Original Article The Journal of Hand Surgery (Asian-Pacific Volume) 2018;23(2):243-247 • DOI: 10.

1142/S2424835518500285

The Effect of Suture Materials on the Biomechanical

Performance of Different Flexor Tendon Repairs
and the Concept of Construct Efficiency
Yoke Wong Rung*, Austin Mun Kitt Loke*, Shian Chao Tay*,†
*Biomechanics Laboratory, Singapore General Hospital,
†
Department of Hand Surgery, Singapore General Hospital, Singapore
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Background: To propose a new term (‘construct efficiency’) for the evaluation of multi strands flexor tendon repairs using differ-
ent suture materials.
Methods: A total of twenty specimens from 4-0 braided polyblend sutures (FiberLoop/FiberWire; Arthrex, Naples, FL) and 4-0 ny-
lon sutures (Supramid Extra II; S. Jackson, Inc., Alexandria, VA) were subjected to tensile testing using Pneumatic Cord-and-Yarn
Grips (Instron Corp., Canton MA, USA). The ultimate tensile strengths of the suture materials were measured. The expected repair
strengths and construct efficiencies were computed based on the experimental results and from available literature on actual re-
pair strengths of the 4-strand Becker, Cruciate repairs and 6-strand Tang, modified Lim-Tsai repairs.
Results: The ultimate tensile strength of nylon suture was 15.4 ± 0.6N, lower than that of braided polyblend suture (45.3 ± 2.3N)
with a difference of 194%. The construct efficiency of multi strand repairs varied with respect to different repair techniques and
suture materials. It was found that the Becker repairs using FiberWire had the highest construct efficiency (55.7%) followed by the
modified Lim-Tsai using Supramid (50.9%), Tang repair using Supramid (49.8%), Cruciate repair using Fiberwire (49.1%), and modi-
fied Lim-Tsai repair using FiberLoop (33.5%).
Conclusions: The construct efficiency is more accurate in showing that, in terms of biomechanical strength, the use of FiberWire
for the 4-strand Becker and Cruciate repair is more efficient than that of using FiberLoop for 6-strand modified Lim-Tsai repair.

Keywords: Flexor tendon repair, Suture tensile strength, Uneven load bearing, Construct efficiency

INTRODUCTION the risk of repair rupture due to excessive loading at the

Early active mobilization is important for rehabilita-
tion after flexor tendon repair to prevent adhesion forma-
tion and stiffness of joints.1) However, doing so increases
Received: Mar. 7, 2016; Revised: Jun. 13, 2016; Accepted: Jun. 17, 2017
Correspondence to: Shian Chao Tay
Biomechanics Laboratory, Singapore General Hospital, Academia, 20
College Road, Level 1, 169856, Singapore
Tel: +65-6576-7962, Fax: +65-6227-3573
E-mail: tay_sc77@yahoo.com
repair site. Increased biomechanical strength of tendon
repair has been frequently highlighted as an important
factor in the prevention of repair rupture.2-4) It is also
widely believed that the strength of flexor tendon repair
is proportional to the number of strands, or core sutures,
crossing the repair site.5-7) Contrary to this belief, our ear-
lier study found that there were no significant difference
between the repair strength of 4-strand Cruciate repairs
and that of 6-strand modified Lim-Tsai repairs when 4-0
braided polyblend suture was used.8) This challenges the
assumption of increasing the number of suture strands in
order to achieve higher repair strength.
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Yoke Wong Rung, et al. Effect of Suture Materials and Concept of Construct Efficiency

Our previous study utilizing free body diagrams dem- METHODS

onstrated that, as a consequence of uneven load bearing
between paired core suture strands, both the modified
Lim-Tsai and Cruciate repairs were able to withstand
only up to two times the tensile strength of the suture
used.9) This highlights the importance of evaluating bio-
mechanical performance of flexor tendon repair, with the
expected tensile strength of suture used to benchmark
the repair strengths of each technique.
In this study, we propose ‘construct efficiency’ as a
new quantitative term when comparing different types of
repair techniques and suture materials. The objective of
the study was to validate ‘construct efficiency’ in evalu-
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Mechanical Testing of Sutures
The Pneumatic Cord-and-Yarn Grips were developed
to conduct mechanical testing for single suture strand
under the American Society for Testing and Materials
(ASTM) Standard D3822 (Standard Test for Tensile
Properties of Single Textile Fibers) (Fig. 1). The grips
were mounted on an Instron 3343 mechanical tester (In-
stron Corp., Canton MA, USA). One end of the tested
suture was passed around the top arm 3 times, then
clamped by the pneumatic gripper. A similar approach
was used to secure the suture to the bottom arm. The

