Nonanatomic Repair Research Articles

Biomechanical Comparison of Two Surgical Repair Techniques of the Distal Biceps Tendon

This study aimed to characterize the relationship between the distal biceps tendon force and the supination and flexion rotations during the initiation phase and to compare the functional efficiency of anatomic versus nonanatomic repairs. Seven matched pairs of fresh-frozen cadaver arms were dissected to expose the humerus and elbow while preserving the biceps brachii, elbow joint capsule, and distal radioulnar soft tissue complex. For each pair, the distal biceps tendon was severed with a scalpel and then repaired with bone tunnels placed at either the anterior (anatomic) or the posterior (nonanatomic) aspect of the bicipital tuberosity on the proximal radius. A supination test with 90° of elbow flexion and an unconstrained flexion test were conducted on a customized loading frame. The biceps tension was applied incrementally at 200 g per step, whereas the radius rotation was tracked with a 3-dimensional motion analysis system. The tendon force needed to produce a degree of supination or flexion was derived as the regression slope of the tendon force-radial rotation plots. A two-tailed paired t test was performed to compare the difference between the anatomic repair and the nonanatomic repair cadavers. Significantly greater tendon force was required to initiate the first 10° of supination with the elbow in flexion for the nonanatomic group compared with the anatomic group (1.04 ± 0.44 N/degree vs 0.68 ± 0.17 N/degree, P= .02). The average nonanatomic to anatomic ratio was 149% ± 38%. No difference existed between the two groups in the mean tendon force needed to produce the degree of flexion. Our results show that anatomic repair is more efficient in producing supination than nonanatomic repair, but only when the elbow is in 90° of flexion. When the elbow joint is not constrained, the nonanatomic supination efficiency improved, and the difference between the techniques was not significant. The present study added to the body of evidence in comparing anatomic versus nonanatomic repair of the distal biceps tendon and serves as a foundation for future biomechanical and clinical studies in this topic. Given no difference when the elbow joint was not constrained, one could argue that surgeon comfort and preference could guide which technique to use when addressing the distal biceps tendon tears. More studies will be needed to clearly define whether there will be a clinical difference between the two techniques.

Non-Anatomic All-Inside Arthroscopic Anterior Talofibular Ligament Repair with a High Position Anchor Shows Inferior Clinical Outcomes: A 3D-CT Based Analysis in Chronic Ankle Instability Patients

Category: Arthroscopy; Sports Introduction/Purpose: In chronic ankle instability (CAI), it is important to repair the anterior talofibular ligament (ATFL) at the anatomic origin site. However, there are limited reports on the clinical outcomes according to anatomical ATFL repair. The purpose of this study is to compare the clinical outcomes after arthroscopic ATFL repair, according to whether the anchor is fixed at an anatomic position. Methods: We performed a retrospective review of consecutive patients who underwent arthroscopic ATFL repair for CAI and were available for a minimum of 2 years follow-up. The patients were divided into three groups according to the anchor position at the distal fibula on 3-dimensional computer tomography: group A, anatomical arthroscopic ATFL repair; group S, sub- anatomical arthroscopic ATFL repair; and group N, non-anatomical arthroscopic ATFL repair. The pain (visual analogue scale [VAS]) score, foot and ankle outcome score (FAOS), and the Karlsson ankle functional score were measured as subjective outcomes. Posturographic analysis and radiologic evaluation using stress radiographs and axial view magnetic resonance imaging were performed as objective outcomes. Results: Of 96 patients, 16 were excluded based on the exclusion criteria, and 80 were evaluated (group A, n = 24; group S, n = 42; and group N, n = 14). The mean age of the patients was 34.5 years, and the mean follow-up period was 27.4 months. A between-group comparison revealed significant differences in the FAOS, Karlsson score, and fall risk evaluated by posturography at the final follow-up. Post hoc analysis revealed that group A patients showed better clinical scores in the FAOS than group N patients in all five domains (all p < 0.017). Patients in groups A and S showed better Karlsson score and fall risk than those in group N (p = 0.004 and 0.013, respectively). In terms of objective outcomes, patients in groups A and S showed better outcomes in fall risk than those in group N (both p = 0.001). Conclusion: Non-anatomic ATFL repair showed inferior outcomes compared to anatomic ATFL repair. When performing arthroscopic ATFL repair, the anchor should be fixed in the anatomical position to improve prognosis.

