon repair, and whilst numerous
studies have sought to compare their merits, there is not a universally recognized best practice
technique. Existing methods of comparing repair techniques are time consuming and often compare
only a few of the numerous tendon repair methods. Comparison between studies should be
approached with caution due to differing experimental methods. Finite element modelling provides
an avenue for rapid analysis of all the commonly used suture techniques.
47
CHAPTER 2: AIMS
We hypothesize that a 3D finite element model of suture repaired tendon will allow analysis of stress
and strain in the intricate suture configurations. The focus of this work is to obtain a description of
tendon tissue sufficient to inform a 3D finite element model of suture repaired tendon. To this end,
the aims of this thesis are:
 Determine the Young’s modulus of tendon transverse to the fibre direction by tensile testing
to describe the orthotropic behaviour of tendon.
 Produce a macro-scale finite element model of a simplified suture repaired tendon. This
model will be further developed into a Grasping Kessler repair. Force will be applied to
simulate tension across the repair, and finite element results will be compared with
laboratory results using the same suture techniques to validate the finite element models.
 Produce a micro-scale finite element model of tendon tissue. This model will include the
tendon fibrils, and surrounding tissue (matrix), thus treating tendon as a fibre reinforced
composite material. The Young’s modulus of the fibrils will be obtained from literature. The
Young’s modulus of tendon transverse to the fibre direction will be used to calculate the
matrix Young’s modulus. Homogenisation will be performed on this model to obtain the
engineering constants which represent tendon microstructure as a homogeneous orthotropic
material. The engineering constants obtained from this micro-scale model will be used to
inform the macro-scale model of suture repaired tendon.
48
CHAPTER 3: METHODS
3.1 Obtaining Tendon Samples
 Porcine front trotters (Kurpas Meats, Manchester, UK)

 Dissection kit
 6 well plates
 Dulbecco’s phosphate buffer solution (without Ca and Mg)(PAA Laboratories, Pasching,
Austria)
Porcine front trotters were obtained from a local abattoir. The flexor digitorum profundus (FDP)
tendon was removed from the two middle toes (Figures 3.1 and 3.2) and stored submerged in
Dulbecco’s phosphate buffer solution (PBS) in 6-well plates until sample preparation. Where stated,
the whole tendon was not removed, instead only the proximal or palmar portion was dissected and
labelled accordingly. Samples were extracted and used within 48 hours of slaughter.
Left Right
Flexor
Digitorum
Distal
Profundus
tendons
Proximal
Figure 3.1 Palmar view of porcine front trotter, showing flexor tendons (grey outline), and region of
flexor digitorum profundus tendons dissected for samples (shaded in grey).
Figure 3.2 Photographs of tendon dissection showing FDP tendon with surrounding flexor digitorum
superficialis (a), FDP tendons in two central toes (b) and two tendons removed from one trotter (c).
49
3.2 Sample Preparation and Measurement
 Scalpel
 Forceps
 Suture:
 Vicryl (4-0, 75cm suture, SH-1 needle, product code W9971; Ethicon, Livingston,
Scotland)
 Prolene (4-0, 90cm suture, RB1 needle, product code W8557;Ethicon, Livingston,
Scotland)
 Cyanoacrylate adhesive (Henkel Loctite Limited., Winsford, UK)
 Ruler
 Digital vernier callipers
 Dulbecco’s phosphate buffer solution (without Ca and Mg) (PAA Laboratories, Pasching,
Austria)
 Digital Camera
Samples were prepared in the same order as the order of dissection. The sample preparation
method differed between experiments. All preparation techniques are detailed in table 3.1 (For
photos, see Appendix 10.1, Table 10.1). Forceps were used to lightly hold the tendon whilst they
were cut to length using a scalpel. If required, suture was also positioned whilst the tendon was held
lightly using forceps. Care was taken to ensure minimal damage to the tendon by minimising any
pressure placed on the tissue, and by preventing the tendon from drying. A ruler was utilised to guide
cutting or suture placement of any dimension which was to be consistent for the given preparation
method.
Once the samples were prepared, relevant measurements were taken using digital vernier callipers
as detailed in table 3.1. Samples were returned to the 6-well plate and submerged in Dulbecco’s
phosphate buffer solution (PBS) until testing. Tensile testing was then performed on the samples
(excluding those prepared by method J) using either a Bose BioDynamic 5110 ElectroForce
Instrument, or an Instron 5569 load frame.
50
Preparation
Notes Measurements
Method
A  Samples cut to approximately 10-15mm in
length.
 Suture was passed through the edge of the
tendon at four evenly spaced points to
produce four loops which were knotted
together as shown below:
Direction of fibre
alignment
 Each suture pass was placed approximately
0.5mm from the tendon edge.
 Suturing was then repeated on opposite edge.
B  Samples cut to approximately 10-15mm in h, w and t

length. measured as in
 Each tendon edge was adhered between two preparation method
pieces of rigid plastic using cyanoacrylate A.
adhesive.
Direction of fibre
alignment
C  Samples cut to approximately 10-15mm in h, w and t
length (unless otherwise stated). measured as in
 Suture was passed once through the tendon, preparation method
at approximately 1mm from the tendon edge. A, along with d,
The suture was then tied in a loop using a shown below:
spacer to ensure the length of all loops was
consistent.
 Suturing was repeated on the opposite edge
of the tendon to produce a second loop.
Direction of fibre
alignment
D  Samples cut to approximately 10-15mm in H, w and t

length. measured as in
 Suture was passed once through the tendon preparation method
along the direction of fibre alignment, A, along with d
approximately 1mm from the tendon edge. shown below:
The suture was then tied in a loop using a
spacer to ensure the length of all loops was
consistent.
 Suturing was repeated on the opposite edge
of the tendon to produce a second loop.
Direction of fibre
alignment
51
E  An approximately 5mm slice of tendon was
cut. This slice was held using forceps whilst
the central portion of the slice was cut. This
central portion is the prepared sample. See
below:
Direction of fibre
alignment
 Note that by removing the two outer slices

from the sample, the epitenon has also been
removed from the test area of the sample.
 During testing, grips were clamped directly
onto the tendon sample ensuring the direction
of fibre alignment was transverse to the
loading direction.
F (and G, see Preparation method F w and t measured

notes)  Samples cut to approximately 35mm in length. as in method A,
 Suture was passed once through the tendon along with a and b,
at approximately 10mm from the cut end. The shown below:
suture was then tied in a loop using a spacer
to ensure the length of all loops was
consistent.
 Suturing was repeated on the opposite end of
the tendon to produce a second loop.
Preparation method G
 Preparation was identical to method F,
however, before the suture was performed, a
slice was removed along the length of the
tendon from either side using a scalpel to
remove the epitenon in the region where the
suture punctures the tendon. See below:
c
Direction of fibre
alignment
H  Sample cut to approximately 35mm in length. w and t measured

 Suture was passed once through the tendon as in method A,
at approximately 10mm from the proximal cut along with a, shown
end. The suture was then tied in a loop using below:
a spacer to ensure the length of all loops was
consistent.
 During testing, a grip was clamped directly
onto the un-sutured end of the sample.
Direction of fibre
alignment
52
I  Sample cut to approximately 25mm in length. w and t measured
 Half a Kessler suture was performed in one as in method A,
end of the tendon, with the transverse pass of along with a, shown
suture placed approximately 10mm from the below:
tendon end. The free ends of the suture at the
cut end of the tendon were then tied in a loop
using a spacer to ensure the length of all loops
was consistent.
 During testing, a grip was clamped directly
onto the un-sutured end of the sample.
Direction of fibre
alignment
J  Suture is passed through the tendon in two Sample was

locations, and then knotted, with sufficient photographed
tension to ensure the suture lies close to the against a ruler
tendon, however, not so tight that the tendon using a digital
bends. camera, and all
 Tensile testing was not performed on this dimensions were
sample. Instead, it was photographed using a measured.
digital camera and measured.
Direction of fibre
alignment
Table 3.1 Description of sample preparation methods showing a schematic of the prepared sample,
notes describing the preparation, and the measurements which were taken.
53
3.3 Tensile testing; Bose Biodynamic Chamber
 Bose BioDynamic 5110 ElectroForce Instrument (Bose Corporation, Eden Prairie,

Minnesota, USA)
 Forceps
Austria)
The Bose BioDynamic 5110 ElectroForce Instrument (Figure 3.3) is suited to small samples due to
limited space within the chamber and a maximal displacement of 6mm.
The chamber was assembled using the plain grips for samples prepared by method A and B, or the
serrated grips for sample E (Table 3.1). For sample E only, the initial distance between the grips was
set to 2.5mm, and measured using digital vernier callipers. The 250N load cell was employed in all
cases.
Samples were tested in the same order as the order of dissection. The sample was placed between
the clamps using forceps and the chamber was filled with Dulbecco’s phosphate buffer solution
(PBS)(unless otherwise stated). The chamber was then secured in place ready for testing. To
change the sample, the chamber was removed but the PBS was not drained.
Using the WinTest 7 software (supplied with the Bose BioDynamic 5110 ElectroForce Instrument),
an increasing displacement was applied to the sample at a rate of 0.05mm/s until a total
displacement of 6mm was reached. The displacement and tensile force was recorded at a sampling
rate of 100 times per second. When 6mm displacement was reached, data recording was ceased
and the actuator was brought back to the starting position, ready test the next sample.
a b
Tendon
Sample E
54
Figure 3.3 Bose biodynamic chamber (a) and tendon sample E held with serrated grips (b).
3.4 Tensile Testing; Instron Tensile Testing Equipment
 Instron 5569 load frame (Instron, High Wycombe, UK)

 Forceps
Austria)
 Bose biodynamic tissue grips (part of the Bose BioDynamic 5110 ElectroForce Instrument)
 Bose serrated grips (part of the Bose BioDynamic 5110 ElectroForce Instrument)
The Instron 5569 load frame can be adapted to suit a wide array of samples. A range of custom
adapters were produced to attach the tendon samples to the tensile testing equipment. The Bose
biodynamic tissue grips, and the Bose serrated grips were also utilised when testing some samples.
Table 3.2 summarises which custom adapters and tissue grips were required for each sample
preparation method. Dimensions of the custom adapters are detailed in figures 10.1 to 10.8
(Appendix 10.2). Figure 3.4 shows an example of the experimental setup when using the Instron
tensile testing equipment.
The 100N load cell was employed for all experiments. The relevant custom adapters were
assembled. For samples E only, the initial distance between the grips was set to 2.5mm and
measured using digital vernier callipers. The tank was filled with sufficient Dulbecco’s phosphate
buffer solution to fully submerge the sample throughout the test (unless otherwise stated).
Samples were tested in the same order as the order of dissection. The sample was secured in
position using forceps and (with the exception of samples E) a pretension of 0.1N was applied to the
sample to remove slack and ensure a consistent starting position. The load and displacement were
then set to zero. An increasing displacement was applied at a rate of 0.5mm/s until the suture,
tendon or grips failed. During testing, displacement and force were recorded at a sampling rate of 20
times per second. When testing was complete, data recording was ceased and the actuator was
brought back to the starting position, ready test the next sample.
Used with sample

Custom equipment name preparation
method:
Top pinned shaft C, D, F, G
Bottom pinned shaft with tank C, D, F, G, H, I
Pin sleeve (x2) D, F, G, H
Top tissue grip adapter (used with Bose tissue grip) H, I
Top serrated grip adapter (used with Bose serrated grip) E
Bottom serrated grip adapter with tank (used with Bose serrated grip) E
Table 3.2 Summary stating which custom adapters and tissue grips were required for each sample
preparation method (refer to table 3.1 for sample preparation methods).
55
Instron tensile testing apparatus
Custom attachment equipment
Instron tensile testing apparatus
Figure 3.4 Example experimental setup when using Instron tensile testing equipment, showing the
top and bottom pinned shaft, and the tank filled with PBS (tendon sample not attached in this
photograph).
3.4.1 Establishing Compliance
When tensile testing is performed, in addition to elongation within the sample, elongation also occurs
in the apparatus subjected to the load, such as the custom adapters and grips. This equipment
elongation is known as compliance. The apparatus is especially stiff relative to the tendon samples
being tested, therefore, compliance in the adapters and grips were regarded as negligible, but
elongation of the suture was not.
A compliance test was conducted for all experiments involving suture as part of the attachment
method. The same length of suture as used in the samples was secured between the actuators. A
pretension of 0.1N was applied and the load and displacement were set to zero. An increasing
displacement was applied at a rate of 0.5mm/s until the suture failed. Displacement and force were
recorded at a sampling rate of 20 times per second. This produced a straight-line graph, the equation
of which was used to correct the displacement in experimental data during analysis.
56
3.5 Tensile Testing Data Analysis
Stress (σ) and strain (ε) were calculated for samples prepared by methods C, D and E using the
below equations.
[5]
[6]
Where: F = Force, A = Cross sectional area, ΔL = change in length and L0 = initial sample length.
The force and change in length were recorded for all samples during tensile testing. In addition,
several sample dimensions were measured prior to testing (Table 3.1). Using this data, the initial
sample length and cross sectional area were calculated. The calculation of cross sectional area
differs for each sample. These calculations are detailed in table 3.3.
Preparation method C Preparation method D Preparation method E

