Knotless Suture Bridge Research Articles

Types of Retears After Knot-tying and Knotless Suture Bridge Rotator Cuff Repair: A Systematic Review and Meta-analysis.

In conventional double-row repair for rotator cuff tears, tying the medial row of anchor sutures can strangulate the tendon. The knotless medial row technique has been recommended to improve vascularity and reduce retear rates. The researchers divided the retear pattern into 2 categories: type 1 (failure at the tendon-bone interface) and type 2 (failure at the musculotendinous junction with healed footprint). To compare studies on knot-tying versus knotless double-row repair for rotator cuff tears according to retear type and clinical and radiological outcomes. Systematic review; Level of evidence, 3. A search of the PubMed, Embase, Scopus, and Cochrane databases was performed following the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Included were studies that directly compared the knot-tying and knotless double-row techniques and provided postoperative patient-reported outcomes and retear rates. The Methodology Index for Non-Randomized Studies (MINORS) criteria were used for methodological quality assessment of the included studies. Odds ratios (ORs) were calculated for dichotomous outcomes, and mean differences (MDs) were calculated for continuous outcomes. Included were 12 studies (n = 1411 shoulders); 1 study had level 1 evidence, 3 studies had level 2 evidence, and 8 studies had level 3 evidence. The MINORS score ranged from 15 to 19, indicating that the methodology was fair to good. There was no statistically significant difference in retear rate between techniques (OR, 0.99; 95% CI, 0.67-1.47; P = .96); however, more type 1 retears were seen in the knotless technique (OR, 0.42; 95% CI, 0.23-0.77; P = .005), and more type 2 retears were seen in the knot-tying technique (OR, 3.15; 95% CI, 1.70-5.83; P = .0003). Higher postoperative Constant scores were seen in the knot-tying technique (MD, 1.28; 95% CI, 0.03-2.53; P = .04); however, there were no significant differences between techniques regarding other postoperative outcomes. There was no significant difference in overall retear rates between the knotless and knot-tying techniques, and both techniques demonstrated similar clinical outcomes. However, type 2 retear rates were significantly greater after knot-tying repair, and type 1 retear rates were significantly greater after knotless repair.

Comparison of Repair Integrity and Functional Outcomes Between Knot-Tying and Knotless Suture-Bridge Arthroscopic Rotator Cuff Repair: A Prospective Randomized Clinical Trial

Comparison of Repair Integrity and Functional Outcomes Between Knot-Tying and Knotless Suture-Bridge Arthroscopic Rotator Cuff Repair: A Prospective Randomized Clinical Trial

Triple-Row Technique Confers a Lower Retear Rate Than Standard Suture Bridge Technique in Arthroscopic Rotator Cuff Repairs

To compare the structural and clinical results between the knotless suture bridge (SB) and triple-row (TR) techniques. This study is a retrospective study and included 212 shoulders with repairable rotator cuff tears treated with the SB technique and 206 shoulders treated with the TR technique. In the TR technique, medial and lateral anchors were placed as they would be for the SB technique, with a middle row anchor added on the edge of footprint to reduce the torn tendons. All patients underwent primary arthroscopic rotator cuff repair and had magnetic resonance imaging 6 months postoperatively to evaluate for retear. Sugaya's classification was used to classify the retear pattern. The function of all patients preoperatively and 2 years postoperatively were assessed by the American Shoulder and Elbow Surgeons shoulder index and the University of California at Los Angeles rating scale. According to Sugaya's classification, 24 (11.3%), 6 (2.8%), and 20 (9.4%) in SB-treated shoulders and 16 (7.8%), 12 (5.8%), and 8 (3.9%) in TR-treated shoulders, respectively had types 3, 4, and 5. There was a statistically significant greater type 5 retear in SB-treated shoulders (P= .038) than in TR-treated shoulders. The average clinical outcome scores at the final follow-up improved significantly relative to those before the surgeries in both groups. There were no statistical differences in the clinical outcome scores at the final follow-up between SB and TR groups. The use of the TR technique in arthroscopic rotator cuff repair resulted in a lower large-size retear rate when compared with the use of the SB technique. No clinical differences were noted in the outcomes between the 2 groups. Level III, therapeutic, retrospective cohort study.