Surgical Options for Chronic Lateral Ankle Instability: How Has the Incidence of the Broström-Gould Procedure Evolved in the Past Decade?

Category: Ankle; Trauma Introduction/Purpose: The past 50 years has seen significant development of surgical techniques aimed at treating chronic lateral ankle instability. Surgical procedures currently being performed can be classified as anatomic ligament reconstruction as well as nonanatomic, and more recently, anatomic repair by tenodesis. Anatomic reconstruction is successful at circumventing important shortcomings associated with nonanatomic repair such as impaired ankle kinematics and biomechanics. One variation of the anatomic repairs described in orthopedic literature demonstrating excellent long-term functional outcomes includes the Broström-Gould (BG) modification. However, there is no detailed depiction of the procedural incidence in recent years. We hypothesize that the incidence of this surgical technique has risen in the past decade. Methods: The Truven MarketScan database was queried to identify patients who underwent a BG procedure from January 2009 to December 2019 based on CPT coding. Population estimates from the US Census Bureau were used to calculate the annual incidence of the BG procedure. Volume and incidence were estimated for annual sums, gender, age subgroups, and four statistical geographical regions of the U.S. Results: In total, 160,457 BG procedures were identified in the database from 2009 to 2019. Annual volumes have increased by 89.9%, from 10,441 to 19,829 total procedures nationwide. Procedural incidence reported per 1,000,000 people increased by 76.6%, at 61.1 in 2019. Increased incidence was demonstrated in males and females ≤65 years, with the highest annual incidence found <55 years of age. Incidence stratified by region rose in the South, West, and Midwest regions of the United States by 81.7%, 75.4%, and 69.2%, respectively. Conclusion: The epidemiology of operative treatment for chronic lateral ankle instability has yet to be clarified in recent years. Our findings demonstrate that the annual volumes and incidence of the BG procedure has increased in the past 11 years. Growth in incidence was found in both sexes below the age of 65 years whereby the greatest annual incidence was found in ages below 55 years. Incidence significantly rose in all regions of the United States except for the Northeast. The insight provided by epidemiologic studies allows orthopedic surgeons to better adapt their practice to the current trends in the field.

Combined Vertical, Horizontal, and Rotational Acromioclavicular Joint Stabilization: “Closing the Circle” Technique

The biomechanical and anatomical complexity of the acromioclavicular joint makes its repair techniques particularly challenging. High rates of reduction subsidence and construction failures transversally affect both anatomic and nonanatomic repair techniques. The importance of addressing both vertical and horizontal instability has been highlighted in recent years. The authors aim to describe a surgical technique that combines vertical, horizontal, and rotational stabilization, in an attempt to restore the coracoacromioclavicular circle of stability.

Nonanatomic All-Inside Arthroscopic Anterior Talofibular Ligament Repair With a High-Position Anchor versus Anatomic Repair: An Analysis Based on 3D CT

Background: In patients with chronic ankle instability, it is important to repair the anterior talofibular ligament (ATFL) at the anatomic origin site. However, there are limited reports on the clinical outcomes according to anatomic ATFL repair. Purpose: To compare the clinical outcomes after arthroscopic ATFL repair according to whether the anchor is fixed at an anatomic position. Study Design: Cohort study; Level of evidence, 3. Methods: We performed a retrospective review of consecutive patients who underwent arthroscopic ATFL repair for chronic ankle instability and were available for a minimum 2-year follow-up. The patients were divided into 3 groups according to the anchor position at the distal fibula on 3-dimensional computed tomography: anatomic arthroscopic ATFL repair (anatomic group), subanatomic arthroscopic ATFL repair (subanatomic group), and nonanatomic arthroscopic ATFL repair (nonanatomic group). The visual analog scale for pain, Foot and Ankle Outcome Score (FAOS), and Karlsson ankle functional score were measured as subjective outcomes. Posturographic analysis and radiologic evaluation using stress radiographs and axial view magnetic resonance imaging were performed as objective outcomes. Results: Of 96 patients, 16 were excluded per the exclusion criteria, and 80 were evaluated (anatomic group, n = 24; subanatomic group, n = 42; nonanatomic group, n = 14). The mean age of the patients was 34.5 years, and the mean follow-up period was 27.4 months. A between-group comparison revealed significant differences in FAOS, Karlsson score, and fall risk evaluated by posturography at the final follow-up. Post hoc analysis revealed that the anatomic group had better clinical scores on the FAOS than did the nonanatomic group in all 5 domains (all P < .017). Patients in the anatomic and subanatomic groups had better Karlsson scores and fall risk than those in the nonanatomic group (P = .004 and P = .013, respectively). In terms of objective outcomes, patients in the anatomic and subanatomic groups had better outcomes in fall risk than did those in the nonanatomic group (both P = .001). There were no differences in clinical scores and objective outcomes between the anatomic and subanatomic groups. Conclusion: Nonanatomic ATFL repair showed inferior outcomes when compared with anatomic ATFL repair. When arthroscopic ATFL repair is performed, the anchor should be fixed in the anatomic position to improve prognosis.

