Augmented Repair Research Articles

Minimizing Retained Foreign Body in Hernia Repair Using a Novel Technique: Reinforced Biologic Augmented Repair (ReBAR)

With the digital age in healthcare upon us, patients are more aware, educated, and concerned about their surgical options for hernia repair. As a result of exposure to the growing litigious environment surrounding synthetic mesh products, patients are demanding hernia repairs with minimal or no foreign body. In response to these pressures, we have developed a novel technique known as the Reinforced Biologic Augmented Repair (ReBAR) which incorporates the data-proven principles of (1) tissue defect closure and (2) primary repair reinforcement, while minimizing the amount of foreign body material exposure long-term. A cohort of 619 (1.2% recurrence) patients representing a variety of hernia types and using multiple methods underwent repair using the ReBAR technique:259 Robotic Inguinal (1.2%), 47 Open Inguinal (4.3%), 59 Robotic Ventral/Incisional (1.7%), 32 Stapled Retrorectus (0%), 54 Open Abdominal Wall Reconstructions (1.8%), and 48 Open Onlay Ventral/Incisional (2.0%) hernia repairs. Increasing consumer demand for alternatives to traditional synthetic mesh repairs has driven the development of the ReBAR technique. Outcomes to this point are equivalent or better using the ReBAR technique as compared to classical methodology, however further study will be required to determine if long-term outcomes are superior to traditional techniques. The easily adaptable ReBAR technique satisfies the patient-centered care goals of today’s healthcare and may drive enhanced overall value of hernia care delivery.

“Current concepts and expert practice report: Augmentation of rotator cuff repairs”

Rotator cuff tears are common shoulder injuries expected to increase with the growth of the aging population. Although a small subset of patients with low functional demands can be treated nonoperatively, surgical intervention is a cost-effective solution, which can restore shoulder function and help patients return to activity sooner. While multiple surgical options are available, rotator cuff repair is a highly utilized procedure with varying success. Due to a large proportion of rotator cuff repairs still failing to completely heal, this procedure requires careful planning to achieve anatomical and biomechanically stability. New technology and techniques are being explored to help increase the success of rotator cuff repairs with an increasing focus on augmentation. The current article gives a brief overview of pertinent anatomy, treatment options, and challenges in healing of rotator cuff repairs. Thereafter, the merits of different types of rotator cuff repair augmentation available will be discussed as well as the authors’ experience in utilizing biologic augmentation and surgical technique.

Trends in the most cited articles in shoulder surgery, 1900–2019

BackgroundOur purpose was to identify the 100 most cited articles in the shoulder surgery literature published in past decade and to compare them with the 100 most cited “classic” shoulder surgery articles to identify trends in the topics of shoulder research. MethodsUsing the term “shoulder,” we searched the Clarivate Analytics’ Web of Science Core Collection database for 2 periods: 2010 through 2019 (“contemporary group,” n = 12,394) and 1900 through 2009 (“classic group,” n = 8790). We used the database sort function to order articles by number of citations. Titles, abstracts, and, when necessary, full text were screened to determine relevance to orthopedic shoulder topics until the 100 most cited articles were determined for each group. We analyzed the following article characteristics: title, author(s), publication year, journal, geographic origin, article type (clinical vs basic research), study design, and level of evidence (for clinical articles). P < .05 was considered significant. ResultsThe 3 journals with the most articles in the contemporary group were the American Journal of Sports Medicine (AJSM) (28%), the Journal of Shoulder and Elbow Surgery (JSES) (28%), and the Journal of Bone and Joint Surgery, American volume (JBJS Am) (23%). The top 3 journals in the classic group were JBJS Am (45%), AJSM (16%), and JSES (15%). The 3 most frequent topics in the contemporary group were rotator cuff tear (43%), instability (14%), and fractures (10%); those in the classic group were pathoanatomy (29%), rotator cuff (28%), and instability (17%). Compared with the classic group, the contemporary group had more articles on outcomes of common shoulder procedures, including rotator cuff repair (25% vs. 17%), arthroplasty (21% vs. 15%), arthroscopy (17% vs. 11%), reverse shoulder arthroplasty (13% vs. 7%), and the Latarjet procedure (7% vs. 2%). More articles reporting complications were found in the contemporary (9%) than in the classic (2%) group (P = .03). The contemporary group contained articles on topics not found in the classic group, such as platelet-rich plasma (8%), scaffolds (3%), infection (3%), Cutibacterium acnes (2%), stem cells (2%), superior capsular reconstruction (2%), bony increased offset reversed shoulder arthroplasty (2%), opioid issues (1%), and tendon transfer (1%). ConclusionThe most cited studies from 1900 to 2009 and 2010 to 2019 reported on the rotator cuff and shoulder instability. The most cited articles from 2010 to 2019 reflect the development of shoulder arthroscopy, shoulder arthroplasty, treatment of surgical complications, and augmentation or biologic interventions for rotator cuff repair. Level of evidenceLevel IV; Review Article

