Background: The Pulvertaft weave continues as a staple technique for tendon coaptations. Many have proposed minor alterations to the original technique to improve its strength, although a lack of consensus exists. The authors' aim was to explore how the number of weaves and suture characteristics contribute to the overall strength of the coaptation.
Methods: A comprehensive electronic search was conducted using the PubMed, Cochrane Library, and Scopus databases. Criteria for inclusion consisted of cadaveric human or animal biomechanical studies evaluating ultimate failure load (in newtons) and the number of weaves, suture characteristics, tendon source, and number of coaptations. Weaves with minimum averages of 75 N were deemed successful, and those with greater than 120 N were considered high performing.
Results: A total of 347 tendon coaptations from 15 studies met inclusion criteria. Average strength by number of weaves was 36.4 N ( n = 52) for one weave, 54.2 N ( n = 58) for two weaves, 115.9 N ( n = 174) for three weaves, and 81.7 N ( n = 63) for four weaves. Statistical differences were observed between one and two weaves ( p < 0.0001); two and three weaves ( p < 0.0001); three and four weaves ( p < 0.003); and two and four weaves ( p < 0.0001). High-performing tendon transfers used three weaves, 3-0 or 4-0 braided sutures, and figure-of-eight or mattress core sutures.
Conclusions: Contrary to the current dogma of "the more the better," the authors' findings show that Pulvertaft weave strength is optimized when three weaves are used to combine donor and recipient tendons. Braided sutures with either figure-of-eight or mattress sutures were associated with the highest strength of repair.
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