SCIENTIFIC ARTICLE

Biomechanical Analysis of the Modied Kessler,

Lahey, Adelaide, and Becker Sutures
for Flexor Tendon Repair
Martin C. Jordan, MD,* Vanessa Schmitt,* Hendrik Jansen, MD,* Rainer H. Meffert, MD,*
Stefanie Hoelscher-Doht, MD*

Purpose To compare the biomechanical properties of the modied Kessler, Lahey, Adelaide,
and Becker repairs, which are marked by either a locking-loop or a cross-lock conguration.
Methods Ninety-six lacerated porcine exor 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.
Results The meaningful gap formation occurred in all 4 repairs at similar tension loads without
any signicant differences. Maximum force was highest in the Becker repair with a
considerable difference compared with the modied 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
N load. Failure by suture pull-out occurred in 42% in the modied Kessler, in 38% in the
Lahey, and in 4% in the Adelaide repairs. The Becker repair failed only by suture rupture.
Conclusions The results of our study suggest that the difference between the 4-strand repairs
with a cross-lock or a locking-loop conguration 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 modied 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.
Clinical relevance 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. (J Hand Surg Am.
2015;-(-):-e-. Copyright 2015 by the American Society for Surgery of the Hand. All
rights reserved.)
Key words 4-strand repair, hand, reconstruction, suture, tendon.

*Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital,

Wuerzburg, Germany.
Received for publication April 8, 2015; accepted in revised form May 29, 2015.
No benets in any form have been received or will be received related directly or
indirectly to the subject of this article.
Corresponding author: Martin C. Jordan, MD, Department of Trauma, Hand, Plastic and
Reconstructive Surgery, University Hospital, Oberduerrbacher Str. 6, 97080 Wuerzburg,
Germany; e-mail: Jordan_M@ukw.de.
0363-5023/15/---0001$36.00/0
http://dx.doi.org/10.1016/j.jhsa.2015.05.032

PURPOSE
Many different kinds of suture techniques have been
introduced to pursue the aim of early active mobilization.1,2 The postoperative treatment is of great importance in order to avoid restricting adhesions and
to gain full excursion at the end of therapy.3,4 To allow
such a benecial mobilization, a highetensile strength
repair is required. In recent years, suture techniques
containing multiple core strands and different locking
congurations have been described to achieve a reliable

2015 ASSH

Published by Elsevier, Inc. All rights reserved.

MODIFIED SUTURES FOR FLEXOR TENDON REPAIR

FIGURE 1: Illustration of the different 4-strand repairs. A, The modied Kessler suture above and a porcine exor tendon repaired in the
same technique below.7 B, Lahey suture.8 C, Adelaide suture.9 D, Becker suture.12

repair strength.5 Despite an increasing knowledge

about the biomechanical behavior of such sutures, there
is no consensus about the ideal technique,1,6 and surgeons encounter a growing number of different repairs.
The purpose of this biomechanical study was to analyze
and compare the modied Kessler,7 Lahey,8 Adelaide,9
and Becker repairs10e12 regarding their primary tensile
strength. These techniques mainly vary in their locking
conguration, and we hypothesized that there would
be a signicant difference in gap formation force, stiffness, and displacement or maximum force between
the repairs.

the knot is buried inside the tendon.7,15 The knot lies in

the transverse component of the suture, and the suture is
anchored with 8 locking loops. Tendons of group 2 were
repaired with a 4-strand Lahey repair.8 The Lahey suture
is a cruciate repair with 8 locking loops. Tendons of
group 3 were repaired with a 4-strand Adelaide suture
(also known as cruciate cross-stitch locked repair or
locked cruciate repair).9 The Adelaide suture is a cruciate
repair with 4 cross-locks. Tendons of group 4 were
repaired with a 4-strand Becker suture (also known as
MGH repair).12 Twelve cross-locks can be found in the
modied Becker suture, which are either exposed or
embedded (Fig. 2). A core suture tendon purchase of
0.7 cm and a 10% shortening was used for all repairs to
ensure the best tensile strength.16e18 Three consecutive
throws were performed for the core and peripheral suture
knots. Anchor conguration was either a locking-loop
(modied Kessler and Lahey) with a size of 1 mm or a
cross-lock (Adelaide and Becker) with the corresponding size of 2 mm (Fig. 2).14,19,20 Each repair was combined with a peripheral suture (Fig. 3). The epitendinous
suture was a running locking suture with 2-mm tendon
purchase, slight tension, which crossed the repair zone
between 8 and 9 times. For all core sutures, a 3-0 polydioxanone (PDS, Ethicon, Somerville, NJ) was used,
and for all peripheral sutures, a 5-0 polydioxanone.
Polydioxanone is a monolament synthetic absorbable
suture material. The tendons were repaired by a trained
orthopedic surgeon (MCJ) experienced in tendon repair
techniques.

