History and Evolution of the Kessler Repair

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  HISTORYOFHANDSURGERY HistoryandEvolutionoftheKesslerRepair Sandeep J. Sebastin, MD, Allison Ho, BS, Teemu Karjalainen, MD, Kevin C. Chung, MD, MS The “grasping technique” described by Isidor Kessler and Fuad Nissim in 1969 is apopular method of flexor tendon repair. Different authors have modified this techniqueto the point where the so-called “modified Kessler technique” bears little resemblance tothe srcinal description. This article sheds light on the life and contributions of IsidorKessler, and examines the evolution of the Kessler technique and the srcin of graspingand locking tendon repairs. We also discuss the problems associated with eponymousdescriptions of tendon repair techniques and propose an alternative descriptive system. (J Hand Surg 2013;38A:552 – 561. Copyright © 2013 by the American Society for Surgery of the Hand. All rights reserved.) Key words  Flexor tendon, history, Kessler, tendon repair. I SIDOR  K ESSLER AND  Fuad Nissim were Israeli sur-geonswhoreportedthegraspingtechniqueofflexortendon repair in 1969. Their technique was pub-lished in  Acta Orthopaedica Scandinavica  in an articletitled “Primary repair without immobilization of flexortendon division within the digital sheath: an experimen-tal and clinical study.” 1 Modifications of their repairrepresent one of the most commonly performed tech-niquesoftendonrepairandarguablythefirstrepairtypetaught to trainees. In a survey of the members of theAmerican Society for Surgery of the Hand carried outin 1995, 72% used the modified Kessler technique fortendon repair. 2 We undertook an extensive literaturesearch on the Kessler technique of tendon repair andanalyzed the current usage of the term “modified Kes-sler.” From these srcinal materials, we will highlightKessler’s contribution to the technique of tendon repairand discuss a descriptive system to clarify differenttendon repair techniques. ISIDOR KESSLER (1926–2007) Dr. Kessler (Fig. 1) was born in Russe, Bulgaria, onAugust 19, 1926. 3 He obtained his degree of Doctor of Medicine at the Faculty of Medicine, University of Sofia, in Bulgaria in 1951. He immigrated to Israel in1951 and completed training in general surgery andorthopedic surgery in 1959. He then served as staff atthe Department of Traumatology of the Tel Aviv Cen-tral Clinic until 1965. It was during this period that hedeveloped a particular interest in surgery of the hand.He was the Sterling Bunnell fellow in the Department FIGURE 1:  Isidor Kessler (1926–2007). (Photograph courtesyof Abraham Hass, Head, Department of Surgery of the Hand,Kaplan Hospital, Rehovot, Israel.) FromtheDepartmentofHandandReconstructiveMicrosurgery,NationalUniversityHealthSystem, Singapore;theSectionofPlasticSurgery,DepartmentofSurgery,UniversityofMichiganHealthSys-tem, Ann Arbor, MI; and the Division of Hand Surgery, Department of Surgery, Central Hospital of CentralFinland,Jyväskylä,Finland. ReceivedforpublicationOctober24,2012;acceptedinrevisedformNovember20,2012.Supportedinpartbygrant2R01AR047328-06fromtheNationalInstituteofArthritisandMuscu-loskeletalandSkinDiseasesandaMidcareerInvestigatorAwardinPatient-OrientedResearch(K24AR053120) and the National Institute on Aging and National Institute of Arthritis and Musculo-skeletalandSkinDiseases(R01AR062066)(toK.C.C.).Nobenefitsinanyformhavebeenreceivedorwillbereceivedrelateddirectlyorindirectlytothesubjectofthisarticle. Correspondingauthor:  Sandeep J. Sebastin, MD, Department of Hand and Reconstruc-tive Microsurgery, National University Hospital, NUHS Tower Block, Level 11, 1E KentRidge Road, Singapore 119228; e-mail:$36.00/0 552    ©    ASSH    Published by Elsevier, Inc. All rights reserved.  of Hand Surgery at the Presbyterian Medical Center inSan Francisco and the Stanford Hospital in Palo Altofrom 1965 to 1966. 4 His mentors during the fellowshipwere Drs. Pratt, Howard, and Niebauer. During hisfellowship, he looked at the ability of polyethylenecoating to provoke fibrous tissue reaction that wouldimprove fixation of silicone implants in the medullarycavities of chickens and monkeys. 4 Later in his career,he applied this knowledge to clinical work with im-plants. 5,6 He then spent 6 months at the RheumatismFoundation Hospital in Heinola, Finland, with Dr.Vainio, studying rheumatoid deformities of the handand wrist. 7,8 Kessler returned to Israel and started a 2-bedunit for hand surgery at Kaplan Hospital in Re-hovot. By 1971, this unit became the first indepen-dent Department for Surgery of the Hand in Israel.During the Yom Kippur War in 1973, the depart-ment had 16 beds and was the leading caregiver forinjuries to the upper limb. In addition to the grasp-ing technique for tendon repair, Kessler also wroteabout reconstruction of a functional hand in pa-tients with multiple digital amputations. He ap-plied the distraction lengthening technique usedfor thumb amputations for lengthening fingers,combined with transposition of digits to producethe best functional and aesthetic results. 