SCIENTIFIC ARTICLE

Tendon With Z-Lengthening Technique and

Construct Assessment: A Biomechanical Study for
Use in Tendon Reconstructions
William J. Weller, MD,* Zach Goldstein, MD,† Fang Li, PhD,‡ Ahmed Aljawad, BS,§ Jeffery A. Greenberg, MD*

Purpose Tendon reconstruction is frequently required under conditions of tendon deficiency.

The authors sought a technique that could obviate the need for tendon harvest yet meet the
minimum load of 45 N required for an early active motion protocol. This study was designed to
determine the ideal suture construct utilizing the tendon with Z-lengthening (TWZL) technique.
Methods Sixty fresh-frozen cadaveric flexor digitorum profundus tendons of the index,
middle, and ring fingers were randomized into 5 different TWZL construct designs using 3-0
braided polyethylene suture. Constructs were tested on an electromechanical actuator until
failure was observed on the load-elongation recording. Data points on maximum yield and
load at 8% strain were recorded for each construct.
Results The maximum yield data revealed the construct with a 4-core suture type configuration
(construct #4) had the highest overall mean load to failure at 150 N compared with all other
constructs. The construct with the highest mean load at 8% strain was that with a 4-core type repair
(construct #4) at 59 N. The constructs with Krackow locking sutures (constructs #2, #3, and #4
were found to withstand a significantly higher mean load at 8% strain than those without Krackow
sutures (#0 and #1). Comparison among constructs with Krackow locking sutures #2 (56 N), #3
(48 N), and #4 (59 N) did not show a significant difference in mean load at 8% strain. Construct
#3, however, had an SD and 95% confidence interval that fell below the 45 N early active motion
threshold, whereas both #2 and #4 had 95% confidence intervals that fell no lower than 50 N.
Conclusions This study provides evidence that the TWZL technique utilizing either construct
#2 or #4 could provide sufficient strength and reproducibility for tendon reconstruction.
Clinical relevance The study describes the application of the TWZL technique for utilization in
tendon reconstruction and quantifies differences in the yield strengths of the 5 proposed
constructs. (J Hand Surg Am. 2020;45(7):661.e1-e10. Copyright Ó 2020 by the American
Society for Surgery of the Hand. All rights reserved.)
Key words Extensor tendon reconstruction, flexor tendon reconstruction, tendon grafting,
tendon lengthening.

From the *The Indiana Hand to Shoulder Center Indianapolis; the †Department of Orthopaedic
Surgery, Indiana University; the ‡Department of Mathematics; and the §Department of
Biomechanical Engineering, Indiana University-Purdue University, Indianapolis, IN.
Received for publication January 19, 2019; accepted in revised form November 22, 2019.
No benefits in any form have been received or will be received related directly or indirectly
to the subject of this article.
Funding for this study was provided via an institutional grant from Acumed, LLC, Hillsboro
OR, grant number: 17014. The funding source played no role in the study design or writing
of this manuscript.
Corresponding author: William J. Weller, MD, Campbell Clinic Orthopedics, 1400 S.
Germantown Rd., Germantown, TN 38138; e-mail: williamjacobweller@gmail.com.
0363-5023/20/4507-0019$36.00/0
https://doi.org/10.1016/j.jhsa.2019.11.017

