Peripheral Suture Research Articles

The Learning Curves of Adelaide- and Gan-Modified Lim-Tsai Flexor Tendon Repair Techniques

Surgical performance that improves with experience is often depicted as representing a "learning curve." Although numerous studies examine the tensile properties of various flexor tendon repairs, few compare the associated learning curves. This study aims to address this gap by comparing the learning curves of Adelaide- and Gan-modified Lim-Tsai repairs. Emphasizing the difference in learning curves is crucial because it highlights the tension between achieving biomechanically superior repairs, which may be challenging to many surgeons, and opting for possibly incrementally less strong but more feasible techniques. We organized a workshop attended by 20 medical students whose experience in surgery was limited to a few suturing exercises. Each participant repaired five porcine tendons in situ either with Adelaide- or Gan-modified Lim-Tsai, followed by a peripheral suture. We tested all tendons with linear static testing to measure ultimate and yield loads. In addition, repair times were recorded for each repair. We used a linear mixed model to compare learning between the techniques. Ultimate loads increased with experience and were higher in Adelaide technique during the first two repairs, compared with Gan-modified Lim-Tsai (80 N vs 63 N and 79 N vs 66 N, respectively). Yield loads also increased with experience but did not differ between the repair techniques at any time point. Mean repair times decreased from 44 to 28 minutes and from 46 to 25 minutes with Adelaide- and Gan-modified Lim-Tsai repairs, respectively. The Adelaide core suture had a higher initial ultimate load capacity despite fewer suture strands, possibly indicating better tension consistency. The ultimate load of the Gan-modified Lim-Tsai repair increased between the first and fifth repair, and repeats were needed to achieve comparable results with the Adelaide repair. The results of this study suggest that both repair methods are suitable for novice surgeons, but Adelaide tends to result in higher strength from the first repair. Generalizability to other repairs should be made with caution.

Suture Tying Force for Cut-Out during Radial Meniscus Tear Repair: A Biomechanical Evaluation of Failure Loads during the Knot-Tying Process.

The purpose of the study was to determine average tensile forces resulting in suture failure while tying a knot during repair of complete radial meniscus tears and to compare the failure tensile force based on meniscus tissue location: the peripheral (red-red) versus inner (white-white). This study was designed as a cadaveric biomechanical study using 24 menisci harvested from fresh frozen cadaveric knees with midbody radial tears. Tears were repaired using 2-0 nonabsorbable suture in both the inner meniscus and the peripheral meniscus. A force gauge was used to measure the tension of a surgeon's knot until failure of either the suture or the meniscus tissue. Statistical analysis was performed comparing suture failure tensile forces between inner and peripheral sutures using 2-sample t test. Suture repairs primarily failed due to meniscal tissue cut-out after suture tensioning (96%). There was no statistical difference in failure mode between medial and lateral meniscus for both the inner (100% cut-out) and the peripheral (92% cut-out; P = 0.703) sutures. The peripheral sutures failed as significantly higher loads (54 ± 26 N) than the inner sutures (36 ± 11 N, P = 0.006). The peripheral meniscus tissue tolerated significantly higher tension at failure (36 ± 7 N) than the inner meniscus (26 ± 7 N, P < 0.001). When tying parallel sutures to repair a radial meniscus tear, suture tensile forces above 30 N may tear through meniscus tissue. Surgeons should not use suture tying forces above 30 N when repairing radial meniscus tears with parallel sutures. The peripheral meniscus can withstand higher knot-tying forces than the inner meniscus, so surgeons should consider tying the peripheral suture before the inner suture.

Meniscal allograft transplantation: A matched-pair analysis reveals worse sportactivity level but similar clinical improvement and survival in women compared to men.

The aim of this study was to assess how gender might affect the clinical outcome and survival of meniscal allograft transplantation (MAT). A total of 358 patients (23.2% women, 76.8% men) were treated with fresh-frozen nonirradiated allografts implantated arthroscopically using a single- or double-tunnel technique without bone plugs and peripheral suture to the capsule with 'all-inside'stitches. Patients were evaluated at baseline and 2-year follow-up with the Lysholm score, visual analogue scale (VAS) pain, the Knee Osteoarthritis Outcome Score (KOOS) subscalesand Tegner score. Women presented higher body mass index (p < 0.0005), poorer baseline VAS (p = 0.012), Lysholm score (p = 0.005), KOOS symptom (p = 0.034) and KOOS pain (p = 0.030), Tegner score (preinjury and basal, p < 0.0001 and p = 0.002, respectively), a lower number of previous (p = 0.039) and concurrent (p = 0.001) anterior cruciate ligament reconstructionsand a higher number of concurrent procedures (p = 0.032) and distal femoral osteotomies (p = 0.024). Worse results were documented in women at 2 years, with lower Lysholm score(p = 0.024) and Tegner score(p = 0.007)and a lower clinical survival rate (p = 0.03) (67.5% vs.82.2%) in the overall patient cohort. However, the matched-pair analysis only confirmed a lower Tegner score value at 2 years (p = 0.016), while underlying the interplay of sex, ageand concomitant cartilage lesions in determining the clinical outcome. The analysis of this large series of patients affected by postmeniscectomy syndrome and treated with MAT revealed gender differences. While both genders benefited from a significant improvement, the female population presents more often with older age, concomitant cartilage lesionsand a lower activity level, all factors contributing towards a lower clinical success after MAT. Level III, comparative study.

