Knotless Suture Research Articles

Comparing the Efficacy of the Knotless Suture Anchor Technique in Bony and Soft Tissue Bankart Lesions: A Cohort Study on Shoulder Instability Patients

Comparing the Efficacy of the Knotless Suture Anchor Technique in Bony and Soft Tissue Bankart Lesions: A Cohort Study on Shoulder Instability Patients

Comparison of Knotless Versus Knot-Tying Suture Anchors for Arthroscopic Repair of Hip Labral Tears.

Both knotless and knot-tying anchors are commonly employed in the arthroscopic repair of hip labral tears. To compare the midterm clinical results of arthroscopic hip labral repair using knot-tying versus knotless suture anchors. Cohort study; Level of evidence, 3. Patients who underwent arthroscopic hip labral repair between January 2017 and January 2021 and who had at least 2 years of follow-up were included. The patients were divided into 2 groups based on the suture anchor type: a 2.9-mm knotless suture anchor (knotless group) or a 1.8-mm knot-tying suture anchor (knot-tying group). All patients underwent femoroplasty for cam lesions and acetabular rim trimming for pincer lesions. The modified Harris Hip Score (mHHS), Hip Outcome Score-Sport-Specific Subscale (HOS-SSS), Hip Outcome Score-Activities of Daily Living (HOS-ADL), 12-item International Hip Outcome Tool (iHOT-12), and visual analog scale (VAS) for pain were administered both preoperatively and postoperatively. The consistency of the outcome scores was assessed using the minimal clinically important difference and Patient Acceptable Symptom State. The statistical significance between groups was evaluated using the Mann-Whitney test and quantile-based analysis of variance. A total of 413 patients were included: 256 patients in the knotless group (median age, 35 years [interquartile range, 31-38 years]; median follow-up, 34 months) and 157 patients in the knot-tying group (median age, 34 years [interquartile range, 30-38 years]; median follow-up, 25 months). There were no significant differences in postoperative mHHS, HOS-ADL, or iHOT-12 scores between the 2 groups. However, there were significant differences, favoring the knotless group over the knot-tying group, in postoperative HOS-SSS (87 ± 2 vs 86 ± 1, respectively) and VAS pain (1 vs 2, respectively) scores (P < .0001 for both). Postoperative synovitis was found in significantly more patients in the knot-tying group than in the knotless group (17 vs 5, respectively; P = .01). In this study, patients who underwent arthroscopic hip labral repair with knotless suture anchors had slightly better postoperative HOS-SSS and VAS pain scores and a lower incidence of postoperative synovitis compared with patients who underwent repair with knot-tying suture anchors.

The Use of Knotless Suture Tape Construct vs Screw Fixation for Lisfranc Injuries: A Cadaveric Biomechanical Study.

Lisfranc injuries are often treated with open reduction and internal fixation using rigid fixation techniques. The use of flexible fixation to stabilize the Lisfranc joint is a newer technique. The purpose of this cadaveric study is to compare the amount of diastasis at the Lisfranc interval under diminished physiologic loads when treated with a knotless suture tape construct and a solid screw. Ten cadavers (20 feet) had native motion at the intact Lisfranc interval assessed at multiple increasing loads (69, 138, and 207 N). The Lisfranc ligamentous complex was then disrupted, and testing repeated to evaluate the amount of diastasis. Randomization was performed to determine the type of fixation for each cadaver: solid screw or knotless suture tape construct. Once fixation was completed, specimens were cyclically loaded for 10 000 cycles at loads, and diastasis was quantified after each load cycle to compare the interventions. Diastasis was measured using motion tracking cameras and retroreflective marker sets. A non-inferiority statistical analysis was performed. Diastasis mean values were confirmed to be >2 mm for all load bearing conditions in the injury model. Posttreatment, diastasis was significantly reduced when compared to the sectioned conditions (P < .01) for both treatment options. Non-inferiority analyses showed that the knotless suture tape construct did not perform inferior to screw fixation for diastasis at the Lisfranc interval at any of the compared load states. Under the loads tested, there is no significant difference in diastasis at the Lisfranc interval when treating ligamentous Lisfranc injuries with a knotless suture tape construct or solid screws. Both reduced diastasis from the injured state and were not different from the intact state. In this cadaveric model with ligamentous Lisfranc injury, diastasis of a knotless suture tape construct is compared to solid screw fixation as tested.