Arthroscopic Bursa-Augmented Rotator Cuff Repair: A Vasculature-preserving Technique for Subacromial Bursal Harvest and Tendon Augmentation

Rotator cuff repairs are associated with suboptimal outcomes and possibly greater incidence of retears if the biological healing environment is compromised. Strategies to optimize tendon–bone healing include the use of bioinductive scaffolds and regenerative stem cell therapy. The subacromial bursa has been shown to have significant pluripotent stem cell potency for tendon healing and has the advantage of easy accessibility and no added cost. However, a reproducible surgical technique for bursal mobilization, harvest, and vascularity preservation has not been described. We describe our technique for vasculature-preserving bursal mobilization and harvest of the entire posterosuperior and lateral subacromial bursa, and its use in rotator cuff repair augmentation is presented. The technique involves mobilization of the bursa as a continuous layer by maintain its medial and lateral vascularity. The bursa is advanced laterally, and the “vascular bursal duvet” and cuff tendons are repaired together as a tendon–bursa unit.

Augmented Repair of Acute Total Achilles Tendon Rupture With Peroneus Brevis Tendon Transfer Using Oblique Transosseous Calcaneal Tunnel: A Prospective Case Series

Acute Achilles tendon rupture is one of the most common tendon injuries. This prospective study aimed to evaluate the functional outcomes of augmented repair of acute Achilles tendon rupture with peroneus brevis tendon transfer and fixation to an oblique calcaneal transosseous tunnel. Functional evaluation was performed using the American Orthopaedic Foot & Ankle Society (AOFAS) score and Achilles Tendon Total Rupture Score (ATRS). Postoperative complications were recorded. This study included 33 males and 9 females, with a mean age of 26.1 ± 4.2 years. The Achilles tendon ruptures were right in 24 patients and left in 18 patients. The cause of rupture was sports injuries in all patients. The mean distance from the calcaneal insertion to the tear site was 4.4 ± 1.3 cm. The mean time from injury to surgery was 2.4 ± 1.6 days. The mean follow-up time was 40.3 ± 4.9 months. The mean AOFAS and ATRS scores were 99.3 ± 1.2 and 95.9 ± 1.9, respectively, at 12 months of follow-up. The mean time to return to work was 12.1 ± 1.2 weeks. The mean time to return to light sports activities was 16.1 ± 1.8 weeks postoperatively. None of the patients developed re-rupture. Augmented repair of acute Achilles tendon ruptures with peroneus brevis tendon transfer is a robust repair with excellent functional outcomes and early weight-bearing and return to sports activities.