Ó 2020 ASSH r Published by Elsevier, Inc. All rights reserved. r 661.e1

661.e2 TENDON WITH Z-LENGTHENING TECHNIQUE
C
OMPLEX OR DELAYED TENDON reconstruction is
frequently associated with tendon deficiency.
Current techniques require a tendon graft or
transfer to fill the tendon gap, with the exception of
sacrificing the flexor superficialis and suturing it to
the flexor profundus for later distal tenodesis, or us-
ing a flexor tendon allograft. 1e8 Whereas some
tendon reconstructions require the harvest of only 1
tendon such as the palmaris longus, which is often
readily available in the same wound, occasionally
there are times when multiple tendons need recon-
struction. These multitendon reconstruction scenarios
subsequently require the harvest of tendons from a
site outside the primary surgical wound and, thus,
can lead to increased morbidity.
A recent publication describes using a native
extensor pollicis longus tendon to reconstruct the
tendon gap in chronic extensor pollicis longus rup-
tures.9 In addition, an earlier study by Urbaniak
et al10 has also described a Z-lengthening technique
with advancement of the distal tendon utilized in
flexor pollicus longus lacerations. Our study was
designed to accomplish 2 purposes: to determine the
feasibility of the tendon with Z-lengthening (TWZL)
technique in cadaveric flexor digitorum profundus
(FDP) tendons; and to analyze the ideal suture
construct based on maximum yield strength. The null
hypothesis for this study proposed that the 5 different
cadaveric FDP TWZL construct designs do not meet
the theoretical maximum yield strength demand of 45
N for early active motion (EAM).
MATERIALS AND METHODS
Pilot study
A pilot study was initially undertaken to determine an
appropriate reinforcement method for biomechanical
testing. The TWZL technique was applied to 6 flexor
digitorum superficialis tendons of the middle finger.
Preliminary testing showed maximum load to failure
between 34 N and 101 N. Based on these data, the
authors devised 5 different TWZL constructs of
varying Krackow lengths and core suture number at
and around the bridge site in order to determine
whether any significant difference in maximum yield
existed between the constructs.
Construct design
The constructs were designed from the most basic to
the most complex in order to see whether addition of
core sutures or Krackow numbers in series would
increase the yield strength by stabilizing the weak
point where the tendon has been split. Construct #0 is
J Hand Surg Am.
the most basic design with no 3-0 reinforcing braided
polyethylene suture (Maxbraid; Biomet-Zimmer,
Warsaw, IN). Construct #1 has a simple Krackow
suture placed at the split juncture site to prevent
propagation of the split. Construct #2 has 2 total cm
of Krackow sutures, with 1 cm placed on either side
of the tendon split interface. Construct #3 differs
from construct #2 in that it has 3 cm of Krackow
suture, 1 cm placed prior to the bridge site, 1 cm over
the bridge site, and the final centimeter distal to the
bridge site. Construct #4 has 2 total cm of Krackow
sutures, with 1 cm placed on either side of the tendon
split interface; however, an additional Krackow su-
ture is placed on top of the previous Krackows at the
split tendon interface in order to add 2 more core
suture strands at this weak point in the tendon. This
creates a 4-core strand configuration at the split
tendon interface for construct #4.
TWZL suturing technique
Twenty fresh-frozen cadaver arms were obtained and
the FDP tendons of the index, middle, and ring fin-
gers were harvested. A standard flexor carpi radialis
approach to the forearm was undertaken from the
musculotendinous junction (MTJ) in the forearm to
the A1 pulley in the palm, utilizing oblique incisions
at the wrist and palmar creases. The transverse carpal
ligament was divided ulnarly in line with the third
web space, and the median nerve was retracted
radially. The FDPs to the index, middle, and ring
fingers were identified as they entered the A1 pulley.
Here the FDPs were transected to simulate a similar
location where the surgeon may have tethered the
tendon stump in a 2-staged flexor tendon recon-
struction scenario. The tendons were individually
freed from the palm by pulling on them in a proxi-
mally directed manner. The remaining lumbrical
muscle origins were removed with a No. 15 scalpel
blade. A 1-cm length of the distal tendon stump was
measured and marked to delineate the interface from
where the tendon would be split in half longitudi-
nally. This 1-cm zone was given the name the bridge
site because it bridges the split interface between the
2 TWZL limbs. Using a No. 15 scalpel blade, the
tendon was split in half longitudinally from just distal
to the MTJ and distally to the 1-cm bridge site
marking. Two limbs were thus created, the limb on
the ulnar side of the tendon having been incised at the
MTJ and then flipped distally, effectively doubling
the tendon length (Fig. 1). Next, the bridge site was
folded back onto itself, effectively forming a tube of
the TWZL construct and thus decreasing the bulk or
node at the bridge site. A simple 3-0 braided nylon
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 TENDON WITH Z-LENGTHENING TECHNIQUE
FIGURE 1: TWZL technique. Top: Retrieve the FDP tendons
from the A1 pulley anchor site, remove the remaining lumbrical
muscle belly, and mark the 1-cm bridge site. Bottom: Split the
FDP longitudinally from the MTJ to the 1-cm bridge site, transect
one of the limbs created at the MTJ, and flip distally. Suture the
bridge site down with 3-0 braided nylon stay suture to make the
construct more tubular.
suture (Surgilon; Medtronic, Minneapolis, MN) was
placed in the bridge site to keep the junction in a
tubular configuration (Fig. 2).
Sixty cards were labelled #0, #1, #2, #3, and #4 so
that there would be 5 different constructs with 12
tendons in each cohort. The tendons were then
randomly assigned to a group. A 3-0 braided poly-
ethylene suture was used to place the Krackow su-
tures according to the construct design to which it
was randomly selected. Five Krackow sutures were
placed for every 1 cm of construct length involved
(see Appendix A for clinical photographs of each of
the constructs). The TWZL construct was completed
by tying back to the first braided polyethylene throw
and 5 square knots were completed. The bridge site
portion of the constructs after completion was com-
parable in bulk to a Pulvertaft weave, and with
J Hand Surg Am.
661.e3
FIGURE 2: TWZL technique. Top: The proximal MTJ interface
is at site A þ B to the left of figure. The distal tendon stump is
depicted at site C þ D to the right of figure. The bridge site is
shown by a 1-cm bracket. Middle: The longitudinally halved
tendon is flipped while the bridge site is kept intact. Bottom: The
limbs are folded together to make the construct more tubular and
a stay suture is placed.
opening of the A1 and A0 pulleys, the likelihood for
catching with flexion was assumed to be limited in
the clinical setting. After TWZL construct comple-
tion, each tendon was labeled according to their
construct number design and digit. They were placed
in moist gauze and stored in a refrigerator while the
remaining tendons were completed.
Biomechanical testing
The tendon constructs were placed in a cooler and
transported to the biomechanical testing facility. The
constructs were individually removed from the cooler
and tested on an electromechanical actuator testing
machine (Test Resources 100 Series Test Instrument,
Shakopee, MN). The construct was mounted such
that a 50-mm length of the tendon construct was
tested on each of the 60 tendons. The sutured TWZL
portion of the tendon was placed equidistant from the
mountings.
Next, a 5-N preload was applied to the construct
and then the load cell was zeroed. The construct was
then loaded at a rate of 0.2 mm/s until failure was
observed on the load-elongation recording. A
high-speed camera (Sony HDR Camera; Sony Cor-
poration, Tokyo, Japan) was utilized to capture
macroscopically the manner in which the tendon failed.
Construct failure via gapping was noted in relation to
where the tendon failed relative to the TWZL sutures
and recorded. This process was repeated identically for
the 60 tendons. There was 1 tendon (tendon 35) test
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661.e4 TENDON WITH Z-LENGTHENING TECHNIQUE