Functional Outcome of Arthroscopic Bankart Repair with Knotless Suture Anchor: A Retrospective Observational Study

Background: The soft tissue in the shoulder plays a significant role in anterior shoulder instability, leading to humeral head displacement from the glenoid fossa. Arthroscopic Bankart repair is a widely accepted method to restore the labrum to the joint rim. This study aims to evaluate the clinical outcomes of Bankart repair by knotless suture anchors at medium-term follow-up, assess the functional outcomes of the knotless suture anchor method for recurrent anterior glenohumeral instability, and conduct clinical assessment using the Rowe score at 6-week, 3-month, 6-month, and 12-month intervals in patients. Methods: In this retrospective study, patients who underwent arthroscopic Bankart repair using a 2.8 mm knotless suture anchor (MINI-VIM PK® ) were enrolled. They were assessed for shoulder stability, range of motion (ROM), and functional outcomes using the Rowe scale at the baseline, 6-week, 3-month, 6-month, and 12-month follow-up intervals as part of the planned early efficacy measures. All the statistical analyses were performed using SPSS software. Results: The mean age of the subjects was 28.10 ± 6.14. In this trial, 51 patients (69.86%) were diagnosed with recurrent shoulder dislocation on the left side, and 22 patients (30.14%) on the right side. The Rowe score demonstrated a significant improvement (P &lt; 0.0001), increasing from 44.73 ± 1.64 to 95.62 ± 18.33 at the 12-month follow-up period. This indicated better clinical outcomes and reduced recurrence of instability with the use of knotless suture anchors. Conclusion: The use of knotless suture anchors demonstrated reduced recurrence rates, improved post-operative shoulder motion, and increased stability without adding complexity to the procedure.

SpeedBridge Technique for Open Distal Triceps Tendon Repair

Background: Distal triceps tendon ruptures occur most commonly in middle-aged males, with possible rupture locations including the musculotendinous junction, mid-tendon, or most commonly, at the tendinous insertion. This surgical technique video demonstrates a hybrid distal triceps tendon repair construct utilizing transosseous sutures, SpeedBridge compression, and knotless suture anchor fixation. Indications: Indications for this procedure include an acute injury with complete avulsion of the distal triceps tendon from the olecranon and extension weakness. The goals of surgical repair include restoration of the tendon footprint on the olecranon and the creation of a strong fixation construct that balances tension to optimize healing and restore functional range of motion. Technique Description: The proximal avulsed tendon is prepared with two number 2 suture tapes placed in a locking Krackow fashion. The locking stitch exit point is determined at a distance proximal to the distal end of the tendon to optimize tension after the reduction of the tendon to the footprint. Two looped sutures are then passed through the tendon at the same exit level as the locking stitch, 1 on the medial and lateral sides of the locking stitch, respectively. Two transosseous tunnels are drilled obliquely, from proximal to distal, through the olecranon. A 4.75-mm suture anchor is then drilled and tapped in the proximal ulna, in between 2 transosseous tunnel exit points, for lateral placement. The medial and lateral locked stitches are passed through the medial and lateral transosseous tunnels, respectively. The SpeedBridge construct is formed by passing one suture from each locking stitch limb back through the tendon using the previously placed looped sutures as shuttling devices. After appropriate tensioning, the sutures are secured into the previously drilled 4.75-mm suture anchor in a specific fashion. Results: Current literature suggests that the SpeedBridge technique for triceps tendon repair demonstrates good functional and clinical outcomes with high satisfaction rates, elbow functional scores, and rates of returning to work/activity, coupled with low complication rates. Conclusion: The hybrid SpeedBridge construct is an effective technique for acute distal triceps tendon repair. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Arthroscopic repair is an effective treatment for dynamic medial ankle instability secondary to posttraumatic and partial injury of the deltoid ligament deep fascicle.