Arthroscopic Double-Row Bony Bankart Bridge Repair Using a Tensionable Knotless System

Posterior labral pathology is common in contact athletes; however, posterior glenoid avulsion fractures, also known as posterior bony Bankart lesions, are less common. Posterior instability affects approximately 10% of all patients with shoulder instability. Diagnosis in these high-risk individuals often follows a traumatic posterior dislocation. The patient feels grossly unstable but may or may not have recurrent dislocations beyond the initial trauma. Surgical correction and favorable surgical outcomes require a full understanding of both the soft-tissue and bony components of the injury. Stable osseous fixation is required to restore appropriate glenoid version, depth, and to prevent malunion. We present a technique to mobilize and stabilize a posterior bony Bankart lesion with a knotless suture bridge construct. We feel that this technique is reliable and reproducible and allows for a superior quality of fragment reduction when compared with systems using larger anchors and knotted systems.

Repair of avulsion fracture of the anterior superior iliac spine by knotless suture bridge: Surgical technique and a review of 5 cases

Background: Avulsion fracture of the anterior superior iliac spine (ASIS) is a rare form of apophyseal avulsion fracture of the pelvis, and there is a lack of evidence-based guidelines for the selection of treatment options. There are various surgical procedures, but there is the risk of secondary removal of internal fixator and growth disturbance caused by epiphyseal fixation. Methods: We treated 5 patients with avulsion fracture of the anterior superior iliac spine by knotless suture bridge technique who visited our hospital from 2015 to 2020.The surgical treatment results were retrospectively analyzed. Results: 5 patients with fractures were healed after the surgery, no associated complications, the mean postoperative follow-up was 29.2 months (6-60months), all patients were not reported pain symptoms (visual analogue score of 0), they don’t have the limitation of daily activities, and the hip joint function recovered well, and very pleased with the results (Harris score 100 points) at the final follow-up. Conclusion: Knotless suture bridge technique is simple and effective in the repair of the avulsion fracture of anterior superior iliac spine. For such patients, this surgical technique can provide stable and reliable fixation, allow early recovery, and provide a feasible scheme for clinical practice.

Rotator Cuff Repair With Knotless Technique Is Quicker and More Cost-Effective Than Knotted Technique

PurposeTo determine the cost-effectiveness of knotted (KT) versus knotless (KL) methods for rotator cuff surgical repair and to assess differences in patients’ outcomes.MethodsWe retrospectively identified all patients who underwent arthroscopic rotator cuff repair at 1 institution by 1 surgeon over 2 6-month periods of time (KT technique from August 1, 2013, through January 31, 2014; and KL technique from December 1, 2014, through May 31, 2015) to calculate the direct and indirect costs associated with arthroscopic KT or KL suture bridge rotator cuff repair. Patient demographics, number of anchors used, tendons repaired, procedure time, operative time, and clinical results were also evaluated. We used univariate generalized linear models with a Gaussian distribution for assessment scores and total and implant cost data.ResultsWe identified 87 patients for inclusion during the 2 time frames (35 KT, 54 KL). After excluding patients for tear size < 4 cm2 (n = 42), ≤ 3 anchors (n = 5), revision surgery (n = 1), and those in whom additional procedures were performed (n = 2), 37 eligible subjects remained (nKT = 15, nKL = 22). Median implant costs were statistically significantly higher in the KL group than in the KT group (MKL = $2,127, MKT = $1,520, β = 413.7, 95% CI: 242.8, 584.6, P < .01), and more anchors were used in the KL group, with KT requiring a median of 4 anchors (IQR: 4, 5) and KL requiring a median of 5 anchors (IQR: 5, 5, P = .02). Procedure time was cut in half with KL repair (estimated 43.5 minutes) versus KT repair (80 minutes) (β = 0.5, 95% CI: 0.4, 0.6, P < .001). Operating room time also was reduced by approximately 40% (79.5 minutes for KL; 121 minutes for KT [β = 0.6, CI: 0.6, 0.7, P < .001]). Once operating room costs were considered, median costs were found to be significantly lower in the KL group (MKL = $3788.40, MKT = $4262.90, β = –492.1, 95% CI: –840.0, –144.1, P < .01). No statistically significant differences were found between groups in mean preoperative, postoperative or postpreoperative differences in the visual analog scale, Simple Shoulder Test, American Shoulder and Elbow Surgeons, or University of California at Los Angeles scores (P > 0.05 for all).ConclusionsDespite using more anchors and incurring higher implant costs, the KL technique for rotator cuff repair required less surgical procedure time and cost less overall than the KT technique and resulted in equivalent clinical results.Level of EvidenceLevel IV Economic and Decision Analyses.