that failed to have the data recording saved; thus, it was
not included in the final analysis.
Statistical analysis
The biomechanical testing data were imported into a
spreadsheet and stress-strain graphs were constructed.
Next, data points on maximum yield and load at 8%
strain were all recorded from the testing data. The
means and SDs were calculated. The 95% confidence
intervals (95% CIs) for maximum yield and load at 8%
strain were calculated for each construct design. The
data for maximum yield and load at 8% strain were
analyzed individually utilizing an ordinary 1-way
analysis of variance model. A Tukey-Kramer adjust-
ment was added to do the pairwise comparison among
the 5 construct types. A post hoc power analysis was
undertaken and found that the sample size should be at
least 8 tendons for each of the 5 construct types in order
to detect a significant difference of 30 N maximum
yield strength between 2 types with a power of at least
0.80. The 30-N value was chosen for the post hoc
power analysis in order to attempt to detect significant
differences among the constructs given the ranges
exhibited in the results in regard to maximum yield and
maximum yield at 8% strain. Specifically, the authors
were interested in trying to determine significant
differences in yield strength among the constructs that
exhibited the higher maximum yield strengths (con-
structs #2, #3, and #4). A 45-N value was felt to be too
large a difference given the ranges; however, if it had
been chosen, a smaller number of tendons would be
required.
RESULTS
Maximum yield
The maximum yield data revealed construct #4 to
have the highest overall mean load to failure at 150
N. Utilizing the 1-way analysis of variance model
with a Tukey-Kramer adjustment to compare the
constructs, construct #4 was found to have a signifi-
cantly higher maximum yield than all other constructs
P less than .05 (Fig. 3).
Load at 8% strain
The construct with the highest mean load at 8% strain
was construct #4 at 59 N. Constructs #2, #3, and #4
were found to withstand a significantly higher load at
8% strain than constructs #0 and #1 (P < .05).
Comparison among constructs #2, #3, and #4, how-
ever, did not show a significant difference in load at

