Horizontal Sutures Research Articles

Radiologic evaluation of the healing of the greater tubercle after humeral hemiarthroplasty with Aequalis-fracture-implants for proximal humeral fracture: a retrospective cohort study in 45 shoulders

IntroductionDevelopment and use of specific anatomic prosthesis for shoulder’s fracture aimed to reach the best rate of consolidation of the greater tubercle, which means a cuff restitution to improve functional results. The lack of bone healing of the tubercles suggested the use of a fenestrated humeral implant with interposition of a bone graft in the metaphyseal part of the prosthesis. This characteristic of specific implant, have few reports in the literature, leading us to the current retrospective study aiming: 1) to evaluate the healing rate of the greater tubercle after implantation of fracture dedicated anatomic implant, which includes a fenestration in the prosthetic metaphysis for the addition of a cortico cancellous graft, 2) to asses on patients with proximal humerus fractures, the bone healing of the greater tubercle close to the intraprosthetic bone graft. HypothesisThe specific “implant-fracture” can achieve a high rate of bone healing of the humeral greater tubercle Patients and methodsBetween January 2001 and December 2020, fifty-one patients were operated on by implantation of fracture dedicated implant for proximal humerus fracture. Six were excluded (2 operated for revision, 2 operated after 3 weeks, 1 died, 1 without follow-up). In total 45 patients were included in radiological analysis, clinical analysis had been performed on 23/45 patients at the longest follow up, the other 22/45 were only analyzed on radiographies. Mean-aged 66 years (range, 47 years -88 years), 25/45 (56%) of women, with 3-4-parts fractures according to Neer’s classification. The techniques of tubercle fixation were isolated cerclages of combined horizontal cerclages and vertical sutures. Position and healing of the greater tubercle was controlled through antero-posterior and lateral X-Rays views at the longest follow-up (mean 50 months, range 3 to 193 months). Peroperative techniques of fixation, clinical and functional outcomes were noted and correlated to the radiologic position of the greater tubercle and the graft evolution. Factors associated with healing and anatomic position had been investigated. ResultsThe rate of greater tubercle healing was 32/45 (73%). Factors significantly associated with greater tuberosity consolidation were higher age (p = 0.04) and the addition of a vertical osteosuture to the horizontal suture of the greater tubercle (p = 0.01). The rate of anatomic position of the greater tubercle was 15/45 (33%) of cases. When the fixation of the tuberosity was made with vertical suture, good position of the tuberosity was observed in 68% (17/24) at the longest follow-up. DiscussionOur results were in accordance with the literature, but the current study underlined there were two types of factors influencing tubercle healing in the literature: the technique of fixation of the tubercle and the patient’s age. Level of evidencelevel IV cohort study without control group.

Transabdominal levatorplasty technique in laparoscopic mesh rectopexy for rectal prolapse.

Rectal prolapse is characterized by a full-thickness intussusception of the rectal wall and is associated with a spectrum of coexisting anatomic abnormalities. We developed the transabdominal levatorplasty technique for laparoscopic rectopexy, inspired by Altemeier's procedure. In this method, following posterior mesorectum dissection, we expose the levator ani muscle just behind the anorectal junction. Horizontal sutures, using nonabsorbable material, are applied to close levator diastasis associated with rectal prolapse. The aim of the transabdominal levatorplasty is to (i) reinforce the pelvic floor, (ii) narrow the anorectal hiatus, and (iii) reconstruct the anorectal angle. We report a novel transabdominal levatorplasty technique during laparoscopic rectopexy for rectal prolapse. The laparoscopic mesh rectopexy with levatorplasty technique was performed in eight cases: six underwent unilateral Orr-Loygue procedure, one modified Wells procedure, and one unilateral Orr-Loygue procedure combined with sacrocolpopexy for uterine prolapse. The median follow-up period was 178 (33-368) days, with no observed recurrences. Six out of seven patients with fecal incontinence experienced symptomatic improvement. Although the sample size is small and the follow-up period is short, this technique has the potential to reduce the recurrence rate and improve functional outcomes, as with levatorplasty of Altemeier's procedure. We believe that this technique may have the potential to become an option for rectal prolapse surgery.

