NOVEL RESEARCH METHODS AND MODELS
Unhas Suture, A Novel Tendon Repair Technique: An In Vitro
Experimental Study Comparing Unhas Suture and Bunnell
Suture in Tensile Strength and Gap Formation
Henry Yurianto, PhD, Ruksal Saleh, PhD, Idrus A. Paturusi, PhD,
Wilhelmus Supriyadi, MD, and Jansen Lee, MD
Downloaded from https://journals.lww.com/techortho by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3FJPxKcC74DHX9zQi7+fJ376gD+ybR759a4YtTV5wDyA= on 10/25/2019
Purpose: Developing a simple and yet strong repair technique that
allows smooth gliding of the tendon within the tendon sheath has
remained a challenge to meet the biomechanical needs of early active
rehabilitation. Our Objective was to compare Unhas and Bunnell suture
technique in terms of strength and gap resistance in tendon repair.
Materials and Methods: Thirty feet of healthy roosters Gallus
domesticus were harvested and assigned randomly into 2 groups of 15
feet each. The tendons were repaired using Unhas suture and Bunnell
suture utilizing monofilament nylon 4-0. Every specimens were tested
by using repaired tendon gap formation apparatus and then measured
when it produced an initial gap and 2-mm gap at the repair site. The
measurements were then analyzed for statistical significance.
Results: Significant difference in initial gap was detected between
repaired tendon using Unhas suture and Bunnell suture. Two-millimeter
gap forces were tested and Unhas suture group was also significantly
higher compared with Bunnell suture group.
Conclusions: Unhas suture was proven to be able to resist gap forces
either in initial gap or 2-mm gap compared with Bunnell suture
Clinical Relevance: Unhas suture may be a reliable alternative in
tendon repair that provides tensile strength, gapping resistance and also
provide easiness which can be performed with conventional suture
material and less operating time.
Key Words: unhas suture—tendon repair—tensile strength—gap formation.
(Tech Orthop 2019;34: 109–114)
S ince the ancient age, starting with eye needles, surgical suture
and misrecognizing tendon as nerve ending with fearing con-
sequences of suturing, development of tendon knowledge and repair
technique has expanded.1–10 Starting with the invention of Bunnel
suture for flexor tendon repair and facing the failure in primary
flexor tendon repair due to adhesions,3,5,6 predominant opinion was
that secondary tendon repair with grafting should be performed.7,8
Since the superior results presented by Verdan and Kleinert in
primary flexor tendon repair,3,10 both experimental studies on flexor
From the Department of Orthopaedic and Traumatology, Dr. Wahidin
Sudirohusodo General Hospital at Hasanuddin University, Makassar,
Indonesia.
The authors declare that they have nothing to disclose.
For reprint requests, or additional information and guidance on the
techniques described in the article, please contact Jansen Lee, MD, at
lee.jansen.88@gmail.com or by mail at Department of Orthopaedic
and Traumatology, Dr. Wahidin Sudirohusodo General Hospital at
University of Hasanuddin, Makassar 90245, Indonesia. You may inq-
uire whether the author(s) will agree to phone conferences and/or visits
regarding these techniques.
Copyright © 2018 The Author(s). Published by Wolters Kluwer Health, Inc.
This is an open-access article distributed under the terms of the Creative
Commons Attribution-Non Commercial-No Derivatives License 4.0
(CCBY-NC-ND), where it is permissible to download and share the work
provided it is properly cited. The work cannot be changed in any way or
used commercially without permission from the journal.