Satisfactory patient-reported outcomes at 5 years following primary repair with suture tape augmentation for proximal anterior cruciate ligament tears

PurposeAn enhanced understanding of anterior cruciate ligament (ACL) healing and advancements in arthroscopic instrumentation has resulted in a renewed interest in ACL repair. Augmentation of a ligament repair with suture tape reinforces the ligament and acts as a secondary stabilizer. This study assesses the 5-year patient-reported outcomes of primary repair with suture tape augmentation for proximal ACL tears.MethodsThirty-seven consecutive patients undergoing ACL repair with suture tape augmentation for an acute proximal rupture were prospectively followed up for a minimum of 5 years. Patients with midsubstance and distal ruptures, poor ACL tissue quality, retracted ACL remnants and multiligament injuries were excluded. Patient-reported outcome measures were collated using the Knee Injury and Osteoarthritis Outcomes Score (KOOS), Visual Analogue Pain Scale (VAS-pain), Veterans RAND 12-Item Health Survey (VR-12) and the Marx Activity Scale. Patients with a re-rupture were identified.ResultsThree patients were lost to follow-up leaving 34 patients in the final analysis (91.9%). The mean KOOS at 5 years was 88.5 (SD 13.8) which improved significantly from 48.7 (SD 18.3) preoperatively (p < 0.01). The VAS score improved from 2.3 (SD 1.7) to 1.0 (SD 1.5) and the VR-12 score improved from 35.9 (SD 10.3) to 52.4 (SD 5.9) at 5 years (p < 0.01). However, the Marx activity scale decreased from 12.4 (SD 3.4) pre-injury to 7.3 (SD 5.2) at 5 years (p = 0.02). Six patients had a re-rupture (17.6%) and have since undergone a conventional ACL reconstruction for their revision surgery with no issues since then. These patients were found to be younger and have higher initial Marx activity scores than the rest of the cohort (p < 0.05).ConclusionPrimary repair with suture tape augmentation for proximal ACL tears demonstrates satisfactory outcomes in 28 patients (82.4%) at 5-year follow-up. Six patients sustained a re-rupture and have no ongoing problems following treatment with a conventional ACL reconstruction. These patients were significantly younger and had higher initial Marx activity scores.Level of evidenceLevel IV.

Use of Mesh in Hiatal Hernia Repair and Gastroesophageal Reflux Disease - Pro

Net augmentation in surgical care of hiatus hernias has many advantages, but is still controversial. Optimal surgical treatment of symptomatic hiatus hernia is to provide long-term correction of the malposition of the stomach and other organs that have been displaced in the thorax, as well as reducing the necessity of risky reoperations. In order to assess the role of net augmentation in repair of the hiatus here, the benefit in the form of the avoidance of symptomatic recurrence and reoperations must be balanced against the risk of net-associated complications. In the present review article, we present a detailed evaluation of current evidence on net augmentation. We conclude that net augmentation in large hernias (> 5 cm), with or without paraesophageal involvement, should be routinely employed, as this reduces the risk of recurrence and the need for complex reoperations with a high risk of complications. Net-associated complications are rare and can largely be avoided with the correct implantation technique and proper net materials. The level of evidence could be improved if more validated register and randomised controlled studies were performed.

Histologic and Functional Outcomes of Conduit Wrapping for Peripheral Nerve Repair: Early Results in a Rat Model.

The concept of utilizing a nerve conduit for augmentation of a primary nerve repair has been advocated as a method to prevent neural scarring and decrease adhesions. Despite clinical use, little is known about the effects of a nerve conduit wrapped around a primary repair. To better understand this, we investigated the histologic and functional effects of use of a nerve conduit wrapped around a rat sciatic nerve repair without tension. Twenty Lewis' rats were divided into two groups of 10 rats each. In each group, unilateral sciatic nerve transection and repair were performed, with the opposite limb utilized as a matched control. In the first group, direct repair alone was performed; in the second group, this repair was augmented with a porcine submucosa conduit wrapped around the repair site. Sciatic functional index (SFI) was measured at 6 weeks with walking track analysis in both groups. Nonsurvival surgeries were then performed in all animals to harvest both the experimental and control nerves to measure histomorphometric parameters of recovery. Histomorphometric parameters assessed included total number of neurons, nerve fiber density, nerve fiber width, G-ratio, and percentage of debris. Unpaired t-test was used to compare outcomes between the two groups. All nerves healed uneventfully but compared with direct repair; conduit usage was associated with greater histologic debris, decreased axonal density, worse G-ratio, and worse SFI. No significant differences were found in total axon count or gastrocnemius weight. In the absence of segmental defects, conduit wrapping primary nerve repairs seem to be associated with worse functional and mixed histologic outcomes at 6 weeks, possibly due to debris from conduit resorption. While clinical implications are unclear, more basic science and clinical studies should be performed prior to widespread adoption of this practice.