Revision Proximal Tibiofibular Joint Reconstruction for the Treatment of Chronic Instability Secondary to Suture Button Construct Failure

Recurrent proximal tibiofibular joint (PTFJ) instability can result from nonanatomic repair using a suture button construct. During initial reconstruction, proper identification of anatomic landmarks is critical for proper placement of suture button construct components and successful patient outcomes. In cases of symptomatic recurrent instability, a PTFJ reconstruction revision is warranted to alleviate symptoms of pain and instability. This Technical Note describes a technique for performing an anatomic PTFJ reconstruction revision and fibular collateral ligament reconstruction in which the semitendinosus is used as a graft for both the FCL and posterior ligamentous complex of the PTFJ. The biceps femoris is also repaired following a tear that resulted from a misplaced suture button.

The Natural History of Medial Meniscal Root Tears: A Biomechanical and Clinical Case Perspective.

Posterior medial meniscus root tears (PMMRTs) make up a relatively notable proportion of all meniscus pathology and have been definitively linked to the progression of osteoarthritis (OA). While known risk factors for development of OA in the knee include abnormal tibial coronal alignment, obesity and female gender, PMMRTs have emerged in recent years as another significant driver of degenerative disease. These injuries lead to an increase in average contact pressure in the medial compartment, along with increases in peak contact pressure and a decrease in contact area relative to the intact state. Loss of the root attachment impairs the function of the entire meniscus and leads to meniscal extrusion, thus impairing the force-dissipating role of the meniscus. Anatomic meniscus root repairs with a transtibial pullout technique have been shown biomechanically to restore mean and peak contact pressures in the medial compartment. However, nonanatomic root repairs have been reported to be ineffective at restoring joint pressures back to normal. Meniscal extrusion is often a consequence of nonanatomic repair and is correlated with progression of OA. In this study, the authors will describe the biomechanical basis of the natural history of medial meniscal root tears and will support the biomechanical studies with a case series including patients that either underwent non-operative treatment (5 patients) or non-anatomic repair of their medial meniscal root tears (6 patients). Using measurements derived from axial MRI, the authors will detail the distance from native root attachment center of the non-anatomic tunnels and discuss the ongoing symptoms of those patients. Imaging and OA progression among patients who were treated nonoperatively before presentation to the authors will be discussed as well. The case series thus presented will illustrate the natural history of meniscal root tears, the consequences of non-anatomic repair, and the findings of symptomatic meniscal extrusion associated with a non-anatomic repair position of the meniscus.

Non-anatomic repair of medial meniscus posterior root tears to the posterior capsule provided favourable outcomes in middle-aged and older patients.

