Re: Wu YF and Tang JB. The impact of transverse components on resistance and ultimate strength of 6-strand tendon repairs. J Hand Surg Eur. 2021

Abstract

We read this article with great interest. As the authors point out, previous studies have shown that narrowing of the transverse part of the Kessler-type suture and changes in the three-dimensional geometry contribute to elongation of the longitudinal strands. In turn, this causes gapping (Peltz et al., 2010; Walbeehm et al., 2009). The Yoshizu #1 repair includes the commonly used Kessler–Pennington and Tsuge techniques (Moriya et al., 2015), which employ two transverse parts at both tendon ends. Thus, the Yoshizu #1 repair may be weak, as stated in the article. Our major concern is: at what point were the Kessler–Pennington corners tightened when Dr Wu performed the Yoshizu #1 repair? After placement, we always complete the Kessler–Pennington suture before the Tsuge suture. At this time, all Kessler– Pennington locking loops should be tightened in turn and the core suture tightly tied so that slight bunching is evident at the junction, as Pennington (1979) described. We believe that this is essential to prevent further elongation and gapping during early loading after tendon repair, when the locking configuration of the corner loop containing the transverse component is placed under stress. If the four locking corners are finally tightened together, the tension tends to be unevenly distributed among the corners, deforming the geometry of the Kessler–Pennington repair. The article under discussion and previous reports on tendon deformation by the core suture of Kessler-type sutures did not mention this problem (Peltz et al., 2010; Walbeehm et al., 2009). We are also concerned about the corner configuration used. The grasping configuration is likely to trigger transverse narrowing and tendon deformation (Walbeehm et al., 2009). This concern is not mentioned in Dr Wu’s article. As the article points out, the Yoshizu #1 repair requires a standard peripheral suture to ensure safe, early active mobilization following primary flexor tendon repair. We thank Drs Wu and Tang for choosing the Yoshizu #1 repair as a survey subject. We plan to develop a new suture technique that is more effective than the Yoshizu #1 repair.