When the intermediate or collicular fascicle of the medial collateral ligament (MCL) is injured, the diagnosis of posttraumatic medial ankle instability (MAI) is supported. The aim of this study was to describe an arthroscopic all-inside MCL repair after posttraumatic MAI secondary to an isolated injury of the MCL deep fascicle with a knotless suture anchor technique. Seven patients (seven men, median age: 23 [19-28] years) with posttraumatic MAI were treated by arthroscopic means after failing nonoperative management. The median follow-up was 34 (13-75) months. The MCL was repaired with an arthroscopic all-inside technique. A tear affecting the deep and intermediate or collicular fascicle of the MCL was observed in all cases. In addition, five patients were diagnosed with an isolated fibular anterior talofibular ligament (ATFL) detachment, and in two patients, both the ATFL and calcaneofibular ligament were involved. All patients reported subjective improvement after the arthroscopic ligament repair. The median American Orthopedic Foot and Ankle Society score increased from 68 (range: 64-70) preoperatively to 100 (range: 90-100) at final follow-up. Posttraumatic MAI can be successfully treated by an arthroscopic all-inside repair of the MCL. The presence of an MCL tear affecting the tibiotalar ligament fibres attached to the area of the anterior colliculus should be considered a sign of posttraumatic MAI. This partial deltoid injury at the level of the intermediate or collicular fascicle will conduct to a dynamic MAI. Level IV.

A novel repair strategy using knotless squeeze anchors for lumbar disc herniation with endplate junction lesions under biportal endoscopic spinal surgery.

Annulus fibrosus-endplate (AF-EP) junction lesions are important determinants for lumbar disc herniation (LDH). Utilizing biportal endoscopic spinal surgery (BESS), we introduce a novel repair method using bioabsorbable PushLock anchors with suture fibers to stretch disconnected AF tissues to the vertebral cortex. The viewing and working portals are established to excise herniated disc materials causing radiculopathy. Through the working portal, a suture strand is passed through the intact AF tissue near the lesion and retrieved using the Suture Crossing Device. Then, the knotless suture limbs are secured into the cortical bone socket of the vertebral body with a PushLock anchor. The procedure is a simple, safe, and feasible knotless suturing technique for the treatment of LDH with AF-EP junction lesions.

“Shoe Shop” Lacing Technique: A New Biceps-Augmented Knotless Suture for Arthroscopic Rotator Cuff Repair

Advancements in rotator cuff tear repair have led to innovative techniques for complex cases. In this article, we introduce the “shoe shop” lacing technique, a knotless, side-to-side, and tendon-to-bone suture method augmented with the long head of the biceps tendon (LHBT) for anterior margin–deficient massive rotator cuff tears. This approach offers simplicity, durability, and potential advantages in biomechanics. The LHBT integration and knotless sutures make it a promising solution for challenging tear patterns. This technique provides an attractive option for arthroscopic repair, improving outcomes in cases where anterior cable reinforcement is essential.

Knotless suture in revision total joint arthroplasty: a prospective randomized controlled trial.

The use of barbed sutures for wound closure in primary total joint arthroplasty (TJA) has been shown to be effective and safe. However, their effectiveness and safety in revision TJA procedures has not been thoroughly studied. This study aims to evaluate the efficacy and safety of using barbed suture closure in revision TJA setting. A total of 80 patients undergoing revision TJA between September 2020 and November 2022 were included in this randomized controlled trial study. Following informed consent, patients were computer-randomized to the treatment arm (barbed suture wound closure) or to the control arm (conventional wound closure). Closure duration, closure rate, number of sutures used and wound related outcomes including complication rates and Patient and Observer Scar Assessment Scale (POSAS) score were compared between groups. The use of barbed sutures decreased closure time by 6min (30.1 vs. 36.1min, P = 0.008) with a higher wound closure rate (6.5 vs. 5.5mm/minute, P = 0.013). Additionally, the number of sutures used for wound closure in the barbed group was significantly lower than in the control group (6.2 vs. 10.1, respectively, P < 0.001). There were no significant differences in the rate of postoperative wound complications (P = 0.556) or patient and observer POSAS scores (P = 0.211, P = 297, respectively) between the two groups at 3-month follow-up. Closure of revision TJA surgical wound utilizing barbed sutures reduced closure time and the number of needles handled by operative staff, with no significant increase in intra- or post-operative complications rate when compared to traditional closure technique. I.