ating the efficiency of the construct of different flexor
tendon repair techniques. This was done by comparing
the construct efficiency of 4-0 braided polyblend sutures
(FiberLoop or FiberWire; Arthrex, Naples, FL) and 4-0
nylon sutures (Supramid Extra II; S. Jackson, Inc., Al-
exandria, VA) in 4-strand repairs (Becker and Cruciate)
and 6-strand repairs (Tang, modified Lim-Tsai).
Pneumatic cord
and yarn grips
Top arm
Gauge length
Bottom arm
gauge length was standardized at 20 mm with 1N of
preload applied to the suture and pulling rate was set at
20 mm/min. The suture was pulled until failure and the
ultimate tensile strength was recorded.
Computation of Construct Efficiency
Ten 4-0 braided polyblend sutures (FibreLoop; Ar-
threx, Naples, FL) and ten 4-0 nylon sutures (Supramid
Extra II; S. Jackson, Inc., Alexandria, VA) were tested in
the experiment. The mean ultimate tensile strength of the
sutures were tabulated in Table 1 and used to compute
their expected repair strengths. Expected repair strength
is defined as mean suture strength multiplied by the
number of suture strands crossing the repair site. Con-
struct efficiency of the flexor tendon repairs was com-
puted as the quotient of the mean actual repair strength
(obtained by Wong et al.,8) Gan et al.10) and Tang et al.11))
and the respective expected repair strength. Construct
efficiency thus quantifies the effectiveness of the flexor
tendon repair technique in achieving its maximum po-
tential strength based on the suture material used.

Fig. 1. Setup of suture material testing.
Statistical Analysis
Mean and standard deviation of the variables were
calculated from the mechanical testing of sutures. One
way ANOVA was adopted to compute the statistical
difference of mean values in between the groups. Post

Table 1. Construct Efficiency for Different Repair Techniques with Different Suture Materials