All-Inside Arthroscopic Tie-Grip Suture Repair for Radial Tear in the Midbody of Lateral Meniscus Using an All-Inside Device and Slotted Cannula

Inside-out repair of meniscal tears is the gold standard surgical approach; however, its use is limited by the need for a posterior incision and neurovascular risk. In this Technical Report, we present details of the all-inside arthroscopic tie-grip approach for repairing a radial tear of the midbody of the lateral meniscus using an all-inside device (TRUESPAN) and a slotted cannula. In contrast to the inside-out approach, this technique helps reduce surgical invasiveness and provides stable fixation as the vertical mattress sutures bundle the circumferential fibers and act as rip stops for the horizontal sutures. However, the operating surgeon must understand proper insertion techniques to successfully use the devices required for this procedure.

Inside-out repair of complex tears in the posterior horn of the lateral meniscus

All-inside meniscus devices are preferred over inside-out sutures for complex tears in the posterior horn of the lateral meniscus due to the ease of use, avoidance of additional skin incisions, and reduced surgical time. However, inside-out sutures have the advantages of being less traumatic due to smaller diameter needles, better healing rate, and less chance of injuries to posterior neurovascular structures due to direct visualization and protection. To the author’s knowledge, the inside-out repair technique has been described only for vertical tears and not for complex tears in the posterior horn of the lateral meniscus. This video describes the technique of repairing complex lateral meniscus tears with inside-out sutures using various suture configurations. The lateral meniscus tear pattern is identified. A posterolateral safety incision is made, and a retractor is placed posterior to the capsule. The popliteal vein is identified at this step and kept under visualization to avoid injury. Meniscal repair configurations such as “H,” “X,” and “A” patterns and simple vertical or horizontal sutures are planned according to the tear pattern. Sutures are passed using inside-out meniscal sutures, 18G spinal needle, self-retrieving suture devices or a combination of those, and tied over the capsule using sliding knots while the repair site is arthroscopically visualized.

Methods for Testing Meniscal Repair Using a 3D-Printed Meniscus

Torn and damaged menisci resulting from trauma are very common knee injuries, which can cause pain and mobility limitations and lead to osteoarthritis. Meniscal injuries can require surgery to repair the tissue damage and restore mobility. Here we describe the biomechanical testing of a 3D-printed meniscus to illustrate methods to determine if it has the strength and durability to effectively repair meniscal tears and restore knee biomechanics. This work was designed to demonstrate the steps needed to test novel meniscus repair devices prior to moving toward animal testing. The first testing step determined the ability of the 3D-printed meniscus to withstand surgical fixation by measuring the suture pull-out force. We show that vertical 2/0 silk or Fiberwire sutures need an average of 1.4 or 1.8 N, respectively, to pull through the meniscus, while horizontal sutures need only 0.7 and 1.2 N, respectively. The next step measured the compressive strength of normal, damaged, and repaired porcine meniscus tissue. Here, we show that meniscectomy decreased the stiffness of meniscus tissue from 26.7 ± 0.85 N to 7.43 ± 0.81 N at 25% strain. Menisci repaired with the 3D-printed tissue restored 66% of the measured force at 25% strain. The final step measured the contact pressures and areas in an ex vivo porcine knee before and after meniscal repair was made with the 3D-printed meniscus tissue. The example 3D-printed meniscus was successfully sutured into the porcine knee joint but failed to restore normal knee contact pressures. This work demonstrates the need for an iterative biomechanical testing process of biomaterial development, 3D-printing optimization, and knee kinematics to develop a durable and functional meniscus repair device. In summary, the methods described here serve as a guide for the functional evaluation of novel meniscus repair devices.

Superior Pedicle Inverted T-reduction Mammaplasty with Short Horizontal Scar.

