A Further Modification

Abstract

Sir:FigureThere are many types of core suture; however, until recently, the modified Kessler stitch had been accepted widely as a standard method for repair of lacerated tendons. Ideally, flexor tendon repair should have smooth opposition of tendon ends with no bulge and minimal gap between tendons, and be sufficiently robust to withstand tension created by mobilization. Over the past decade, the two-strand repair has been superseded by four-strand repair as the norm in flexor tendon repair. There are a number of methods of performing a four-strand core suture using either one or two knots (e.g., Savage, cruciate, augmented Becker, double Kessler) (Fig. 1). We present a further method of performing a four-strand core suture, which is a modification of the previously widely used modified Kessler two-strand core suture.Fig. 1: The cruciate method of tendon repair.The technique involves starting in the middle of the cut tendon end and inserting a modified Kessler core. This will pass through only one lateral half of the tendon, thus apposing only this lateral half of the tendon. The surgeon then continues with the same suture to insert a further modified Kessler core suture into the unopposed half of the cut tendon ends. Once this second modified Kessler core suture has been inserted, either end of the suture will be in the middle of the tendon on opposite cut tendon ends. This completes the four strands and the suture is finally tied as a single knot to bridge the gap between the tendons (Fig. 2).Fig. 2: Schematic representation of the four-strand, single-knot, modified Kessler stitch.The strength of a repair is proportional to the number of strands that pass across the laceration.1 Four-strand techniques are approximately twice as strong as two-strand repairs1 and have proved to be clinically more reliable, allowing more aggressive early rehabilitation without a greater rupture rate.1,2 However, the complexity of many four-strand techniques makes them difficult to learn and may result in uneven tendon repairs. Studies have also shown that one-knot techniques for core sutures are better for tendon healing than two-knot techniques,3,4 being sufficiently small to not interfere with tendon healing or obstruct gliding beneath pulleys. The technique described allows for a four-strand repair; however, unlike a number of other techniques, this technique is easy to adopt, as it is a modification of a well-recognized two-strand repair. It allows for a single knot, unlike a four- or six-strand modified Kessler stitch, which results in two or three knots, respectively, meaning that a propensity for adhesions to form is reduced.5 It also reduces bunching and allows even distribution of tension across the tendon repair by means of using two evenly placed loops through the tendon on either side of the repair. The senior author has found that this technique provides reliable tendon repair and is simple to insert and easy to adopt when previously having used a modified Kessler core suture. Waseem Bhat, M.R.C.S. Sohail Akhtar, F.R.C.S.(Plast.) Department of Plastic and Reconstructive Surgery, Leeds General Infirmary, Leeds, United Kingdom DISCLOSURE The authors declare no conflict of interest (personal or financial) in the publication of this article.