Expected repair Construct efficiency

Repair Suture Number of Mean suture Mean actual repair
strength (N) for actual repair
technique material strands (a) strength (N) (b) strength (N) (d)
(c) = (a) x (b) strength (%) (d)/(c)
Modified Lim-Tsai Supramid 6 15.4 92.4 47.010) 50.9
Modified Lim-Tsai FiberLoop 6 45.3 271.8 91.08) 33.5
Becker FiberWire 4 45.3 181.2 101.08) 55.7
Cruciate FiberWire 4 45.3 181.2 89.08) 49.1
Tang Supramid 6 15.4 92.4 46.011) 49.8
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120
Nylon 93.6% difference
Braided polyblend
100
80
Load (N)
*
60 194% difference
40
20
0 the suture.4,12,14,15) In both methods, the ultimate tensile
Suture strength Mod Lim-Tsai repair
strength
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Fig. 2. Comparison of ultimate tensile strength of suture materials and
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6-strand modified Lim-Tsai technique. The (*) showed a significant
difference between two groups (p < .001).
hoc test with Bonferroni correction was conducted if
the mean values were statistically different in between
groups. A p value of less than 0.05 was considered to be
statistically significant.
RESULTS
Ultimate Tensile Strength of Sutures and Modified
Lim-Tsai Repairs
As shown in Fig. 2, there was a significant differ-
ence (p < .001) in ultimate tensile strength between the
4-0 braided polyblend suture (45.3 ± 2.3N) and the 4-0
nylon suture (15.4 ± 0.6N). The difference in ultimate
tensile strength of the two sutures is 194%. On the other
hand, our previous published data reported that the repair
strength of modified Lim-Tsai repairs using FiberLoop
(91.0 ± 11N)8) was higher than Supramid (47.0 ± 8N).10)
The difference of repair strengths in between the two re-
pair groups was 93.6%.
Construct Efficiency
As shown in Table 1, the modified Lim-Tsai repair
using Supramid had a higher construct efficiency (50.9%)
as compared to the one using FiberLoop (33.5%), pro-
ducing a 17.4% difference in between the two groups.
On the other hand, the Becker repair using FiberWire
had the highest construct efficiency (55.7%) followed
by the modified Lim-Tsai using Supramid, Tang repair
using Supramid, Cruciate repair using Fiberwire, and
modified Lim-Tsai repair using FiberLoop.
DISCUSSION
Based on current literature, there are two methods
typically employed in the evaluation of the mechani-
cal properties of suture materials. The first method, no-
knot suture material test, involves the passing of a suture
around two metal rods several times, and attaching the
suture ends to the rods with adhesive tape.12,13) The sec-
ond method, a knotted suture material test, is carried out
by tying a knot between two metal rods after mounting
strength of suture is measured when the suture is pulled
to failure by using a mechanical tester. However, these
methods may be inaccurate; In the no-knot method, su-
ture slippage may occur when advanced suture materials
(such as braided polyblend) are stronger than the adhe-
sives used. For the knotted method, the presence of a
knot is widely acknowledged to weaken the suture.10,15-17)
With the use of the Cord-and-Yarn Grips, there is no
need for tying a knot, which allows an accurate measure-
ment of tensile strength of the suture material. The grips
were developed for the specific purpose of testing the
strength of cord-like materials, in accordance with the
ASTM standard. Therefore, the suture strength measured
in this study is more accurate.
It is believed that the biomechanical strength of the
repair technique is directly proportional to the suture
strength. Therefore, we can compute the efficiency of a
repair based on the suture material. Suture strength of
FiberLoop was found to be 194% stronger than that of
Supramid (Fig. 2). However, the actual repair strength of
modified Lim-Tsai repair using FiberLoop was 91.0N,
or only 93.6% higher than that of Supramid (47.0N).
This demonstrated that repair strength did not increase
proportionally to suture strength. Thus, another term is
needed to evaluate the efficiency of a repair technique.
‘Construct efficiency’ quantifies the efficiency of a
repair technique and tells us how good the technique is
in harnessing the tensile strength of the suture material
being used. Conversely, it is also able to tell us which
suture material is more efficient with respect to a repair
technique. As shown in Table 1, the construct efficiency
of modified Lim-Tsai repair was higher for Supramid
than for Fiberloop, although Fiberloop had higher repair
strength. This shows that superior suture strength is not
always associated with higher efficiency.
In one of our earlier study,8) 60% of the modified
Lim-Tsai repair using FiberLoop failed by suture pull-
out; the rest either by suture breakage (25%) or knot un-
raveling (15%). On the other hand, Gan at el.10) reported
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Yoke Wong Rung, et al. Effect of Suture Materials and Concept of Construct Efficiency
that 100% of the modified Lim-Tsai repairs using Supra-
mid failed by suture breakage. Suture breakage occurs
when tensile loads reach the ultimate tensile strength of
Supramid, while suture pull-out occurs when the holding
force of the Lim-Tsai locking loop was reached in the re-
pairs using FiberLoop. Therefore, the FiberLoop suture
was too strong and it always pulled out from the tendon
before it could reach its expected repair strength.
As shown in Table 1, all the repair techniques could
only achieve roughly 50% or less of their expected
strength. This implies that the repair techniques evalu-
ated were not efficient and do not maximize the strength
of the suture used. Therefore, we believe that with the
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concept of ‘Construct Efficiency’ we may be able to op-
timize and improve flexor tendon repair techniques. The
construct efficiency of the 6-strand modified Lim-Tsai
was lower than the 4-strand repairs. Whether this was
due to the modified Lim-Tsai technique not suited for a
high friction braided suture, or the increasing inefficien-
cy in increasing the number of core sutures in a repair
technique, is something that needs further investigation.
The limitation of this study was that the measurement
of suture strength was conducted in an in vitro labora-
tory setting. However, the biomechanical properties of
the suture material might be altered with exposure to
biological environment in vivo . On the other hand, the
current study compared four repair techniques using
two different suture materials. Additional repair tech-
niques associated with different suture materials should
be tested in the future confirm the Validity of the term,
Construct Efficiency.
CONFLICT OF INTEREST STATEMENT
There are no conflicts of interest to declare by the au-
thors.
ACKNOWLEDGMENTS
We would like to acknowledge Zeus Yi Wei Lim
from the SGH Biomechanics Laboratory for assisting
with manuscript submission.
FUNDING STATEMENT
This work was supported by the SingHealth Foun-
dation Grant [grant numbers SHF/FG564P/2014]; the
Surgery Academic Clinical Program grant (Biomechanics
Lab Programme) and the Singapore Ministry of Health’s
National Medical Research Council under its Centre
Grant (NMRC/CG/016/2013).
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