Superior pedicle breast reduction is a very popular technique among plastic surgeons. This technique has had many variations looking for fewer complications and better long-lasting results. The aim of this article is to present a novel technique of breast reduction, making variations in the design of the periareolar incision, using a superior pedicle with a constant vertical incision of 5 cm and a shortened horizontal incision. The superior pedicle inverted T-mammoplasty with a shortened horizontal scar technique was performed in 1200 patients who underwent surgery between 2010 and 2023; follow-up examination was carried out for an average of 1 year (3 months to 3 years). A patient satisfaction survey was conducted. Patient satisfaction rate was 99%. There were no cases of total necrosis of the areola-nipple complex, 2.7% of the patients presented partial necrosis of the areola-nipple complex, 1.4% of the patients presented local infection, 1.7% presented dehiscence at some point of the vertical or horizontal suture, 4% of the patients presented a widened scar, 8% of the patients presented alteration in the sensibility of the areola-nipple complex, and 0.6% of the patients presented hematoma. With this technique, a rise of the areola-nipple complex of up to 22cm was achieved. The superior pedicle inverted T-mammaplasty with shortened horizontal scar technique showed a lower number of surgical complications compared with other techniques previously used for breast reduction, even when applied in gigantomasty. It provides lasting results and a high rate of patient satisfaction.

3D C-arm navigated acromioclavicular joint stabilization

IntroductionSurgical treatment options for acromioclavicular joint separations are varied. Frequently, suspension devices (SD) are inserted for stabilization under arthroscopic view. This study investigates the feasibility and accuracy of three-dimensional (3D) digital-volume-tomography (DVT) C-arm navigated implantation with regard to the general trend toward increasingly minimally invasive procedures.Materials and methodsThe implantation of a TightRope® suture button system (SD) via a navigated vertical drill channel through the clavicle and coracoid was investigated in 10 synthetic shoulder models with a mobile isocentric C-arm image intensifier setup in the usual parasagittal position. Thereby, in addition the placement of an additive horizontal suture cerclage via a navigated drill channel through the acromion was assessed.ResultsAll vertical drill channels in the Coracoclavicular (CC) direction could be placed in a line centrally through the clavicle and the coracoid base. The horizontal drill channels in the Acromioclavicular (AC) direction ran strictly in the acromion, without affecting the AC joint or lateral clavicle. All SD could be well inserted and anchored. After tensioning and knotting of the system, the application of the horizontal AC cerclage was easily possible. The image quality was good and all relevant structures could be assessed well.ConclusionIntraoperative 3D DVT imaging of the shoulder joint using a mobile isocentric C-arm in the usual parasagittal position to the patient is possible. Likewise, DVT navigated SD implantation at the AC joint in CC and AC direction on a synthetic shoulder model. By combining both methods, the application in vivo could be possible. Further clinical studies on feasibility and comparison with established methods should be performed.

Acute Dislocation of the Elbow: An All-Arthroscopic Repair of the Lateral Ligament Complex

The elbow is one of the most commonly dislocated joints. While conservative management is frequently performed for simple elbow dislocations, the importance of primary surgical treatment is still undetermined. However, promising results have been reached after surgical repair. We propose an arthroscopic surgical repair of the lateral ligament complex (LCL), performed with a horizontal suture and 2 Fibertak Knotless implants (Arthrex) placed on the LCL origin, one anterior and the other posterior. Operative treatment should be performed in patients with moderate and gross elbow laxity to avoid post-traumatic sequelae and decrease revision rates. Arthroscopic techniques create fewer complications. This procedure allows one to address intra-articular elbow joint pathology with less chance of wound complications and the ability to use bone anchors if desired.

