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Moving away from original to modified Kessler tendon repair is likely unwise

Growing clinical evidence from different centres indicates that suture knots outside the surface of repaired digital flexor tendons are not detrimental to the recovery of the digital function (Giesen et al., 2009, Munz et al., 2021; Reissner et al., 2018; Pan et al., 2020). For decades in our department, the flexor tendons in the digital sheath area have been repaired with a 6-strand core suture using the two or three knots on the tendon surface (Tang, 2005, 2007, 2019). The need for tenolysis remains low, and functional recovery has been generally excellent or good. In the light of these findings regarding knot location, we consider that moving from the original Kessler repair (with the knots on the tendon surface) 40 to 50 years ago, to the modified Kessler repair (with the knots between the tendon ends) was likely wrong. The Kessler repair currently in use is different from that originally used by Kessler in the 1960s (Sebastin et al., 2013). The currently used Kessler repair has knots on the tendon surface, while the modified Kessler has knots between two tendon stumps (Chen et al., 2018). We found this shifting in the repair method in the late 20th century had neither clinical support with outcome data nor biomechanical testing data of in vivo healing tendons. The changes were made based on experts’ opinions (Level V evidence). Here are reasons to argue against this evolution to the use of modified Kessler method.