History and Nomenclature of Multistrand Repairs in Digital Flexor Tendons

History and Nomenclature of Multistrand Repairs in Digital Flexor Tendons

SURGICAL TECHNIQUE History and Nomenclature of Multistrand Repairs in Digital Flexor Tendons Robert Savage, MS,* Jin Bo Tang, MD† Multistrand core su...

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SURGICAL TECHNIQUE

History and Nomenclature of Multistrand Repairs in Digital Flexor Tendons Robert Savage, MS,* Jin Bo Tang, MD† Multistrand core suture repairs have become the mainstay of digital flexor tendon repair in recent decades. Here we briefly describe the history of the development of these multistrand repair methods and their correct nomenclature. A historical account, their evolution, the correct use of nomenclature, and some technical points are reviewed. (J Hand Surg Am. 2015;(-):-e-. Copyright Ó 2015 by the American Society for Surgery of the Hand. All rights reserved.) Key words Flexor tendon repair technique, historical account, evolution, nomenclature.

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ULTISTRAND CORE SUTURE REPAIRS,

4- or 6strand repairs in particular, have become the mainstay of digital flexor tendon repair in recent decades.1e4 An astonishing number of research articles and clinical reports have involved these new methods, such that the naming of repairs is sometimes confusing and occasionally misused. Here we briefly describe the history of the development of these multistrand repair methods and their nomenclature.

HISTORICAL ACCOUNTS AND NOMENCLATURE OF SAVAGE AND TANG REPAIRS In 1985, Savage2 described a 6-strand repair and the mechanics of 3 types of suture anchor points. He used this to describe the part of tendon which the suture attempts to grip, and also discussed, described, and illustrated how the best of the 3 anchor points, with accompanying paired sutures, could make a 6-strand repair. Savage tested both an interrupted 6-strand repair and a continuous 6-strand repair. These repairs are referred to as the Savage repair. In 1996, Sandow and McMahon3 reported a modification of Savage’s 6-strand repair: a 6-strand repair using a single-cross From the *Department of Orthopaedic Surgery, Royal Gwent Hospital, Newport, United Kingdom; and the †Department of Hand Surgery, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China. Received for publication February 23, 2015; accepted in revised form November 15, 2015. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Jin Bo Tang, MD, Department of Hand Surgery, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China; e-mail: [email protected]. 0363-5023/15/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2015.11.012

anchor point, which required fewer needle passes to complete. It was simplified to a 4-strand repair using the same single-cross grasp from 1996 onward: effectively a 4-strand modified Savage repair now known as the Adelaide repair. In 1991, Tang and Shi5 reported a 6-strand repair that combined the principle of 6 strands described by Savage2 with the simplicity of the repair by Tsuge et al.6 This technique was published in the English literature in 19927 and 1994,1 respectively. As we understand it, Tang and Shi’s version of the 6-strand repair has become known as the Tang repair, not the Tsuge repair, which describes a 2-strand repair. Over 40 years later, the terms “Kessler repair” (or “modified Kessler”) and “Tsuge repair” (or “suture”) describe 2-strand repairs. When 2 such sutures or repairs are put together to make 4-strand repairs, they are called “double Kessler” or “double Tsuge,” respectively. Sixstrand repairs using their elements are arranged in a particular fashion that has a specific name after the designer or a terminology to specify the design.8,9 A more recent evolution of the Tang repair is the MTang repair,4,8 which is also a 6-strand repair but is made with 2 looped sutures rather than 3 looped sutures as in the Tang repair. The M-Tang repair is currently the method one of us (J.B.T.) most commonly uses. ILLUSTRATIONS AND TECHNICAL POINTS OF SAVAGE AND TANG REPAIRS Here, we illustrate the repairs of Savage (Fig. 1A) and Tang (Fig. 1B) and the Adelaide repair of Sandow (Fig. 1C), which is a 4-stranded version of the 6-strand single-cross grasp repair.4 Figure 2 illustrates the

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Published by Elsevier, Inc. All rights reserved.

