Scandinavian Journal of Surgery 97: 333340, 2008

PRIMARY FLEXOR TENDON REPAIR TECHNIQUES

A. Viinikainen1, H. Gransson2, J. Ryhnen3
1 2 3

Department of Hand Surgery, Helsinki University Central Hospital, Helsinki, Finland Department of Hand and Microsurgery, Tampere University Hospital, Tampere, Finland Department of Hand Surgery, Oulu University Hospital, Oulu, Finland

Key words: Flexor tendon repair; tendon sutures; core suture; peripheral suture; gap formation; yield force; tensile strength; suture techniques; suture materials

FLExOR TENDON FORCES The postoperative forces subjected to the tendon repair depend on the rehabilitation technique used. Flexor tendon forces have been investigated in healthy tendons at the wrist level during carpal tunnel release (1, 2). The mean force during active extension and passive exion has been reported between 29 N and between 219 N during active unresisted exion. Increasing wrist and metacarpophalangeal joint exion enhances exor tendon forces during active interphalangeal exion (1). Also static exed nger position (holding exercise) creates a higher FDP force than dynamic extension-exion movement (1). The actual postoperative exor tendon forces have been estimated to be 50% higher (3) than the forces measured in healthy tendons due to factors increasing tendon gliding resistance and work of exion. In the normal state the gliding resistance of the human exor tendon is on the average 0.27 N (4). All tendon repair methods have been shown to increase the gliding resistance signicantly compared to intact tendon. The number of exposed suture loops and knots outside on the tendon surface, the suture calibre, and the suture material correlate with the increased gliding resistance (4, 5). In addition to the suture technique, also tissue oedema due to injury to the subcutaneous tissue and tendon sheath increases the gliding resistance and work of exion in vivo (6). Immediate mobilization increases the gliding resistance and work of exion more than initial immobilization during the rst ve postoperative days (6). Thus, a period of initial immobilization has been suggested

to decrease the forces subjected to the repair during early rehabilitation. REPAIR STRENgTH Initially the strength of tendon repair depends only on the properties of the repair technique. Postoperatively tenomalacia may develop at the suture-tendon junction decreasing initial repair strength (7). With immobilization the strength of the tendon repair has been shown to decrease signicantly within the rst three weeks of healing (8). However, early passive (9) and especially early active motion (8, 10, 11) have been shown to prevent the initial weakening leading to progressively increasing repair strength starting from the time of repair. The initial strength of the repair depends on the material properties and knot security of the sutures as well as on the holding capacity of the suture grips of the tendon. The biomechanical properties of the suture depend on the material itself and can be improved by increasing the number of strands crossing the repair site (12) and the suture calibre (13, 14). The holding capacity of the repair of the tendon depends on the conguration (12, 1517), size (18, 19), and number (20) of the grips. The exor tendon repair can be regarded as a composite of the core and the peripheral sutures (21, 22) with both inuencing signicantly the repair strength. Lotz et al. (21) showed that in a repair consisting of the 2-strand modied Kessler 4-0 core suture and simple running 6-0 peripheral suture, the applied load was carried from 64% to 77% by the peripheral suture at its point of rupture. After failure of the peripheral suture the total force is transferred onto the core suture. If the holding capacity of the core suture is exceeded, but not its material strength, the repair may still increase in strength with concomitantly progressing gap formation (21, 23). Ultimate failure nally occurs either by suture pullout or, if the holding capacity of the suture grips of the tendon exceeds the material strength, by suture breakage (14, 23, 24).

Correspondence: Anna Viinikainen, M.D. Department of Hand Surgery Helsinki University Central Hospital P.O. Box 266 FIN - 00029 HUS Helsinki, Finland Email: anna.viinikainen@hus.