Biomechanical analysis of four different medial row configurations of suture bridge rotator cuff repair

BackgroundRotator cuff tendon rupture after suture bridge repair occasionally occurs at the medial row, with remnant tendon tissue remaining at the footprint. While concentrated medial row stress is suspected to be involved in such tears, the optimal suture bridge technique remains controversial. MethodsThis study aimed to investigate the construct strength provided by suture bridge techniques having four different medial row configurations using artificial materials (n = 10 per group): Group 1, four-hole (two stitches per hole) knotless suture bridge; Group 2, eight-hole (one stitch per hole) parallel knotless suture bridge; Group 3, eight-hole non-parallel knotless suture bridge; and Group 4, eight-hole knot-tying suture bridge. Each construct underwent cyclic loading from 5 to 30 N for 20 cycles, followed by tensile testing to failure. The ultimate failure load and linear stiffness were measured. FindingsGroup 2 had the highest ultimate failure load (mean 160.54 N, SD 6.40) [Group 4 (mean 150.21 N, SD 9.76, p = 0.0138), Group 3 (mean 138.80 N, SD 7.18, p < 0.0001), and Group 1 (mean 129.35 N, SD 4.25, p < 0.0001)]. The linear stiffness of Group 2 (mean 9.32 N/mm, SD 0.25) and Group 4 (mean 9.72 N/mm, SD 0.40) was significantly higher (p = 0.0032) than that of Group 1 (mean 8.44 N/mm, SD 0.29) and Group 3 (mean 8.61 N/mm, SD 0.31). InterpretationIn conclusion, increasing the number of suture-passed holes, arranging the holes in parallel, and a knotless technique improved the failure load following suture bridge repair.

Comparison of Two Arthroscopic Rotator Cuff Repair Techniques: Knot-tying Versus Knotless Suture-bridge Technique

Comparison of Two Arthroscopic Rotator Cuff Repair Techniques: Knot-tying Versus Knotless Suture-bridge Technique

Arthroscopic Rotator Cuff Repair With a Knotless Suture Bridge Technique: Functional and Radiological Outcomes After a Minimum Follow-Up of 5 Years

To evaluate clinical and radiological outcomes of knotless suture bridge repair after a minimum of 5years of follow-up. A prospective consecutive series of full-thickness supraspinatus atraumatic chronic tears was evaluated in the study. Tears were medium or large. Further inclusion criteria were minimum clinical follow-up of 5years with magnetic resonance imaging (MRI) at 24months and fatty infiltration <2. Patients with shoulder stiffness, arthritis, or rotator cuff tear involving the subscapularis tendon were excluded. An arthroscopic cuff repair was performed using a knotless double-row suture bridge technique with braided suture tapes. Clinical outcomes were evaluated using the Constant score, the American Shoulder and Elbow Surgeons score, strength score, and a visual analog scale. Tendon healing was analyzed according to Sugaya MRI classification at 24months. A Sugaya score of 1 or 2 was considered as tendon healing. Statistical analysis was performed with the Student's t-test. P= .05 were considered statistically significant. Sixty-eight patients were included in this series. Mean follow-up was equal to 68.8 ± 7months. At last follow-up, the mean visual analog scale, American Shoulder and Elbow Surgeons score, and Constant scores improved significantly from 5.5 ± 1.6, 48.2 ± 13.1, 37.8 ± 8.3, to 2.1 ± 2.1 (P= 5.43 E-14), 87.4 ± 15.8 (P= 7.15 E-27), and 82.8 ±14.7 (P= 1.01 E-33), respectively. Anteflexion improved from 99.3° ± 13.4° preoperatively to 136.6° ± 15.9° at last follow-up (P= 3.08 E-21). Strength score was significantly higher postoperatively (18.4 ± 6.7 vs 8.3 ± 3.5). MRI showed 88% (n= 57) of Sugaya 1-2 repairs. Patients with unhealed rotator cuffs showed significantly lower functional results than the Sugaya 1-2 group. No correlation between degree of retraction and rate of healing was observed. Four symptomatic patients (6%) required revision for failed rotator cuff repair. Despite potential confounding factors, arthroscopic knotless suture bridge repair of rotator cuff tears with acromioplasty demonstrated excellent long-term results of tendon healing, pain relief, and improvement of shoulder function. Level IV, therapeutic case series.