Squeaking Shoulder Following Arthroscopic Shoulder Surgery: A Case–Control Study

Background: To date, the occurrence of unusual squeaking noises during shoulder movements following shoulder arthroscopic surgeries have been minimally reported. Purpose: The aim of this study was to report the incidence, natural history, possible risk factors and functional outcomes of patients who reported to have squeaking noises following shoulder arthroscopic procedures. Methods: In this 2-year case-control study, all patients who underwent arthroscopic shoulder in a single institution were included. All patients were then evaluated preoperatively and postoperatively for demographics, pathology, surgical factors, and functional outcomes. The possible risk factors and functional outcomes of the patients who experienced squeaking following shoulder arthroscopic surgeries were then compared with those patients who did not experience squeaking following shoulder arthroscopic surgeries. Results: Of the 360 patients included in the study, the incidence of squeaking following arthroscopic shoulder surgeries was 2.23%, and the incidence of squeaking following arthroscopic shoulder labral repair was 3.1%. The age, gender, hand dominance, body mass index, participation in sports, pathology, side of pathology, use of knot-tying versus knotless suture anchors, number of suture anchors, and surgical duration were not significantly different between patients who experienced squeaking and patients who did not. All patients had comparative functional outcomes preoperatively and postoperatively (at the 3-month, 6-month, and 1-year follow-ups). Conclusion: This case-control study provides an analysis of a series of patients with squeaking of the shoulder following arthroscopic shoulder surgeries. No risk factors or etiology of the condition have been identified in the series. However, there is no functional compromise among these patients who experienced squeaking following shoulder arthroscopic surgeries.

All-Suture Anchor vs. Knotless Suture Anchor for the Treatment of Anterior Shoulder Instability-A Prospective Cohort Study.

All-suture or soft-anchors (SA) represent a new generation of suture anchor technology with a completely suture-based system. This study's objective was to assess Juggerknot® SA, for arthroscopic Bankart repair in recurrent shoulder instability (RSI), and to compare it to a commonly performed knotless anchor (KA) technique (Pushlock®). In a prospective cohort study, 30 consecutive patients scheduled for reconstruction of the capsulolabral complex without substantial glenoid bone loss were included and operated on using the SA technique. A historical control group was operated on using the KA technique for the same indication. Clinical examinations were performed preoperatively and 12 and 24 months postoperatively. RSI and WOSI at 24 months were the co-primary endpoints, evaluated with logistic and linear regression. A total of 5 out of 30 (16.7%) patients suffered from RSI in the SA group, one out of 31 (3.2%) in the KA group (adjusted odds ratio = 10.12, 95% CI: 0.89-115.35), and 13.3% in the SA group and 3.2% in the KAgroup had a revision. The median WOSI in the SA group was lower than in the KA group (81% vs. 95%) (adjusted regression coefficient = 10.12, 95% CI: 0.89-115.35). Arthroscopic capsulolabral repair for RSI using either the SA or KA technique led to satisfying clinical outcomes. However, there is a tendency for higher RSI and lower WOSI following the SA technique.

Optimizing pectoralis major tendon repair: a modified knotless suture anchor technique using high-strength suture and tape