Outcomes of pulmonary valve leaflet augmentation for transannular repair of tetralogy of Fallot

ObjectiveTo evaluate the midterm results of pulmonary valve leaflet augmentation in transannular repair of tetralogy of Fallot (TOF). MethodsFrom 2007 to 2019, 131 patients underwent a transannular repair with pulmonary leaflet augmentation for TOF (n = 120) and double outlet right ventricle with pulmonary stenosis (n = 11). Patch material was expanded polytetrafluoroethylene (n = 76), glutaraldehyde-treated autologous pericardium (n = 47) and bovine pericardium (n = 8). ResultsMedian age at repair was 8.9 months (interquartile range, 5.4-14.8). There was no operative mortality. Median follow-up was 6.25 years (interquartile range, 2.77-7.75). Freedom from severe pulmonary regurgitation (PR) was 85% (95% confidence interval [CI], 77%-90%) and 76% (95% CI, 66%-83%) at 1 and 5 years, respectively. Freedom from moderate or greater PR was 69% (95% CI, 60%-76%) and 30% (95% CI, 21%-39%) at 5 and 10 years, respectively. Three patients required pulmonary valve replacement for PR. Nine patients required pulmonary balloon valvuloplasty. Freedom from intervention for pulmonary valve stenosis was 98% (95% CI, 93%-99%) and 94% (95% CI, 87%-97%) at 1 and 5 years, respectively. One patient with severe PR had an indexed right ventricular volume >160 mL/m2. Use of expanded polytetrafluoroethylene resulted in a greater freedom from moderate or greater PR (log-rank test P < .001; Cox regression hazard ratio, 0.40; 95% CI, 0.25-0.63; P < .001). ConclusionsAt midterm follow-up of transannular repair with pulmonary valve leaflet augmentation, severe PR occurs in less than 50% of patients. The expanded polytetrafluoroethylene patch performs better than pericardium.

Short-term results and surgical technique of arthroscopic centralization as an augmentation for medial meniscus extrusion caused by medial meniscus posterior root tear.

The purpose of this study was to perform medial meniscus (MM) centralization for medial meniscus extrusion (MME) associated with medial meniscus posterior root tear (MMPRT) and to examine the short-term results. The hypothesis is that arthroscopic centralization as an augmentation of MMPRT repair improves clinical outcomes and the extrusion distance of MM in short-term results. Twenty-six patients (mean age 62.1 ± 6.0years) who underwent arthroscopic centralization as an augmentation of MMPRT repair were included. Clinical evaluation was performed before and 2years after surgery using Lysholm score and knee injury and osteoarthritis outcome score (KOOS). Image evaluation used MRI and plain X-ray images. The extrusion distance and MME ratio were compared on MRI images before and 2years after surgery. The degree of osteoarthritis (OA) was evaluated using Kellgren-Lawrence classification. The degree of OA and hip-knee-ankle (HKA) angle were compared by plane X-ray images before and 2years after surgery. In clinical results, both Lysholm score and KOOS improved significantly after surgery. In image evaluation, the extrusion distance decreased significantly from 4.8 ± 0.7mm before surgery to 2.7 ± 0.3mm 2years after surgery (p < 0.05). The MME ratio was significantly improved from 40.2 ± 7.0% before surgery to 22.6 ± 3.6% after surgery (p < 0.05). There was no significant difference in HKA angle at 2years after surgery (p = 0.13). The arthroscopic centralization for medial meniscal extrusion associated with MMPRT significantly improved clinical outcomes and the extrusion distance of MM. It is also one of the surgical techniques that can suppress medial meniscus extrusion. IV, therapeutic case series.

Clinical outcomes and structural integrity rate of arthroscopic augmented rotator cuff repairs using extracellular porcine matrix patch.