Techniques in Orthopaedics$  Volume 34, Number 2, 2019
tendon injury, repair, and healing as well as clinical investigations
have expanded the knowledge.11 However, the problem of restoring
normal tendon gliding and hand function and primary end-to-end
repair within the tendon sheath has not been overcome.12 Early
controlled rehabilitation has improved the results after flexor tendon
repair by decreasing adhesion formation, increasing repair strength,
and improving the functional outcome.13,14 Later clinical inves-
tigations have shown that controlled active mobilization further
improves the functional outcome.3,15–18
Today, the flexor tendon repair is considered a composite
of the core suture and the peripheral suture.10,19,20 Both tech-
niques have been developed to meet the biomechanical needs of
early active rehabilitation. Stronger core suture techniques to
withstand the forces of active motion have been developed
usually by increasing the number of strands forming different
types of multistrand repairs.21–23 However, multistrand repairs
are technically demanding in clinical settings increasing tendon
handling and requiring more surgical time, which limits their
clinical use. Developing a simple and yet strong repair techni-
que that allows smooth gliding of the tendon within the tendon
sheath has remained a challenge.3
The ideal tendon repair would have high tensile strength and
gap resistance but would minimize suture material on the tendon
surface so as not to interfere with tendon gliding or healing. Efforts
to develop such repairs have resulted in innovations as Strickland
stressed 6 characteristics of an ideal tendon repair.24–26 Makassar,
the largest city of Eastern Indonesia, bears a high burden of road
traffic accidents, gangsters, and criminals. Tendon injuries cases
are undeniably high and demands a practical tendon repair tech-
nique. Considering the limited resources, the author concluded that
an ideal tendon repair must be affordable in addition to the criteria
proposed by Strickland. There are variations of tendon repair
available27,28 and the author has developed a new core suture
technique which is called as Unhas suture named after University
of Hasanuddin (Unhas), Makassar, Indonesia. The illustration of
the suture is depicted in Figure 1.
MATERIALS AND METHODS
This study was conducted to compare Unhas and Bunnell
suture technique in terms of strength and gap resistance in
tendon repair on rooster (male chicken/Gallus domesticus)
tendons. Chicken have been chosen as one of animal models to
characterize flexor tendon injury in some researches.29–31
Specimen Preparation
Thirty feet of healthy roosters G. domesticus were used in
this study in which the roosters were selected randomly with the
age of 4 to 7 months and body weight ranging 1500 to 2000 g.
The roosters were initially prepared by being bathed and their
feet were cleaned. The roosters were then sacrificed and their
feet were harvested for the study. The rest part of the roosters
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Yurianto et al
FIGURE 1. Schematic view of Unhas suture.
were used for other purposes. Longitudinal incision was per-
formed on the third toe of each foot followed by identification
of the flexor perforantus digitorum pedis profundus while the
other tendons were cut off. In full extension, the tendon was
marked 6-cm proximal from the insertion and then harvested
from the mark made to the distal. Sharp incision was made in
the middle of the harvested tendon. Any damaged or torn ten-
dons, dry tendons, or exposed tendons for > 8 hours after
harvesting were excluded in this study.
Repair Technique
The specimens were assigned randomly into 2 groups of
15 feet each. The tendons from the first group were repaired
using Bunnell suture and the second were Unhas suture. Core
tendon repair was performed by using monofilament nylon 4-0
and peripheral suture using monofilament nylon 6-0.
Bunnell Suture
Bunnell suture is a classic intratendinous crisscross suture
technique that transmits the stress directly across the juncture
by the suture material and depends on the strength of the suture
itself.26 The schematic illustration of Bunnel suture is depicted
in Figure 2.
Unhas Suture
Unhas suture is a modified tendon repair technique
adopted from Tsuge Method which is classified as 2-strand core
suture with the knot placed on the surface of the tendon. The
technique involves purchasing the needle in the center of ten-
don with the distance of 10 mm from the end of the tendon (A
to B, C to D, G to H, and I to J) and secure locking loops with
diameter of 2 mm (E to F and K to L) and sufficient depth (1/3
FIGURE 2. Schematic illustration of Bunnell suture.
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Techniques in Orthopaedics$  Volume 34, Number 2, 2019
of the diameter of tendon) to ensure the optimal core sutures.
The illustrations are depicted in Figure 3.
Peripheral Suture
Peripheral suture used in this study was a circumferential
epitenon simple running suture of 6-0 monofilament nylon. The
running suture loops were ~4 mm long (2 mm from bite to the
cut tendon end) with the depth of ~1 to 1.5 mm. The illustration
is depicted in Figure 4.