To describe a non-anatomic arthroscopic all-inside repair technique for middle-aged and older patients with medial meniscus posterior root tears (MMPRTs) and to evaluate the short- to mid-term clinical and radiologic results. The hypothesis was that this procedure would yield good clinical outcome results and structural healing in middle- and older-aged patients. This was a retrospective study evaluating patients who had undergone MMPRT repair by suturing the meniscal root directly to the capsule, rather than by the transtibial technique, between 2013 and 2016. This all-inside repair technique was performed for patients with type II MMPRTs who were over 40years old. Exclusion criteria included tibial osteotomy due to malalignment, concomitant multiple-ligament injuries and follow-up time less than 2years. The Lysholm score, Tegner activity score and International Knee Documentation Committee (IKDC) score were evaluated preoperatively and at the final follow-up. Medial meniscal extrusion, the International Cartilage Repair Society (ICRS) grades of the medial compartment, and the healing status of the medial meniscus root were assessed on magnetic resonance imaging preoperatively and at the final follow-up. Twenty-nine patients (mean age 61.7 ± 7.9) were included; the mean follow-up duration was 46.2 ± 7.9months. The mean Lysholm score significantly improved from 33.7 ± 20.9 preoperatively to 81.7 ± 19.9 at the final follow-up (p < 0.001), the median Tegner activity score improved from 1.0 (range 1-4) to 3.0 (range 2-4, p < 0.001), and the mean IKDC score improved from 20.1 ± 16.4 to 69.6 ± 16.2 (p < 0.001). On MRI, 9 (31%) cases had complete healing; 17 (59%) had partial healing; and 3 (10%) had failed healing (ICCs ≥ 0.92). Mean meniscal extrusion significantly increased from 2.3 ± 1.7mm preoperatively to 3.5 ± 1.5mm postoperatively (p < 0.001, ICCs ≥ 0.92). Non-anatomic arthroscopic all-inside repair of MMPRTs to the posterior capsule yielded good to excellent clinical results and a high rate of healing in the medial meniscus root on MRI in middle-aged and older patients at short- to mid-term follow-up, despite increased meniscal extrusion. This method is an alternative to the transtibial pullout repair technique for treating MMPRTs in middle- and older-aged patients. Level IV.

All-inside Techniques for Meniscal Radial Root Tear Repair

Meniscal radial root tears can disrupt the load-bearing function of the meniscus and worsen instability in anterior cruciate ligament–deficient knees. Paracentral radial tears adjacent to the root (types 1, 2, and 4) repaired with a transtibial pullout suture technique can lead to over-medialization of the meniscal root and a high-tension nonanatomic repair. We propose 2 all-inside techniques for anatomic repair of medial and lateral meniscal radial root tears with (1) an all-inside meniscal repair device and (2) an antegrade suture passer. We present the technical requirements and tips for these techniques. For lateral meniscal radial root repair with an all-inside meniscal repair device, ideal viewing is from an anterolateral portal with device entry from an anteromedial portal to reduce the risk of vascular injury. We recommend at least 2 stitches across the tear, with the depth setting limited to 18 to 20 mm for a central stitch and 16 mm or less for a peripherally placed stitch. For root repair with an antegrade suture passer, viewing should be from an anteromedial portal with the passer entering from an anterolateral portal. At least 2 stitches should be placed across the tear, with 1 central and 1 peripheral or 1 superior and 1 inferior.

Acute distal biceps tendon ruptures: anatomy, pathology and management - state of the art

All patients with acute complete distal biceps tendon ruptures who are not low demand or medically unfit to proceed with surgery are offered operative repair. This restores arm shape, supination strength and function, and decreases their cramping symptoms. Surgical repair technique varies significantly depending on location and training centre. Nuances in technique and appropriate implant selection need to be noted in order to achieve a strong repair allowing early active range of motion. Intimate knowledge of distal biceps tendon anatomy is key to avoid complications associated with the different approaches. The cumulative body of evidence on complications, coupled with knowledge of the different biomechanical construct strengths of the alternative methods of fixation, points to the use of the cortical button technique without the addition of an interference screw. Subtle variations in drill hole positioning on the bicipital tuberosity secures either an anatomic or non-anatomic repair. Anatomic repair results in greater supination peak torque and fatigue strength, and in greater flexion fatigue strength. It is advisable to perform an anatomic repair in elite athletes or those patients who significantly rely on supination strength and endurance for their livelihood. A universal postoperative protocol is suggested for all repairs.