BackgroundRupture of the pectoralis major tendon is infrequent but has shown an increased incidence in athletes, particularly weightlifters during bench presses. Various techniques for repair exist, yet no established gold standard has been defined. MethodsWe present a modified surgical technique utilizing knotless suture anchors for pectoralis major tendon repair. The technique involves bringing the tendon end superiorly and inferiorly to the decorticated bone surface, ensuring broader tendon-to-bone contact. Knotless anchors with a unique suture locking mechanism facilitate tension adjustment. Additionally, the repair's strength is reinforced by employing both surgical tape and high-strength suture. ResultsThe utilization of both surgical tape and high-strength suture in conjunction with knotless suture anchors provides a secure and stable construct. This approach minimizes the risk of failure, reduces the potential for neurovascular injury associated with bicortical drilling, preserves imaging quality due to the absence of metal artifacts, and helps avoid the risk of fracture associated with traditional methods. However, surgeons should be aware of a potential disadvantage of increased surgical costs compared to traditional techniques. ConclusionsOur modified technique offers multiple advantages, including increased tendon-to-bone contact, enhanced stability, reduced neurovascular risks, and avoidance of potential fractures. This makes it a valuable option for successful pectoralis major tendon repairs. Surgeons should consider its benefits and weigh them against the associated costs for optimal patient care.

Laparoscopic Treatment of Perforated Peptic Ulcer: A Propensity Score-Matched Comparison of Interrupted Stitches Repair versus Knotless Barbed Suture.

Background: Peptic ulcers result from imbalanced acid production, and in recent decades, proton pump inhibitors have proven effective in treating them. However, perforated peptic ulcers (PPU) continue to occur with a persistent high mortality rate when not managed properly. The advantages of the laparoscopic approach have been widely acknowledged. Nevertheless, concerning certain technical aspects of this method, such as the best gastrorrhaphy technique, the consensus remains elusive. Consequently, the choice tends to rely on individual surgical experiences. Our study aimed to compare interrupted stitches versus running barbed suture for laparoscopic PPU repair. Methods: We conducted a retrospective study utilizing propensity score matching analysis on patients who underwent laparoscopic PPU repair. Patients were categorised into two groups: Interrupted Stitches Suture (IStiS) and Knotless Suture (KnotS). We then compared the clinical and pathological characteristics of patients in both groups. Results: A total of 265 patients underwent laparoscopic PPU repair: 198 patients with interrupted stitches technique and 67 with barbed knotless suture. Following propensity score matching, each group (IStiS and KnotS) comprised 56 patients. The analysis revealed that operative time did not differ between groups: 87.9 ± 39.7 vs. 92.8 ± 42.6 min (p = 0.537). Postoperative morbidity (24.0% vs. 32.7%, p = 0.331) and Clavien-Dindo III (10.7% vs. 5.4%, p = 0.489) were more frequently observed in the KnotS group, without any significant difference. In contrast, we found a slightly higher mortality rate in the IStiS group (10.7% vs. 7.1%, p = 0.742). Concerning leaks, no differences emerged between groups (3.6% vs. 5.4%, p = 1.000). Conclusions: Laparoscopic PPU repair with knotless barbed sutures is a non-inferior alternative to interrupted stitches repair. Nevertheless, further research such as randomised trials, with a standardised treatment protocol according to ulcer size, are required to identify the best gastrorraphy technique.

Ulnar Collateral Ligament Repair With Internal Brace Using Linked Knotless Suture Anchors

This article presents an adaptation of the internal brace ulnar collateral ligament (UCL) repair technique using knotless suture anchors, which shows promise for improved postsurgical functionality and a shortened recovery period in patients with UCL injuries. Traditional methods of UCL reconstruction often require a lengthy 12- to 18-month recovery period, presenting a significant challenge for athletes keen to return to their sport. The modified technique uses smaller sutures and drill holes, thereby eliminating the need for larger anchors and simplifying the surgical process. Furthermore, we provide a comprehensive exploration of the rehabilitation protocol involved after surgery, which includes various phases of physical therapy and use of the “thrower’s ten” program to improve shoulder and elbow stability, strength, and mobility. This technique paves the way for a promising alternative to traditional UCL reconstruction or repair methods, with the potential to significantly enhance clinical outcomes, improve recovery times, and positively impact athletes’ lives.