Cross sectional = area is Cross sectional = area is Cross sectional = area is
area shown on below area shown on below area shown on below
diagrams diagrams diagrams
A = ht - 4ts [7] A = ht – hs [8] A = wt [9]

Initial length = d Initial length = d Initial length = initial distance
between clamps = 2.5mm
Table 3.3 Details of calculations used to determine cross sectional area and initial sample length. (h,
t and w are defined in table 3.1. s = suture diameter = 0.2mm.)
57
3.6 Finite Element Modelling; Model of Sample Preparation Method C
 Abaqus (version 6.9; Simulia, Providence, Rhode Island, USA)
A finite element model of sample preparation method C (Table 3.1) was developed using Abaqus,
and compared to experimental results. The geometry of the tendon is described in figure 3.5. Rather
than model the whole geometry of the tendon, we have taken advantage of symmetry and modelled
one eighth of the full tendon sample. This reduces computational expense during analysis of the
model. Boundary conditions are employed to define the symmetry so that the full tendon sample is
effectively analysed.
Figure 3.5 Geometry of tendon sample C as modelled in finite element. Dimension h was set to
2.5mm, 5mm and 7.5mm to produce the three different models representing samples of length 5mm,
10mm and 15mm respectively. (dimensions in mm)
The boundary conditions are shown in figures 3.6. Three boundary conditions are employed to
describe the symmetry in the model. A displacement boundary condition was applied to the suture
hole rather than applying a force (Figure 3.6,d). The tendon was defined as an isotropic linear elastic
material with a Young’s modulus of 200MPa and a Poisson’s ratio of 0.4. All parts were divided into
3D hexahedron quadratic elements with reduced integration (Abaqus code: C3D20R) from the
Abaqus Standard element library. Seed sizes of 0.0002m were employed to describe the size of the
mesh.
58
a b
c d
Figure 3.6 Boundary conditions applied to the model of tendon sample C
3.7 Finite Element Modelling; Suture Repaired Tendon, Simple Model
A simple model was initially produced of a suture repaired tendon in line with best practice use of
finite element (FE) software. This enables faster troubleshooting during the early stages of producing
a model. It also allows the user to observe whether the results converge towards a solution as the
model is developed and refined.
The geometry of the suture and tendon are described in figures 3.7 and 3.8 respectively. The shape
of the suture is cut from the tendon to produce a hole where the suture will sit. The Suture is then
located in place within the hole (Figure 3.9). Rather than model the whole geometry of the suture
repaired tendon, we have taken advantage of symmetry and only modelled one eighth of the full
repair. This reduces computational expense during analysis of the model. Boundary conditions are
employed to define the symmetry in the model so that the full suture repaired tendon is effectively
analysed. Figure 3.9.b shows a schematic of the full suture repair which this FE model represents.
59
Fillet radius =
Arc 0.00125
Extrusion
0.01
point
0.005
Extrusion
point
Delete construction
0.00325 lines 0.0002
Figure 3.7 Steps to produce the sweep sketch of the suture (a-c) and the dimensions of the section
sketch (d) (not to scale, dimensions in m).
0.00175
Contact Friction coefficient 0.005

Materials Suture: isotropic, linear
elastic. E = 1000MPa, ν =
0.4
0.02
Tendon properties varied
Elements C3D20R
Seeds Suture = 0.0001m
0.00325 Tendon = 0.00051m
Figure 3.8 Tendon geometry (dimensions in m). Table 3.4 Summary of simplified of model
a b
0.01
Suture
Tendon
Cut ends
of tendon
Fibre
direction
Figure 3.9 Assembly of tendon and suture (dimensions in meters) (a) and schematic of full suture
repaired tendon which the finite element model represents (b).
60
The key attributes of the model are summarised in table 3.4. The contact between the tendon and
suture was defined using a coefficient of friction of 0.05, which is equal to that observed between the
tendon and sheath (Uchiyama et al., 1995). All parts were divided into 3D hexahedron quadratic
elements with reduced integration (Abaqus code: C3D20R) (unless otherwise stated) from the
Abaqus Standard element library. Seed sizes of 0.00051m and 0.0001m were employed for the
tendon and suture respectively to describe the size of the mesh.
Figure 3.10 shows the boundary conditions (BC) applied to the model. Two BC’s are employed to
define the symmetry within the model, so that the full tendon is effectively accounted for during
analysis. A further BC is applied (Figure 3.10.c) to prevent free body motion which would prevent
analysis.
a b
c d
Figure 3.10 Boundary conditions applied to the simplified model (a-c) and traction applied to the
suture (d).
The suture was defined as an isotropic linear elastic material with a Young’s modulus of 1GPa, and a
Poisson’s ratio of 0.4. The material properties of the tendon were varied for different analyses.
Traction was applied to the end of the suture at the cut end of the tendon (Figure 3.6) which was
varied for different analyses.
61
3.7.1 Validating the model and considering sensitivity to material properties
The tendon was defined as an orthotropic linear elastic material. The Poisson’s Ratio was kept
constant at 0.4, however, the Young’s modulus was varied. Young’s Modulus values of 0.2, 2, 20,
200 and 2000MPa were tested. Traction was applied to the suture end at the cut end of the tendon
(Figure 3.10.d) in the negative Z direction. For each tendon material, traction of 100,000, 200,000,
2
300,000 and 400,000N/m was applied to simulate an increasing load. For each analysis, the
displacement of the suture end was recorded. This was compared with laboratory data whereby the
same experiment was performed (Table 3.1, preparation method H).
3.8 Finite Element Modelling; Suture Repaired Tendon, Kessler Model
 All purpose translucent silicone sealant (B&Q, Eastleigh, UK)

 Prolene suture (4-0, 90cm suture, RB1 needle, product code W8557;Ethicon, Livingston,
Scotland)
 Digital camera
The geometry of the suture and tendon is described in figures 3.11 and 3.12 respectively. The shape
of the suture geometry is cut from the tendon to produce a hole where the suture will sit. The Suture
is then located in place within the hole. Figure 3.13.a shows the full assembly of the suture and
tendon. As with the simple suture model, we have taken advantage of symmetry and only modelled
one quarter of the full repair. Figure 3.13.b shows a schematic of the full suture repair which this FE
model represents. The key attributes of the model are summarised in table 3.5.
To determine the geometry of the Kessler suture repair, a suture repair was produced using Prolene
suture, photographed using a digital camera and measured (figure 3.14). Rather than suturing into
tendon, which is opaque, rods of silicone sealant were produced and dried to provide a translucent
material in which the suture could be placed. This permitted internal measurements to be taken of
the suture repair.
The contact between the tendon and suture was defined using a coefficient of friction of 0.005. All
parts were divided into 3D hexahedron quadratic elements with reduced integration (Abaqus code:
C3D20R) from the Abaqus Standard element library. Seed sizes of 0.00051m and 0.00044m were
employed for the tendon and suture respectively to describe the size of the mesh.
Figure 3.15 shows the boundary conditions (BC) applied to the model. A BC is employed to define
the symmetry within the model, so that the full tendon is effectively accounted for during analysis. A
further two BC’s are applied to prevent free body motion during analysis.
62
The suture was defined as an isotropic linear elastic material with a Young’s modulus of 1GPa, and a
Poisson’s ratio of 0.4. The material properties of the tendon were varied for different analyses.
Traction was applied to the end of the suture at the cut end of the tendon (Figure 3.15.d) which was
varied for different analyses.
r=0.00125
Extrusion point
Delete construction lines

0.01 r=0.0001
r=0.00125
0.001 Extrusion point
Extrusion point r=0.0001
Delete construction lines
Second suture part
First suture part
Figure 3.11 Geometry of the two suture parts (a & b), and assembly of the two parts (c).
0.0035
0.02
0.00325
Figure 3.12 Geometry of tendon (dimensions in m)
63
b
a
Fibre direction Contact Friction coefficient 0.005
Materials Suture: isotropic, linear
elastic E = 1000MPa, ν =
0.01 0.4
tendon properties varied
Elements C3D20R
Seeds Suture = 0.00044m
Tendon = 0.00051m
Figure 3.13 Assembly, showing tendon as Table 3.5 Summary of Kessler model
transparent to allow full view of suture
(dimensions in m) (a) and full schematic of
grasping Kessler suture which this model
represents (b).
Figure 3.14 Photographs of Grasping Kessler suture.
64
a b
c d
Figure 3.15 Boundary conditions applied to the model (a-c) and traction applied to the suture (d).
3.8.1 Validating the model and considering sensitivity to material properties
Analyses of the Kessler FE model were performed using the same method performed on the simple
suture model (Section 3.7.1). This was compared with laboratory data whereby the same experiment
was performed (Table 3.1, preparation method I).
65
3.9 Finite Element Modelling; Obtaining Orthotropic Material Properties of Tendon
A composite material, with a complex structure on the micro-scale can be represented by a simple
homogeneous material for study on the macro-scale. The process of defining this homogeneous
material is known as homogenisation, which is performed on our tendon model to obtain the
engineering constants of an orthotropic material; the tensile modulii, E1, E2 and E3, the shear modulii,
G12, G13 and G23, and the Poisson’s ratio’s ν12, ν13 and ν23. These constants are then used to inform
the Simple suture model and the Kessler suture model (Sections 3.7 and 3.8 respectively). Figure
3.16 illustrates the relationship between the micro-scale model of tendon microstructure, the macro-
scale suture repaired tendon model and the laboratory experiments using porcine tendon.
Figure 3.16 Schematic illustrating the relationship between the micro-scale model of tendon
microstructure, the process of homogenisation of this model, the macro-scale model of a suture
repaired tendon, and the laboratory testing of porcine tendon.
66
3.9.1 Model of tendon microstructure
To obtain the engineering constants required to describe tendon as an orthotropic material, a finite
element model of tendon microstructure was produced using Abaqus. A number of assumptions
were required to ensure the model was of sufficient complexity to obtain meaningful results, however
of sufficient simplicity to ensure a feasible study.
The fibril and surrounding interfibrillar material was considered to be the fundamental repeating unit
cell in the tendon (Figures 3.17 and 3.18). Crimp, helical winding and the hierarchical bundle
configuration were not modelled. Furthermore, any influence which the cells inflict on the tendon
extracellular matrix and microstructure was neglected.
Figure 3.17 Finite element model representing Figure 3.18 Finite element model
tendon microstructure, showing fibrils and showing fibrils alone.
matrix.
Contact Rigid contact with no
separation permitted
Materials Fibrils: Isotropic, linear
elastic. Properties varied.
Matrix:Isotropic Linear
Elastic. Properties varied
Elements C3D20R
Seeds Fibril = 114nm
Matrix = 114nm
Table 3.6 Summary of the microstructure model.
The microstructure of the fibrils and interfibrillar material (which we shall name the matrix hereafter,
using the composite material definition of the term) is assumed analogous to an aligned fibre
reinforced composite material. Whilst the length of individual fibrils is unknown due to difficulties in
locating their terminus, it is well established that fibrils have an extremely high aspect ratio, and as
such, we regard the tendon as a continuous fibre composite.
67
Fibril diameter was set to 100nm based on transmission electron microscopy observations which
established that fibril diameter ranges from 20 to 180nm (Baek et al., 1998). Whilst this range of fibril
size exists in vivo, we have assumed all fibrils possess the same diameter.
Sixteen fibrils were modelled, arranged in a square packing formation with a fibril to matrix ratio of
60:40. Analysis of photomicrograph images have concluded the fibril volume fraction (V f) to range
from 0.45±0.07 to 0.59±0.03 in ligament tissue (Baek et al., 1998), however, finite element models of
tendon microstructure use a Vf approaching 0.6 (Reese et al., 2010), which we also employ in the
microstructure model. To produce the desired volume fraction, the unit of tendon tissue modelled
was 456 x 456 x 456 nm. Separation or sliding between the surfaces of the fibrils and matrix was not
permitted.
The key attributes of the model are summarised in table 3.6. All parts were divided into 3D
hexahedron quadratic elements with reduced integration (Abaqus code: C3D20R) from the Abaqus
Standard element library. A seed size of 114nm was employed for all parts to describe the size of the
mesh. The academic licence of Abaqus limits the permissible number of nodes in a model to 20,000
which prevented the use of a fine mesh in this model.
In addition to the standard field outputs which the analysis computes, the integration point volume
(IVOL) was also specified as a field output. This information is required to calculate the orthotropic
material properties.
The fibrils and matrix were assumed to be isotropic. Based on the composition of the structures this
assumption is unlikely to be accurate, however, quantitative data is not currently available regarding
the anisotropic nature of fibrils or matrix.
The tensile modulus and Poisson’s ratio of the fibrils and matrix were varied to consider the potential
range of material properties obtainable by the homogenisation method. This provides allowances for
variation of tendon properties between different tendon anatomical locations, and between different
patients. Furthermore, this allows us to establish the sensitivity of our finite element model to varying
material properties.
68
3.9.2 Homogenisation
Using the finite element model of tendon microstructure, four different analyses were performed,
from which the engineering constants are calculated (Figures 3.19 to 3.22). (Note that directions 1, 2
and 3 coordinate with the Cartesian coordinates X, Y and Z respectively.)
45.6nm displacement applied to surface 45.6nm displacement applied to surface
Bottom face unable to move in x direction & Bottom face unable to move in x direction &
centre-node on this face is unable to move centre-node on this face is unable to move in
in any direction. any direction.
Figure 3.19 Boundary conditions Figure 3.20 Boundary conditions for