FIGURE 3: Mean maximum yield for the 5 tendon constructs. Different colored stars denote statistically significant differences in mean
maximum yield among the constructs; similar color stars denote no significant difference. The 95% CIs are shown in gray boxes and the
range of the values for each construct is shown in vertical brackets. Mean maximum yield values are denoted by blue diamond figures
for each construct.

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 TENDON WITH Z-LENGTHENING TECHNIQUE 661.e5

FIGURE 4: Load (N) at 8% strain by construct. Different colored stars denote statistically significant differences in mean load at 8%
strain among the constructs; similar color stars denote no significant difference. The 95% CIs are shown in gray boxes and the range of
the values for each construct are shown in vertical brackets. Mean loads for each construct at 8% strain are denoted by blue diamond
figures for each construct.

8% strain (P ¼ .32 for #2 vs #3; P ¼ .05 for #3 vs #4;
P ¼ .90 for #2 vs #4) (Fig. 4).
Mode of failure
The tendon constructs displayed 5 different modes of
failure. The most common mode of failure was split
propagation (50 tendons), where the tendon under
load continued to split into the bridge site (Fig. 5).
The second most common mode of failure was failure
of the tendon adjacent and proximal to the bridge site
tendon split interface (5 tendons). The tendon failed
distal to the construct in 2 tendons and only 1 tendon
failed with both split propagation and distal tendon
failure. One tendon also failed at the superior mount
on the actuator testing machine.
DISCUSSION
The null hypothesis for this study proposes that the 5
different cadaveric FDP TWZL construct designs do
not meet the theoretical maximum yield strength
demand of 45 N for EAM. The results from this study
show that the null hypothesis can be rejected because
Figure 3 shows constructs #1, #2, #3, and #4 resulted
in maximum yield strengths above the 45-N
threshold.
Although maximum yield is a valid parameter to
measure from a biomechanical properties standpoint,
it is not truly indicative of how the tendon or tendon
construct behaves when stress is applied at physio-
logical levels. Previous biomechanical testing shows
that native tendons exhibit elastic properties until
about 4% strain. Above 4%, and up to 10% strain, the
tendon undergoes plastic deformation or microscopic
failure of the collagen fibrils. At strain larger than
10% to 13% macroscopic failure occurs.11e13 Like a
native tendon, the reconstructed TWZL tendon
construct will also undergo strain as load is applied.
However, unlike the native tendon, which distributes
the load evenly, the reconstructed TWZL part of the
tendon, specifically the bridge site, is at highest risk
for failure if the construct is loaded prior to tendon
healing as it would be with an EAM protocol. This is
demonstrated by the observed mode of failure where
85% of tendons failed by split propagation into the
bridge site at maximum yield.
With the risk of split propagation in mind, we
sought to propose an acceptable degree of strain that
would be able to withstand the load imparted to the
TWZL flexor tendon constructs at their earliest po-
tential application of load. In the clinical setting, this
would be at initiation of an EAM protocol. According

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661.e6 TENDON WITH Z-LENGTHENING TECHNIQUE

FIGURE 5: Modes of failure. The distal tendon is oriented at the top of each photograph.