Poster 123: Biomechanical Comparison of Four All-inside Meniscus-Based Repairs to Radial Tears of Human Cadaveric Lateral Menisci

Objectives: Meniscal injuries are among the most common orthopedic injuries in the United States. Radial meniscus tears were historically treated with partial meniscectomy, often leading to poor outcomes. Radial tear repair preserves meniscal tissue, may delay knee degeneration, and leads to better long-term outcomes. Repair techniques for radial tears vary and should be evaluated for differences in biomechanical properties and failure mechanisms. All-inside, meniscus-based suture repairs have shorter operating times, minimize risk of nerve injury, and are increasingly possible with novel devices. Our objective was to evaluate the strength based on load-to-failure of four all-inside meniscus-based repair techniques for radial tears in human cadaveric lateral menisci. We chose two techniques that bridged the tear directly – the Double Vertical (DV, Figure 1) and Double Vertical Cross (DVX, Figure 2). We chose two other techniques that added horizontal reinforcing stitches to engage the bridging stitches – the All-inside Rebar (AR, Figure 3) and our novel Oblique Box (OB, Figure 4). We hypothesized that AR and OB would have higher load to failure than DV and DVX. Methods: 36 fresh-frozen human adult lateral menisci were randomized into four groups of nine. Dissection, repair, and testing were completed one meniscus at a time to minimize the time period from thawing to testing. Each meniscus was dissected from its tibial bone block, and a complete radial tear was created at the midbody of the meniscus. Suture repairs were performed using 2-0 braided suture and a straight needle. Menisci were repaired using the DV, DVX, AR, and OB techniques with meniscus- based suturing to simulate the all-inside, meniscus-based approach. All suture dimensions were standardized as indicated on Figures 1-4, and all knots were tied on the superior surface of the menisci. The suture patterns for all repair types used loops that passed above the superior and below the inferior surfaces of the meniscus. The DV repair used two sutures in loops perpendicular to the tear. DVX used two sutures in loops that crossed over the tear. AR used two sutures in loops parallel to the tear acting as reinforcing rebar and two bridging sutures perpendicular to the tear and outside the rebar sutures. OB used two sutures to create a trapezoidal reinforcing box on either side of the tear and two bridging sutures in loops perpendicular to the tear and inside the box. The repaired menisci were loaded on an Instron 5944 test frame with 2 kN load cell using custom clamps. They underwent cyclic loading of 5-30 N for 500 cycles at 10 mm/min, a 30-minute resting period, and a single trial of load-to-failure at 10 mm/min. The ultimate load at failure was analyzed via one-way ANOVA with Tukey’s test for pairwise comparisons and significance set at p<0.05. Results: Failure occurred due to suture cutout in all specimens. Repair constructs that lacked a reinforcing-type suture (DV and DVX) cut through or “cheese-wired” at lower loads than repairs with reinforcing sutures (AR and OB). Mean ± standard deviation ultimate load values for each repair group were 60 N ± 24.5 for DV, 58 N ± 17.4 for DVX, 168 N ± 33.9 for AR, and 105 N ± 9.0 for OB. The ultimate load for all repair techniques were significantly different from each other by Tukey’s test with the exception of the DV and DVX comparison. These results show that reinforcing vertical suture meniscus repairs with some type of horizontal suture (e.g. AR or OB) significantly increases ultimate load at failure for all-inside, meniscus-based techniques. Conclusions: In a cadaveric lateral meniscus model, all-inside radial repairs using rebar suture, or horizontal suture reinforcing techniques, had higher ultimate load at failure and reduced risk of “cheese wiring”. The AR repair sustained the highest ultimate load at failure, nearly 3x stronger than the two non-reinforcing type repair constructs. These data may provide useful information for surgeons during repair to radial meniscus tears. Future biomechanical study should compare all-inside vs. inside-out repairs to maximize patient outcomes. Cross reference of repair patterns with clinical outcomes using the prospective registry data may support optimal surgical techniques to improve meniscus repair outcomes.

