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

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.

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).

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A. Viinikainen, H. Gransson, J. Ryhnen

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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Primary exor tendon repair techniques

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.

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

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,

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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

Mod. Kessler

Locking

3-0 polyesther

Simple run.

6-0 polyprop.

26

9.5

21 (2mm)

35

23

Mod. Pennington

Locking

3-0 polyesther

Simple run.

6-0 polyprop.

47 (initial)

68

Tsuge

Locking

4-0 loop polyesther

Simple run.

6-0 nylon

27

33

Mod. Kessler

Grasping
Locking
Locking

3-0 polyesther
3-0 polyesther
3-0 polyesther

Simple run.

6-0 polyprop.

48

6.4
6.8
11.8

20 (2mm)
25 (2mm)
57 (2mm)

38
46
68

16
16
23

Savage

Locking
Locking

3-0 polyesther
4-0 polyesther

Simple run.
Simple run.

6-0 polyprop.
6-0 polyprop.

45
50

12.5
11.4

56 (2mm)
36 (2mm)

68
56

23
23

Cruciate

Grasping
Grasping
Locking
Cross-stitch

4-0 polyesther
3-0 polyesther
3-0 polyesther
4-0 polyesther

Simple run.
Simple run.

6-0 polyprop.
6-0 nylon

5.9
6.7
10.2

44 (2mm)
20 (2mm)
22 (2mm)
52 (initial)

56
36
40
66

31
16
16
50

Double loop

Locking

4-0 loop nylon

Simple run.

6-0 polyprop.

41 (initial)

48

68

Mod. Kessler

Locking
Locking

3S 3-0 polyesther
3SB 3-0polyesther

Simple run.
Simple run.

6-0 polyprop.
6-0 polyprop.

44
55

10.3
10.8

47 (2mm)
58 (2mm)

53
66

25
25

Savage

Locking

4-0 polyesther

Simple run.

6-0 polyprop.

63

16.7

63 (2mm)

76

23

Mod. Becker

Locking
Locking
Locking

3-0 nylon
3-0 polyesther
3-0 polyethylene

Simple run.
Simple run.
Simple run.

5-0 nylon
5-0 nylon
5-0 nylon

48 (2mm)
58 (2mm)
60 (2mm)

69
82
124

24
24
24

Triple loop

Locking

4-0 loop nylon

Simple run.

6-0 polyprop.

56 (initial)

64

68

2-strand

4-strand

6-strand

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

Primary exor tendon repair techniques

337

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

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-

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.

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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A. Viinikainen, H. Gransson, J. Ryhnen

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.

Primary exor tendon repair techniques

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.
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Received: October 9, 2008