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MULTISTRAND REPAIRS IN DIGITAL FLEXOR TENDONS

FIGURE 1: A Savage 6-strand repair using a continuous suture with 3 anchor points (AP) in each tendon. The transverse section shows the location of anchor points around the tendon. B Tang 6strand repair using 3 Tsuge sutures. Anchor point placement and orientation around the tendon are the same as for the Savage repair. C Adelaide 4-trand repair using 2 single-cross grasp anchor points in each tendon end. With the permission of Sage Publishers. Redrawn from the original article.

configuration of the M-Tang repair and the step-bystep surgical method. To make these repairs, we maintain that suture purchase needs to be sufficient (7e10 mm) in each tendon stump. A certain tension within the sutures placed across the repair helps to resist gaps: tension-free repair should be avoided. Suture anchor points should have sufficient size ( 2 mm in diameter); otherwise the anchor point will not be secure. We believe that it is not possible to achieve no suture bulkiness during tendon repair. In fact, repaired tendons tolerate slight roughness and bulk at the repair site, but marked bulkiness at the repair site and deformity or twisting at the repair site should always be avoided.

FIGURE 2: AeE Configuration of the M-Tang repair and stepby-step surgical method.

TABLE 1. Descriptions Several Essential Tendon Repair Techniques and Their Differences Repair Nomenclature

IMPORTANCE OF CORRECT USE OF TENDON REPAIR NOMENCLATURE We believe that an appropriate embellishment to some prior review articles9,10 would be useful for readers, to avoid confusion. For clarity and future reference, we summarize the nomenclature of these tendon repair methods, which are in active clinical use or of important historical influence, in Table 1. J Hand Surg Am.

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Suture Description

Strands

Kessler or modified Rectangular suture in version tendon

2

Double Kessler

2 groups of Kessler repair

4

Tsuge

Repair using looped suture

2

Double Tsuge

2 groups of Tsuge repair

4

Savage

6-strand using Savage anchor point

6

Adelaide (modified Savage)

4-strand with single cross anchor point

4

Tang

6-strand made with 3 looped sutures

6

M-Tang

U-shaped suture plus Tsuge repair

6

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MULTISTRAND REPAIRS IN DIGITAL FLEXOR TENDONS

Editor’s note: I thank both Drs Savage and Tang for adding their collective wisdom and experience to this confusing array of nomenclature for flexor tendon repairs. As they point out, the mechanism and biomechanical properties of the repair may be more important than the specific name appended. However, when using an eponym, it is important to convey the correct information.

3. Sandow MJ, McMahon MM. Single-cross grasp six-strand repair for acute flexor tenorrhaphy: modified Savage technique. Atlas Hand Clinics. 1996;1:65e76. 4. Tang JB. Release of the A4 pulley to facilitate zone II flexor tendon repair. J Hand Surg Am. 2014;39(11):2300e2307. 5. Tang JB, Shi D. Subdivisions of “no man’s land” of the digital flexor tendons and different management of tendon injuries in subdivisions. Chin J Surg. 1991;29(10):608e611. 6. Tsuge K, Ikatu Y, Matsuishi Y. Repair of flexor tendons by intratendinous tendon suture. J Hand Surg Am. 1977;2(6):436e440. 7. Tang JB, Shi D. Subdivision of flexor tendon “no man’s land” and different treatment methods in each sub-zone: a preliminary report. Chin Med J (Engl). 1992;105(1):60e68. 8. Tang JB, Amadio PC, Boyer MI, et al. Current practice of primary flexor tendon repair: a global view. Hand Clin. 2013;29(2):179e189. 9. Wu YF, Tang JB. Recent developments in flexor tendon repair techniques and factors influencing strength of the tendon repair. J Hand Surg Eur Vol. 2014;39(1):6e19. 10. Chauhan A, Palmer BA, Merrell GA. Flexor tendon repairs: techniques, eponyms, and evidence. J Hand Surg Am. 2014;39(9): 1846e1853.

David T. Netscher, MD Deputy Editor of Review REFERENCES 1. Tang JB, Shi D, Gu YQ, Chen JC, Zhou B. Double and multiple looped suture tendon repair. J Hand Surg Br. 1994;19(6):699e703. 2. Savage R. In vitro studies of a new method of flexor tendon repair. J Hand Surg Br. 1985;10(2):135e141.

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