All-Arthroscopic Falciform Portal Biceps Tenodesis

Biceps tenodesis has been proven to be an effective treatment for biceps tendon and superior labral pathology. Many techniques including both open and arthroscopic approaches have been reported. Open techniques afford management of the entire proximal biceps tendon but are limited by wound healing issues, increased bleeding, and increased surgical time. Arthroscopic tenodesis offers benefits in terms of surgical efficiency, cosmesis, and bleeding risk. However, standard arthroscopic tenodesis only addresses intra-articular biceps pathology. In this report we describe an all-arthroscopic biceps tenodesis technique at the suprapectoral region of the humerus using knotless suture anchor fixation.

Immediate Effects of the Self-Retaining Barbed Suture Material Application &#x0D; for Gastrojejunostomy During Mini Gastric Bypass Laparoscopic Surgery

Background. The safety of self-retaining barbed suture material application when closing wounds of hollow organs and forming anastomoses remains controversial. Data on the use of self-retaining barbed suture material at the stage of a single anastomosis formation during mini gastric bypass laparoscopic surgery (mini gastric bypass - MGB) in the treatment of morbid obesity is scarce and includes both examples of suturing a technological hole after the implementation of a hardware technique, and totally hand-sewn intracorporeal knotless formation of a gastrojejunostomy.The aim of the study was to evaluate the immediate effects of single-row continuous sutures performed with self-retaining barbed unidirectional suture material for intracorporeal hand-sewn gastrojejunostomy during MGB.Methods. The study included 116 patients with grade II-III obesity who underwent MGB. The total duration of operations and the duration of the gastrojejunostomy stage, the volume of intraoperative blood loss, the frequency and severity of intra- and postoperative complications were prospectively studied in accordance with the unified classifications of Satava-Kazaryan and Accordion, respectively. The first group consisted of 56 patients; a conventional synthetic (polydioxanone) monofilament suture material was used for hand-sewn gastrojejunostomy in patients of this group. The second group consisted of 60 patients; gastrojejunostomy was performed with single-needle unidirectional self-retaining barbed absorbable polyester monofilaments in patients of this group. The study groups did not differ significantly in demographic characteristics, body mass index (BMI), the nature of comorbid pathology and the frequency of previous operations.Results. The use of unidirectional self-retaining barbed suture material for a hand-sewn intracorporeal single-row gastrojejunostomy in MGB was accompanied by a significant reduction in the total duration of interventions due to a reduced gastrojejunostomy stage if compared with the use of conventional synthetic monofilaments. The median volume of blood loss during operations did not exceed 50 ml and had no significant differences between groups. Intraoperatively, in patients of the study groups there were registered only complications of the first degree of severity, according to the Satava-Kazaryan classification, with a frequency of 6.7-8.9% (p = 0.737). In the postoperative period, the development of minor complications (first severity of the Accordion system) occurred in 19.6% and 16.7% of patients of the first and second groups, respectively (p = 0.810). The duration of hospital stay was 3.0 (2.5; 3.0) and 2.7 (2.7; 3.0) days in the first and second groups, respectively (р=0,790).Conclusion. The achieved reduced duration of MGB due to the reduced stage of gastrojejunostomy with self-retaining barbed unidirectional suture material, and comparable immediate effects of surgical treatment in patients of the first and second groups demonstrate significant outcomes. Further study is necessary to investigate long-term effects of the knotless suture application for a single anastomosis formation during MGB surgery.

Tommy John Ligament Repair with Ulnar Collateral Ligament Internal Brace

Ulnar collateral ligament (UCL) injuries commonly occur in overhead athletes as a result of excess valgus stress on the elbow and can be functionally debilitating, requiring surgical intervention. Since the advent of the first initial UCL reconstruction technique pioneered by Dr. Frank Jobe performed on professional baseball player Tommy John, UCL, or Tommy John Ligament reconstruction has successfully returned athletes to sport following injury and shown enhanced clinical outcomes with minimal complication rates. Tommy John surgery continues to evolve with the development of various techniques over recent years. This technical note describes a UCL repair with an internal brace using knotless suture anchors and aims to contribute to the current literature a technique that is efficacious and reproducible and offers satisfactory stability, functionality, and return to play.