for calculating E1, E2ν12, ν13 andν23. calculating E3.
Top surface is displaced by 45.6nm in x Top surface is displaced by 45.6nm in x

direction and prevented from movement in y direction and prevented from movement in z
direction direction
Centre-node on bottom face is unable to Centre-node on bottom face is unable to

move in any direction. move in any direction
Figure 3.21 Boundary conditions Figure 3.22 Boundary conditions

for calculating G12. for calculating G13 and G23.
69
3.9.2.1 Calculating E1& E2
The analysis described in figure 3.19 was performed on the model to obtain data necessary to
calculate E1 & E2. A report was printed from the analysis containing the volume of each integration
point (IVOL), the mises stress at each integration point (S.mises) and the maximum principal strain
at each integration point (E.max). The following calculations were then performed to obtain E1.
[10]
[11]
[12]
As the material is orthotropic, pulling the model direction 2 would be effectively the same as pulling it
in the direction 1 therefore: E2 = E1.
3.9.2.2 Calculating E3
calculate E3. A report was printed containing the volume of each integration point (IVOL), the mises
stress at each integration point (S.mises) and the maximum principal strain at each integration point
(E.max). The following calculations were then performed to obtain E3.
[13]
[14]
[15]
3.9.2.3 Calculating G12
calculate G12. A report was printed containing the volume of each integration point (IVOL), the stress
in the 12 direction (S.S12) and the strain in the 12 direction (E.E12). The following calculations were
then performed to obtain G12.
[16]
[17]
[18]
70
3.9.2.4 Calculating G13 and G23
calculate G13. A report was printed containing the volume of each integration point (IVOL), the stress
in the 13 direction (S.S13) and the strain in the 13 direction (E.E13). The following calculations were
then performed to obtain G13.
[19]
[20]
[21]
As the material is orthotropic, applying shear in the 13 direction would be effectively the same as
applying a shear in the 23 direction therefore: E13 = E23.
3.9.2.5 Calculating ν12, ν13 and ν23
calculate ν12 and ν13. A report was printed from the analysis containing the volume of each
integration point (IVOL), and the strain at each integration point in the three principal directions (E11,
E22 and E33). The following calculations were then performed to obtain ν12, and ν13.
[22]
[23]
[24]
[25]
[26]
As the material is orthotropic, pulling the model direction 2 would be effectively the same as pulling it
in the direction 1 therefore: ν23 = ν13.
71
CHAPTER 4: RESULTS: TRANSVERSE TENDON PROPERTIES
The objective of this work was to produce a Finite Element model to simulate the application of
tension on suture repaired tendons and study the resultant stress patterns within the tissue. Key to
the success of this model is the suitable mechanical description of tendon and its response to
loading. As we have discussed, tensile properties are well documented when tendon is loaded along
the direction of fibre alignment, and the tissue is known to be highly anisotropic, however, few
studies have quantified the tensile properties transverse to the direction of fibre alignment. This is of
interest since the complex geometry of a suture repair inflicts multi-directional loading on the tendon
tissue.
Tendon can be considered as a fibre reinforced composite material, whose fibres are the fibrils, and
whose matrix is the tissue surrounding the fibrils. The tensile modulus of fibrils has been quantified
using atomic force microscopy (van der Rijt et al., 2006, Wenger et al., 2007, Svensson et al., 2010).
Whilst the modulus of the matrix has been assumed for finite element modelling (Reese et al., 2010,
Goh et al., 2004), it has not been directly measured. Measuring the modulus of tendon transverse to
the fibre direction will provide a quantitative description of tendon anisotropy, and will permit the
calculation of the tensile modulus of the matrix.
Tensile testing was performed using porcine tendon samples (Section 3.1) to determine the
transverse modulus of tendon. Initial experiments guided the development and optimisation
experimental procedure.
4.1 Anchoring the Tendon
The maximum length of transverse fibre samples is limited by the diameter of the tendon. As such,
samples are small, and anchoring methods suited to longitudinal testing, such as drying or freezing
the ends, are unsuitable for such small samples.
A preliminary experiment was conducted to assess two potential anchoring methods for transverse
samples (Table 3.1, preparation methods A and B). Four samples of approximately 10mm lengths of
tendon were prepared using each anchor type and tested in air using the Bose biodynamic chamber
(Section 3.3).
Only one cyanoacrylate adhesive sample could be tested using the Bose biodynamic chamber due
to limited space in the chamber. The adhesive on the sample which was tested withstood just over
2N before failure (Figure 4.2). All other cyanoacrylate samples were tested by hand, and failed at the
adhesive join. It was concluded that cyanoacrylate provides an unsuitable anchor as all samples
demonstrated adhesive failure.
72
Cotton was used instead of suture during this experiment for samples prepared by method B. The
cotton did not fail in any sample and loads of up to 9N were withstood. However, loading was uneven
over the four cotton loops (Figure 4.1). The suture technique was the most suitable anchor method,
however, to prevent uneven loading over the loops, only one loop was used in subsequent work
(Table 3.1 preparation method C). Surgical suture was recommended for future use as it is produced
to a consistent standard, whereas cotton may present variability in strength between samples.
The Bose biodynamic chamber can apply a maximum displacement of 6mm to a sample. None of
the samples yielded at 6mm displacement, therefore a larger displacement is required. Future tests
were conducted on the Instron tensile testing equipment (Section 3.4) which can accommodate
much greater displacements.
Figure 4.1 Anchor method A demonstrating Figure 4.2 Anchor method B demonstrating
uneven loading. adhesive failure (white arrow).
73
4.2 Preliminary Test Using Preparation Method C
Twelve samples were prepared using method C and vicryl suture (Table 3.1) and tested in air using
the Instron tensile testing equipment (Section 3.4). Figure 4.3 shows the mean stress with increasing
strain. Suture knot slip was suspected in two samples, which were therefore excluded from the
calculation of mean stress. Compliance within the system was determined (Described in section
3.4.1, results in Appendix 10.3, Figure 10.9) and accounted for during data analysis. (Individual
sample data is included in appendix Figure 10.10, along with accompanying photographs in Figure
10.11)
Stress (MPa)
Figure 4.3 Mean stress with increasing strain for preliminary test using preparation method C.
The gradient of the stress-strain curve was observed in the approximately linear region for each
sample (excluding the samples where knot slip was suspected) and the mean gradient was
calculated (see Appendix 10.3, Figure 10.12 for observations of gradients). The mean gradient was
0.2025 MPa, which is the transverse tensile modulus of tendon predicted by this experiment.
Whilst it has been assumed for this experiment that drying of the tendon does not affect mechanical
properties during tensile testing, visual observations during dissection suggest that tissue dries
rapidly. As such, this assumption may be incorrect, and further investigation was required to
establish the effects of testing in air.
74
4.3 Effects of Testing Samples in Air
It was hypothesized in section 4.2 that samples would not dry out enough to affect tendon
mechanical properties since sample testing is complete in less than one minute. The effects of
testing in air were investigated to validate this hypothesis. Two groups of samples were prepared
using Vicryl suture and preparation method C (Table 3.1). One sample group was tested in air (n=3),
whilst the other was tested in PBS (n=8). The Instron tensile testing equipment was employed to
apply tension to samples until the tendon failed (Section 3.4) Compliance data from section 4.2 was
used to account for compliance during data analysis.
Samples tested in air were compared with the ten samples detailed in section 4.2 which used the
same method. A t-test was performed at nine points along the two curves. All but two points showed
no significant difference (P ranged from 0.044 to 0.454, see Appendix 10.4, Figure 10.14 for
comparison of data).
Mean stress and strain was calculated for the wet and dry samples (Figure 4.4, for individual sample
data see Appendix 10.4, Figure 10.13). A paired t-test was performed between the wet and dry data
at intervals of 20% strain (P ranged from 0.127 to 0.993). Samples tested in PBS withstood greater
stress than samples tested in air, but this difference was not significant. Whilst the data closely
agrees at the beginning of the test, there is less agreement as the experiment progresses,
suggesting that drying impacts on the material properties. Going forward, all samples were
submerged in PBS during testing.
Figure 4.4 Tensile test conducted in air and PBS, showing close agreement at the start of the tensile
test, however a difference in stress at higher strains as the test progressed.
75
4.4 Epitenon Effects, First Experiment
Literature comparing tendon suture techniques has shown that techniques which loop around the
epitenon can withstand greater stress than those which do not (Section 1.7.2). To test the extent to
which the epitenon affects the mechanical properties of the tendon, two groups of eight samples
were prepared using Vicryl suture and tested in PBS using the Instron mechanical testing equipment.
One group was prepared by method C and the other by method D (Table 3.1). Compliance within the
system for each sample was determined (Described in section 3.4.1, results shown in Appendix
10.5, Figures 10.15 and 10.16) and accounted for during data analysis. The suture failed in one
sample prepared by method D, therefore, this sample was excluded from further analysis.
The mean stress and strain were calculated (Figure 4.5, individual sample data shown in Appendix
10.5, Figures 10.17 and 10.18), and a t-test was performed at 40% strain intervals. At strains of up to
160%, the stress was significantly higher for preparation D, which looped suture around a greater
amount of epitenon, however, the gradient of the approximately linear region of the stress-strain
curve for both preparation methods was closely similar, suggesting that the epitenon does not affect
the tensile modulus.
Figure 4.5 Tensile test of two preparation methods (C and D), showing higher peak stress for
samples which loop around a greater amount of epitenon. The gradient of the approximately linear
region for the two preparation methods is closely similar. * = significant difference.
76
Whilst the observed differences and similarities between the two preparation methods may be due to
the greater purchase of epitenon in preparation method D, they may also be due to the differing
orientation of the suture, relative to the fibre direction of the tendon. The suture pass in method C is
placed transverse to the fibre direction, effectively looping the suture around the fibre bundles,
whereas the suture pass in method D is aligned parallel to the fibre direction (Table 3.1).
Furthermore, the suture purchases a greater amount of tendon material in method D. As such an
additional experiment was conducted to further investigate effects of the epitenon.
4.5 Epitenon Effects, Second Experiment
Two groups of six tendon samples were prepared using Prolene suture, one group using preparation
method F, and the other using method G (Table 3.1). These were tested until failure using the
Instron tensile testing equipment (Section 3.4, individual sample results shown in Appendix 10.6,
Figures 10.19 and 10.20). The mean force and displacement were calculated, and the force was
normalised for tendon width, to take into account the slices of tendon which were removed during
preparation method G. The suture pass is aligned in the same direction with respect to the fibre
direction in each preparation method, therefore the only difference between the samples is the
presence of the epitenon.
Figure 4.6 shows the normalised force plotted against displacement for the two sample groups. A
paired t-test was performed at 5, 10, 15 and 20mm displacement, which showed no significant
difference at any point (P ranged from 0.059 to 0.890).Based on the data from our two experiments
to assess the effect of the epitenon, it was concluded that the epitenon has a negligible effect on
tendon Young’s modulus.
Figure 4.6 Tensile tests of preparation method F (with epitenon) and G (without epitenon), showing
displacement plotted against the force normalised for sample width.
77
4.6 Effects of Sample length
Results of previous tests were compared against each other. In particular, the samples submerged in
PBS from section 4.3, were compared against sample preparation C from section 4.4. These two
sets of data were obtained using the same testing conditions, yet the peak stress was notably higher
in the data form section 4.3. The mean length of the section 4.3 samples was 12.57mm, compared
with 13.68mm for section 4.4 samples. (Appendix 10.7, Figure 10.21 compares these two data sets)
It was hypothesized that a longer sample resulted in a reduced peak stress. This would indicate an
error in calculating stress and strain for this attachment geometry.
To investigate the effects of sample length, six tendons were obtained (Section 3.1), and each was
cut into three pieces 5mm, 10mm and 15mm in length. These 18 samples were then prepared using
Prolene suture and method C, and tested using the Instron tensile testing equipment (Section 3.4).
Compliance of the system was measured, as described in section 3.4.1, and accounted for during
calculations of strain (see Appendix 10.7, Figure 10.22 for compliance data).
Figure 4.7 shows the mean stress plotted against strain of the three different sample lengths
(individual sample results shown in appendix Figures 10.23, 10.24 and 10.25). As sample length is
increased, the peak stress, and tensile modulus (gradient of the linear region) reduces. Since all
samples are made from the same material, all should have the same peak stress and tensile
modulus. This suggests that the calculations used to determine stress are not suitable for the
attachment technique. The calculations assume that stress is constant throughout the tendon cross
section at a given time point. To investigate whether this assumption is correct, a simple finite
element model of the 5mm, 10mm and 15mm samples was produced.
Figure 4.7 Tensile test of 5mm, 10mm and 15mm samples. * = significant difference.
78
The finite element models of tendon samples were produced as described in section 3.6. The mean
measurements of the 18 porcine tendon samples were used to produce the finite element models
(see Appendix 10.7, Table 10.2 for sample measurements).
The finite element results (Figure 4.8) show high stress is concentrated around the hole where the
suture anchors the tendon, and in the central portion of the tendon, whereas the outer ends of the
suture experience little stress. This is contrary to the assumption during calculations that the stress is
uniform over the tendon cross section (Table 3.3), confirming that stress is calculated incorrectly.
This is more pronounced with the 15mm samples as a greater amount of tissue is not stressed. To
resolve this problem, the samples need to be clamped differently to ensure the stress is uniform over
the cross section.
Figure 4.8 a, b and c show finite element models of tendon simulating preparation method C. d, e
and f show tendon samples prepared by method C during tensile testing in the laboratory. An
effective 1mm total displacement has been applied to the finite element models. Areas of low stress
are shown in blue, ranging through the spectrum to areas of high stress in red. Grey shows the areas
of highest stress in the model. d shows stress levels and corresponding colour in the three finite
element models where stress is in Pascals.
79
4.7 Final Anchoring Method; Proximal vs Distal
A new experimental technique was developed to ensure the stress would be constant across the
cross section of the sample. Preparation method E was used to obtain a small sample of tendon
which could be clamped using the serrated grips supplied with the Bose biodynamic chamber.
Eight proximal and eight distal samples were prepared to investigate whether tensile modulus
differed between the two locations. (One of the distal samples was damaged and could not be
tested.) Tension was applied until 6mm displacement was reached using the Bose biodynamic
chamber (Section 3.3, individual sample data shown in Appendix 10.8, Figures 10.26 and 10.28).
Stress and strain were calculated, and the tensile modulus was obtained by calculating the gradient
of the approximately linear region of the stress-strain curve (Appendix 10.8 Figures 10.27 and
10.29). The mean tensile modulus of tendon in the distal and proximal locations was then calculated
(Figure 4.9). The transverse tensile modulus was significantly greater in the proximal samples
(p=0.05).
Due to the relatively small number of samples, the experiment was repeated with 12 samples in the
two groups (Appendix 10.8, Figures 10.30 to 10.33). The data agreed with the previous experiment
and confirmed a significant difference between the transverse modulus of the proximal and distal
samples (P=0.002) (Figure 4.10).
Although the initial length of the samples was smaller than in previous experiments, the maximum
displacement of 6mm achievable with the Bose biodynamic chamber was not suffice to test the
samples to failure. As such, a further test was conducted using the Instron tensile testing equipment.
Mean Modulus (MPa) ± SD Mean Modulus (MPa) ±SD