MATERIAL AND METHODS

Specimens
For this study, 96 fresh-frozen porcine exor digitorum
profundus tendons were used. Porcine exor tendons
have similar biomechanical properties to human exor
tendons and are frequently used for biomechanical
studies.13 Tendons from the forelimb were dissected
between the A2 and the A4 pulleys.14 All tendons were
measured to ensure equal sample size. Tendons with
deviating diameter or defects were excluded. Harvested
tendons were stored inside saline-soaked gauzes and
deep-frozen at e20
C. Before testing, tendons were
thawed at room temperature for 12 hours and a scalpel
was used to carefully create a defect in the middle of
each tendon. Throughout testing, tendons were kept
moist using saline spray to avoid desiccation.
Repair and material
Tendons were randomly assigned to 1 of 4 groups with
24 specimens per group. Group 1 tendons were repaired
with a 4-strand modied Kessler suture (Fig. 1), in which
J Hand Surg Am.

Biomechanical testing
Tests were conducted using a mechanical testing machine (Z020; Zwick/Roell GmbH, Ulm, Germany) and
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MODIFIED SUTURES FOR FLEXOR TENDON REPAIR

FIGURE 3: Epitendinous repair. A, Peripheral running, simplelocking suture was added to each core suture. B, Porcine exor
tendon repaired with a core and epitendinous suture.

30 N were applied. Load and displacement were continuously recorded to generate a load-displacement
curve. The length increase of the tendon was recorded from the load-displacement graph at the nal (four
hundredth) cycle of each load level.
Statistics
Investigated parameters were 2-mm gap formation
force (N), stiffness (N/mm), maximum force (N),
displacement (mm) at 10, 20, and 30 N and mode
of failure (pull-out vs rupture). A power analysis was
performed using a power of 80% that proved the sample
size to be adequate. Results are presented as mean value
including SD. The Shapiro-Wilk test was performed
to analyze the distribution. Analysis of variance with
Tukey post hoc test and the Kruskal-Wallis-test were
used for comparison of the means. A P value of less
than .05 was considered to be statistically signicant.

FIGURE 2: Different anchor techniques. A, Grasping loop

without locking conguration. B, Locking-loop conguration
with Pennington lock.29 C, Cross-lock conguration (exposed).
D, Cross-lock conguration (embedded).10,11,21

the test Xpert II software (Version 3.6, Zwick/Roell).

Pretesting up to 300 N achieved sufcient gripping of
the tendon ends without slipping. Uniaxial testing was
performed using a 20-kN load cell and 2 stainless steel
clamps. The distance between the 2 clamps was standardized with a gap of 3 cm. Tendon length of 1.5 cm
was clamped at each side. Two different test settings
were applied, a static (n 12) and a cyclic (n 12)
testing. The static test had 3-N preload and an advancement rate of 20 mm/min and was an axial load to
failure test. The 2-mm gap formation force, stiffness, and
maximum force were measured under static conditions
(Fig. 4). Stiffness (N/mm) was calculated as the slope of
the linear section of the load-displacement curve from
the initial loading portion of the test.
The cyclic loading protocol consisted of 3 levels.
First, each repair was loaded from 0 to 10 N at 20
mm/min for 400 cycles. Afterwards, another 400 cycles
from 0 to 20 N were conducted. If the repair withstood
this level without failure, another 400 cycles from 0 to
J Hand Surg Am.

RESULTS
2-mm Gap formation force
There was no difference in 2-mm gap formation force
among the 4 repairs (Fig. 5).
Maximum force
The mean maximum force for the Becker repair was
signicantly higher than for the Lahey and modied
Kessler repairs. The difference between the modied
Kessler, the Lahey, and the Adelaide repair did not
reach a signicant level (Fig. 5).
Stiffness
The Adelaide repair showed a statistically higher stiffness in comparison with all other suture techniques.
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MODIFIED SUTURES FOR FLEXOR TENDON REPAIR

FIGURE 5: Results for the different repairs. A, Tension force to

produce a 2-mm gap at the repair site and maximum force before
failure. B, The Adelaide suture exhibits a signicantly (P < .05)
elevated stiffness. C, There is no notable displacement during
cyclic testing between the repairs except for the Lahey and the
Adelaide suture at a tension level of 10 N (P < .01).

FIGURE 4: Biomechanical testing. A, Load-displacement graph

generated during static testing. A 2-mm gap generally occurred
before rupture of the epitendinous suture. B, Cyclic testing with
different load levels.