The Zipknot Technique: A Modified Tension Band Repair Technique for Isolated Supraspinatus Tears

Tension band repair frequently is used for small rotator cuff tears. This Technical Note describes a variation using a single knotless suture anchor but with a specific lark’s head knot technique to pass the sutures through the tendon that improves bone–tendon contact and tendon healing while preventing a dog-ear deformity.

Robot-assisted right wedge-shaped sleeve lower bilobectomy with knotless suture anastomosis: a case report

BackgroundIn bronchoplasty of wedge resections, it is necessary to transect the bronchus at a sharp angle and depth. As a result, anastomoses after wedge resections have the disadvantages of poor visibility and operability. Here, we report a case of right wedge-shaped sleeve bilobectomy that was successfully performed with continuous knotless suturing using robotic assistance.Case presentationAn 81-year-old male patient was referred for the treatment of a tumor in the right lower lobe, which protruded into the bronchus intermedius. The tumor was diagnosed as squamous cell carcinoma by transbronchial biopsy, cT1cN1M0 stage IIB carcinoma for which surgery was indicated. Because the pulmonary middle lobe artery was involved and a resection margin from the tumor protruding into the bronchial mucosal epithelium was necessary, a right wedge-shaped sleeve bilobectomy was performed. The bronchial anastomosis was performed with robotic assistance. After dissection of pulmonary vessels and interlobes, the upper lobe bronchial bifurcation was transected in a wedged shape, and a lower bilobectomy was performed. The bronchi were sutured continuously with knotless sutures. A continuous suture was performed from the ventral to the caudal side. After suturing to the dorsal side, another continuous suturing was performed from the cranial side. Continuous sutures were made until each thread passed through the other. Pericardial fat was wrapped around the anastomosis.ConclusionsA better visual field could be obtained owing to robot-assisted surgery, and robotic arms enabled an accurate and safe operation. Furthermore, continuous suturing using a knotless suture made it easier for the sutures to be handled and enabled bronchial anastomosis without assistance.

Association of Periprosthetic Fibula Fracture With Knotless Suture Button (TightRope) Fixation for Ankle Syndesmosis in Elite Athletes

Background: Suture button fixation is frequently used to stabilize the distal tibiofibular syndesmosis in athletes sustaining an isolated ligamentous syndesmosis injury. Purpose: To report on a series of periprosthetic fibula fractures adjacent to the lateral suture button after a subsequent unrelated ankle injury or progressive stress injury after initial ankle syndesmosis stabilization using the knotless TightRope (Arthrex). Study Design: Case series; Level of evidence, 4. Methods: Eight elite athletes with periprosthetic fibula fractures and stress injuries around the lateral suture buttons were evaluated. In all athletes, the knotless TightRope had been used to stabilize an isolated ligamentous ankle syndesmotic injury, after which all patients recovered and returned to professional sports at their preinjury level. The athletes subsequently developed an acute fibula fracture or a fibula stress fracture related to the 3.7-mm drill hole in the fibula adjacent to the lateral suture buttons after a mean of 14.1 months (range, 5-29 months). The management of these complications was analyzed. Results: Five athletes sustained a periprosthetic fibula fracture in the form of undisplaced spiral Weber B injuries after a subsequent, unrelated injury. Poor healing response was noted with initial nonoperative treatment for the first 2 athletes, and surgical intervention was performed with successful union of the fracture and return to sports. The subsequent 3 athletes had early surgery with uneventful recovery. Another 3 athletes developed stress injuries adjacent to the fibula suture button without a history of acute trauma. In 2 of the 3 athletes, the position of lateral suture buttons was in the anterior third of the fibula. Initial nonoperative management yielded poor healing response, and subsequent surgical intervention was required to enable healing and return to sports. Conclusion: Nonoperative management of fractures adjacent to the fibula suture button of a knotless TightRope may lead to a delay in union. Therefore, early surgical intervention should be considered in elite athletes, whose return-to-sports time is critical. Care is needed to ensure that the fibula hole for the suture button is centrally located because the eccentric placement of the fibula hole in the anterior third of the fibula may contribute to the development of a stress reaction or stress fracture. Surgical intervention for a periprosthetic fibula stress fracture leads to satisfactory resolution of symptoms.