0.25 0.25
*
0.2 * 0.2
0.15 0.15
* *
0.1 0.1
0.05 0.05
0 0
DISTAL (n=7) PROXIMAL (n=8) DISTAL (n=12) PROXIMAL (n=12)
Figure 4.9 Mean transverse tensile modulus Figure 4.10 Mean transverse tensile modulus
and standard deviation of initial experiment and standard deviation of repeated experiment
(n=6) using the improved anchoring method. (n=12) using the improved anchoring method.
* = significant difference * = significant difference
80
4.8 Final Anchoring Method; Effects of Varying Strain Rate
The displacement rate during the previous experiment was 0.05mm/s. The initial sample length was
2.5mm, thus a strain rate of 2%/s was applied. The in vivo strain rate exerted on tendons ranges
from 1%/s which is considered quasi-static to 10%/s during normal daily activity (Wren et al., 2001,
Lewis and Shaw, 1997). Whilst literature has reported the effects of varying the strain rate applied to
tendon samples tested in the longitudinal direction, little attention has been paid to the transverse
direction.
To consider potential effects of varying strain rate on the transverse tensile modulus of tendon, 12
distal tendon samples were prepared using method E (Table 3.1) and tested using the Instron tensile
testing equipment (Section 3.4). Six were tested at a strain rate of 1%/s and six at a rate of 10%/s.
Stress and strain were calculated (Appendix 10.9, Figures 10.34 and 10.36), and tensile modulus
was obtained by calculating the gradient of the approximately linear region of the stress-strain curve
(Appendix 10.9, Figure 10.35 and 10.37).The mean tensile modulus of tendon for the two strain rates
were then calculated (Figure 4.11). The difference in strain rate resulted in no significant difference in
modulus.
Tangential Modulus (MPa) of Proximal Tendon

Samples at Different Strain Rates ±SD
0.4
0.35
0.3
0.25
0.2
0.15
0.1
0.05
0
strain rate 1%/s strain rate 10%/s
Figure 4.11 Mean transverse tensile modulus and standard deviation of proximal tendon samples
when a strain rate of 1%/s and 10%/s is applied. No significant difference between 1%/s and 10%/s.
81
4.9 Final Anchoring Method; Determining Transverse Modulus
Using preparation method E (Table 3.1) and the Instron tensile testing equipment (Section 3.4), 12
proximal and 12 distal samples were tested to failure at a strain rate of 1%/s. The mean tensile
modulus was calculated for each sample group (Figure 4.12) (the modulus in the approximately
linear region of each sample was determined, then a mean was calculated for the proximal and distal
samples, see Appendix 10.10, Figures 10.38 to 10.41 for individual sample data). There was no
significant difference when comparing these results with data from the second experiment detailed in
section 4.7 (Figure 4.10, P=0.105 and P = 0.009 for distal and proximal samples respectively)
demonstrated repeatability of the experiment.
The mean modulus of distal and proximal samples was 0.1035 ±0.0454MPa and 0.2551
±0.0818MPa respectively. These two figures were taken as the upper and lower boundaries of
tendon elastic modulus in the transverse orientation, taking tissue site variability into account.
Mean Modulus (MPa) ±SD. Strain Rate 1%/s

0.35 *
0.3
0.25
0.2
*
0.15
0.1
0.05
0
DISTAL (n=12) PROXIMAL (n=12)
Figure 4.12 mean transverse tensile modulus and standard deviation of transverse tendon samples
tested to failure at a strain rate of 1%/s. * = significant difference.
4.10 Calculating matrix modulus
The upper and lower limits of matrix modulus (Em) were calculated using data from experimental
results and from literature. We have determined that the upper and lower limits of transverse
modulus (ECT) are 0.2551MPa and 0.1035MPa respectively (Section 4.8). Results of atomic force
microscopy in the literature have reported values for the fibril modulus (Ef) ranging from 200MPa to
3000MPa (Table 1.4), which we shall use as our upper and lower limits of fibril modulus. The fibril
volume fraction (Vf) is 0.6 as in the microstructure model (Section 3.9.1). Using this data, the upper
and lower limits of the matrix modulus (Em) were calculated as follows:
82
4.10.1 Em upper limit
Maximum matrix modulus would occur if fibril modulus is minimum (200MPa) and when transverse
modulus is maximum (0.2551MPa):
Em = 0.1021 MPa
4.10.2 Em lower limit
Minimum matrix modulus would occur if fibril modulus is maximum (3000MPa) and when transverse
modulus is minimum (0.1035MPa):
Em = 0.0416 MPa
4.10.3 Checking Em values
In order to validate the matrix modulus values we have obtaines, the longitudinal tensile modulus
(ECL) is calculated from our transverse tensile modulus values. This is then compared with values
published in literature to ensure the resultant longitudinal tensile modulus agrees with literature.
Using lower modulus limit values:
ECL = 1800 MPa

Using upper modulus limit values:
ECL = 120 MPa
The upper and lower bounds of the range of longitudinal tensile modulus values quoted in literature
for human tendon are 362 MPa and 2000 MPa respectively (Table 1.3). The upper limit which we
have calculated lies within this range, and the lower limit is close to this range. This validates the
values of transverse tensile modulus and matrix modulus obtained through our experimental
methods.
83
CHAPTER 5: RESULTS: FINITE ELEMENT SUTURE REPAIRED TENDON MODEL
Tendon is a complex hierarchical structure, and many suture repair techniques are intricate. When
building a finite element model it is best practice to begin with an extremely simple model, which is
then developed, incorporating more levels of complexity. This approach permits rapid
troubleshooting in the early stages as analysis of a simple model requires less computing expense.
As the model is developed, the results will ideally converge towards a solution akin to the scenario
which is being modelled. If the complex model is produced initially, this convergence would not be
seen.
5.1 Initial Simplified Model
In line with best practice, the initial finite element model was a highly simplified version of a suture
repair (Figure 5.1.a). The suture passes once through the tendon to form the anchor (Figure 5.1.b)
and symmetry was used in the finite element model as described in section 3.7. The tendon and
suture were defined simply as isotropic linear elastic materials. Table 5.1 summarises the attributes
of the initial finite element model.
Contact Friction coefficient 0.05