The effect of tendon rotation on distal biceps repair

BackgroundThe distal biceps tendon externally rotates from proximal to distal before inserting onto the radius. Our hypothesis is that an externally rotated (anatomic) repair would re-create native supination moment arm and flexion force, whereas an internally rotated (nonanatomic) repair would result in reduced force transmission.MethodsThe mechanical tests performed in this study measured isometric moment arms and elbow flexion force using a validated elbow simulator as previously published. Mechanical testing was performed on 8 native cadaveric elbows (61 ± 15 years). The distal biceps tendons in all specimens were then incised from their footprint and repaired with anatomic and nonanatomic tendon rotations. After each repair, the specimens were retested. The repair sequence was randomly assigned.ResultsGross observation showed repair site bunching with the nonanatomic repairs. There was no statistical difference in the moment arms between the native, anatomic, and nonanatomic rotations for the 3 forearm angles (P ≥ .352). Analysis showed no statistical difference in flexion force ratio for the elbow at 90° (P ≥ .283).DiscussionThe study showed that biceps tendon rotation does not play a role in supination moment arm or flexion force. Twisting the distal biceps tendon around the tendon axis does not change the direction of its applied force on the tuberosity. Tendon bunching in nonanatomic reattachments increases repair site width, which may lead to tendon-ulnar impingement during forearm rotation.

Arthroscopic Acetabular Labral Repair Using the Q-FIX Suture Anchor

The goal of acetabular labral repair is to preserve/restore labral function. Maintaining labral function necessitates recreating the labrum's anatomy, especially avoiding a nonanatomic repair of the labrum to the acetabular rim. The purpose of this report is to detail the technique of acetabular labral repair using this Q-FIX all-suture anchor.

Biomechanical Effects of Peripheral Stabilization for the Extruded Medial Meniscus and its Effect on Tibiofemoral Contact Biomechanics

Objectives: To quantitatively evaluate the biomechanical effects of a novel peripheral stabilization technique for the treatment of posterior medial meniscus root (PMMR) avulsions and to identify an optimal diagnostic position to assess for the presence of meniscal extrusion. Methods: Meniscal extrusion and tibiofemoral contact mechanics were measured using 3D digitization and pressure sensors, respectively, in ten nonpaired, human cadaver knees. The PMMR of each knee was tested under 6 states: (1) intact; (2) complete root detachment; (3) anatomic transtibial pull-out root repair; (4) anatomic transtibial pull-out repair with peripheral stabilization; (5) nonanatomic transtibial pull-out repair; and (6) nonanatomic transtibial pull-out repair with peripheral stabilization, with randomization of the order of conditions 3 &amp; 4, and 5 &amp; 6. The testing protocol loaded knees with a 1000 N axial compressive force at four flexion angles (0°, 30°, 60°, 90°) in each state. Meniscal extrusion was recorded at 0° and 90° in both loaded and unloaded states at three locations along the peripheral rim of the medial tibial plateau. Degree of meniscal extrusion was defined as the radial displacement of the medial meniscus from three corresponding points on the posteromedial edge of the tibial plateau: (1) posterior border of MCL; (2) posteromedial capsule midway between the MCL and posterior root; and (3) the direct posterior capsule. Peak contact pressure, contact area, and total contact pressure were also recorded for all states at all flexion angles. Results: Statistical analysis investigated the independent effects of flexion, state, and loading using three, distinct two-factor models. In unloaded knees in full extension, the highest degree of meniscal extrusion was observed at the posterior border of the MCL across all repair testing states (p &lt; 0.001). At full extension, loaded knees exhibited significantly higher extrusion in comparison to unloaded across all knee states at the MCL position (mean 1.1 mm, 95% CI [0.8, 1.4], p &lt;0.001). Significantly more extrusion was observed at 90° of flexion (mean 0.7 mm, 95% CI [0.36, 1.1], p &lt; 0.001). In loaded knees at 90° of flexion, all repair states had significantly lower extrusion than the root tear state (all p &lt;0.05). Only anatomic repair with peripheral stabilization had significantly lower extrusion than both nonanatomic repairs with or without peripheral stabilization (both p &lt; 0.01). Differences in the contact mechanics between repair techniques were most notable at higher flexion angles, demonstrating significantly higher average and peak contact pressures for non-anatomic repair variations when compared to anatomic repairs with and without peripheral stabilization (all p &lt;0.05). Root tear states were significantly higher than intact states for all comparisons except for peak pressure at 0° of flexion (all p &lt; 0.01). Conclusion: Anatomic and anatomic with peripheral suture repair techniques best restore contact mechanics of the knee. In current clinical scenarios where knees are unloaded and imaged in full extension, extrusion is best measured in the coronal plane at the posterior border of the MCL. However, this is likely a “best-case” scenario, as this study has shown that the degree of extrusion increases as the knee is loaded and flexed to 90°. When only a non-anatomic repair can be performed the addition of this peripheral stabilization technique may be beneficial for patients in reducing pathologic extrusion of the meniscus. [Table: see text]