9–12 Kes-sler authored about 100 peer-reviewed articles.He served as the head of the department until hisretirement in 1991. 3 He was an Associate Profes-sor of Surgery at the Hebrew University-HadassahMedical School in Jerusalem. Kessler founded theIsraeli Society for Hand Surgery and served as itssecond president, and he is considered the father of hand surgery in Israel. He was a Founding Memberof the International Federation of Societies forSurgery of the Hand and was named a Pioneer of Hand Surgery in 2001 at the Eighth InternationalCongress of the International Federation of Soci-eties for Surgery of the Hand in Istanbul, Turkey.He was a corresponding member of the AmericanSociety for Surgery of the Hand since 1980 andan honorary member of the Bulgarian Societyfor Surgery of the Hand since 1996. Dr. Kessler FIGURE 2:  Kessler’s description of the grasping technique of tendon repair. (Reprinted from Kessler I. The “grasping” techniquefor tendon repair.  Hand   1973;5(3):253–255, 14 with permission from Elsevier.) KESSLER REPAIR   553  JHS   Vol    A  , March    passed away on March 14, 2007, at age 81. 3 Wetried assiduously to obtain information about Dr.Fuad Nissim and spoke with Dr Abraham Hass, thecurrent head of the Hand Unit founded by Dr.Kessler. He had no knowledge or informationabout Dr. Nissim. THE KESSLER GRASPING TECHNIQUE Kessler and Nissim thought that the current meth-ods of tendon repair were unsatisfactory becausethey required immobilization during healing,which led to adhesions between the repaired ten-dons and the surrounding tissues. They tried earlymobilization of repaired tendons using the Bunnellsuture technique, but this failed to hold the tendonends together. 1 They proposed a new graspingtechnique that could withstand early movementafter repair 1 (Fig. 2). The srcinal report by Kes-sler and Nissim included preliminary data for test-ing this new technique on 40 chicken tendons and7 clinical cases. Although only 19 of 40 chickentendons remained intact, all ruptures occurred asthe result of suture breakage and not suture pull-out. 1 The high rate of suture breakage was likelybecause of the weakness of the 0.008-inch twistedwire used for suturing, and it suggested promisefor successful future application of this new tech-nique.Doctors Urbaniak, Mortenson, and Cahill intro-duced the Kessler grasping technique to a greaternumber of surgeons at the annual meeting of theAmerican Society for Surgery of the Hand in LasVegas in 1973. Urbaniak and colleagues 13 (Urba-niak JR, Mortenson RA, Cahill JD. Presented atthe Annual Meeting of the American Society forSurgery of the Hand, Las Vegas, NV, February1973) presented the results of their analysis of thetensile strengths of 5 different end-to-end tendon-suturing techniques. The techniques studied in-cluded a circumferential interrupted suture andtechniques described by Nicoladoni, Mason andAllen, Bunnell, and Kessler (Fig. 3). A total of 20examples of each of the 5 techniques were tested incanine tendons using 4-0 stainless-steel sutures.The strongest end-to-end suture technique was theMason–Allen technique, with a tensile strength of 4,030 g. The Kessler grasping technique was aclose second, with a tensile strength of 3,970 g. Inboth repair techniques, the mode of failure wassuture breakage in 16 of 20 specimens and suture FIGURE 3:  The 5 techniques of end-to-end tendon repair tested by Urbaniak et al. 15 (Reprinted with permission from Urbaniak JR, Cahill JD, Mortenson RA. Tendon suturing methods: analysis of tensile strengths. In:  Symposium on Tendon Surgery in the Hand  . Rosemont, IL: American Academy of Orthopaedic Surgeons; 1975:70–80. 15 ) 554  KESSLER REPAIR   JHS   Vol    A  , March    pullout in 4 of 20 specimens. In addition, thestrengths of the Bunnell technique and the Kesslergrasping technique were compared during healing.By the fifth day of healing, Kessler’s techniquewas 3 times stronger than the Bunnell suture. 14 The Kessler grasping suture used by Urbaniak and colleagues 13 (Urbaniak JR, Mortenson RA,Cahill JD. Presented at the Annual Meeting of theAmerican Society for Surgery of the Hand, LasVegas, NV, February 1973) differed from the src-inal description by Kessler and Nissim 1 (Fig. 4). Inthe Kessler repair, the suture is anchored to thetendon at all 4 corners with a knot. This knotprevents the suture from moving within the tendonsubstance. In the variant of Urbaniak et al, a loopis used at each corner, instead of a knot. The sutureis therefore not anchored to the tendon and canmove freely within the tendon substance. Kesslerrealized that the description by Urbaniak et aldiffered from his srcinal description, so he pub-lished “The grasping technique for tendon repair”in 1973 to clarify his technique. 14 However, the FIGURE 4:  The Kessler grasping technique compared with the variant by Urbaniak et al 15 of the Kessler technique. KESSLER REPAIR   555  JHS   Vol    A  , March  


Jul 24, 2017
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