Suture material Linear elastic, a
Young’s modulus =
Suture b
1GPa
Poisson’s ratio = 0.49
Tendon Material Linear elastic,
Young’s modulus =
500 MPa
Poisson’s ratio =0.49
Elements Abaqus code C3D8
Seeds Tendon: 0.00051m
Tendon
Suture: 0.00046m
Boundary Seefigure 3.10,
Conditions (BC) displacement BC
applied to suture instead
of force (Figure 3.10.d)
Forces none
Table 5.1 Brief description of the initial Figure 5.1 Initial model of the suture repaired
suture repair model. tendon (a) and schematic of the simplified suture
repair which this model represents (b).
84
5.2 Locking
The elements in the simplified model were not sufficiently able to deform; a problem known as
locking. This arose as a result of the chosen value of Poisson’s ratio, and the element type used in
the model.
The Poisson’s ratio of both tendon and suture were initially 0.49 in the finite element model, defining
the materials as near-incompressible. When materials are near-incompressible, the elements
become unable to deform sufficiently during analysis, resulting in calculation errors. The Poisson’s
ratio was therefore reduced to 0.4 for both the suture and tendon to overcome this problem.
Locking can also arise when using certain elements. 3D hexahedral linear elements (Abaqus code
C3D8) were used in the initial model. These are 3D elements with eight nodes, whereby a node is
located at each corner of the hexahedron. The edges of these elements permit some flex, however,
where large strains are present they are not sufficiently flexible. 3D hexahedral quadratic elements
(Abaqus code C3D20) have 12 additional nodes located at the centre of each edge. The edges of
quadratic elements permit increased flexibility due to the additional nodes. The additional nodes
increase computing expense since more calculations are required. Reduced integration can be
employed (Abaqus code C3D20R) which reduces the required calculations and thus reduces the
computational expense of analysis. The elements in the suture repaired model were changed to
C3D20R elements to prevent locking.
5.3 Modified Geometry
During tensile testing of the simplified suture repair performed on porcine tendons (Table 3.1,
preparation method H), initial load application pulled the suture to lie against the side of the tendon
(Figure 5.2). When tension was applied to the suture in the simplified finite element model, the suture
moved away from the side of the tendon (Figure 5.3).
It was hypothesized that the unexpected suture deformation in the finite element model may be a
result of incorrect model geometry. To investigate the accuracy of the geometry, a sample of porcine
tendon was prepared by preparation method J (Table 3.1) and photographed against a ruler (Figure
5.4). Dimensions of the simplified repair were determined from the photographs (Figure 5.5). Figures
3.7, 3.8 and 3.9.a show the amended dimensions and assembly of the finite element model. Notably,
the sharp bend in the suture was smoothed out, and the initial position of the suture was no longer
touching the side of the tendon (Figure 5.6.a). When a load was applied to the new finite element
model, the deformation agreed with experimental observations (Figure 5.6.b).
85
a b
Suture is
Suture is tight against
loose and the side of
not touching the tendon
the tendon
Figure 5.2 Photographs of simplified suture repair performed on porcine tendon (Sample preparation
method H, Table 3.1) showing a sample prior to load application (a) and a sample subject to initial
load application (b).
a b
Suture lying
against side
Gap
of tendon
between
suture and
tendon
Figure 5.3 Finite element model of simplified tendon repair before (a) and after (b) load application.
a. b.
c. d.
Figure 5.4 Photographs of sample prepared by method J (Table 3.1) showing the geometry of a
simplified suture repair (a to c) and tightest bend of Prolene suture without permanent deformation of
the suture (d).
86
Figure 5.5 Dimensions of simplified tendon repair determined from photographs of samples
prepared by method J (Table 3.1)
a b
Smoother Suture not
Suture
bend touching
pulled
side of
towards side
tendon
of tendon
Figure 5.6 Finite element model simplified tendon repair with amended dimensions before (a) and
after (b) load application.
87
5.4 Simplified Suture Repair: Model Validation
Sensitivity tests were performed on the finite element model described in section 3.7, using the
method described in section 3.7.1. The Young’s modulus of the tendon was varied, force was
applied to the suture, and the displacement of the suture end was recorded (see Appendix 10.11,
Table 10.3 for raw data).
The finite element results were compared with results from tensile testing of porcine tendon samples.
Ten tendon samples were prepared by method H (Table 3.1) and tested to failure using the Instron
tensile testing equipment (Section 3.4). One sample failed because the suture knot slipped, and was
therefore excluded from further analysis. The mean force of the remaining 9 samples was calculated
and plotted against displacement (see Appendix 10.11, Figure 10.42 for individual samples).
Figure 5.7 shows the finite element and laboratory results. When considering the gradient of the
force-displacement curve, a tendon Young’s modulus of 200MPa and 20MPa provided a force-
displacement relationship which agreed closest with laboratory data. The gradient of the line
obtained from laboratory data was 0.642. The gradient of the lines obtained from finite element
modelling ranged from 0.062 to 0.299.
The maximum load applied to the finite element models was 0.02512N. At higher loads, areas of
high strain were present within the model and the elements were unable to sufficiently deform. In
contrast, over 18N of force was applied to the tendon samples in the laboratory. Furthermore,
pretension of 0.1N was applied to laboratory samples prior to testing.
Figure 5.7 Finite element and laboratory results from tensile testing the simplified tendon repair,
showing line of best fit equation.
88
5.5 Grasping Kessler Suture Repair and Model Validation
The suture configuration in the simplified finite element model (Figure 5.6) is not a formation used for
tendon repair. However, it permitted initial troubleshooting in development of the finite element
model. The next stage of development was to recreate a suture formation used in vivo for tendon
repair. The Grasping Kessler method was chosen as it has one of the more simple formations.
Kessler-based suture techniques are also commonly used in vivo.
A new finite element model was produced to simulate the Grasping Kessler repair, as described in
section 3.8. Sensitivity tests were performed on the Kessler finite element model described in section
3.8, using the method described in section 3.8.1. The Young’s modulus of the tendon was varied,
force was applied to the suture, and the displacement of the suture end was recorded (see Appendix
10.11, Table 10.4 for raw data).
The finite element results were compared to experimental data obtained using porcine tendon
samples. Ten samples were prepared by method I (Table 3.1) and tested to failure using the Instron
tensile testing equipment (Section 3.4). The mean force was calculated and plotted against
displacement (see Appendix 10.11, Figure 10.43 for individual samples).
Figure 5.8 shows the finite element and laboratory results. Errors occurred during analysis when a
Young’s modulus of 2,000MPa was used to describe tendon in the Kessler finite element model. A
tendon Young’s modulus of 200MPa provided a force-displacement relationship which agreed
closest with laboratory data. The laboratory data lies between data obtained with a Young’s modulus
of 20 and 200MPa. The gradient of the line obtained from laboratory data was 0.910. The gradient of
the lines obtained from finite element modelling ranged from 0.0095 to 1.0368 when the Young’s
modulus of tendon was set to 0.2MPa and 200MPa respectively.
Higher loads could be applied to the Kessler finite element models than the simplified models. The
highest load applied to the Kessler finite element model was 0.15N. Above this load, areas of high
strain within the model prevented elements from deforming sufficiently and the analysis was unable
to complete.
89
Figure 5.8 Finite element and laboratory results from tensile testing the Kessler tendon repair,
showing line of best fit equation.
90
5.6 Stress and Deformation in the Grasping Kessler Suture Repair
Stress and deformation data was obtained from the finite element model of the Kessler suture repair.
The tendon is defined as an isotropic, linear elastic material with a Young’s modulus of 200MPa and
a Poisson’s ratio of 0.4, which was the material which agreed closest with experimental data (Figure
5.8). Figure 5.9 shows the stress and deformation of the Kessler repaired tendon when the suture
end is displaced by 0.5mm. The areas of highest stress concentration are around the grasping loops
of the Kessler suture (Figure 5.9). Figure 5.10 shows the deformation of the Kessler suture repaired
tendon when load is applied to the suture, comparing the finite element model with a photograph
from a laboratory sample.
a b
Area of highest stress,

shown here in grey
Figure 5.9 Kessler finite element model undergoing a suture displacement of 0.5mm, showing
tendon stresses (a) and cut view, showing internal tendon stresses in the anchor region of the
Kessler repair (b). (Blue = low stress. Grey = highest stress.)
Figure 5.10 Deformation of the Kessler suture repaired tendon during load application as observed
in the laboratory (a) and during finite element analysis (b) (E = 0.2MPa,ν = 0.4, traction =
-2
1,400,000Nm ).
91
CHAPTER 6: RESULTS: HOMOGENISATION
6.1 Preliminary validation
A model of tendon microstructure was produced as described in section 3.9.1. The fibrils and matrix
were defined as linear elastic materials. As a preliminary analysis, the materials of both the fibrils
and matrix were given a Young’s modulus of 1700MPa and a Poisson’s ratio of 0.3. Homogenisation
was performed as described in section 3.9.2 to obtain the material constants, which are summarised
in table 6.1. Since the materials of the fibrils and matrix are identical, the engineering constants
should describe an isotropic material where E 1 = E2 = E3 = 1700MPa, G12 = G13 = G23 = 653.8MPa
and ν12 = ν13 = ν23 = 0.3. The results agree with these values, which validates our model and method
of homogenisation.
E1 (MPa) 1700.170582
E2 (MPa) 1700.170582
E3 (MPa) 1699.99701
v12 0.300130459
v13 0.300037122
v23 0.300037121
G12 (MPa) 653.846147
G13 (MPa) 653.8461509
G23 (MPa) 653.8461509
Table 6.1 Material constants obtained when fibrils and matrix are both linear elastic materials with a
Young’s modulus of 1700 MPa and a Poisson’s ratio of 0.3.
6.2 Varying material properties of fibrils and matrix
From literature the upper and lower values reported for the Young’s modulus of fibrils tested in PBS
are 200MPa and 3000MPa respectively (Table 1.4). From transverse tensile testing of porcine
tendon we have concluded the Young’s modulus of the matrix to range from 0.0416MPa to
0.1021MPa. The objective was to vary the Young’s modulus of the fibrils and matrix between the
upper and lower limits to obtain the engineering constants for different combination of potential
microstructure material properties. Table 6.2 shows the engineering constants obtained for three
different combinations of material properties.
Due to the large difference in Young’s modulus between the fibrils and matrix, the engineering
constants (Table 6.2) violate the stability requirements asserted by Abaqus when the fibril modulus is
1600MPa and 3000MPa. As such, it is not possible to use these values to describe tendon tissue in
the suture repaired tendon models. The engineering constants obtained when the fibril modulus was
200MPa were not in violation of requirements for stability, however, since the other two fibril-matrix
combinations were not suitable, it was not possible to perform material sensitivity studies with these
data.
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Poisson’s ratio (same
0.3 0.3 0.3
for fibrils and matrix)
Matrix Modulus (MPa) 0.1021 0.1021 0.1021
Fibril Modulus (MPa) 200 1600 3000
E1 (MPa) 0.514044 0.486545 0.486623