Utilization of Transtibial Centralization Suture Best Minimizes Extrusion and Restores Tibiofemoral Contact Mechanics for Anatomic Medial Meniscal Root Repairs in a Cadaveric Model

Background: Although posterior medial meniscal root (PMMR) repairs are often successful, postoperative meniscal extrusion after a root repair has been identified as a potential clinical problem. Purpose/Hypothesis: The purpose was to quantitatively evaluate the tibiofemoral contact mechanics and extent of meniscal extrusion after a PMMR repair. It was hypothesized that the addition of a centralization suture (into the posterior medial tibial plateau) would help restore normal joint load-bearing characteristics and restore the native amount of meniscal extrusion after a root tear. Furthermore, we hypothesized that the amount of meniscal extrusion would be greatest in loaded and flexed knees when measured at the posterior border of the medial collateral ligament (MCL). Study Design: Controlled laboratory study. Methods: Meniscal extrusion and tibiofemoral contact mechanics were measured using 3-dimensional digitization and pressure sensors in 10 nonpaired, human cadaveric knees. The PMMR of each knee was tested under 6 states: (1) intact; (2) type 2A PMMR tear; (3) anatomic transtibial pull-out root repair; (4) anatomic transtibial pull-out repair with centralization; (5) nonanatomic transtibial pull-out repair; and (6) nonanatomic transtibial pull-out repair with centralization, with randomization of the order of conditions 3 and 4, and 5 and 6. The testing protocol loaded knees with a 1000-N axial compressive force at 4 flexion angles (0°, 30°, 60°, 90°) in each state. Meniscal extrusion was measured with a 3-dimensional coordinate digitizer at 0° and 90° in both the loaded and unloaded states and calculated from the difference from the articular margin of the tibia to the periphery of the meniscus. Peak contact pressure, contact area, and total contact pressure were also recorded for all states at all flexion angles. Statistical analysis investigated the independent effects of flexion, state, and loading using 3 distinct 2-factor models. Results: Differences in the contact mechanics between repair techniques were most notable at higher flexion angles, demonstrating significantly higher average and peak contact pressures for nonanatomic repair states when compared with anatomic repairs with and without centralization (all P < .05). In unloaded knees at full extension, the magnitude of medial meniscal extrusion was significantly higher at the posterior border of the MCL compared with the posterior medial tibia (P < .001) and adjacent to the root attachment on the tibia locations (P < .001). Both anatomic repair states had no significant difference in the degree of extrusion when compared with the intact state. Conclusion: The anatomic transtibial pull-out root repair and the anatomic transtibial pull-out root repair with centralization techniques best restored contact mechanics of the knee and meniscal extrusion when compared with root tear and nonanatomic repair states at time zero. There were no significant differences in contact pressure or magnitude of extrusion between the anatomic repair state and the anatomic repair with centralization state. We found that extrusion is best measured in the coronal plane at the posterior border of the MCL for unloaded knees. However, the degree of extrusion increased as the knee was loaded and flexed to 90°. Clinical Relevance: When there are concerns about meniscal extrusion with a medial meniscal root repair, the addition of a centralization suture may be beneficial for patients in reducing pathologic meniscal extrusion and restoring joint contact mechanics.

Satisfactory mid-term outcome of subacromial balloon spacer for the treatment of irreparable rotator cuff tears.