Clinical outcomes after repair of an isolated radial tear in the middle segment of the lateral meniscus - All-inside suture repair vs trans-capsular suture repair –

Background/objectiveFor radial tears, all-inside suture (AIS) repair was clearly biomechanically superior, compared to conventional trans-capsular suture (TCS) repairs. However, clinical comparative studies of these two repairs techniques have not to be performed. Therefore, the aim of this study was to compare the clinical outcomes after AIS repair and TCS repairs for isolated radial tear at middle segment of lateral meniscus (RTMLM) in stable knees of young athletes. MethodsTwenty-six athletes (mean age, 19.1 years) underwent AIS repair with the double horizontal suture technique, using SutureLasso™ (Arthrex, Naples, FL) for isolated RTMLM (AIS group), and 20 athletes (mean age, 19.0 years) underwent inside-out repair, one of TCS repairs, with tie-grip suture technique (TCS group). All athletes were assessed for preoperative and two-year postoperative Knee injury and Osteoarthritis Outcome Score (KOOS). At six-month after repair, the lateral meniscal extrusion on mid-coronal plane on MRI and healing status on second-look arthroscopy were also evaluated in all patients. ResultsIn both groups, KOOS improved to either good or excellent postoperatively, while complete healing was found in only 23 and 25% at second-look arthroscopy. We identified no group-dependent differences in KOOS or healing status on arthroscopy. However, a close examination of failure rates revealed significant lower rates in AIS group relative to that of TCS group (p = 0.048). Moreover, the change from preoperative to postoperative lateral meniscal extrusion in AIS group was significantly smaller than that in TCS group (p = 0.038). ConclusionsAIS and TCS repairs for RTMLM were comparable in providing satisfactory clinical results with low rates of complete healing on arthroscopy. However, AIS repair could have lower failure rate of healing on arthroscopy and minimize postoperative lateral meniscal extrusion more effectively than TCS repair on MRI.

Let's talk about incisions

Let's talk about incisions

Mitral Para-valvular leakage following usage of non-pledgeted compared to Teflon-pledgeted sutures

Background: Despite a wide variety of mitral prosthesis suturing, pledgeted annular sutures are preferred to lower the incidence of para-valvular leakage (PVL). However, there is limited evidence in the literature on the effect of non-plegeted sutures on such serious complication. Objective: The purpose of this study was to determine the safety and practicality of employing non-pledgeted sutures for Mitral valve replacement (MVR), especially regarding postoperative PVL. Patients and methods: Data on 100 patients with MVR were gathered from Cairo University Hospitals. Cases were split into two groups: group 1 underwent surgery using non-pledgeted horizontal sutures where in group 2 we used Teflon-pledgeted sutures. Preoperative, operative, and postoperative factors including follow-up echocardiographic examination one year following discharge, were compared between the two groups. Results: Both groups had similar preoperative characteristics, with group 1 including 49 patients compared to 51 patients in group 2. Data showed significantly shorter cross clamping (AXC) time in group 1 (p value < 0.05), intraoperative TEE has never observed para-prosthetic leakage in both groups, there was no significant difference regarding both mean ICU and hospital stay.

Reductive annuloplasty with autopericardium in surgical treatment of mitral insufficiency

BACKGROUND: Despite the widespread usage of all-type rings in the surgical treatment of patients with mitral valve insufficiency (MV) and dilatation of its fibrous annulus, the researches on this topic are in progress.
 AIM: To study the short- and long-term results of narrowing annuloplasty of the MV utilizing an autopericardium strip of calculated length.
 MATERIALS AND METHODS: The study group consisted of 21 patients (average age 60.9 4.3 years, women 23.8 %) with MV insufficiency of non-rheumatic ethiology. The narrowing of the fibrous annulus during valve reconstruction has been performed along with the posterior 2/3 of their circle using interrupted horizontal sutures. With those sutures, an autopericardial strip of the calculated length has been secured to the annulus. The length of the strip has been calculated according to the original method, according to the data obtained during preoperative transesophageal echocardiography. The length of the strip was 2/3 ∙ D (mm), where D the existing length of the anterior leaflet of the MV in the middle portion from the fibrous annulus to the free edge in the zone of the A2 segment. The control group consisted of 38 patients with non-rheumatic MV insufficiency (average age 59.1 3.5 years, women 23.7 %); the strengthening and narrowing of the fibrous annulus have been performed using a strip made from a wicker vascular prosthesis. The length was 55 mm, equal for all the patients. In both groups, in addition to the narrowing of the fibrous annulus, other types of mitral valve-sparing surgery (partial resection of MV leaflets, suture leaflets techniques, their combination) and combined procedures (coronary bypass surgery, left ventricle reconstructions for postinfarction aneurysms) have been also performed.
 RESULTS: In the studied groups, the safety and reliability of the performed restrictive MV annuloplasty procedures have been demonstrated. During the follow-up period up to 8 years (average 3.5 0.7 years), there was no recurrence of significant mitral regurgitation, which would require repeated surgery in both groups. Narrowing annuloplasty of the fibrous annulus of MV with a strip from the autopericardium of an individual calculated length allows to perform a more accurate anatomical correction of the valve compared with the control group. The existing methods of mitral annuloplasty, their advantages and disadvantages are discussed.
 CONCLUSIONS: The proposed method of restrictive annuloplasty of the MV with an autopericardial strip of the calculated length allows to perform a reliable and safe correction of the dilated fibrous annulus in patients with mitral insufficiency during valve-preserving operations.