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According to Lotz et al. (21), the ultimate strength of the core suture is actually irrelevant to the overall strength of the repair composite because of the stiffness imbalance between the core and the peripheral suture leading to overloading and rupture of the weaker peripheral suture. Hence, the stiffness and strength of the core and peripheral suture should be modied to balance load-sharing within the repair composite. Static tensile testing studies have usually focused on the failure region of the load deformation curve and have considered the ultimate force as the strength of the repair (Table 1). However, at ultimate point the disruption of the repair has already started, and a gap of several millimetres often already exists at the repair site (21, 23). The failure of the peripheral suture has been shown to occur in the proximity of the yield point of the load deformation curve triggering increasing gap formation at the repair site (23, 25). Thus, the yield force can be considered the maximum strength of the intact repair composite. It can be assumed that should the repair remain intact during rehabilitation, the forces subjected to the repair should not exceed its yield force. CORE SUTURES
NUMBER OF STRANDS

Two-strand repair techniques (Fig. 1) have been generally used in exor tendon repair. The strength of the locking conguration of the modied Kessler repair (27) (also called as the Pennington modied Kessler or Pennington repair) (Fig. 1C, Table 1) is strong enough to withstand the forces of passive rehabilitation, but not early active motion, clinically seen as increased rupture rates (28). The modied Pennington conguration (Fig. 1D) has been intro-

Fig. 1. Two-strand repair techniques. A: Tsuge (26), B: Modied grasping Kessler, C: Modied locking Kessler (i.e. Pennington modied Kessler (27)), D: Modied Pennington (18).

duced by Hatanaka and Manske (9, 18) to increase repair strength. The rst multi-strand repair was introduced by Savage (12) who incorporated six suture strands across the repair site (Fig. 2F) and demonstrated improved gap resistance and ultimate force, sufcient to withstand the estimated forces of early active motion (29). Several investigators have studied multistrand techniques with 4- and 6-strand core sutures performed with single-stranded suture (Fig. 2). These techniques have demonstrated improved gap and ultimate forces compared to various 2-strand techniques in static tensile testing and increased gap resistance and fatigue strength in cyclic tensile testing (13, 36). However, most these studies have compared techniques with multiple variables, e.g. the number of strands, suture material, suture conguration, or suture calibre, at the same time. The effect of increasing the number of strands by performing multiple similar but separate core sutures has been investigated in only few congurations. The 4- and 6-strand modied Kessler (Fig. 2A, H) (23, 30, 37), Savage (Fig. 2D, g) (23, 38), and Tsuge (Fig. 3A, B) (39, 40) repairs have demonstrated improved gap and ultimate forces compared to the respective 2strand techniques (Table 1). Increasing the number of strands also improved the yield force and stiffness in the Pennington modied Kessler and Savage repairs (23, 41) (Table 1). These improved biomechanical properties are probably due to both the higher material strength and improved holding capacity of the repair technique of the tendon as the number of separate suture grips increases along with the number of strands. Also double-stranded sutures (i.e. loop or looped suture) have been used to perform multi-strand repairs (Fig. 3). Most these techniques are multi-strand modications of the Tsuge repair (Fig. 1A). Barrie et al. (32) evaluated the inuence of increasing the number of strands from four to eight by using either single- or double-stranded suture in the cruciate nonlocked and cruciate cross-stitch locked congurations. Although the material strength increased, gap resistance did not improve. Multi-strand repairs are technically demanding in clinical settings requiring multiple subsequent needle passes that increase tendon handling and easily lead to uneven loading of the strands. Thus, multiple concomitantly passed suture strands have been investigated in the aim to improve the holding capacity with a simpler repair technique (25, 41). Two different coated braided polyester triple-stranded sutures [the strands either remaining free (triple-stranded suture) or bound parallel to each other to form a ribbon-like structure (triple-stranded bound suture)] were developed and used in the Pennington modied Kessler conguration, thus producing two different 6-strand repairs with the technical performance of a 2-strand repair (Fig. 4). Both these 6-strand repairs reached improved stiffness, yield force, gap forces, and ultimate force compared to the Pennington modied Kessler repair performed with conventional singlestranded suture (23) (Table 1). Furthermore, the triple-stranded bound suture improved the strength of

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Fig. 2. Multi-strand core suture techniques performed with single-stranded suture. A: Double modied locking Kessler (30), B: Cruciate non-locked (31), C: Cruciate cross-stitch locked (32), D: 4-strand Savage (33), E: Augmented Becker (also called as MgH repair) (34), F: 6-strand Savage (12), g: Modied Savage (35), H: Triple modied Kessler (30).

3S

3SB

Fig. 3. Multi-strand core suture techniques performed with doublestranded suture. A: Double loop suture (39), B: Triple loop suture (39), C: Lim (42), D. Yoshizu (40).