To answer the question whether arthroscopic subacromial balloon spacer (InSpace Balloon-ISB) implantation results in improved outcomes in patients suffering by irreparable massive rotator cuff tears (MRCT). Secondarily, we aimed to compare the outcomes of a combined ISB and arthroscopic partial repair procedure with those of a single ISB implantation without any repair. A retrospective single-centre case series, based on prospectively collected data of patients who were suffering by irreparable MRCT, was conducted. An ISB implantation along with an arthroscopic non-anatomic repair or debridement was carried out in all patients included in this study. Patients were functionally evaluated with the use of the American Shoulder and Elbow Surgeons Shoulder Score and the Constant score. Individual's pain was pre- and postoperatively measured with the Visual Analogue Scale (0-100/100). Patients' satisfaction and postoperative complications were also documented. As for the active range of motion (RoM), shoulder's forward flexion, external rotation at 0° and of 90° of abduction, and internal rotation were also pre- and postoperatively assessed. Thirty-one patients [mean age: 65.2years, standard deviation (SD): 8.5, and range: 50-80years] with a mean follow-up of 22.1months (SD: 9.8; range: 6-31months) were reviewed. All final postoperative clinical and functional scores were significantly improved in comparison with the preoperative values (p < 0.05). The vast majority of the patients declared fully or almost fully satisfied with their treatment (80.6%), while most patients were free of pain at their last follow-up (83.9%). We identified 18 patients (group A), who were treated with a combined ISB implantation and arthroscopic non-anatomic repair and 13 patients (group B) who received an ISB implant without any repair. The long head of biceps, where existed, was tenotomized in both groups. No significant difference was found between the baseline demographic and clinical characteristics of the two groups. As for the mean final postoperative scores and RoM, the differences between the two groups were insignificant (p > 0.05). The use of ISB implantation for patients suffering by MRCT leads to significantly improved mid-term outcomes and high patents' satisfaction. The additional use of arthroscopic partial repair with ISB was not proven superior to the single ISB implantation. IV; therapeutic case series.

Kinematics and Laxity of the Ankle Joint in Anatomic and Nonanatomic Anterior Talofibular Ligament Repair: A Biomechanical Cadaveric Study

Background: Although it is crucial to accurately identify the anterior talofibular ligament (ATFL) attachment site, it may not be feasible to fully observe the ATFL attachment site during arthroscopic surgery. As a result, the repair position might often be an unintentionally nonanatomic ATFL attachment site. Hypothesis: Anatomic ATFL repair restores kinematics and laxity to the ankle joint, while nonanatomic ATFL repair does not. Study Design: Controlled laboratory study. Methods: Seven normal fresh-frozen human cadaveric ankles were used. The ankles were tested with a 6 degrees of freedom robotic system. The following ankle states were evaluated: intact, ATFL injured, ATFL anatomic repair, and ATFL nonanatomic repair. The ATFL nonanatomic repair position was set 8 mm proximal from the center of the ATFL attachment site of the fibula. For each state, a passive plantarflexion (PF)–dorsiflexion (DF) kinematics test and a multidirectional loading test (anterior forces, inversion moment, and internal rotation moment) were performed. Results: The kinematics and laxity of the anatomic repair were not significantly different from those of the intact state. In nonanatomic repair, the inversion-eversion angle showed significant inversion (3.0°-3.4°) from 5° to 15° of DF, and the internal rotation–external rotation angle showed significant internal rotation (2.0°) at neutral PF-DF versus the intact state. In addition, internal rotation laxity was significantly increased (5.5°-5.8°) relative to the intact state in the nonanatomic repair at 30° and 15° of PF. There were no significant differences in anterior-posterior translation between the repairs. Conclusion: Although the anatomic ATFL repair state did not show significant differences in kinematics and laxity relative to the intact state, the nonanatomic ATFL repair state demonstrated significant inversion and internal rotation kinematics and internal rotation laxity when compared with the intact state. Clinical Relevance: Nonanatomic repair alters kinematics and laxity from the intact condition.

Options for Failed Rotator Cuff Repair.

Failed rotator cuff repairs can pose a clinical challenge to the treating orthopedic surgeon. There are many nonsurgical and surgical options available to address the failed rotator cuff repair. Surgical options include revising the primary repair, partial or nonanatomic repair, tendon transfer, biological augmentation or use of tissue-engineered grafts for reconstruction, or total joint arthroplasty (typically with a modern reverse total shoulder arthroplasty system). The treating surgeon must assess the patient's functional status, health status, and expectations in order to customize the appropriate treatment plan for addressing the failed rotator cuff repair. With the abundance of treatment options available, there is typically an adequate solution to help the patient regain function and experience less pain.