Structural failure rate in rotator cuff repairs is still high. The purpose of the study is to assess the structural integrity of a series of augmented rotator cuff repairs with porcine matrix patch and report the functional outcomes. Between 2014 and 2017, 44 consecutive patients underwent arthroscopic double-row repair of medium to massive rotator cuff tears with extracellular porcine dermal matrix augmentation. At one-year follow-up, magnetic resonance imaging scan was performed to assess the integrity of the repair. Oxford Shoulder Score (OSS), Constant Score (CS) and Visual Analogue Scale pain score, together with range of motion were used to assess patients. Patients mean age was 68 (53-82); mean follow-up was 17.2 (12-24) months. On magnetic resonance imaging scans, seven rotator cuff repair failures (15.9%) were observed: tear size was an independent predictor of re-rupture at one-year follow-up. Clinical scores showed a statistically significant improvement at three months and until final follow-up (p< 0.001). No complications occurred. Observed structural failure rate of 15.9% is lower than those reported in the literature for standard rotator cuff repair of medium to massive tears in similar cohorts to ours. Extracellular matrix augmentation for rotator cuff repair was shown to be a safe and reliable support to the repairs and patients recovered good shoulder function.Level of Evidence: Level IV.

What’s New in Hand and Wrist Surgery

What’s New in Hand and Wrist Surgery

Modified Broström-Gould With Gracilis Autograft Augmentation Surgery and Accelerated Noncasted Rehabilitation in High Demand Patients With Lateral Ankle Instability

Lateral ankle instability that has failed conservative management can be physically debilitating. Good outcomes are obtained from Broström-Gould augmented repair techniques, however there are few studies evaluating the use of a gracilis autograft augmentation coupled with an accelerated rehabilitation program in high functional demand patients. We believe that the modified Broström-Gould technique utilizing a Gracilis autograft will provide significant improvements in stability while maintaining normal ankle biomechanics in young, high demand patients. The prospective cohort study involved 19 patients (20 ankles) who underwent surgery for chronic lateral ankle instability by a single surgeon, at a single institution between October 2014 and April 2016. Patients were followed for 33.8 ± 11.7 (range 12-48) months. Patients were assessed both pre- and postoperatively for talar tilt angle radiographically and with both American Orthopaedic Foot and Ankle Society Ankle and Hindfoot scores and Karlsson-Peterson scores. A Tegner activity score was taken at the last follow-up. The mean American Orthopaedic Foot and Ankle Society score increased from 68.85 ± 10.57 to 91.56 ± 5.31 points (p < .01) and mean Karlsson-Peterson score increased from 50.9 ± 15.53 to 88.11 ± 8.64 points (p value <.01) when compared preoperatively to mean postoperative follow-up of 33.8 months. Tegner activity score was 7.05 ± 0.89 at last follow-up. The technique was found to be effective in treating chronic lateral ankle instability and in combination with an accelerated rehabilitation protocol, patients returned to their premorbid level of activity with improved stability and no significant effect on donor graft site morbidity.

Anterior cruciate ligament tear patterns in young patients: An arthroscopic multicenter study