Knotless Suture Bridge Technique in High-Grade Bursal-Sided Rotator Cuff Tears. Is This The Way Forward?

We present our technique in managing high-grade bursal-sided rotator cuff tears. In this technique, the remaining intact cuff tissue is not sacrificed. The suture bridge technique is used to uniformly tension the torn tissue to the rotator cuff footprint. No knots are tied on the rotator cuff to minimize the tension on the cuff. The sutures are then anchored on the lateral cortex of the humerus. This technique allows repair with minimum tension while preserving the original length of the rotator cuff.

Comparison of arthroscopic double-pulley knotless suture bridge and conventional arthroscopic suture bridge for rotator cuff repair

Objective To compare arthroscopic double-pulley knotless suture bridge with conven-tional arthroscopic suture bridge in repair of rotator cuff tear. Methods From May 2013 to May 2015, 70 patients with rotator cuff tear were repaired at our department. They were 38 males and 32 females, with a mean age of 53.7 years. They were randomized into 2 equal groups to receive repair either using arthroscopic double-pulley knotless suture bridge (the experimental group) or using conventional arthroscopic suture bridge (the control group). The 2 groups were compared postoperatively in terms of VAS (visual analogue scale), Constant, ASES (American Shoulder and Elbow Surgeons) and UCLA (University of California at Los Ange-les)scores, shoulder range of motion, and rotator cuff retear. Results The 2 groups were compatible with no significant differences in gender, age, laterality, tear type, or preoperative function or range of motion of the shoulder joint (P >0.05). At 12 months postoperatively, the VAS, Constant, ASES and UCLA scores and shoulder range of motion in the experimental group were respectively 1.1±1.3, 86.0±8.9, 13.3±0.8, 32.0±2.9, 156.8°±15.0° and 55.9°±5.8°, significantly improved than the preoperative values (P 0.05). No case of rotator cuff retear occurred in the experimental group while 5 cases were observed in the control group, showing a significant difference (0 versus 14.3%) (P< 0.05). Conclusions Compared with conventional arthroscopic suture bridge, arthroscopic dou-ble-pulley knotless suture bridge presents no significant differences in range of motion or function of the shoulder joint in repair of rotator cuff tear. However, the latter may lead to a lower incidence of rotator cuff retear and, additionally, is less skillfully demanding. Key words: Rotator cuff tear; Arthroscopy; Surgical procedures, minimally