E2 (MPa) 0.514044 0.486545 0.486623
E3 (MPa) 123.686094 962.633270 1804.901788
ν12 0.253848 0.253048 0.253039
ν13 0.022246 0.021551 0.021499
ν23 0.022246 0.021551 0.021499
G12 (MPa) 0.120712 0.120845 0.120853
G13 (MPa) 5.665204 44.072305 82.478908
G23 (MPa) 5.665204 44.072305 82.478908
Table 6.2 Material properties of the fibrils and matrix and engineering constants obtained from
homogenisation.
6.3 Incrementally decreasing Young’s modulus of matrix
An alternative approach was adopted to avoid violation of the stability requirements asserted by
Abaqus. The Young’s modulus of the fibrils and matrix were initially set to 1600MPa, and 1000MPa
respectively and the engineering constants were obtained. The Young’s modulus of the matrix was
then reduced by an order of magnitude, and the engineering constants were obtained again. This
was repeated until the engineering constants were in violation of the requirements for stability. The
resultant engineering constants are summarized in table 6.3.
Poissons
Ratio 0.3 0.3 0.3 0.3 0.3
Fibril Modulus
1600 1600 1600 1600 1600
(MPa)
Matrix 0.1
Modulus 1000 100 10 1
(MPa)
E1 (MPa) 1331.031627 360.6245005 46.13252132 4.751048729 0.504750555
E2 (MPa) 1331.031627 360.6245005 46.13252132 4.751048729 0.504750555
E3 (MPa) 1360.970271 1002.429677 966.5762966 962.9909984 962.6324329
ν12 0.298320823 0.268011764 0.254911608 0.253220532 0.253705858
ν13 0.286305936 0.106071965 0.032033916 0.022529523 0.021439595
ν23 0.286305936 0.106071965 0.032033916 0.022529523 0.021439595
G12 (MPa) 503.1115299 102.8961735 11.65915112 1.181960429 -1.410340965
G13 (MPa) 513.3786443 171.9071495 60.75475776 45.64068793 44.06861932
G23 (MPa) 513.3786443 171.9071495 60.75475776 45.64068793 44.06861932
Table 6.3 Combinations of fibril modulus and matrix modulus used in microstructure model, and
resultant engineering constants obtained after homogenisation.
With a fibril and matrix modulus of 1600 and 0.1 MPa respectively, the resultant engineering
constants violate the requirements for stability. However, all other combinations (Table 6.3) complied
with stability requirements.
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6.4 Using Orthotropic Material Description in Simple Suture Repaired Model
A simple suture repair model was produced for each orthotropic material described in table 6.3. Trial
and error was employed to determine the maximum load that could be applied to the suture in each
macro-scale model before errors occurred due to excessive strain. An increasing traction was
applied to the suture in each model up to the maximal load, and the suture displacement was
recorded at each load increment (Appendix 10.12, Table 10.5). Data obtained from the finite element
tests was compared with the experimental data obtained in section 5.4 (Figure 6.1, see Appendix
10.11, Figure 10.42 for individual lab data samples).
The finite element results which agrees closest to experimental data are those using the orthotropic
material obtained when the fibril modulus is 1600MPa and the matrix modulus is 1000MPa. Finite
element results approach the laboratory results as the modulus of the matrix is increased. The
maximum load applied to the finite element model was 0.0023N.
Figure 6.1 Tensile tests using simplified tendon repair, results from lab and finite element results
using the orthotropic material description for tendon tissue.
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6.5 Using Orthotropic Material Description in Kessler Suture Repaired Model
A Kessler suture repair model was produced for each orthotropic material described in table 6.3.Trial
and error was employed to determine the maxiumum load that could be applied to the suture in each
macro-scale model before errors occurred due to excessive strain. An increasing traction was
applied to the suture in each model up to the maximal load, and the suture displacement was
recorded at each load increment (Appendix 10.12, Table 10.6). Data obtained from the finite element
tests was compared with the experimental data obtained in section 5.5 (Figure 6.2, see Appendix
10.11, Figure 10.43 for individual lab data samples).
The finite element results which agrees closest to experimental data are those using the orthotropic
material obtained when the fibril modulus is 1600MPa and the matrix modulus is 1000MPa. Finite
element results approach the laboratory results as the modulus of the matrix increases. The
maximum load applied to the finite element model was 0.0018N.
Figure 6.2 Tensile tests using Kessler tendon repair, results from lab and finite element results using
the orthotropic material description for tendon tissue.
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CHAPTER 7: DISCUSSION AND RECOMMENDATIONS
Tendon repair is performed using one of many suture techniques. At present there is no best
practice method of tendon repair. Comparisons between different repair methods employ two
approaches, ex vivo tensile testing or in vivo clinical studies. Finite element modelling of suture
repairs has received little attention, however, such analysis would permit direct comparison between
all the suture techniques, showing localised stress and strain in the repair, which cannot be obtained
by other methods. This additional information would be beneficial in achieving a best practice
technique for tendon repair.
The objective of this thesis was to develop a finite element model of suture repaired tendon. It was
necessary to determine the transverse mechanical behaviour of tendon tissue to inform the finite
element model. We have developed a method of tensile testing tendon in the transverse direction,
and modelled tendon microstructure using finite element software, Abaqus. A finite element model
has been produced of a simplified suture repair and a Grasping Kessler suture repair. Tendon
material properties have been varied in these models and data has been compared with laboratory
tests of the same suture configurations. At present, an isotropic linear elastic description of tendon
with a Young’s modulus of 200MPa and a Poisson’s ratio of 0.4 provided a suture repair model
which agreed closest with experimental data (Figure 5.8).
7.1 Development of Transverse Tensile Testing Method
Whilst developing a tensile testing method to investigate tendon in the direction transverse to the
fibres, several observations were made regarding testing methods and tendon tissue. We will first
discuss these observations, before considering the findings of transverse tensile testing.
7.1.1 Testing Samples in Air
No significant difference in mechanical behaviour was observed between samples tested in air and
samples submerged in PBS (Figure 4.4). Data initially agreed closely, however, as the test
progressed there was less agreement between the two groups. Tensile testing of each sample was
completed in 30 seconds, which is a short amount of time to observe the effects of drying in the
tissue. The increasing difference between data as time progressed suggests that the difference may
become significant for longer time periods. It was initially hypothesised that drying would not affect
tendon mechanical properties since testing time was short, and although the difference was not
significant, an increasing disagreement between data was unexpected. As such it was decided that
all future testing would be performed in PBS.
Observations of bovine Achilles tendon fibrils concluded that the mechanical properties are
dramatically affected by drying of the fibril. Fibrils were tested both in ambient conditions, and PBS.
Hydrated fibrils had a lower Young’s modulus and lower peak stress than those tested at ambient
conditions (van der Rijt et al., 2006). This is contrary to our observations during tendon tensile
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testing, whereby samples tested in PBS withstood a higher peak stress. This suggests that for
tendon tensile tests, the differing stress-strain response in PBS compared with air may not be related
to drying of the fibrils. Findings by Van de Rijit et al. have implications on other research which used
AFM to test collagen fibrils which tested samples in ambient conditions rather than PBS (Wenger et
al., 2007).
Several studies have performed ex vivo tests of suture repaired tendons in ambient conditions rather
than PBS (Trail et al., 1992, Dogramaci et al., 2008). Drying may have affected the mechanical
properties of the tendon in these studies, which may have introduced inaccuracy to the results.
7.1.2 Epitenon Effects
It is well documented in literature that suture techniques which better exploit the strength of the
epitenon withstand higher loads (Section 1.7.2). With this in mind we performed two experiments to
consider the contribution made by the epitenon to the strength of the tendon itself.
The first experiment compared two different anchor arrangements (preparation methods C and D,
Table 3.1); one having a greater purchase than the other on the epitenon. Method D, which anchors
to a greater amount of epitenon, withstood significantly higher loads than method C (Figure 4.5).
However, this could be due to other factors rather than the greater purchase of epitenon. The
direction of fibre alignment relative to the suture pass is different in the two preparation methods. In
addition, a greater amount of tendon tissue is anchored in samples prepared by method D. The
differing geometries of samples may have affected results of this epitenon experiment. Further
testing was performed to establish the effects of the epitenon, as discussed below.
For the second experiment, the suture arrangement of each test group were the same, however one
group had the epitenon removed (preparation methods F and G, Table 3.1). Results suggested that
the presence of epitenon provides negligible strength benefits to the tendon (Figure 4.6). This result
was unexpected and contradictory to evidence of increased strength by incorporating the epitenon in
a suture repair. In this experiment, the suture is only supported by a very small amount of epitenon at
the location where the tendon is pierced. The Bunnell repair, for example, loops around part of the
epitenon rather than piercing it (Figure 1.8.a), thus a greater amount of epitenon resists the force
applied to the suture. The lack of difference observed when the epitenon was removed may be due
to the very small amount of epitenon involved in the simplified suture arrangement.
Since the epitenon provided negligible strength to the simplified suture configuration, the epitenon
was neglected during development of the finite element model. However, we have not considered
whether the epitenon provides additional strength to the Grasping Kessler repair, which we later
modelled in finite element. Ex vivo tensile testing to establish whether the epitenon contributes to the
strength of the Grasping Kessler would confirm whether the epitenon needs to be accounted for in
the finite element model.
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7.1.3 Method of Anchoring the Tendon Samples
Reducing sample length of preparation method C increased the Young’s modulus and ultimate
tensile stress (Figure 4.7). As the material properties do not change, the Young’s modulus and
ultimate tensile stress should be unaffected by sample length. The calculations assume that stress is
constant throughout the tendon cross section at a given point, however, the finite element model
simulating preparation method C showed that this is not the case (Figure 4.8).
A hook like attachment, similar to preparation method C, was used by Lynch et al. who investigated
the anisotropy of tendon. Corrections were not made during calculations to account for the uneven
loading arising from the hook like attachment (Lynch et al., 2003). As such, the Young’s modulus and
peak stress obtained during this paper may not be characteristic of the true transverse Young’s
modulus of tendon tissue. During study of the bovine iris, calculations were performed to account for
the geometry of the hook-like attachment and the uneven stress pattern which arises (Heys and
Barocas, 1999). However, rather than correct for the uneven stress pattern, the ideal resolution
would be to ensure the uneven loading does not arise.
An amended anchoring method was developed to resolve the problem of uneven loading
(preparation method E, Table 3.1). Rather than a hook like attachment, a small sample of tendon
was cut, and held in serrated tissue grips to attach it to the tensile testing equipment. This method
removes the uneven stress pattern associated with a hook-like attachment.
The compression from the clamps which hold the tendon sample introduces compressive stresses at
the ends of the sample. The standard method of performing a tensile test would employ a dog-bone
shaped sample. Such a sample is thicker at the clamp, so the compressive stresses do not result in
sample failure near the clamp. The central portion is narrow, ensuring failure occurs in this region.
The dog-bone shape ensures stress is constant throughout the cross section where failure occurs
and therefore the calculation of stress and strain is simple (Callister, 2010). Due to dimension
limitations, it is not possible to produce a dog-bone shaped transverse tendon sample. A sample
which has a greater length than its width would improve upon the current test method, which could
be achieved with the use of a microtome.
Preparation method E is similar to the anchoring method used by Lake et al. during testing of the
supraspinatus tendon, however, our method used a scalpel rather than a microtome for sample
cutting, and sample dimensions differ between the two techniques. The use of a microtome would
improve our experimental procedure by improving accuracy of geometry and measurements.
However, microtome cutting requites freezing and mounting. Freezing affects the mechanical
properties of tendon tissue (Clavert et al., 2001) and this drawback may outweigh the benefits of
using this cutting technique.
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7.1.4 Proximal and Distal Samples
Comparison between proximal and distal samples demonstrated regional variations in tendon
Young’s modulus (Figure 4.10). This reflects the regional variation noted during longitudinal loading
other tendons, such as the human FDP, which has a lower Young’s modulus on the palmar side
compared with the dorsal side (Soejima et al., 2003).
When considering suture repairs for lacerated tendons, knowledge of the typical material properties
in the damaged area would benefit repair selection. Repairs could be tailored to the region which is
injured. For example, where the laceration is in a tendon zone which has a low tensile modulus, a
suture repair with a stronger anchor could be employed. For a strong tendon, a suture technique
which has better gliding characteristics, and a less complex anchor could be employed. Tailoring the
technique to the mechanical strength of the injured tendon may ensure the best possible outcome is
achieved for the given injury.
7.1.5 Strain Rate
The transverse Young’s modulus was unaffected by varying the strain rate from 1%/s to 10%/s
(Figure 4.11). This strain rate range is representative of that experienced in vivo during active
mobilisation (Wren et al., 2001, Lewis and Shaw, 1997). This is consistent with work by Lynch et al.
who found no variation in transverse Young’s modulus of Ovine tendon with strain rates of 0.01%/s
and 1%/s (Lynch et al., 2003). Conversely, when tendon is loaded along the direction of fibre
alignment, it demonstrates strain-rate dependence (Wren et al., 2001, Lewis and Shaw, 1997). The
reasons for the different response to strain rate variation in the transverse and axial direction are
unclear.
7.2 Transverse Young’s modulus
The transverse Young’s modulus of tendon was found to be 0.1035 ±0.0131MPa and
0.2551±0.0236MPa for distal and proximal samples respectively (±SEM) (Figure 4.12). This is in
close agreement with work by Lynch et al. who concluded the transverse Young’s modulus of ovine
flexor tendon to be 0.157±0.154MPa.Conversely Lake et al. found the transverse Young’s modulus
of the human supraspinatus tendon to range from 1 to 40MPa (Lake et al., 2010). The supraspinatus
tendon undergoes complex multi-directional loading, and therefore, its transverse properties may
differ compared with tendons which experience unidirectional loading.
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7.3 Matrix Young’s Modulus
The Young’s modulus of the matrix was found to range from 0.0416MPa to 0.1021MPa (Section 4.9).
This does not agree with the matrix modulus determined by Tissakht et al. who found the matrix
modulus of the knee meniscus to be 2.69MPa. However, to obtain the meniscus matrix modulus, the
tensile modulus was determined in the radial direction (Tissakht and Ahmed, 1995). This is
analogous to the transverse modulus of the tendon and the contribution of the fibrils to the Young’s
modulus have not been accounted for in this study.
Using the rule of mixtures, the longitudinal modulus was calculated, based on the Young’s modulus
of the fibrils and matrix. The calculated longitudinal modulus ranged from 120 MPa to 1800 MPa
(Section 4.9.3). This closely agrees with the range of values quoted in literature for the longitudinal
tensile modulus of tendon (Table 1.3) which validates the Young’s modulus we have obtained for the
matrix and in the transverse direction.
7.4 Finite Element Model: Isotropic Linear Elastic Material Description
The simplified suture finite element model agreed closest with experimental data when the Young’s
modulus was 200MPa and 20MPa (Figure 5.7). The Grasping Kessler finite element model agreed
closest to experimental data with a Young’s modulus of 200MPa. Results of the Grasping Kessler
agree with those of the simplified suture model (Figure 5.8). A Young’s modulus of 200MPa lies
between that of the fibrils (200MPa to 3000MPa, Table 1.4), and that of the matrix (0.0416 MPa to
0.1021 MPa, Section 4.9). These results were expected and suggest that both fibrils and matrix
contribute to resisting the force pulling the suture.
Varying the tendon material properties by four orders of magnitude resulted in variation of the
gradient of the force-displacement curve by two orders of magnitude in the simplified suture and
Grasping Kessler models (Figures 5.7 and 5.8). This demonstrates some sensitivity to varying
material properties. At higher modulus values, the results vary less than at lower modulus values,
therefore, sensitivity to material properties is more profound for the transverse tendon modulus,
which is lower than the longitudinal modulus.
Limitations of the finite element models prevent definitive conclusions being made from this
investigation. The main limitation of this study is the restricted load which can be applied to the finite
element model which is less than 0.03N and 0.3N for the simplified and Kessler model respectively
(Figures 5.7 and 5.8). At higher loads, some areas of the model exhibit high strain and the elements
are unable to sufficiently deform. The ex vivo samples withstood over 18N, which is substantially
greater than the loads which can be applied to the finite element models. Furthermore, a pretension
of 0.1N was applied to ex vivo samples, and we therefore do not have laboratory data below 0.1N.
Whilst the force-displacement graph of ex vivo samples follows a straight line, this trend may not be
continued at loads below 0.1N. To permit greater application of force to the finite element model, a
hyperelastic material description can be employed to describe tendon. This will enable high strain in
100
the model, thus allowing greater deformation of the elements in response to loading and is
recommended for further development of the finite element model.
7.4.1 Kessler Deformation and Stress
Visual observations confirm that the deformation of both the simplified and Kessler suture FE
simulations agree with ex vivo sample deformation (Figures 5.2 and 5.6 for simplified model and
Figure 5.10 for Kessler model).
Large acellular regions have been observed around the grasping loops of the Kessler repair
following immunohistochemical staining (Wong et al., 2010). The same paper hypothesised that the
acellular regions may be due to suture presence and tensile stress. The areas of highest stress
observed using our finite element model coincide with the region of acellularity (Figure 5.9),
supporting the hypothesis that areas of high stress results in acellularity in suture repaired tendons.
7.5 Finite Element Model: Orthotropic Linear Elastic Material Description
It was hypothesised that modelling tendon as a fibre reinforced composite would provide a finite
element model which would closer represent the behaviour of suture repaired tendon. Fibril modulus
was set to 1600MPa, and the matrix modulus was varied from 1000 to 0.1MPa. Unexpectedly, as the
matrix modulus in the micro-scale FE model approached that obtained from laboratory tests, the
force-displacement curve in the macro-scale FE models of the simplified and Kessler suture repairs
showed less agreement with laboratory results (Figures 6.1 and 6.2). This suggests that an accurate
description of tendon tissue may not be obtained by modelling the fibrils and matrix, and that the
micro-scale model may be over-simplified.
Our experimental observations of transverse Young’s modulus involved tensile testing however, the
suture repaired tendon models involve more complex loading than tension alone. The Grasping
Kessler is imposing compression on the tendon in the transverse direction at the grasping loops.
Tendon tissue may behave differently in compression and tension in the transverse direction.
Tendon is aooriximately 70% water, causing high osmotic pressure in the tissue which resists
compression (Dubinskaya et al., 2007). This has been neglected in the finite element model of
tendon microstructure.
We have assumed the modulus of the fibrils and matrix to be isotropic and linear elastic, however,
Yang et al. provided evidence that fibrils are anisotropic following micromechanical bending of
bovine achilles fibrils using atomic force microscopy (Yang et al., 2008). Furthermore, whilst fibrils
exhibit linear elastic behaviour in ambient conditions, when tested in PBS fibrils display both elastic
and viscous behaviour (van der Rijt et al., 2006). A linear elastic, isotropic description of fibrils is not
characteristic of true tendon tissue. Development of the material description of the fibrils within the
micro-scale model may provide a model which approaches true tendon tissue behaviour.
101
Cells within the tendon have been neglected from the micro-scale FE model. However,
decellularized tendons demonstrate different mechanical properties to fresh tendon (Nyland et al.,
2009). Whilst this may be a result of the decellularization process, it may also be due to the absence
of cells in the tissue. Fibroblasts apply traction to the extracellular matrix (Marinkovic et al., 2012),
which plays a role in development of tendon structure (Harris et al., 1981) and may contribute to
tendon mechanical properties.
7.6 Finite Element and Homogenisation Validation
Further validation work is recommended to develop the FE models and ensure they sufficiently
represent suture repaired tendon.
Work to date has focussed on the Young’s modulus of tendon, maintaining a constant Poisson’s
ratio. It is well documented that the Poisson’s ratio of tendon in the longitudinal direction is greater
than 0.5 (Lynch et al., 2003), however, for a linear elastic material Abaqus only permits Poisson’s
ratio values between 0 and 0.5. It would therefore be appropriate to perform analyses varying the
Poisson’s ratio to establish the sensitivity of the model to change in this parameter.
An important validation step is to refine the mesh and check for convergence of the results. This
should be performed until the error in the model has reduced to acceptable levels. Localised mesh
refinement is recommended in areas which exhibit high changes in stress. This enables mesh
refinement in areas of interest, whilst maintaining minimal calculations and computing expense.
Homogenisation can be performed by two methods, which provide upper and lower limits. The
homogenous material description which accurately represents the composite lies between the upper
and lower limit. The homogenisation method employed in this work apply displacement boundary
conditions to the micro-scale model of tendon tissue. To define the other limit, force boundary
conditions should be applied to the model.
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8 CONCLUSIONS
We have developed a finite element model for the study of tendon repairs when subject to a low
tensile force. This model was informed by ex vivo tensile testing, which established the transverse
tensile modulus of tendon ranges from 0.1035MPa to 0.2551MPa. The finite element model of a
simplified repair and a Kessler repair agreed closest with experimental results when the tendon was
defined as an isotropic linear elastic material with a Young’s modulus of 200MPa and a Poisson’s
ratio of 0.4. Incorporating a hyperelastic description of tendon is recommended further development
of this model to enable analysis of higher forces.
A nano-scale model of tendon tissue has been developed, modelling the fibrils and surrounding
matrix. The Young’s modulus of the matrix was varied, relative to the fibril modulus, and
homogenisation was performed to obtain the orthotropic engineering constants. When this data was
used in the macro-scale finite element models of suture repaired tendon, results showed poor
agreement with experimental data. Further development of this model is recommended to approach
a closer representation of tendon tissue.
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109
10 APPENDICES
10.1 Photographs of Preparation Methods
Table 10.1 shows photographs of preparation methods described in Table 3.2.
Preparation
Photo
Method
A
Direction of fibre
alignment
B Below shows sample B after failure following tensile testing
Direction of fibre
alignment
Direction of fibre
alignment
D
No photo for this sample
Direction of fibres
110
E Below right shows sample held in Bose serrated grips
Direction of fibre
alignment
F (and G, see Preparation method F