Biomechanical Testing
Every specimens were tested by using repaired tendon gap
formation apparatus adapted from the previous study conducted
by Zhao et al.32 Each of the repaired tendons end was mounted
with custom-made clamps such that the repaired site is centrally
located. The grip-to-grip distance was ~40 mm with the repair site
centrally located. The upper part of the clamp was connected to
load cell and actuator. The tendon was then pulled proximally by
the actuator against the weight at the rate of 0.1 mm/s. Digital
indicator A12 showed the force causing gap formation in kilo-
gram force and then converted to Newton (1 kg force = 9.8 N).
The force was then measured when it produced an initial gap and
2-mm gap at the repair site. The tendon was kept moist by
dropping 0.9% saline solution every several seconds through the
testing procedures. The gap formation apparatus is shown in
Figure 5 and the illustrations of specimen perparations to bio-
mechanical testing are depicted in Figure 6.
Statistical Methods
Mann-Whitney test was used to compare the force causing
the initial gap and 2-mm gap between repaired tendons using
Bunnell suture and Unhas suture. In those cases, a level of
P < 0.05 was considered to be significant.
RESULTS
Seventeen roosters G. domesticus were sacrificed to obtain
the specimens. A total of 30 specimens were used and 4
specimens were ineligible due to damaged tendon before dis-
traction test. The mean (and SD) initial gap forces in repaired
tendon using Unhas suture was 9.76 ± 0.55 N and Bunnell
suture was 9.16 ± 0.66 N. The mean initial gap forces of
repaired tendon using Unhas suture was significantly higher
than that of Bunnell suture (P < 0.05).
Two-millimeter gap forces tested with the result of Unhas
suture group was 19.54 ± 1.12 N and Bunnell suture group was
15.24 ± 1.7 N. The statistical analysis between the 2 groups was
significantly higher in Unhas suture group (P < 0.05). The
comparison of gap forces between Unhas suture and Bunnell
suture is shown in Table 1.
DISCUSSION
The gap resistance and ultimate strength of repaired tendon
are the primary parameters that define the mechanical properties
of a surgical repair. Adequate mechanical strength is essential for
a repair to resist gapping and failure. Maintaining a certain
baseline tension on the core suture during surgery greatly benefits
gap resistance.19,33 Peripheral suture could also significantly
increase the strength of tendon repairs.19,20,34,35,39,40
Gap formation is one of the most frequent complications
following tendon suture and postoperative rehabilitation in which
it is believed as one of the major causes of adhesion formation
after tendon repair,32,36–39 and the formation itself occurs during
the first few weeks of tendon repair.32,37 If a gap could be
detected when it was small, it might be possible to use
Copyright © 2018 The Author(s). Published by Wolters Kluwer Health, Inc.
Techniques in Orthopaedics$  Volume 34, Number 2, 2019
FIGURE 3. Schematic Illustrations in Performing Unhas Suture which comprises of 2-strand core suture with locking loops at each ends.
modifications in the therapy.32 To prevent gap formation, strong
and yet simple suture techniques has remained a challenge.
Since Tsuge technique requires looped suture or double
arm suture which are not always available in every health
service centers, Unhas suture simply uses the conventional
suture material. Author defined Unhas suture as a simple
intratendon sutures, parallel with the tendon collagen fibers,
which carries stress of the repair away from the ends of the
tendon. The nodes provide approximation of ends of tendon
rupture, thus reducing the tendon gap formation so the tendon
healing is guaranteed.
Unhas suture is believed to be closed to an ideal suture
technique including repair strength, gapping resistance, main-
taining glide, reducing tendon damage, minimizing adhesion
formation, and also provide easiness which can be performed
with conventional suture material and less operating time. In
this study, Unhas suture was proven statistically significant in
FIGURE 4. Schematic illustration of simple running suture.
Copyright © 2018 The Author(s). Published by Wolters Kluwer Health, Inc.
Unhas Suture, a Novel Tendon Repair Technique
resisting gap forces compared with that of Bunnell suture.