Fig. 4. The Pennington modied Kessler repairs performed with the coated braided polyester triple-stranded suture and triplestranded bound suture.

the repair compared to the repairs performed with the triple-stranded suture. This was considered to be due to the at structure of the triple-stranded bound suture enhancing the holding capacity of the locking loops of the tendon repair through increased contact in the suture-tendon interface. Further investigations are needed to evaluate the inuences of the repair method on the gliding resistance in situ and tendon healing in vivo.
LOOP CONFIgURATION

Pennington (27) rst described the precise relation of the longitudinal and transverse strands in the grasping and locking modied Kessler repairs (Fig. 1B, C,

and Fig. 5). Several studies have demonstrated that locking loops improve the ultimate force and gap resistance compared to grasping loops in exor tendon repair (9, 15, 16, 32). The biomechanical advantages of the locking loops are obtained only with 3-0 or heavier core suture (9, 14). With 4-0 suture the material strength is inferior to the holding capacity of the suture grips of the tendon leading to failure by suture rupture before the true biomechanical properties of the locking loops are obtained. Locking congurations differ in the tendon-suture interface and can be categorized into two groups (17): circle-locks [e.g. the modied locking Kessler (27), circle-loop models (17), and the loops located in the Tsuge repair (26) and its multi-strand modications

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A. Viinikainen, H. Gransson, J. Ryhnen TABLE 1

Examples of ex vivo static tensile testing results of exor tendon repairs.

Core technique

Locking/ grasping

Core suture

Peripheral technique

Peripheral suture

Yield force (N)

Stiffness (N/mm)

Gap force (N)

Ultimate force (N)

Reference

2-strand Mod. Kessler Mod. Pennington Tsuge 4-strand Mod. Kessler Grasping Locking Locking Locking Locking Grasping Grasping Locking Cross-stitch Locking 3-0 polyesther 3-0 polyesther 3-0 polyesther 3-0 polyesther 4-0 polyesther 4-0 polyesther 3-0 polyesther 3-0 polyesther 4-0 polyesther 4-0 loop nylon Simple run. Simple run. Simple run. Simple run. Simple run. Simple run. 6-0 polyprop. 6-0 polyprop. 6-0 polyprop. 6-0 polyprop. 6-0 nylon 6-0 polyprop. 48 45 50 6.4 6.8 11.8 12.5 11.4 5.9 6.7 10.2 20 (2mm) 25 (2mm) 57 (2mm) 56 (2mm) 36 (2mm) 44 (2mm) 20 (2mm) 22 (2mm) 52 (initial) 41 (initial) 38 46 68 68 56 56 36 40 66 48 16 16 23 23 23 31 16 16 50 68 Locking Locking Locking 3-0 polyesther 3-0 polyesther 4-0 loop polyesther Simple run. Simple run. Simple run. 6-0 polyprop. 6-0 polyprop. 6-0 nylon 26 9.5 21 (2mm) 47 (initial) 35 68 27 23 9 33

Savage

Cruciate

Double loop 6-strand Mod. Kessler

Locking Locking Locking Locking Locking Locking Locking

3S 3-0 polyesther 3SB 3-0polyesther 4-0 polyesther 3-0 nylon 3-0 polyesther 3-0 polyethylene 4-0 loop nylon

Simple run. Simple run. Simple run. Simple run. Simple run. Simple run. Simple run.

6-0 polyprop. 6-0 polyprop. 6-0 polyprop. 5-0 nylon 5-0 nylon 5-0 nylon 6-0 polyprop.

44 55 63 -

10.3 10.8 16.7 -

47 (2mm) 58 (2mm) 63 (2mm) 48 (2mm) 58 (2mm) 60 (2mm) 56 (initial)

53 66 76 69 82 124 64

25 25 23 24 24 24 68

Savage Mod. Becker

Triple loop

The size of the gap at the measured force in parentheses. Mod. = modified, 3S = triple-stranded, 3SB = triple-stranded bound, simple run. = Simple running, polyprop. = polypropylene.