DISCUSSION
The results of our study indicate that the locking-loop
and cross-lock congurations affected the biomechanical behavior of the different repairs. More specically,
there were similarities in gap formation and displacement and differences in stiffness, maximum force, and
mode of failure.
The various locking congurations may have individual mechanical properties in end-to-end exor
tendon repair.1,21e23 Some of the previous studies
claimed a superior repair strength for the cross-lock
conguration;22,23 however, in our study, the gap
formation appeared in all tested repairs at a similar
tension force without a measurable difference between
the locking-loop and the cross-lock congurations.
This result is an extension to the nding of Xie and
Tang21 who demonstrated similar locking power for
the cross-lock and circle-lock component.

There was no difference between the remaining repairs

(Fig. 5).
Displacement
There was a signicant difference in displacement at
10 N between the Lahey and the Adelaide repairs. No
other signicant difference appeared during cyclic
loading under 10, 20, and 30 N.
Mode of failure
In the modied Kessler repair group, 10 out of 24
tendons failed by suture pull-out, and in the Lahey
group, 9 out of 24 failed in this manner. In the Adelaide group, 1 out of 24 failed by suture pull-out. The
Becker repairs all failed by suture rupture. The rupture
occurred between the tendon ends.
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MODIFIED SUTURES FOR FLEXOR TENDON REPAIR

The applied pre-tension or the core suture might

explain why there was no difference in gap formation
in our study. Wu and Tang18 reported that using suture
tension with a 10% shortening of the tendon area
encompassed by the core suture increased the resistance
to gap formation of the repair. It is possible that the
applied pre-tension prevented potential differences in
gap formation that would otherwise have been quantiable, even if this effect is controversial.22 Furthermore, we used a 3-0 core suture and a 5-0 epitendinous
suture, which are both stronger than the 4-0 and 6-0
sutures used by many surgeons.1,5,24,25 Throughout our
testing, the 2-mm gap consistently occurred before
failure of the epitendinous suture, which emphasizes
the important role of this additional suture in order to
avoid gap formation. Overall, our data suggest that the
previously described superiority of the cross-lock
component could be reversed by a strong epitendinous suture as has been suggested by Croog et al23
and by the application of core suture pre-tension. This
nding is supported not only by the 2-mm gap formation in our results but also by the similar displacement that represents the stability under repetitive load.
Despite the fact that our studied locking congurations did not differ in their resistance to gap formation, the repairs including locking loops were
marked by a higher rate of suture pull-out and less
maximum tensile strength. Hatanaka and Manske26
showed that there is a relationship between the size
of the locking-loop and the repair strength. Increasing
the tendon area encompassed by the locking loop
causes a proportional increase in maximum tensile
strength.26 In our study, especially the Lahey suture
had low repair strength that might be explained by the
narrow locking loops, which impair proper anchorage
to the tendon. The small locking loops with cross
diameter of 1 mm in the Lahey and modied Kessler
repair were further narrowed by the applied pretension of the core suture. Peltz et al27 demonstrated
that a loss of the loop conguration was caused by
axial tension under radiographic control. This might
aggravate anchorage of the suture to the tendon. While
using such small locking loops, it is further difcult to
ascertain the exact location of the transverse and
longitudinal suture, thus it might rather be a grasping
loop instead of a locking loop with less holding capacity. Therefore, the Lahey repair, including its
narrow locking loops, seems to be the less favorable
repair of our tested techniques. The same problem
applies to the modied Kessler suture that has also
small locking loops and likewise low repair strength.
Because the modied Kessler and Lahey repairs are
both locking loop and have a small lock size, we are
J Hand Surg Am.

unsure whether 1 or 2 of these factors lead to the

inferior mechanical performance. According to the
result of Xie et al,19 a locking size of 1 mm produced
signicantly lower locking strength than a repair
showing a locking size of 2 or 3 mm. Therefore, the
small lock size can be considered a factor that leads to
lower strength in these 2 repair methods in our study.
Nevertheless, we cannot state whether the locking
loop is the cause of lower strength because the repairs
including locking loops tested here both had a small
diameter, and small diameter has been proven to lead
to lower strength.
Beside the locking diameter, we found that the
number of anchor points can also raise the maximum
strength as seen in the Becker repair with its 12 cross
locks. Still, the maximum tensile strength is a less
important parameter because it appears far beyond
the gapping. The Adelaide repair stands out by only
a small amount of displacement, high stiffness, and
almost no suture pull-out. Therefore, we found it to be a
reliable suture technique. However, a clear recommendation cannot be made because all repairs demonstrated sufcient repair strength.28 Furthermore, this
study is a biomechanical analysis in a nonhuman
model, and it can be questioned if our results show a
clinical difference. Factors like friction, bulk, or adhesions were not addressed. The number of repetitive
loads during our cyclic testing is limited and does not
present the full course of mobilization until healing.
ACKNOWLEDGMENT
The authors thank the IZKF (Interdisciplinary Center
for Clinical Research, University Clinics of Wuerzburg) for supporting our biomechanical studies and
Alice K. Jordan for writing assistance.
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