Locking loops in which the type of suture used to hold the
tendon on either side in Unhas suture technique is superior
compared with Bunnell suture technique which uses grasping
loops.19,22,24 Locking loops provide better grasp of tendon
fibers and prevent suture pullout. As grasping loops do not
tighten around tendon fibers it would be expected that grasping
repairs would fail by suture pullout with repetitive load.24,40
In Human, various studies had evaluated the forces to
tendon during passive and active mobilization.41–43 Tendon
forces up to 9 N were present during passive mobilization of the
fingers.19,42,44 In this study, the mean initial gap forces in
repaired tendon using Unhas suture was 9.76 N and using
Bunnell suture was 9.16 N and the result was higher compared
with the forces present during passive mobilization in which
FIGURE 5. Repaired tendon gap formation apparatus.
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Yurianto et al Techniques in Orthopaedics$  Volume 34, Number 2, 2019

FIGURE 6. A, Specimen preparation and marking of tendon. B, Sharp incision to the marked tendon. Tendon repair with Unhas suture
technique (C) and Bunnell suture technique (D). Initial gap formation in biomechanical testing in Unhas suture technique (E) and Bunnell
suture technique (F). Two-millimeter gap formation in biomechanical testing in Unhas suture technique (G) and Bunnell suture
technique (H).

Unhas suture and Bunnell suture were assumed to be able to Tendon forces up to 35 N were present during active
resist the gap formation in passive mobilization under super- unresisted finger motion.19,42,44 According to Urbaniak and
vision if applied in human tendon repair. coauthors, an average tension in a human profundus tendon to

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Techniques in Orthopaedics$  Volume 34, Number 2, 2019
TABLE 1. Comparison of Gap Forces Between Unhas Suture and
Bunnell Suture
Unhas Suture Bunnell Suture P
Gap forces (N)
Initial gap* 9.76007 ± 0.54692 9.15587 ± 0.65760 0.024
2-mm gap* 19.53540 ± 1.11499 15.24307 ± 1.69949 < 0.001
*The values are given as the mean and SD.
be 14.7 N and found that tensile strength of tendon repair
decreases to approximately one-fifth of its initial strength at first
week. Taking into account of increased resistance from edema
after surgery and a decrease in suture strength during initial
weeks after repair.45 In this study, the mean 2-mm gap forces
developed in repaired tendon using Unhas suture was 19.53 N
and using Bunnell suture was 15.2 N. This value is above the
average tension developed in a human profundus tendon but
still needs further evaluation for adequacy in resisting forces
developed during active motion.
There were limitations to this study. These values are
estimated from experiments on rooster tendons and therefore
requires further studies which included cadaveric studies and
with the intact pulley system to support its use on clinical
setting. Cyclic loading was not conducted and linier load to
failure may not mimic physiological conditions.23,46,47 In this
study, Nylon 4-0 was chosen due to the size of our tendon
specimens and its use is supported by multiple researches both
in vitro and in vivo.19 Possible of using other specimens, size,
thread materials, and number of loops could be applied depends
on the study design.
In summary, in the present in vitro study, Unhas suture
technique was statistically significant higher in tensile strength and
resisting gap formation compared with those of Bunnell suture.
REFERENCES
1. Mackenzie D. The history of sutures. Med Hist. 1973;17:58–168.
2. Deepak M, Subraramanian CS, Senthilvelan, et al. A prospectic
randomised study on cosmetic outcome between simple suturing and
mattress suturing in hernioplasty. Int J Modn Res Revs. 2014;2:
418–420.
3. Viinikainen A. Development of a New Flexor Tendon Repair Technique
Performed With Bioabsorbsorbable Poly-L/D-Lactide (PLDLA) 96/4
Suture: An Experimental Ex Vivo Study [Academic Dissertation]
Helsinki: University of Helsinki; 2008.
4. Manske PR. History of flexor tendon repair. Hand Clin. 2005;21:
123–127.
5. Strickland JW. Development of flexor tendon surgery: twenty-five years
of progress. J Hand Surg Am. 2000;25:214–235.
6. Kotwal PP, Ansari MT. Zone 2 flexor tendon injuries: venturing into the
no man’s land. Indian J Orthop. 2012;46:608–615.
7. Rawson S, Cartmell S, Wong J. Suture techniques for tendon repair: a
comparative review. Muscles Ligaments Tendons J. 2013;3:220–228.
