Comparison of a suture technique with the modified Kessler method: Resistance to gap formation

doi:10.1016/0363-5023(94)90182-1

The Journal of Hand Surgery

Volume 19, Issue 5, September 1994, Pages 777-781

https://doi.org/10.1016/0363-5023(94)90182-1 Get rights and content

Abstract

We performed an in vitro study using canine flexor tendons to compare the tensile properties of a suture technique for flexor tendon repair with the standard modified Kessler technique. The technique employs a central wire loop that connects the two transverse limbs of the modified Kessler suture. Both techniques were studied with and without a Lembert epitendinous stitch. The technique combined with an epitendinous suture provided the strongest resistance to gap formation, and its load at gap initiation was 100% greater than the load in tendons repaired with the modified Kessler and an epitendinous suture. Because of its increased resistance to gap formation, this suture technique may provide a safer margin for controlled early active motion after flexor tendon repair.

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Cited by (42)

Astrocyte reactivity in spinal cord and functional impairment after tendon injury in rats
2021, Heliyon
Citation Excerpt :
Tendon was exposed through a posterior midline skin incision at the ankle. Afterwards, the tendon was totally transected from 0.5 cm above the calcaneal insertion followed by tendon suture in accordance to the Kessler method and simple skin suture (Barmakian et al., 1994). No immobilization, movement restriction or analgesy was utilized.
Astrocyte reactivity in the spinal cord may occur after peripheral neural damage. However, there is no data to report such reactivity after Achilles tendon injury. We investigate whether changes occur in the spinal cord, mechanical sensitivity and gait in two phases of repair after Achilles tendon injury. Wistar rats were divided into groups: control (CTRL, without rupture), 2 days post-injury (RUP2) and 21 days post-injury (RUP21). Functional and mechanical sensitivity tests were performed at 2 and 21 days post-injury (dpi). The spinal cords were processed, cryosectioned and activated astrocytes were immunostained by GFAP at 21 dpi. Astrocyte reactivity was observed in the L5 segment of the spinal cord with predominance in the white matter regions and decrease in the mechanical threshold of the ipsilateral paw only in RUP2. However, there was gait impairment in both RUP2 and RUP21. We conclude that during the acute phase of Achilles tendon repairment, there was astrocyte reactivity in the spinal cord and impairment of mechanical sensitivity and gait, whereas in the chronic phase only gait remains compromised.
Biomechanical comparison of different tendon suturing techniques for three-stranded all-inside anterior cruciate ligament grafts
2019, Orthopaedics and Traumatology: Surgery and Research
In all-inside anterior cruciate ligament (ACL) reconstruction, it is usually difficult to obtain sufficient autologous semitendinosus tendon length for quadruple stranded graft in Asians, females, and those with short stature. The purpose of this study was to compare biomechanical properties of three different types of suture preparations for tripled graft and determine which method could achieve sufficient strength for ACL through in vitro study. The hypothesis of this study was that suturing with a rip-stop (RS) stitch for tripled-strand graft would lead to stronger mechanical properties than suturing with buried-knot four sutures.
Twenty-four bovine digital extensor tendons harvested from forelimbs were prepared for tripled-strand graft in three different ways: (1) buried-knot four sutures, (2) two RS sutures, and (3) four RS sutures. These grafts were directly connected to cylindrical metal rods of a tensile testing machine. All specimens underwent cyclic loading followed by a load-to-failure test. Preparation time, elongation, stiffness, and ultimate failure load were compared.
For biomechanical comparison, the group with buried-knot four sutures was excluded because six (75%) specimens failed during the cycle load test. The group with four RS sutures showed lower total elongation (two RS sutures: 8.42 ± 5.28 mm; four RS sutures: 3.86 ± 0.83 mm, p = 0.030), higher stiffness (two RS sutures: 247.28 ± 53.39 N/mm; four RS sutures: 329.27 ± 55.56 N/mm, p < 0.001), and higher ultimate failure load (two RS sutures: 567.74 ± 60.50 N; four RS sutures: 736.46 ± 32.50 N, p = 0.009). The most common failure mechanism of triple stranded graft was tendon split across sutures.
The method with four RS sutures showed sufficient strength for triple stranded graft for all-inside ACL reconstruction without increasing preparation time.
III, controlled laboratory study.
Biomechanical evaluation of 4-strand flexor tendon repair techniques, including a combined kessler-tsuge approach
2015, Journal of Hand Surgery
Citation Excerpt :
To examine whether the epitendinous suture benefits the high-tension sector, we performed the core repairs with and without an epitendinous suture. We found no significant differences in terms of ultimate force, similar to previous reports20,26,27; the epitendinous repair failed before the core repair in each case. Many authors avoid the epitendinous suture in biomechanical testing to eliminate confounding variables.20,23
To test the ultimate tensile strength and stiffness of 3 flexor tendon repair techniques using looped suture material.
Seventeen fresh porcine flexor tendons were randomized to a single-throw, 4-strand Kessler technique with a looped structure, a double-throw, 4-strand Tsuge technique with 2 looped structures, or a single-throw, 4-strand Kessler–Tsuge technique with a looped structure. Thirty additional fresh porcine flexor tendons were randomized to the same techniques but with a running epitendinous repair. We measured ultimate tensile strength to failure and stiffness and recorded the cause of failure.
The Tsuge technique had the highest mean ultimate tensile strength at 75 N (SD, 14 N) versus 63 N (SD, 13 N) for the Kessler–Tsuge method and 46 N (SD, 11 N) for the Kessler technique. Differences between the Tsuge and Kessler–Tsuge, the Kessler–Tsuge and Kessler, and the Tsuge and Kessler techniques were significant. Mean suture stiffness was 6.8 N/mm for the Tsuge technique, 5.7 N/mm for the Kessler–Tsuge technique, and 4.6 N/mm for the Kessler technique. The difference between the Tsuge and Kessler techniques was significant. Analyzing the tests with or without an epitendinous suture separately did not affect the significance of the differences.