notes) below shows the suture pass through the tendon
below shows sample under tension
Direction of fibre
alignment
Preparation method G
below shows removal of slice of tendon to remove epitenon
111
H
Sample in Bose self-tightening tissue grips below

Direction of fibre
alignment
Direction of fibre
alignment
J
Direction of fibre
alignment
Table 10.1 Photographs of preparation methods described in Table 3.2
112
10.2 Custom adapters and Tissue Grips used with Instron Equipment
Figures 10.1 to 10.8 detail the custom adapters used with the Instron tensile testing equipment to
test tendon samples. The Bose tissue grips used with the Instron tensile testing equipment are also
shown. Table 3.2 details which custom adapters are employed when testing each sample
preparation method.
Figure 10.1 Top pinned shaft.
Figure 10.2 Bottom pinned shaft with tank.
113
Figure 10.3 Pin sleeve.
Figure 10.4 Top tissue grip adapter, components.
Figure 10.5 Top tissue grip adapter, assembled.
114
Figure 10.6 Top serrated grip adapter, components.
Figure 10.7 Bottom serrated grip adapter with tank, components.

115
Figure 10.8 Bottom serrated grip adapter with tank, assembled.
116
10.3 Appendix for Preliminary Test Using Preparation Method C
Figure 10.9 shows the force-elongation curve obtained when determining the compliance of the
system tested in section 4.2. The equation of the line is y = 4.7067x. This equation was used to
correct the displacement measurements during sample tensile testing.
Figure 10.10 shows the stress strain relationship of all samples tested in section 4.2. Samples V6L
and V3R were excluded from calculation of the mean due to suspected suture knot slip. Figure 10.11
shows photographs of sample V5L taken throughout tensile testing of the sample, alongside the
stress-strain relationship for sample V5L.
Figure 10.12 shows the approximately linear region of the stress-strain curve for each sample
(excluding samples V6L and V3R) along with the equation of each line; y = mx + c, where m = the
gradient of the line.
Figure 10.9 Compliance of system used in section 4.2
Figure 10.10 stress strain relationship of all samples in section 4.2

117
Figure 10.11 Photographs of sample V5L during tensile testing, alongside the stress-strain response
of this sample.
Figure 10.12 Approximately linear region of stress strain curve, and equation of each line.
118
10.4 Appendix for Effects of Testing Samples in Air
Figure 10.13 shows the stress strain relationship of all samples tested in section 4.3. The
comparison between the samples tested in air in section 4.3 and samples tested in section 4.2 is
shown in Figure 10.14.
Figure 10.13 Stress – strain data of all samples in section 4.3
Figure 10.14 Mean of samples tested in air from Section 4.3 (second set, n=3) compared with mean
of samples tested in air in Section 4.2 (first set, n=10) * = significant difference.
119
10.5 Appendix for Epitenon Effects, First Experiment
Figures 10.15 and 10.16 shows the force-elongation curve obtained for preparation method C and D
respectively when determining the compliance of the systems tested in Section 4.4. The equations of
the compliance lines are y = 2.1955x for method C and y = 1.8053x for method D. These equations
were used to correct the displacement measurements during sample tensile testing.
Figure 10.17 shows the stress strain relationship of all samples prepared by method C, tested in
section 4.4. Figure 10.18 shows the stress strain relationship of all samples prepared by method D,
tested in section 4.4.
Figure 10.15 Compliance for preparation Figure 10.16 Compliance for preparation
method C. method D.
Figure 10.17 All preparation method C samples tested in Section 4.4

120
Figure 10.18 All preparation method D samples tested in Section 4.4
10.6 Appendix for Epitenon Effects, Second Experiment
Figure 10.19 shows the stress strain relationship of all samples prepared by method F, tested in
Section 4.5. Figure 10.20 shows the stress strain relationship of all samples prepared by method G,
tested in Section 4.5.
Figure 10.19 all preparation method F samples tested in Section 4.5

121
Figure 10.20 all preparation method G samples tested in Section 4.5
10.7 Appendix for Effects of Sample length
Figure 10.21 shows the comparison between the two different tests performed on different days.
Figure 10.22 shows the force-elongation curve obtained when determining the compliance of the
system tested in section 4.2. The equation of the line is y = 2.026x-0.544. This equation was used to
correct the displacement measurements during sample tensile testing.
Individual stress-strain results for 5mm, 10mm and 15mm samples are shown in figures 10.23, 10.24
and 10.25 respectively. Measurements were taken of the 18 samples (Section 4.6) as per method C
in table 3.1. Table 10.2 shows all measurements, along with the mean values which were used in the
finite element model described in sections 3.6 and 4.6.
122
Figure 10.21 Comparison of samples tested using the same methods, on different days. “PBS”
samples are those tested in PBS from section 4.3 (note that preparation method C was used for
these samples. “Preparation C” samples are those tested by preparation method C in section 4.4
(note that these samples were submerged in PBS during testing.
Figure 10.22 Compliance for samples tested in section 4.6.
123
Figure 10.23 individual 5mm length samples tested in section 4.6
Figure 10.24 Individual 10mm length samples tested in section 4.6
124
Figure 10.25 Individual 15mm length samples tested in section 4.6
sample length w t h d
1 15 7.6 6.1 15.7 3.9
10 7 4.1 10.4 3.6
5 6.5 4.3 5.1 3.7
2 15 6.2 4.6 14.7 3.7
10 6.7 3.6 10.9 4.5
5 8.3 4.7 4.6 4.1
3 15 7.6 5.7 15.8 4.5
10 7.7 4.8 10.6 4.1
5 5.6 4.9 5.5 4.4
4 15 8.1 6.3 15.1 5.6
10 6.8 4.9 10.3 3.3
5 6.2 3.8 5.5 3.4
5 15 6.6 4.7 14.4 2.2
10 6.8 4 10.5 2.7
5 7.4 4.1 5.8 3.8
6 15 7.2 5.2 15.3 3.5
10 6.9 4.6 9.9 3.6
5 5.5 4.6 5.3 3.9
mean 15 7.2 5.4 15.2 3.9
10 7.0 4.3 10.4 3.6
5 6.6 4.4 5.3 3.9
mean 6.9 4.7 3.8
Table 10.2 Measurements of the 18 tendon samples from section 4.6.
125
10.8 Appendix for Final Anchoring Method; Proximal vs Distal
Figure 10.26 shows the individual sample data for the initial proximal samples. Figure 10.27 shows
the portion of each proximal sample used to calculate Young’s modulus, along with the equation of
each line. The mean gradient of the samples was calculated to obtain the mean Young’s modulus for
the proximal samples.
Figure 10.28 shows the individual sample data for the initial distal samples. Figure 10.29 shows the
portion of each distal sample used to calculate Young’s modulus, along with the equation of each
line. The mean gradient of the samples was calculated to obtain the mean Young’s modulus for the
distal samples.
The experiment was repeated with a greater number of samples. Figure 10.30 shows the individual
sample data for the second proximal samples. Figure 10.31 shows the portion of each proximal
sample from the second experiment used to calculate Young’s modulus, along with the equation of
each line. Figure 10.32 shows the individual sample data for the second distal samples. Figure 10.33
shows the portion of each distal sample from the second experiment used to calculate Young’s
modulus, along with the equation of each line.
Figure 10.26 Individual proximal samples from initial experiment (n=8)
126
Figure 10.27 Portion of sample data used to calculate Young’s modulus of proximal samples from
initial experiment. Equations of each line are shown. The transverse modulus for proximal samples is
calculated by finding the mean gradient of these 8 lines.
Figure 10.28 Individual distal samples from initial experiment (n=7)
127
Figure 10.29 Portion of sample data used to calculate Young’s modulus of distal samples from initial
experiment. Equations of each line are shown. The transverse modulus for proximal samples is
calculated by finding the mean gradient of these 7 lines.
Figure 10.30 Individual proximal samples from second experiment
128
Figure 10.31 Portion of sample data used to calculate Young’s modulus of proximal samples from
second experiment. Equations of each line are shown. The transverse modulus for proximal samples
is calculated by finding the mean gradient of these 12 lines.
Figure 10.32 Individual distal samples from second experiment
129
Figure 10.33 Portion of sample data used to calculate Young’s modulus of distal samples from
second experiment. Equations of each line are shown. The transverse modulus for proximal samples
is calculated by finding the mean gradient of these 12 lines.
130
10.9 Appendix for Final Anchoring Method; Effects of Varying Strain Rate
Figure 10.34 shows the individual sample data for 1%/s strain. Figure 10.35 shows the portion of
each sample tested at 1%/s strain rate used to calculate Young’s modulus. Figures 10.36 shows the
individual sample data for 10%/s strain rate. Figure 10.37 shows the portion of each sample tested at
1%/s strain rate used to calculate Young’s modulus.
Figure 10.34 Individual samples tested at 1%/s strain rate
Figure 10.35 Portion of sample data used to calculate Young’s modulus of 1%/s strain rate samples
from. Equations of each line are shown. The transverse modulus is calculated by finding the mean
gradient of these 6 lines.
131
Figure 10.36 Individual samples tested at 10%/s strain rate
Figure 10.37 Portion of sample data used to calculate Young’s modulus of 10%/s strain rate
samples. Equations of each line are shown. The transverse modulus is calculated by finding the
mean gradient of these 6 lines.
132
10.10 Appendix for Final Anchoring Method; Determining Transverse Modulus
Figure 10.38 shows the individual distal sample data. Figure 10.39 shows the portion of each distal
sample used to calculate Young’s modulus. Figure 10.40 shows the individual proximal sample data.
Figure 10.41 shows the portion of each distal sample used to calculate Young’s modulus.
Figure 10.38 Individual samples tested using the Instron equipment at strain rate of 1%/s. Distal
samples.
Figure 10.39 Portion of sample data used to calculate Young’s modulus of distal samples. The
transverse modulus is calculated by finding the mean gradient of these 12 lines.
133
Figure 10.40 Individual samples tested using the Instron equipment at strain rate of 1%/s. Proximal
samples.
Figure 10.41 Portion of sample data used to calculate Young’s modulus of proximal samples. The
transverse modulus is calculated by finding the mean gradient of these 12 lines.
134
10.11 Appendix for Simplified and Kessler Suture Repair: Model Validation
Table 10.3 a to e shows the material properties used to describe tendon in the simplified suture
model for each analysis, and the suture displacement for each applied force. Figure 10.42 shows
the force-displacement curve for the individual samples tested by method H.
Table 10.4 a to d shows the material properties used to describe tendon in the Kessler suture
model for each analysis, and the suture displacement for each applied force. Figure 10.43 shows
the force-displacement curve for the individual samples tested by method H.
a Material Properties of Tendon b Material Properties of Tendon