Knotted Versus Knotless Suture Bridge Repair of the Achilles Tendon Insertion

Background: Surgical treatment of insertional Achilles tendinopathy often involves detachment and debridement of the Achilles tendon insertion. A recent study has shown that knotted suture bridge fixation of the Achilles to the calcaneus is biomechanically superior to single-row fixation, but there is an absence of literature on the use of different suture bridge constructs to repair the Achilles tendon. Hypothesis: There will be no significant difference in the load to failure, mode of failure, tendon strain, tendon stiffness, repair site gapping, or footprint size when comparing knotted suture bridge repair to knotless suture bridge repair of the Achilles tendon after detachment for insertional Achilles tendinopathy. Study Design: Controlled laboratory study. Methods: A single specimen from each pair of 10 cadaveric Achilles tendons was randomized to 1 of 2 Achilles insertion repair groups: knotted (n = 10) or knotless (n = 10) suture bridge repair. Repaired footprint size was measured, and then cyclic testing from 10 to 100 N for 2000 cycles was performed. This was followed by measurement of tendon strain, repair site displacement, load to failure, and tendon stiffness. Results: The knotted suture bridge repair had a significantly higher load to failure compared with the knotless suture bridge (mean ± SD, 317.8 ± 93.6 N vs 196.1 ± 12.1 N, respectively; P = .001). All constructs failed at the tendon-suture interface. Tendon strain after cyclic testing was significantly greater in the knotless (1.20 ± 1.05) compared with the knotted (0.39 ± 0.4) suture repair groups (P = .011). There was no significant difference in footprint size between the knotted (230.3 ± 63.3 mm2) and knotless (248.5 ± 48.8 mm2) groups (P = .40). There was also no significant difference in stiffness (knotted = 76.4 ± 8.0 N/mm; knotless = 69.6 ± 10.9 N/mm; P = .17) and repair site displacement after cyclic testing (knotted = 2.8 ± 1.2 mm; knotless = 3.6 ± 1.1 mm; P = .17). Conclusion: During suture bridge repair of the Achilles tendon after detachment, knots at the proximal suture anchors significantly improve the biomechanical strength of the repair. Clinical Relevance: This study demonstrated that the knotless suture bridge repair had a significantly lower load to failure than the knotted suture bridge. Surgeons should be aware of these biomechanical differences, as they influence the postoperative rehabilitation protocol and may lead to higher surgical complication rates.

Arthroscopic Rotator Cuff Repair Using Modified Mason-Allen Medial Row Stitch

Background: When using a method of suture bridge technique, there may be a possibility of strangulation of the rotator cuff tendon at the medial row. The style of knots chosen to secure the medial row might conceivably be a factor to reduce this possibility. Purpose: To compare the clinical results and repair integrity of arthroscopic rotator cuff repair between a knotless and a conventional knot-tying suture bridge technique for patients with full-thickness rotator cuff tears and to evaluate retear patterns in the cases with structural failure after arthroscopic repair by magnetic resonance imaging (MRI). Study Design: Cohort study; Level of evidence, 2. Methods: After arthroscopic repair for medium-sized rotator cuff tears, 110 patients available for postoperative MRI evaluation at least 6 months were enrolled in this study. According to the repair technique, 51 shoulders were enrolled in a knotless suture bridge technique group (group A) and 59 shoulders in a conventional knot-tying suture bridge technique group (group B). The mean age at the time of the operation was 61.0 years (range, 44-68 years) in group A and 57.6 years (range, 45-70 years) in group B. The mean follow-up period was 21.2 months (range, 12-34 months) and 22.1 months (range, 13-32 months), respectively. Results: The Constant score of group A increased from the preoperative mean of 65.2 points to 79.1 points at the last follow-up (P < .001). The corresponding figures for group B improved from 66.6 points to 76.3 points (P < .001). The preoperative Shoulder Rating Scale of the University of California at Los Angeles (UCLA) score was 21.1 points in group A and 18.3 points in group B. The UCLA score at the last follow-up was 31.0 points in group A and 27.9 points in group B (P < .001, P < .001). Retear rate was significantly lower in group A (5.9%) than group B (18.6%) (P < .001). In group B, retear occurred at the musculotendinous junction in 72.7%, but group A had no medial cuff failure. Conclusion: In arthroscopic suture bridge repair of full-thickness rotator cuff tears, clinical results of both a knotless and a conventional knot-tying group showed improvement without significant difference between the 2 groups. However, the knotless group had a significantly lower retear rate compared with the conventional knot-tying group. A knotless suture bridge technique could be a new supplementary repair technique to conventional technique.

Double-row Labral Repair

Arthroscopic repair of Bankart lesions has advanced significantly in recent years. However, failure rates still remain high with certain patient populations and pathologies. Recent anatomic and biomechanical research has demonstrated that double-row labral repairs significantly improve restoration and pressurization of the native capsulolabral footprint compared with a standard single-row repair. In addition, double-row repair eliminates the need for knot tying, minimizing foreign body material in the glenohumeral joint. We describe an arthroscopic double-row labral repair technique using a knotless suture bridge. Preloaded suture anchors are placed medially on the glenoid neck, and the sutures are passed through the detached capsulolabral tissue. These sutures are then tensioned and fixed to the glenoid face with knotless suture anchors creating a low-profile, biomechanically stable double-row labral repair.