Biomechanical Analysis of the Modified Kessler, Lahey, Adelaide, and Becker Sutures for Flexor Tendon Repair

Abstract

To compare the biomechanical properties of the modified Kessler, Lahey, Adelaide, and Becker repairs, which are marked by either a locking-loop or a cross-lock configuration. Ninety-six lacerated porcine flexor tendons were repaired using the respective core suture and an epitendinous repair. Biomechanical testing was conducted under static and cyclic loads. Parameters of interest were 2-mm gap formation force, displacement during different loads, stiffness, maximum force, and mode of failure. The meaningful gap formation occurred in all 4 repairs at similar tension loads without any significant differences. Maximum force was highest in the Becker repair with a considerable difference compared with the modified Kessler and Lahey sutures. The Adelaide repair showed the highest stiffness. Overall, the displacement during cyclic loading demonstrated similar results with an exception between the Lahey and the Adelaide repairs at 10 Nload. Failure by suture pull-out occurred in 42% in the modified Kessler, in 38% in the Lahey, and in 4% in the Adelaide repairs. The Becker repair failed only by suture rupture. The results of our study suggest that the difference between the 4-strand repairs with a cross-lock or a locking-loop configuration is minor in regard to gap formation. A strong epitendinous suture and the application of core suture pretension might prevent differences in gapping. However, the modified Kessler and Lahey repairs had an inferior maximum tensile strength and were prone to early failure caused by the narrow locking loops with their limited locking power. We suggest that surgeons should use pre-tension in repaired tendons to improve gap resistance and should avoid narrow locking loop anchoring to the tendon.