(39, 42)] and cross-locks [e.g. the augmented Becker (34), Savage (12), modied Savage (35), and crossstitch cruciate (32)]. The cross-locks are further divided into exposed and embedded, which both are present e.g. in the Savage technique. The circle-locking loops and either exposed or embedded crosslocks have not been shown to differ signicantly in regard to gap or ultimate forces (17). The size of the locking loop inuences the biomechanical properties of the repair technique (18, 19, 43). In the modied Pennington technique increasing the cross-sectional area of each loop from 5% to 15% improved the ultimate force, while further increase did not improve strength and the tendency for gap

formation increased (18). In the 4-strand cruciate repair the locking loops of 25% reached the highest gap force, ultimate force, and stiffness (43).
CORE SUTURE PURCHASE

The length of the core suture purchase determines the segment of the tendon incorporated into the repair. Several investigators have examined 2- and 4- strand locking and grasping congurations and the optimal range of core suture purchase has been determined as 1.0 cm with increased gap force, ultimate force, and stiffness (44, 45). The purchase of 0.4 cm resulted in signicantly weaker repairs, while further increase

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over 1.0 cm did not improve the biomechanical properties (45).

VOLAR VERSUS DORSAL PLACEMENT OF SUTURES

Previously, the volar placement of sutures was favored to avoid injury to the dorsally raising vasculature of the exor tendons. As diffusion from the synovial uid has been shown to be the major nutrient pathway in all parts of the tendon (46), dorsal placement of sutures has also been advocated. In an in situ testing model dorsally placed core sutures reached signicantly higher breaking strength compared to volar suture placement which was considered to be due to the biomechanics of the joint and pulley system creating palmar compression and dorsal distraction at the repair (47).
PLACEMENT OF THE KNOTS

The location and number of knots have been shown to inuence the strength of the tendon repair (12, 38, 48). Ex vivo decreasing the number of knots and placing them outside the repair on the tendon surface increases the strength of the repair compared to knots placed between the tendon ends. In vivo, however, the knots-inside repairs were signicantly stronger compared to the knots-outside repairs after six weeks, and an increase in the amount of suture material up to 26% of the tendon cross-sectional area did not have any deleterious effects on the tensile strength of the repairs (48).

SUTURE CALIBRE

Despite numerous investigations on the tendon repair techniques, only a few have focused on the effect of the suture calibre on the biomechanical properties of exor tendon repairs. Increasing the suture calibre has been shown to increase the ultimate force in static testing (9, 14, 23, 49) and fatigue strength in dynamic testing (13). However, it has not been shown to improve the yield force or gap resistance of the repairs (23, 49). The strength of the 4-0 suture has been reported to be less than the holding capacity of several locking and grasping repair techniques with failure occurring predominantly by suture rupture (13, 14, 19, 23, 44, 50). With 3-0 suture failure both due to suture rupture and pullout has been reported (9, 13, 14, 16, 23, 24). The use of 3-0 suture has been recommended to offer a margin of safety for the tendon repair through increased material strength (9, 13, 14), but it does not improve the strength of the intact repair composite (23).
SUTURE MATERIALS

Fig. 5. Schematic drawing of the locking and grasping loops. In the grasping loop, the loop opens when tension is applied to the suture ends. In the locking loop the suture tightens around the tendon bres when loaded.

The ideal suture material for exor tendon repair should be strong enough; inextensible to prevent gapping; easy to use and knot, with good knot holding capacity; absorbable, but maintains its tensile proper-

ties until tendon repair has achieved adequate strength; and have minimal tissue response (51). Earlier stainless steel was used as core suture material due to its superior tensile strength and good tissue properties but was abandoned because it was difcult to handle. Recently, a promising new metal suture, Nitinol (NiTi), has been introduced as a possible new tendon repair material (52). NiTi is a shape memory alloy with high strength and stiffness comparable to those of stainless steel, but has better handling properties. Non-absorbable synthetic sutures, especially coated braided polyester, monolament nylon, and monolament polypropylene all have good biocompatibility and are today used in exor tendon repair. Coated braided polyester suture is the most common core suture material, though nylon is also used, especially in repairs performed with looped suture. Monola-

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Fig. 6. Peripheral suture techniques. A: Cross stitch (60), B: Lin (66), C: Halsted (64), D: Horizontal intraber (67), E: Simple running (63), F: Simple running supercial and simple running deep (65).