Youngs modulus (Mpa) 0.2 Youngs modulus (Mpa) 2
Poissons Ratio 0.4 Poissons Ratio 0.4
Simplified suture model response Simplified suture model response
Suture Suture
Traction Traction
Force (N) Displacement Force (N) Displacement
(N/m2) (N/m2)
(mm) (mm)
400000 0.02512 0.66 400000 0.02512 0.35
300000 0.01884 0.55 300000 0.01884 0.32
200000 0.01256 0.45 200000 0.01256 0.29
100000 0.00628 0.36 100000 0.00628 0.27
c Material Properties of Tendon d Material Properties of Tendon

Youngs modulus (Mpa) 20 Youngs modulus (Mpa) 200
Suture Suture
Traction Traction
Force (N) Displacement Force (N) Displacement
(N/m2) (N/m2)
(mm) (mm)
400000 0.02512 0.29 400000 0.02512 0.28
300000 0.01884 0.28 300000 0.01884 0.27
200000 0.01256 0.26 200000 0.01256 0.25
100000 0.00628 0.24 100000 0.00628 0.23
e Material Properties of Tendon

Youngs modulus (Mpa) 2000
Poissons Ratio 0.4
Simplified suture model response
Suture
Traction
Force (N) Displacement
(N/m2)
(mm)
400000 0.02512 0.28
300000 0.01884 0.27
200000 0.01256 0.25
100000 0.00628 0.22
Table 10.3 a to e, showing results of sensitivity tests of the simplified model
135
Figure 10.42 Tensile testing results of samples prepared by method H.
136
a Material Properties of Tendon b Material Properties of Tendon
Youngs modulus (Mpa) 0.2 Youngs modulus (Mpa) 2
Suture Suture
Traction Displacement Traction Displacement
(N/m2) Force (N) (mm) (N/m2) Force (N) (mm)
200000 0.012566 0.197542 200000 0.012566 0.0558619
400000 0.025133 0.443209 400000 0.025133 0.113834
600000 0.037699 0.745575 600000 0.037699 0.179415
800000 0.050265 1.095770 800000 0.050265 0.256619
1000000 0.062832 1.488000 1000000 0.062832 0.352018
1200000 0.075398 1.899160 1200000 0.075398 0.457336
1400000 0.087965 2.319520 1400000 0.087965 0.575423
1600000 0.100531 0.713351
1800000 0.113097 0.805353
2000000 0.125664 0.918891
c Material Properties of Tendon d Material Properties of Tendon

Youngs modulus (Mpa) 20 Youngs modulus (Mpa) 200
Suture Suture
Traction Displacement Traction Displacement
(N/m2) Force (N) (mm) (N/m2) Force (N) (mm)
200000 0.012566 0.0237252 200000 0.012566 0.0111382
400000 0.025133 0.0475386 400000 0.025133 0.0227944
600000 0.037699 0.0719122 600000 0.037699 0.0331788
800000 0.050265 0.0958463 800000 0.050265 0.0445024
1000000 0.062832 0.12121 1000000 0.062832 0.0557757
1200000 0.075398 0.148654 1200000 0.075398 0.0663319
1400000 0.087965 0.180121 1400000 0.087965 0.0778349
1600000 0.100531 0.217282 1600000 0.100531 0.099751
1800000 0.113097 0.260349
2000000 0.125664 0.306858
2200000 0.13823 0.375708
2400000 0.150796 0.459329
Table 10.4 a to d, showing results of sensitivity tests of the simplified model
137
Figure 10.43 tensile testing results of samples prepared by method I.
138
10.12 Orthotropic Material Description, Simple and Kessler Validation
Table 10.5 a to d shows the material properties used to describe the fibrils and matrix, and the
suture displacement for each applied force in the simplified suture model. Table 10.6 a to d shows
the material properties used to describe the fibrils and matrix, and the suture displacement for
each applied force in the Kessler model.
a Microstructure Properties b Microstructure Properties

Fibril Modulus (Mpa) 1600 Fibril Modulus (Mpa) 1600
Matrix Modulus (Mpa) 1000 Matrix Modulus (Mpa) 100
Poissins Ratio 0.3 Poissins Ratio 0.3
Macroscale model response Macroscale model response
Suture Suture
Traction Force Traction Force
Displacement Displacement
(N/m2) (N) (N/m2) (N)
(mm) (mm)
36000 0.002262 1.8634 18000 0.001131 1.38933

27000 0.001696 1.38783 13500 0.000848 1.01883
18000 0.001131 0.901338 9000 0.000565 0.659947
9000 0.000565 0.432525 4500 0.000283 0.311974
c Microstructure Properties d Microstructure Properties

Suture Suture
(N/m2) (N) (N/m2) (N)
(mm) (mm)
9000 0.000565 0.992579 2250 0.000141 0.269789
6750 0.000424 0.722119 1687.5 0.000106 0.19917
4500 0.000283 0.463235 1125 0.000071 0.129289
2250 0.000141 0.217748 562.5 0.000035 0.000062
Table 10.5 a to d Results from simple suture finite element model using homogenized material
description for tendon tissue.
139
a Microstructure Properties b Microstructure Properties
Matrix Modulus Matrix Modulus
(Mpa) 1000 (Mpa) 100
Suture Suture
(N/m2) (N) (N/m2) (N)
(mm) (mm)
2000 0.000126 0.072916 2000 0.000126 0.109967

4000 0.000251 0.146204 4000 0.000251 0.221899
6000 0.000377 0.219975 6000 0.000377 0.336207
8000 0.000503 0.294296 8000 0.000503 0.452776
10000 0.000628 0.369227 10000 0.000628 0.571456
12000 0.000754 0.444744 12000 0.000754 0.692934
14000 0.00088 0.520835
16000 0.001005 0.597465
18000 0.001131 0.674708
20000 0.001257 0.752855
22000 0.001382 0.830789
24000 0.001508 0.909911
26000 0.001634 0.989271
28000 0.001759 1.06902
c Microstructure Properties d Microstructure Properties

Suture Suture
Traction Traction Force
Force (N) Displacement Displacement
(N/m2) (N/m2) (N)
(mm) (mm)
1000 6.28319E-05 0.076978 200 0.000013 0.020439

2000 0.000125664 0.156618 400 0.000025 0.041038
3000 0.000188496 0.239390 600 0.000038 0.061714
Table 10.6 a to d Results from Kessler suture finite element model using homogenised material
description for tendon tissue.
140

Development of A Finite Element Model For The Study of Tendon Repair Techniques

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DEVELOPMENT OF A FINITE ELEMENT MODEL FOR THE

STUDY OF TENDON REPAIR TECHNIQUES

A thesis submitted to the University of Manchester for the degree of

SHELLEY DYAN RAWSON

WORD COUNT 35,321

Firstly, it is a pleasure to offer my utmost gratitude to my supervisors Dr Sarah Cartmell and Dr

1.1 Prevalence of Injury and Current Clinical Outcome

c Stage 3: Fibroblasts synthesise collagen d Stage 4: Remodelling

Type of Movement Tendon Force (kgf) Tendon Force (N)

1.5 Tendon Mechanical Properties

1.5.1 Young’s Modulus

1.5.3 Variations within the Tissue

Youngs Modulus (MPa)

As well as elastic behaviour, characterised by immediate elongation in response to an applied load,

1.6 History; Developments which Influenced Tendon Repair

1.6.1 Primary Repair

1.7 Suture; Evaluation of Techniques

d. Modified locking Kessler e. Four strand double modified f. Modified Pennington, 2

g. Becker. h. Grasping Cruciate, 4 strand, i. Locking Cruciate, 4 strand,

j. Savage, 6 strand, x-stitch k. Locking Lee, 2 strand, l. Tsuge, 2 strand, anchor

1.7.3 Peripheral Circumferential Suture

An abundance of external suture increases gliding resistance of a repair, as demonstrated by

1.8 Methods of Evaluating Tendon Repair

1.8.1 Animal Surrogates for Human Tendon

1.8.3 Drawbacks of Current Evaluation Methods

1.9.1 Material Behaviour under Tension

Where: E = Young’s modulus, σ = Stress, ε = strain, ν = Poisson’s ratio, ε x = strain in x direction, εy

In contrast to polypropylene, tendon exhibits complex mechanical behaviour. Tendon is anisotropic,

1.9.4 A Brief History of the Finite Element Method

Figure 1.12 Flow diagram of FE modelling process using Abaqus.

1.10.2 Initial Assumptions

1.10.3 Draw and assemble the parts

1.10.4 Describe interactions

1.10.6 Define boundary conditions and loads.

A boundary condition is a constraint which dictates or prevents movement or rotation of selected

1.10.8 Submit model for analysis

1.10.9 Validating the model

1.11 Use of FE Modelling for Analysis of Tendon

(Wakabayashi Mechanical environment of

(Herchenhan Crimp formation in

Cells not defined - -

(Bendjaballah fibrils 1D truss not noted not noted

As we have previously discussed, assumptions and simplifications are necessary in order to

1.11.2 Modelled Structure

3.1 Obtaining Tendon Samples

 Porcine front trotters (Kurpas Meats, Manchester, UK)

B  Samples cut to approximately 10-15mm in h, w and t

D  Samples cut to approximately 10-15mm in H, w and t

 Note that by removing the two outer slices

F (and G, see Preparation method F w and t measured

H  Sample cut to approximately 35mm in length. w and t measured

J  Suture is passed through the tendon in two Sample was

 Bose BioDynamic 5110 ElectroForce Instrument (Bose Corporation, Eden Prairie,

 Instron 5569 load frame (Instron, High Wycombe, UK)

Used with sample

Custom attachment equipment

Instron tensile testing apparatus

3.4.1 Establishing Compliance

Preparation method C Preparation method D Preparation method E

A = ht - 4ts [7] A = ht – hs [8] A = wt [9]

 Abaqus (version 6.9; Simulia, Providence, Rhode Island, USA)

Figure 3.6 Boundary conditions applied to the model of tendon sample C

3.7 Finite Element Modelling; Suture Repaired Tendon, Simple Model