The modified double-throw, 4-strand Tsuge was the strongest suture technique in this study. It may be a clinically acceptable, albeit slightly weaker alternative to the more complicated Tsuge method.
A combined Kessler–Tsuge approach might be an option for flexor tendon repair.
Zone I flexor tendon rehabilitation with limited extension and active flexion
2005, Journal of Hand Therapy
Citation Excerpt :
These concepts are reviewed in detail elsewhere and are beyond the scope of this article.2,40 Guidelines for loading a flexor tendon repair with a conventional suture, two-strand core with an epitendinous suture110–114 have been formulated based on mathematical modeling of internal forces as they relate to joint position and external load with drag eliminated.40 For the purpose of that study,40 the wrist was positioned at 45 degrees extension to reduce the resistance of the antagonistic extensors while the digital joints were positioned in (1) the relaxed position, (2) the position of immediate active SAM, and, (3) the full-fist position.
This article describes an immediate active motion protocol for primary repair of zone I flexor tendons treated with tendon to tendon, or tendon to bone repair, and reviews clinical results. A rehabilitation protocol is proposed that will limit excursion of the zone I repair by blocking full distal interphalangeal (DIP) extension and by applying controlled active tension to both the unrepaired flexor digitorum superficialis (FDS) and the repaired flexor digitorum profundus (FDP). The rehabilitation technique utilized a dorsal protective splint with a relaxed position of immobilization with 30 degrees of wrist flexion, 40 degrees of metacarpophalangeal (MP) joint flexion, and a neutral position for the proximal interphalangeal (PIP) joints without dynamic traction. In addition, within the confines of the dorsal splint, the involved DIP joint was splinted at 40-45 degrees to prevent DIP joint extension during the early wound healing phases. Relaxed composite flexion was used to apply active tension to both the uninjured FDS, and the repaired FDP. This technique applies excursion of approximately 3mm to the zone I tendon in a limited arc (45–75 degrees). The modified position of active flexion applies low loads of force (< 500 g), even with drag considered. This technique is supported by previous mathematical studies of excursion and internal tendon force, and clinical experience. Forty nine cases treated over a 10-year period were reviewed, and eight were excluded for incomplete follow-up. The use of this protocol for 41 zone I flexor digitorum profundus repairs by 12 different surgeons using varied surgical techniques was evaluated. None of the tendon to tendon repairs used more than two suture strands for the core repairs. Mean total active range of motion was 142 degrees (PIP 95 degrees plus DIP 47 degrees), or 81% of normal. Three tendons ruptured in non–protocol-related incidents and were excluded from the study. Results from this clinical study support the use of limited DIP extension combined with active tension with conventional repair in zone I.
Flexor tendon biology
2005, Hand Clinics
Optimizing biomechanical performance of the 4-strand cruciate flexor tendon repair
2004, Journal of Hand Surgery
The purpose of this study was to determine whether increasing the size of the locking loop increased the repair strength of the cruciate 4-strand suture technique and to quantify the biomechanical properties that various peripheral suture techniques provide in the cruciate 4-strand suture technique.
Fifty-six deep flexor tendons harvested from adult sheep hind limbs were divided randomly into 7 groups of 8. Four groups were repaired using the cruciate core technique without a peripheral suture. The locking loops were set using 10%, 25%, 33%, or 50% of the tendon width and loaded to failure using a distraction rate of 20 mm/min. The 3 groups of tendons then were repaired by using the established optimal locking loop size. These 3 groups were combined with a simple running, cross-stitch, or the interlocking horizontal mattress (IHM) peripheral suture. Repairs were tested to failure and the load at a 2-mm gap, load at failure, and stiffness were determined for all samples.
Repairs with locking loops of 25% had the greatest biomechanical properties with load to 2-mm gap formation, load to failure, and stiffness of 10 N, 46.3 N, and 3.9 N/mm, respectively. Those with 33%, 50%, and 10% locking loops followed. Repairs with 10% locking loops failed owing to the suture cut out of the tendon. All other groups failed because of suture breakage. By using the cruciate core technique with a 25% locking loop the IHM/cruciate combination was markedly better than both the cross-stitch/cruciate and simple running/cruciate combinations.
The ideal-sized bite of the locking loops for the cruciate repair is 25% of the tendon’s width. Peripheral sutures are vital to the biomechanical properties of the repair. The IHM peripheral suture technique provided the greatest improvement in biomechanical properties.

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Original communicationComparison of a suture technique with the modified Kessler method: Resistance to gap formation☆

Abstract

Flexor tendon injuries: the results of primary repair

J Hand Surg

Flexor tendons: acute injuries

Controlled passive motion following flexor tendon repair in zone two and three

Elongation of the repair configuration following flexor tendon repair

J Hand Surg

Primary flexor tendon repair: the mechanical limitations of the modified Kessler technique

J Hand Surg

Bunnell's surgery of the hand

The “grasping” technique for tendon repair

Hand

Primary repair without immobilization of the flexor tendon division within the digital sheath

Acta Orthop Scand

Primary repair of flexor tendons

Orthop Clin North Am

A tendon suture which permits immediate motion

Boston Med Surg J

A method of tendon repair

Am J Surg

Ein Vorchlag zür Sehnennaht

Wien Klin Wochenschr

Original communication
Comparison of a suture technique with the modified Kessler method: Resistance to gap formation☆