IntroductionIn the last decade, there has been a renewed interest in anterior cruciate ligament (ACL) preservation surgeries in the younger patients. Several ACL preservation techniques such as primary repair, augmented repair, and scaffold repair have been described based on the particular tear type and pattern. The purpose of this study was to determine the distribution of tear patterns in young patients presenting with an acute ACL injury. MethodsA prospective observational study was performed at two tertiary children’s hospitals. Patients under 18 years undergoing ACL reconstruction within 8 weeks of initial injury were included from 2017 to 2019. Tear patterns were classified by two orthopedic surgeons from each of the two centers during arthroscopic ACL reconstruction into 4 types: I. Avulsion off the femur, II. <10% of total ACL length tear from femoral end, III. Mid-substance tear and IV. Single bundle tear. For reliability, the four surgeons classified ACL injury (2 rounds each) based on de-identified intraoperative videos of 33 randomly selected surgical ACL cases. Inter and intra-rater reliability studies were calculated using Kappa statistics. Results224 patients (123 males, 101 females) with mean age of 16 (range: 9–18) years were enrolled in this study. Fifty-seven (25%) patients reported contact injury while 167 (75%) reported non-contact. Isolated ACL injury was recorded in 70 (31%) patients, while concomitant injuries were recorded in 154 patients (69%). The most common associated injury was lateral meniscus tear (35%), followed by lateral and medial meniscus tears (20%). According to our classification, 31 (14%) patients were Type I, 30 (13%) were Type II, 139 (62%) were Type III, 18 (8%) were Type IV. The intra-rater reliability was excellent for 2 reviewers, good for 1 and marginal for another. The overall inter-rater reliability for all 4 reviewers was marginal for both readings. There was no statistical difference in the occurrence of type of tear based on the mechanism of injury (contact vs non-contact) or age of the patients. ConclusionsThis is the first multicenter study using an arthroscopic assessment to classify the location of ACL tear in the young population. It gives us further insight on the possible application for surgeries to preserve the ACL in this group. Larger studies incorporating these findings with MRI evaluation and ACL repair techniques are needed to confirm the utility of this information to decide the eligibility for repair in pediatric patients.

Augmented Repair of Large to Massive Delaminated Rotator Cuff Tears With Autologous Long Head of the Biceps Tendon Graft: The Arthroscopic “Cuff-Plus” Technique

An anatomic and tension-free repair is the goal of arthroscopic rotator cuff repair. However, this purpose is not always achievable in large and massive tears, and sometimes, even when intraoperative results seem acceptable, clinical and radiologic outcomes can be disappointing shortly afterward. Superior capsule reconstruction has been claimed as a valid and viable joint-preserving option for treating irreparable rotator cuff tears. However, the role of the superior capsule in repairable cuff tears has also been questioned. The aim of this article is to present the so-called arthroscopic cuff-plus technique. This technique consists of superior capsule reconstruction using the proximal part of the long head of the biceps tendon associated with a tension-free repair of the rotator cuff tendons in large to massive delaminated tears.

Preliminary Clinical Outcomes Following Biologic Augmentation of Arthroscopic Rotator Cuff Repair Using Subacromial Bursa, Concentrated Bone Marrow Aspirate, and Platelet-Rich Plasma

PurposeTo evaluate the clinical outcomes of patients who underwent arthroscopic rotator cuff repair augmented using subacromial bursa, concentrated bone marrow aspirate (cBMA), and platelet-rich plasma.MethodsSixteen patients were included in the study who underwent arthroscopic rotator cuff repair augmented using subacromial bursa, cBMA, and platelet-rich plasma from January 2018 to July 2018 and had a minimum 1-year follow-up. American Shoulder and Elbow Surgeons (ASES), Simple Shoulder Test, Constant-Murley, and Single Assessment Numerical Evaluation (SANE) scores were collected preoperatively and at terminal follow-up. To determine the clinical relevance of ASES scores, the minimal clinically important difference, substantial clinical benefit, and the patient acceptable symptomatic state thresholds were used. In vitro cellular proliferation of subacromial bursa (nucleated cells/gram) and cBMA (nucleated cells and colony-forming units/cc) samples was evaluated and correlated to clinical outcomes scores.ResultsMean follow-up was 12.6 ± 1.8 months (range 12-19 months). Patients achieved significant improvement in ASES (45.8±22.5pre vs 88.5 ± 14.6post, Δ44.7 ± 20.7; P = .001), Simple Shoulder Test (4.3 ± 3.2pre vs 10.4 ± 1.6post, Δ5.7 ± 3.9, P = .002), Constant-Murley (44.3 ± 18.2pre vs 83.6 ± 17.5post, Δ37.2 ± 21.8; P = .001), SANE (13.3 ± 10.7pre vs 86.3 ± 17.5post, Δ71.9 ± 22.9; P = .001), and pain scores (5.0±2.8pre vs 1.1 ± 1.6post, Δ3.5±2.5, P = .001) at final follow-up. With regards to ASES score, 93.8% of patients achieved the minimal clinically important difference, 93.8% the substantial clinical benefit, and 62.5% reached or exceeded the patient acceptable symptomatic state criteria. There was a significant positive correlation of nucleated cell count of cBMA with postoperative SANE score (r = 0.707; P = .015) and delta in ASES score (r = 0.727; P = .011). All other correlations were found to be nonsignificant (P > .05, respectively).ConclusionsPatients undergoing arthroscopic rotator cuff repair augmented using the Mega-Clot with bursa technique achieved significant improvement in functional outcomes at a minimum 1-year follow-up, with 93.8% of patients reaching substantial clinical benefit.Level of EvidenceLevel IV, therapeutic case series.