to previous studies, the minimum load threshold for
a flexor tendon construct to be able to withstand an
EAM protocol should be at least 45 N.14e17 Thus,
any proposed reconstruction technique should
meet, and ideally exceed, this 45-N threshold. To
address the question of what degree of strain is
tolerated by the TWZL construct before significant
split propagation occurs, we selected 8%, because
this represents approximately 4 mm of elongation
of the 50-mm TWZL tendon construct length that
was tested. In addition, Lieber et al18,19 has shown
that muscle and tendon adaptions are possible after
surgical tensioning procedures in rabbit models with
strain as high as 15%; therefore, our value of 8% is a
smaller, but acceptable, degree of strain. We then
reviewed the biomechanical testing data to evaluate
how much load our TWZL constructs withstood at
8% strain.
The results in Figure 4 showed that at 8% strain
constructs #2, #3, and #4 all exhibited mean loads of
greater than 45 N. Only construct #3 had a range and
95% CI that fell below the 45-N threshold, whereas
both constructs #2 and #4 had 95% CIs that fell no
lower than 45 N. Constructs #2 and #4 also exhibited
overall higher mean loads at 8% strain, but not
significantly compared with construct #3. Consid-
ering these data, constructs #2 and #4 more consis-
tently sustained loads greater than 45 N at an
appropriate strain in this biomechanical model. These
loads are above the threshold recommended for EAM
and, thus, suggest that they would be able to with-
stand this rehabilitation method. Although the 95%

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 TENDON WITH Z-LENGTHENING TECHNIQUE
CI of construct #4 is larger than the other constructs,
this is likely due to the small differences in the
tightness of the Krackow sutures coming into play
with higher loads. It is unlikely to have had an effect
on the study findings.
The limitations of this study include that it is a
biomechanical study and does not replicate the
angular forces or resistance to gliding that occur in
the in vivo setting of finger motion. Furthermore, it
does not evaluate at what load the tendon fails after
repetitive cyclical loading, which would be of interest
and is a potential avenue for future research. Lastly,
there is the risk of adhesions forming from the split
portion of the tendon; but if an EAM protocol can be
initiated, this can possibly be mitigated. However,
even intrasynovial tendon grafts form adhesions;
therefore, there is some risk of adhesions forming
regardless of the technique or graft handling.
The option of having a less morbid and simplified
procedure for tendon reconstruction is attractive,
especially if an EAM protocol can be instituted with
confidence that the reconstruction can withstand the
forces of therapy at time 0. This study provides
biomechanical evidence that the TWZL technique
outlined by either construct #2 or #4 could provide
sufficient strength and reproducibility for tendon
reconstruction.
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14. Waitayawinyu T, Martineau P, Luria S, Hanel D, Trumble T.
Comparative biomechanic study of flexor tendon repair using
FiberWire. J Hand Surg Am. 2008;33(5):701e708.
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661.e8 TENDON WITH Z-LENGTHENING TECHNIQUE

APPENDIX A. Electronic Component

FIGURE A1: Construct #0 clinical photograph. Note no stabi-
lizing suture is placed at the split tendon interface; the only suture
is a stay suture to keep the tendon tubularized. Distal tendon is
oriented to the top of the photograph and proximal to the bottom
of the photograph.
FIGURE A2: Construct #1 clinical photograph. Note that 1
simple Krackow suture is placed at the split tendon interface.
Distal tendon is oriented to the top of the photograph and prox-
imal to the bottom of the photograph.

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 TENDON WITH Z-LENGTHENING TECHNIQUE 661.e9

FIGURE A3: Construct #2 clinical photograph. Note 1-cm of the
Krackow suture is placed on either side of the split tendon
interface to make a 2-cm total suture construct. Distal tendon is
oriented to the top of the photograph and proximal to the bottom
of the photograph.
FIGURE A4: Construct #3 clinical photograph. Note 3 cm of the
Krackow suture construct is centered over the bridge site. Distal
tendon is oriented to the top of the photograph and proximal to
the bottom of the photograph.

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661.e10 TENDON WITH Z-LENGTHENING TECHNIQUE

FIGURE A5: Construct #4 clinical photograph. Note 2 cm of

Krackow sutures are centered over the split tendon interface, and
an additional Krackow suture is placed at the split tendon inter-
face to make a 4-core repair at that juncture. Distal tendon is
oriented to the top of the photograph and proximal to the bottom
of the photograph.

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