Orbicularis–levator–tarsus fixation suturing in buried suture double-eyelid blepharoplasty

BackgroundIn buried suture methods, the levator aponeurosis is fixed to the subcutaneous tissue in the pretarsal region using a suture. However, loosening of the suture occurs frequently and causes regression or disappearance of the double-eyelid folds. To avoid potential loosening of the suture after surgery, we modified the horizontal suture technique commonly used in buried suture double-eyelid blepharoplasty. MethodsIn our procedure, the levator aponeurosis was sutured horizontally, and then the subcutaneous tissue in the pretarsal region was sutured vertically by the same suture. After the two ends of the suture were tied, three tissue layers, namely, the levator aponeurosis, pretarsal fascia, and orbicularis oculi muscle, were fixed together in the pretarsal region. ResultsA total of 873 Asian patients underwent double-eyelid blepharoplasty during the past 8 years. No loss of the double-eyelid folds occurred in 563 patients who were followed up for more than six months, and 531 patients, accounting for 94% of the sample, were satisfied with the postoperative results. ConclusionSince the suture was perpendicular to both the levator aponeurosis and the pretarsal orbicularis oculi muscle, pulling on the suture fixation site during blinking was effectively reduced. As a result, regression or disappearance of the double-eyelid folds due to loosening of the suture along the orientation of the muscle fibers was avoided, and the long-term stability of the double-eyelid folds was ensured.

Patellar Tendon Imbrication

Background: Patella alta is a common cause of patellar instability. Patellar tendon imbrication is a successful surgery addressing the deformity by shortening the patellar tendon without necessitating an osteotomy. Indications: Symptomatic patella alta causing patellar instability in both skeletally immature and adult patients. Technique Description: The patellar tendon is exposed, and levels of imbrication as determined preoperatively by radiographic measurements are outlined on the tendon with a marking pen. A third line is then made proximal to the level of dissection that is half the distance of the lengthening. From the distal marking, a flap of tendon, the anterior half, is elevated by sharp dissection using a fresh No. 15 blade proximal to the predetermined level. Next, “redundancy-reducing” 2-0 vicryl sutures are placed and left untied by entering at the proximal marking, passing deep to the tendon, and emerging at the middle of the intact posterior section of tendon, followed by placement of 3 structural #2 Ethibond/Ti-Cron horizontal sutures into the patellar tendon that will create and maintain the imbrication. These sutures are then tied proximally while applying downward pressure to the patella to avoid tying under tension. Next, the “redundancy-reducing” sutures are tied thus imbricating the redundant posterior section of tendon. In a “pants over vest” fashion, the distal end of the anterior section of isolated tendon is repaired with ‘‘0’’ absorbable suture. The knee is then flexed beyond 90° to assess competence of the suture lines and to assess the need for quadriceps lengthening. Results: Radiographic shortening is maintained at a minimum of 2 years on 27 patients/32 knees. There were no complications directly related to the technique. Discussion/Conclusion: Patellar tendon imbrication is a safe and effective procedure to correct patella alta in the setting of lateral patellar instability. On average, the technique allowed 1 cm of patellar tendon shortening and maintained the correction at a minimum 2-year follow-up. In the skeletally immature patient, this technique allows correction of patella alta by avoidance of a tibial tuberosity osteotomy.