High-Strength Suture Tape Augmentation Improves Cyclic Gap Formation in Transosseous Patellar Tendon Repair: A Biomechanical Study

PurposeTo compare gap displacement at various intervals of cyclic testing and biomechanical load to failure of a Krackow patellar tendon repair augmented with high-strength suture tape versus the standard Krackow transosseous technique for inferior pole patellar tendon rupture.MethodsTwelve matched pairs of cadaveric knees were used (8 males and 4 females; mean age 79.6 years, range 57 to 96). An inferior pole patellar tendon rupture was simulated after random assignment of specimens in each pair to the standard or augmented Krackow technique. Each specimen was then repetitively cycled from 90° to 5° for 1,000 cycles. A differential variable reluctance transducer was used to measure gap displacement. After cyclic loading, load to failure was determined by pulling the tendon at a rate of 15 mm/s until a sudden decrease in load occurred.ResultsCompared with the control repair, specimens with augmented repair demonstrated significantly less displacement at all testing intervals up to 1,000 cycles (P < .05). Two patellar tendons failed before the end of cyclic loading, and 4 specimens had inadequate tendon length for loading. Among the 18 remaining specimens, no significant difference in load to failure was observed between the experimental group (n = 11) and the control group (n = 7) (1,006.5 ± 332.1 versus 932.8 ± 229.1 N, respectively; P = .567).ConclusionsSignificantly greater gap displacement was observed in the standard Krackow repair group compared with the augmented Krackow group at all cyclic loading intervals. This suggests that the Krackow transosseous procedure augmented with high-strength suture tape is biomechanically viable for inferior pole patellar tendon repair.Clinical RelevanceThis biomechanical study supports the use of high-strength suture tape augmentation of Krackow transosseous repair for inferior pole patellar tendon rupture.

Outcomes of Plantaris Tendon Augmentation in Acute Achilles Tendon Rupture Repair

Category:Trauma; Ankle; Hindfoot; SportsIntroduction/Purpose:Given the lack of consensus regarding the optimal surgical treatment for acute Achilles tendon ruptures, identifying techniques to maximize functional outcomes is crucial. Augmentation of Achilles tendon repair with the plantaris tendon is an established surgical technique that is thought to improve outcomes by reinforcing the repair site as well as decreasing soft tissue adhesions, though no studies have specifically looked at outcomes of its use. The purpose of this study is to compare the outcomes of acute Achilles tendon repairs managed with and without plantaris tendon augmentation.Methods:A retrospective review of patients undergoing open repair of acute Achilles tendon ruptures with a single fellowship- trained foot & ankle surgeon from 2010-2016 was performed. Patients <18 years of age, those whose procedures were >21 days from the date of injury, or whose repair was augmented with a flexor hallucis longus (FHL) tendon transfer or V-Y advancement were excluded. Operative report review determined if repair included plantaris augmentation. Augmentation involved weaving the tendon through the Achilles above and below the rupture site creating a box type biologic augmentation. Patients were contacted at >=2 years postoperatively to complete the Foot & Ankle Ability Measure (FAAM)-Activities of Daily Living (ADL) and -Sports subscales, visual analog scale (VAS) for pain, as well as surveyed regarding their satisfaction with the surgical outcome using a 5- point Likert scale. Mann-Whitney U, Chi-squared and Fisher’s exact tests were performed to compare patient variables and postoperative outcomes.Results:One hundred twenty-eight patients undergoing repair of an acute Achilles tendon rupture were included, including 59 (46.1%) with plantaris tendon augmentation and 69 (53.9%) without. The two patient cohorts did not differ in any preoperative patient variables (p>0.0892). Patients with and without plantaris augmentation did not experience any significant difference in the rate of postoperative complications (p=1.000), including a 0% re-rupture rate in each group. Additionally, at an average follow-up of 57.1 months, the groups did not differ in FAAM-ADL score (p=0.7116), FAAM-Sports score (p=0.4024), the Single Assessment Numeric Evaluation (SANE) as part of the FAAM-Sports subscale (p=0.2572), VAS pain (p=0.1885), or outcome satisfaction (p=0.7317).Conclusion:Our study demonstrates that plantaris tendon augmentation does not improve patient functional outcomes following acute Achilles tendon repair, but also is not associated with increased complication rates. Further studies, including either higher-level prospective, randomized clinical studies or biomechanical evaluation of the technique, are indicated to justify this adjunctive procedure.