8. Adamson JE, Wilson JN. The history of flexor-tendon grafting. J Bone
Joint Surg. 1961;43-A:709–716.
9. Verdan CE. Primary repair of flexor tendons. J Bone Joint Surg Am.
1960;42:647–657.
10. Singh R, Rymer B, Theobald P, et al. A review of current concepts in
flexor tendon repair: physiology, biomechanics, surgical technique and
rehabilitation. Orthop Rev. 2015;7:101–105.
Copyright © 2018 The Author(s). Published by Wolters Kluwer Health, Inc.
Unhas Suture, a Novel Tendon Repair Technique
11. Strickland JW. The scientific basis for advances in flexor tendon
surgery. J Hand Ther. 2005;18:94–110.
12. Tang JB. Clinical outcomes associated with flexor tendon repair. Hand
Clin. 2005;21:199–210.
13. Lister GD, Kleinert HE, Kutz JE, et al. Primary flexor tendon repair followed
by immediate controlled mobilization. J Hand Surg. 1977;2:441–451.
14. Strickland JW, Glogovac SV. Digital function following flexor tendon
repair in zone II: a comparison of immobilization and controlled passive
motion techniques. J Hand Surg. 1980;5:537–543.
15. Cullen KW, Tolhurst P, Lang D, et al. Flexor tendon repair in zone 2
followed by controlled active mobilisation. J Hand Surg. 1989;14B:
392–395.
16. Small JO, Brennen MD, Colville J. Early active mobilisation following
flexor tendon repair in zone 2. J Hand Surg. 1989;14B:383–391.
17. Bainbridge LC, Robertson C, Gillies D, et al. A Comparison of post-
operative mobilization of flexor tendon repairs with“passive flexion-
active extension” and “controlled active motion” techniques. J Hand
Surg. 1994;19B:517–521.
18. Baktir A, Türk CY, Kabak S, et al. Flexor tendon repair in zone 2
followed by early active mobilization. J Hand Surg. 1996;21B:624–628.
19. Tang JB, Xie RG. Biomechanics of core and peripheral tendon repairs.
In: Tang JB, Amadio PC, Guimberteau JC, Chang J, eds. Tendon
Surgery of the Hand. Philadelphia: Elsevier Saunders; 2012:2035.
20. Merrell GA, Wolfe SW, Kacena WJ, et al. The effect of increased
peripheral suture purchase on the strength of flexor tendon repairs.
J Hand Surg Am. 2003;28:464–468.
21. Mishra V, Kuiper JH, Kelly CP. Influence of core suture material and
peripheral repair technique on the strength of Kessler flexor tendon
repair. J Hand Surg. 2003;28B:357–362.
22. Shaieb MD, Singer DI. Tensile strengths of various suture techniques.
J Hand Surg. 1997;22B:764–767.
23. Barrie KA, Tomak SL, Cholewicki J, et al. The role of multiple strands
and locking sutures on gap formation of flexor tendon repairs during
cyclical loading. J Hand Surg. 2000a;25A:714–720.
24. Tanaka T, Amadia PC, Zhao CF, et al. Biomechanical properties of
locking versus grasping suture. Summer Bioengineering Conference,
Minnesota Orthopaedic Biomechanics Laboratory; Rochester, Minnesota,
2003;635–636.
25. Viinikainen A, Goransson H, Ryhanen J. Primary flexor tendon repair
techniques. Scand J Surg. 2008;97:333–340.
26. Cannon DL. Flexor and extensor tendon injuries. In: Canale ST, Beaty
JH, eds. Campbell’s Operative Orthopaedics, 12th ed. Philadelphia:
Elsevier Mosby; 2013:3249.
27. Ryan JD. Principles and Techniques of Tendon Repair. Georgia: The
Podiatry Institute; 2010. Available at: www.podiatryinstitute.com/pdfs/
Update_2010/2010_52.pdf. Accessed January 15, 2016.
28. Sebastin SJ, Ho A, Karjalainen T, et al. History and evolution of the
kessler repair. J Hand Surg. 2013;38A:552–561.
29. Strick MJ, Filan SL, Hile M, et al. Adhesion formation after flexor
tendon repair: a histologic and biomechanical comparison of 2- and
4-strand repairs in a chicken model. J Hand Surg Am. 2004;29:15–21.