Technical Modifications That Might Improve Long-term Outcomes of the Ross Procedure in Children

BackgroundFailure of the pulmonary valve autograft (PVA) after the Ross procedure (RP) has discouraged its widespread use and has led to modifications or alternatives to the procedure. We sought to analyze whether certain technical modifications could improve results of the RP in children. MethodsSixty-nine patients (median age, 12 years; range, 0.25-17.9) underwent the RP between January 1996 and December 2018. A concomitant Konno procedure was performed on 20 of 69 patients (29%). Prior interventions included balloon valvuloplasty in 30 (44%) and/or surgical valvuloplasty in 39 (57%). Technical modifications included using the native aortic root for external annuloplasty, implanting the autograft using uniplanar horizontal sutures through the aortic wall, normalizing the sinotubular junction, and wrapping the native root remnant around the PVA. ResultsOperative mortality was 1 of 69 patients (1.5%), with no late deaths. No patient had neoaortic valvar stenosis and 7 of 68 (10%) had mild regurgitation on discharge echocardiogram. At latest follow-up (median, 9.4 years; range, 0.4-21.3) there was no significant change in Z scores of annulus, sinus, or sinotubular junction diameters when compared with those at discharge. Three patients (4.4%) required late autograft replacement, 2 PVA repair, and 2 resection of a pseudoaneurysm. Actuarial freedom from PVA replacement was 87% at 20 years. Freedom from right ventricular outflow tract catheter reintervention or reoperation was 83% and 80%, respectively. ConclusionsTechnical modifications of the RP used in this cohort might successfully prolong the life of the PVA without compromising its growth, an important advantage in pediatric patients.

LATERAL MENISCUS TEARS IN ACL INJURED KNEE

Anterior cruciate ligament (ACL) tears can be associated with injuries to the lateral meniscus (LM) in about 20-30% cases. The lateral meniscus is more mobile than the medial and besides contributing to load transmission, it also stabilizes the knee in pivot-shift testing. The LM tears more often in the acute setting and its incidence does not rise in cases of chronic ACL instability. Lateral meniscus tears can be minor or major depending how severely the knee function gets impaired. Major tears are the complete radial tears, longitudinal bucket handle tears and posterior root tears. Male gender, high body mass index and contact injury mechanism are all risk factors for an LM tear. Anatomic factors which can contribute to LM tears include a high posterior tibial slope, varus malalignment and greater asymmetry between medial and lateral slopes. The lateral meniscus must be saved and repaired whenever possible to prevent residual knee instability and progressive lateral compartment arthritis, which can set in soon after a meniscectomy. The development of techniques and technology have rendered most tears amenable to repair. Longitudinal tears can be repaired by the all-inside or inside-out technique and the needles and devices must be inserted through a high anteromedial or transpatellar portal to prevent injury to the popliteal neurovascular structures. A lateral safety incision must always be used for inside-out repairs. Radial tears can be repaired by two horizontal sutures, a cross stich, a cross-tag or a hash-tag suture configuration. Lateral meniscus posterior root repairs are repaired by transtibial technique, either by drilling an independent anatomic tunnel or the sutures pulled out via the ACL tibial tunnel. The lateral meniscus has high healing rates and repairs yield improvement in functional outcome, beside delaying radiographic arthritis.