ment polypropylene is mainly used in the peripheral sutures. Coated braided polyester suture demonstrates signicantly higher tensile strength and stiffness compared to monolament nylon and polypropylene sutures and maintains its tensile properties in the body temperature while the stiffness of both polypropylene and nylon suture has been shown to decrease signicantly (50, 51, 53). In ex vivo exor tendon repair coated braided polyester suture provides better gap resistance and increases repair stiffness compared to monolament polypropylene and nylon (50). The disadvantage of the coated braided polyester suture is the poor knot holding capacity requiring ve square throws per knot to prevent slippage (54). Also a braided polyblend polyethylene suture (Fiberwire) has been introduced for exor tendon repair. The polyblend polyethylene suture has signicantly higher ultimate force and stiffness compared to coated braided polyester, monolament nylon, and polypropylene sutures, and a similar ultimate force but higher stiffness compared to braided stainless steel (24, 50). In ex vivo exor tendon repair the polyblend polyethylene and braided stainless steel repairs reached signicantly higher ultimate force and stiffness compared to coated braided polyester and especially nylon and polypropylene repairs. The gap resistance of the polyblend polyethylene repairs did not improve compared to coated braided polyester repairs (24, 50). Bioabsorbable suture materials have not been widely used in exor tendon repair due to lack of sufcient tensile strength half-life and fear of increased tissue reaction and adhesion formation. In canine exor tendon repair with active mobilization the polydioxanone repairs decreased signicantly in strength already during the rst two weeks and were signicantly weaker compared to coated braided polyester repairs during the six-week follow-up (10). Furthermore, in biomechanical testing ex vivo, both polydioxanone (PDS) and polyglycolide-trimethyl-

ene carbonate sutures (Maxon) have signicantly higher elasticity compared to non-absorbable coated braided polyester suture (55) making them biomechanically less suitable for exor tendon repair. Histologically, an increased inammatory reaction was found around the polydioxanone compared to polyester sutures, but no inuence on adhesion formation was detected. The bioabsorbable poly-L/D-lactide (PLDLA) 96/4 has recently been suggested a novel suture candidate for exor tendon repair with long enough tensile strength half-life of 1013 weeks in vitro and retaining over 75% of its tensile strength after 6 weeks of subcutaneous implantation in vivo (56). In the rabbit Achilles tendon implanted PLDLA suture demonstrated good biocompatibility with formation of a signicantly thinner brous tissue capsule and fewer inammatory cells compared to polyglyconate suture (Maxon) during a 12 week follow-up (57). The biomechanical properties and knot holding capacity of the PLDLA suture are good considering exor tendon repair (54).
TENDON REPAIR DEVICES

Several tendon repair devices have been developed with the aim to meet the biomechanical needs of active mobilization. Mersilene mesh sleeve attached with cross-stitch peripheral sutures, Dacron splint attached either internally or dorsally, and an internal stainless steel anchor reached higher repair strength but were not suitable for clinical use (5860). A device with two intratendinous stainless steel anchors joined by a single multilament 2-0 stainless steel suture (Teno Fix) has been investigated both experimentally and clinically but its clinical benets are questionable (61, 62). Until today none of the tendon repair devices that have been developed has become into common use in exor tendon repair.

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PERIPHERAL SUTURE TECHNIqUES Originally the circumferential epitendinous suture was considered merely a tiding up suture to improve tendon gliding within the sheath (63). Later it has been shown to improve the gap resistance and ultimate force of the repair (64). As many new, stronger epitendinous suture techniques grasp not only the epitenon but also the tendon substance, the term peripheral suture has become widely used. The simple running peripheral suture (Fig. 6E, F) is the most investigated and used technique in exor tendon repair with simple technical performance. The strength and stiffness of the running peripheral suture can be increased with deeper suture grasps (21, 65), by increasing suture purchase from 1 mm to 2 mm or 3 mm (22), and by increasing the number of suture passes (20). Also several new but more complicated peripheral sutures have been developed and have demonstrated improved gap resistance, stiffness, and ultimate force of the tendon repair (20, 60, 66, 67). The cross-stitch (60), Lin running locking (66), Halsted (horizontal mattress) (64), and horizontal intrabre (67) methods with their variations have shown to be the strongest, but the complexity of many of these techniques limits their clinical application. REFERENCES
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Received: October 9, 2008