30. Lee H, Hou Z, Liu P, et al. An experimental study comparing active
mobilization to passive flexion-active extension-active flexion after
flexor tendon repair in zone 2. J Hand Surg Am. 2013;38:672–676.
31. Hast MW, Zuskow A, Soslowsky LJ. The role of animal models in
tendon research. Bone Joint Res. 2014;3:193–202.
32. Zhao C, Amadio PC, Tanaka T, et al. Effect on gap size on gliding
resistance after flexor tendon repair. J Bone Joint Surg Am. 2004;86A:
2482–2488.
www.techortho.com | 113
Yurianto et al
33. Beredjiklian PK. Biologic aspects of flexor tendon laceration and repair:
current concepts review. J Bone Joint Surg Am. 2003;85A:539–550.
34. Uslu M, Isik C, Ozsahin M, et al. Flexor tendon repair: effect of core
suture caliber with increased number of suture strands and peripheral
sutures: a sheep model. Orthop Traumatol Surg Res. 2014;100:611–616.
35. Diao E, Hariharan JS, Soejima O, et al. Effect of peripheral suture depth
on strength of tendon repairs. J Hand Surg Am. 1996;21:234–239.
36. Boyer MI, Gelberman RH, Burns ME, et al. Intrasynovial flexor tendon
repair. an experimental study comparing low and high levels in vivo
during rehabilitation in canines. J Bone Joint Surg Am. 2001;83:
891–899.
37. Gelberman RH, Boyer MI, Brodt MD, et al. The effect of gap formation
at the repair site on the strength and excursion of intrasynovial flexor
tendons. An experimental study on the early stages of tendon-healing in
dogs. J Bone Joint Surg Am. 1999;81:975–982.
38. Ejeskär A, Irstam L. Elongation in profundus tendon repair: a clinical
and radiological study. Scand J Plast Reconstr Surg. 1981;15:61–68.
39. Amadio PC. Friction of the gliding surface: implications for tendon
surgery and rehabilitation. J Hand Ther. 2005;18:112–119.
40. Amis AA. The mechanical properties of finger flexor tendons and
development of stronger tendon suturing techniques. In: Schuind F, An
KN, Cooney WP III, Garcia-Elias M, eds. Advances in the
114 | www.techortho.com Copyright © 2018 The Author(s). Published by Wolters Kluwer Health, Inc.
Techniques in Orthopaedics$  Volume 34, Number 2, 2019
Biomechanics of the Hand and Wrist. New York: Springer Science
+Business Media; 1994:41–57.
41. Kursa K, Lattanza L, Diao E, et al. In vivo flexor tendon forces increase
with finger and wrist flexion during active finger flexion and extension.
J Orthop Res. 2006;24:763–769.
42. Schuind F, Garcia-Elias M, Cooney WP III, et al. Flexor tendon forces:
in vivo measurements. J Hand Surg Am. 1992;17:291–298.
43. Vanhees M, Thoreson AR, Larson DR, et al. The effect of suture
preloading on the force to failure and gap formation after flexor tendon
repair. J Hand Surg Am. 2013;38:56–61.
44. An KN. In vivo force and strain of tendon, ligament, and capsule. In:
Guilak F, Butler DL, Goldstein SA, Moonet D, eds. Functional Tissue
Engineering. USA: Springer-Verlag; 2003:96–105.
45. Mitsunaga KA, Szabo RM. What is the best method of rehabilitation after
felxor tendon repair in zone II: passive mobilization of early active motion?
What is the best suture configuration for repair of flexor tendon lacerations?
In: Wright HG, ed. Evidence-Based Orthopaedics: The Best Answers to
Clinical Questions, 1st ed. Philadelphia: Saunders Elsevier; 2009:91–103.
46. Choueka J, Heminger H, Mass DP. Cyclical testing of zone ii flexor
tendon repairs. J Hand Surg Am. 2000;25:1127–1134.
47. Pruitt DL, Manske PR, Fink B. Cyclic stress analysis of flexor tendon
repair. J Hand Surg Am. 1991;16:701–707.