Tibiofemoral Contact Mechanics After Horizontal or Ripstop Suture in Inside-Out and Transtibial Repair for Meniscus Radial Tears in a Porcine Model

To compare tibiofemoral contact mechanics after horizontal or ripstop (horizontal plus vertical) sutures in inside-out and transtibial repair for meniscal radial tears with 10 porcine knees in each group. Ten matched pairs of porcine knees were tested under a 1500-N axial compressive load at 0°, 30°, 60°, and 90° of knee flexion. Each knee underwent 4 testing conditions consecutively: (1) intact, (2) medial meniscal radial tear, (3) horizontal suture repair configuration, and (4) ripstop suture repair configuration. Tekscan sensors measured tibiofemoral contact pressure and contact area in the medial and lateral compartments. All repair groups improved their contact mechanics when compared with the tear state among all flexion angles analyzed (all P < .05). Furthermore, ripstop sutures with both inside-out and transtibial repairs restored intact knee contact area and pressures (peak and mean) in the medial compartment at all flexion angles, whereas the horizontal sutures alone failed to do so for contact pressures at 60° and 90° and for contact surface areas at all flexion angles. However, the aforementioned parameters were not significantly different between inside-out sutures and transtibial sutures, regardless of horizontal or ripstop configuration (P > .05). Radial tears of the meniscus in a porcine model significantly decreased medial contact area and increased mean and peak contact pressure. Both inside-out and transtibial ripstop repairs for radial tears aid in restoring intact tibiofemoral contact mechanics at all assessed knee flexion angles. Our results suggest that both inside-out and transtibial ripstop repairs for radial tears can restore tibiofemoral contact mechanics to the intact state. Since the study were performed in an open fashion porcine model, the results should be carefully used in clinical practices, and the efficacy of the techniques through arthroscopic method should be further explored.

Biomechanical comparison of vertical suture techniques for repairing radial meniscus tear

PurposeThe aim of this study was to (1) develop suture techniques in repairing radial meniscal tear; (2) to compare the biomechanical properties of the proposed repair techniques with the conventional double horizontal technique.MethodsThirty-six fresh-frozen porcine medial menisci were randomly assigned into four groups and a complete tear was made at the midline of each meniscus. The menisci were subsequently repaired using four different repair techniques: double vertical (DV), double vertical cross (DVX), hybrid composing one vertical and one horizontal stitch, and conventional double horizontal (DH) suture technique with suturing parallel to the tibia plateau. The conventional double horizontal group was the control. The repaired menisci were subjected to cyclic loading followed by the load to failure testing. Gap formation and strength were measured, stiffness was calculated, and mode of failure was recorded.ResultsGroup differences in gap formation were not statistically significant at 100 cycles (p = .42), 300 cycles (p = .68), and 500 cycles (p = .70). A trend was found toward higher load to failure in DVX (276.8 N, p < .001), DV (241.5 N, p < .001), and Hybrid (237.6 N, p < .001) compared with DH (148.5 N). Stiffness was also higher in DVX (60.7 N/mm, p < .001), DV (55.3 N/mm, p < .01), and Hybrid (52.1 N/mm, p < .01), than DH group (30.5 N/mm). Tissue failure was the only failure mode observed in all specimens.ConclusionOur two proposed vertical suture techniques, as well as the double vertical technique, had superior biomechanical properties than the conventional technique as demonstrated by higher stiffness and higher strength.

Rebar Repair of Radial Meniscus Tears: A Reinforced Suture Technique

The purpose of this paper is to describe the rebar repair as a technique for repair of radial meniscus tears and compare the rebar technique with current techniques used for meniscus repairs. This technique consists of 4 sutures placed with the inside-out technique. First, the vertical mattress reinforcement sutures are placed anteriorly and posteriorly to the tear. Then, 2 parallel horizontal sutures are placed directly in juxtaposition to the vertical sutures, ensuring the needles pass on the side of the reinforcing stitch away from the tear. This technique is less technically challenging than other meniscus repair techniques that require drilling of a transtibial tunnel. Overall, the rebar technique offers a more optimal way for stabilizing the meniscus by using 2 reinforcement sutures that run with the circumferential fibers to help restore the natural hoop stress of the meniscus. Also, the placement of the vertical mattress sutures in the rebar technique offers more direct reinforcement to the horizontal mattress sutures as compared with other techniques, which reduces the risk of pull-out tears.