Open operative treatment of chronic ankle instability

Category: Ankle Introduction/Purpose: Ankle sprains are one of the most common musculoskeletal injuries. Though most patients recover fully without intervention, 10-30% will develop chronic ankle instability and require conservative or surgical management. The aim of this article is to provide an evidence-based literature review and assessment of the quality of literature regarding open operative interventions for chronic ankle instability. Methods: A comprehensive evidence-based literature review of Pubmed, Embase, Cochrane and Web of Science databases, conducted March 9, 2016; and updated February 22, 2017 identified 1635 articles, of which, 71 were relevant in assessing the efficacy of common open operative interventions for treatment of chronic ankle instability. The open operative procedures described in included articles were classified into the following four main categories: Anatomic repair, Non-anatomic repair, Anatomic reconstruction and Non-anatomic reconstruction. The 71 studies were then assigned a level of evidence (I-V) to denote quality. They were then reviewed to provide a grade of recommendation (A-C, I) in support of or against the operative intervention in treatment of chronic ankle instability. Results: Among the open operative treatment options available for chronic ankle instability, there is good evidence (Grade A) in support of anatomic reconstructive procedures. There is fair evidence (Grade B) from level II and III studies in support of anatomic repair and non-anatomic reconstruction procedures. Insufficient evidence was available to grade internal brace and non-anatomic repair procedures. Conclusion: Good quality evidence exists in support of open operative treatment of chronic ankle instability. Future studies should aim to elucidate roles for each of the classifications of open operative intervention in specific circumstances and patient populations. Furthermore, with good evidence to support more traditional techniques for repair of chronic ankle instability, high quality studies should be conducted on more novel minimally invasive and arthroscopic operative techniques to assure equal efficacy and safety to open techniques summarized here.

Paper #13 - The Effect of Tendon Rotation on the Distal Biceps Repair

Introduction: The course of the distal biceps tendon externally rotates from proximal-to-distal before inserting onto the radial tuberosity (Fig. 1, A). 1 Athwal G.S. et al. JHS. 2007; 32: 1225-1229 Abstract Full Text Full Text PDF PubMed Scopus (151) Google Scholar The importance of biceps external rotation in supination and flexion strength is currently not known; yet, it could be an important surgeon-controlled repair step that influences patient outcomes. Our hypothesis is that an externally rotated biceps (anatomic) repair would recreate the native supination moment arm and flexion force, while an internally rotated (non-anatomic) repair would result in reduced force transmission.

Graft Utilization in the Bridging Reconstruction of Irreparable Rotator Cuff Tears: A Systematic Review

Background: Rotator cuff tears are one of the most common conditions affecting the shoulder. Because of the difficulty in managing massive rotator cuff tears and the inability of standard techniques to prevent arthropathy, surgeons have developed several novel techniques to improve outcomes and ideally alter the natural history. Purpose: To systematically review the existing literature and analyze reported outcomes to evaluate the effectiveness of using a bridging graft reconstruction technique to treat large to massive irreparable rotator cuff tears. Study Design: Systematic review. Methods: A systematic search of PubMed, EMBASE, CINAHL, and CENTRAL was employed with the key terms “tear,” “allograft,” and “rotator cuff.” Eligibility was determined by a 3-phase screening process according to the outlined inclusion/exclusion criteria. Data in relation to the primary and secondary outcomes were summarized. The results were synthesized according to the origin of the graft and the level of evidence. Results: Fifteen studies in total were included in this review: 2 comparative studies and 13 observational case series. Both the biceps tendon and the fascia lata autograft groups had significantly superior structural integrity rates on magnetic resonance imaging at 12-month minimum follow-up when compared with their partial primary repair counterparts (58% vs 26%, P = .036; 79% vs 58%, P < .05), respectively. Multiple noncomparative case series investigating allografts, xenografts, and synthetic materials for bridging reconstruction of large to massive rotator cuff tears demonstrated high structural healing rates (74%-90%, 73%-100%, and 60%-90%, respectively). Additionally, both comparative studies and case series demonstrated a general improvement of patients’ functional outcome scores. Conclusion: Using a graft for an anatomic bridging rotator cuff repair results in improved function on objective testing and may be functionally better than nonanatomic or partial repair of large to massive rotator cuff tears. Allograft or xenograft techniques appear to be favorable options, given demonstrated functional improvement, imaging-supported graft survival, and lack of harvest complication risk. More high-quality randomized controlled studies are needed to further assess this technique.