No Differences in Clinical Outcomes of Suture Tape Augmented Repair Versus Broström Repair Surgery for Chronic Lateral Ankle Instability.

Background:Suture tape (ST) augmented repair, an alternative to traditional Broström repair (BR), may protect the repaired anterior talofibular ligament during ligament healing. No systematic review of cohort studies has been conducted to compare traditional BR with ST-augmented repair for chronic lateral ankle instability.Purpose:To review the current evidence in the literature to ascertain whether ST-augmented repair is superior to traditional BR in managing chronic lateral ankle instability.Study Design:Systematic review; Level of evidence, 3.Methods:A literature search was performed to identify relevant articles published in PubMed, Embase, and Cochrane Library databases in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The search included cohort studies comparing the efficacy of BR and ST-augmented repair procedures in terms of incidence of instability recurrence, functional scores, talar tilt angle (TTA), anterior talar translation (ATT), and complication rate. Methodological quality was assessed using the Jadad scale for randomized studies and the Newcastle-Ottawa Scale for nonrandomized studies.Results:A total of 4 clinical trials with 254 patients were included. No significant differences were detected between BR and ST-augmented repair procedures in terms of incidence of recurrent instability, American Orthopaedic Foot & Ankle Society score, Foot and Ankle Outcome Score, Foot and Ankle Ability Measure, TTA, ATT, or complication rate. The ST group appeared to have a shorter operation time compared with the BR group.Conclusion:No significant differences were found between ST-augmented repair and BR surgery regarding incidence of recurrent instability, functional outcome scores, or complication rates. Although technically challenging, the ST-augmented repair procedure appears to be a safe and fast option.

Regulatory T-cell expansion in oral and maxillofacial Langerhans cell histiocytosis

Langerhans cell histiocytosis (LCH) is a rare myeloid-origin neoplasm characterized by the expansion and dissemination of CD1 a+/CD207+ dendritic cells (LCH cells), but the rarity of its occurrence has long impeded progress in understanding its pathology. We focus on the potentially important role that regulatory T cells (T-reg) play in the oral and maxillofacial LCH tumor microenvironment (TME). Nine cases of oral and maxillofacial LCH, diagnosed from 2009 to 2019, were collected retrospectively from the affiliated hospitals of Southern Medical University. Immunohistochemistry was conducted characterizing T cells and T-reg phenotype. Data were evaluated by 1-sample Wilcoxon's test. Significantly increased frequency and abnormal distributions of T-reg were identified in all the LCH lesion sections. Proliferating T-reg account for a mean average of 11.5% of the total T-cell subsets, with significant difference (Wilcoxon's test; P < .05). T-reg expansion in the localized inflammatory TME leads to a failure of immune regulation by suppressing antitumor response, which can be a latent and significant factor contributing to LCH progression. However, T-reg may also acquire the capability for aiding in initiating T-cell responses under the "cytokine storm" at the beginning of LCH onset. T-reg might contribute to the augmentation of tissue repair by transforming growth factor-β (TGF-β), explaining the self-limiting character of LCH.