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Schellnegger M, Lin AC, Holzer-Geissler JCJ, Haenel A, Pirrung F, Hecker A, Kamolz LP, Hammer N, Girsch W. Biomechanical Comparison of Three Modified Kessler Techniques for Flexor Tendon Repair: Implications in Surgical Practice and Early Active Mobilization. J Clin Med 2024; 13:5766. [PMID: 39407826 PMCID: PMC11477230 DOI: 10.3390/jcm13195766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2024] [Revised: 09/16/2024] [Accepted: 09/23/2024] [Indexed: 10/20/2024] Open
Abstract
Objective: Managing flexor tendon injuries surgically remains challenging due to the ongoing debate over the most effective suture technique and materials. An optimal repair must be technically feasible while providing enough strength to allow for early active mobilization during the post-operative phase. This study aimed to assess the biomechanical properties of three modified Kessler repair techniques using two different suture materials: a conventional two-strand and a modified four-strand Kirchmayr-Kessler repair using 3-0 Prolene® (2s-KK-P and 4s-KK-P respectively), and a four-strand Kessler-Tsuge repair using 4-0 FiberLoop® (4s-KT-FL). Methods: Human flexor digitorum profundus (FDP) tendons were retrieved from Thiel-embalmed prosections. For each tendon, a full-thickness cross-sectional incision was created, and the ends were reattached using either a 2s-KK-P (n = 30), a 4s-KK-P (n = 30), or a 4s-KT-FL repair (n = 30). The repaired tendons were tested using either a quasi-static (n = 45) or cyclic testing protocol (n = 45). Maximum force (Fmax), 2 mm gap force (F2mm), and primary failure modes were recorded. Results: In both quasi-static and cyclic testing groups, tendons repaired using the 4s-KT-FL approach exhibited higher Fmax and F2mm values compared to the 2s-KK-P or 4s-KK-P repairs. Fmax was significantly higher with a 4s-KK-P versus 2s-KK-P repair, but there was no significant difference in F2mm. Suture pull-out was the main failure mode for the 4s-KT-FL repair, while suture breakage was the primary failure mode in 2s- and 4s-KK-P repairs. Conclusions: FDP tendons repaired using the 4s-KT-FL approach demonstrated superior biomechanical performance compared to 2s- and 4s-KK-P repairs, suggesting that the 4s-KT-FL tendon repair could potentially reduce the risk of gapping or re-rupture during early active mobilization.
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Affiliation(s)
- Marlies Schellnegger
- Division of Macroscopy and Clinical Anatomy, Gottfried Schatz Research Center, Medical University of Graz, 8036 Graz, Austria; (A.C.L.); (N.H.)
- COREMED—Cooperative Centre for Regenerative Medicine, Joanneum Research Forschungsgesellschaft mbH, 8036 Graz, Austria (L.P.K.)
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria; (J.C.J.H.-G.); (W.G.)
| | - Alvin C. Lin
- Division of Macroscopy and Clinical Anatomy, Gottfried Schatz Research Center, Medical University of Graz, 8036 Graz, Austria; (A.C.L.); (N.H.)
- Institute of Anatomy and Cell Biology, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Judith C. J. Holzer-Geissler
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria; (J.C.J.H.-G.); (W.G.)
| | - Annika Haenel
- Division of Macroscopy and Clinical Anatomy, Gottfried Schatz Research Center, Medical University of Graz, 8036 Graz, Austria; (A.C.L.); (N.H.)
| | - Felix Pirrung
- Division of Macroscopy and Clinical Anatomy, Gottfried Schatz Research Center, Medical University of Graz, 8036 Graz, Austria; (A.C.L.); (N.H.)
| | - Andrzej Hecker
- COREMED—Cooperative Centre for Regenerative Medicine, Joanneum Research Forschungsgesellschaft mbH, 8036 Graz, Austria (L.P.K.)
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria; (J.C.J.H.-G.); (W.G.)
| | - Lars P. Kamolz
- COREMED—Cooperative Centre for Regenerative Medicine, Joanneum Research Forschungsgesellschaft mbH, 8036 Graz, Austria (L.P.K.)
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria; (J.C.J.H.-G.); (W.G.)
| | - Niels Hammer
- Division of Macroscopy and Clinical Anatomy, Gottfried Schatz Research Center, Medical University of Graz, 8036 Graz, Austria; (A.C.L.); (N.H.)
- Department of Orthopedic and Trauma Surgery, University of Leipzig, 04103 Leipzig, Germany
- Division of Biomechatronics, Fraunhofer Institute for Machine Tools and Forming Technology IWU, 01187 Dresden, Germany
| | - Werner Girsch
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria; (J.C.J.H.-G.); (W.G.)
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Kang A, McKnight RR, Fox PM. Flexor Tendon Injuries. J Hand Surg Am 2024; 49:914-922. [PMID: 39093238 DOI: 10.1016/j.jhsa.2024.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 05/13/2024] [Accepted: 05/27/2024] [Indexed: 08/04/2024]
Abstract
Flexor tendon injuries are complex, and management of these injuries requires consideration of the surgical timing, injury location, approach, and soft tissue handling. Complications are common, including adhesions, tendon rupture, infection, and a high reoperation rate for zone 2 repairs. Special considerations are given to chronic ruptures, concomitant fractures, and pediatric cases. We discuss current concepts that may improve patient outcomes.
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Affiliation(s)
| | - Richard Randall McKnight
- Department of Orthopedic Surgery, Stanford University School of Medicine, Stanford, CA; Robert A. Chase Hand and Upper Limb Center, Stanford University Medical Center, Stanford, CA
| | - Paige M Fox
- Robert A. Chase Hand and Upper Limb Center, Stanford University Medical Center, Stanford, CA; Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, CA; Division of Plastic Surgery, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA.
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