Biomechanical Analysis of a New Odd-Numbered Strand Suture Technique for Early Active Mobilization After Primary Flexor Tendon Repair

PurposeThe placement of multi-strand sutures during flexor tendon repair is complex and challenging. We developed a new, simpler nine-strand suture, which we term the Tajima nines. The Tajima nines repair method is a new odd-numbered strand tendon technique. MethodsFourteen porcine flexor tendons were transected and repaired using the Tajima nines repair method, without placement of peripheral sutures. This technique is a modification of the Lim and Tsai repair method; it uses a 4-0 monofilament nylon, three-strand line, and two needles. The repaired tendons were tested for linear, noncyclic, load-to-failure tensile strength. The initial gap, 2-mm gap-formation force, and ultimate strength were measured. ResultsThe initial gap-formation force was 27.9 ± 7.5 newtons (N), the 2-mm gap-formation force was 39.2 ± 4.7 N, and the ultimate strength was 76.7 ± 17.2 N. Eight, three, and three of the fourteen tendons repaired using the Tajima nines method demonstrated failure because of thread breakage, knot failure, and suture pull-out, respectively. ConclusionsThis biomechanical study demonstrated that Tajima nines repair was associated with particularly high initial tension at the repair site; there were minor variations in the initial load and 2-mm gap-formation load. Our results suggest that Tajima nines repair with peripheral suturing allows the repaired flexor tendon to tolerate the stresses encountered during early active mobilization. Clinical RelevanceThis simple nine-strand technique will be particularly useful for inexperienced surgeons who perform early active mobilization after primary flexor tendon repair, because the technique is a modification of the Lim and Tsai repair method using a triple strand instead of a double strand.

Gap Resistance and Tensile Strength of a Q Suture Technique During Curved Loading: An ExVivo Porcine Flexor Tendon Study.

This study aimed to determine the mechanical properties of the double Q suture technique in angular motion and to compare the gap formation associated with tendon repairs during curved and linear loading. Eighty porcine flexor tendons were repaired with one of two 4-strand sutures: double Q suture or double modified Kessler plus peripheral running sutures. The repaired tendons were cyclically loaded sequentially against a pulley with a radius of 2.0, 1.5, and 1.0 cm or linearly without any pulleys. The number of tendons that formed an initial or 2-mm gap at the repair site during cyclic loading, the gap size between tendon ends when cyclic loading ended, and the ultimate strength were recorded. The gap at the repair site formed gradually from the dorsal to volar aspect during curved loading. No double Q repairs, but half of the double Kessler plus running suture repairs, formed an initial or 2-mm gap on the volar aspect during curved loading. The double Q group had a significantly smaller gap size on the dorsal aspect than the double Kessler plus running suture group at all three radii of curvature. The ultimate strength was similar between the two groups. There were no significant differences in linear motion between these two repairs. The double Q suture is superior to the conventional 4-strand tendon core suture plus running peripheral sutures in gap resistance in angular motion. This study provides insight into the formation of an unbalanced gap on the dorsal and volar aspects of tendon repair during curved loading. The double Q suture provides a simple and efficient option for flexor tendon repair considering the high risk of gap formation on the dorsal aspects of the tendon repair in angular motion.

Cyclic testing of six-strand suture techniques for zone 2 flexor tendon lacerations

BackgroundBiomechanical analysis using cyclic testing for repaired flexor tendons is a clinically relevant method. The aim of this study was to evaluate the tensile properties of two six-strand suture techniques, the triple looped suture and Yoshizu #1 suture techniques using cyclic testing under simulating early active mobilization conditions. MethodsTwenty-five flexor digitorum profundus tendons harvested from fresh frozen human cadaver hands were repaired in zone 2 utilizing one of three repair techniques: the 2-strand modified Kessler (MK) technique as a control, the triple looped suture (TLS) and Yoshizu #1 suture (Y1) techniques. In each suture technique, 4-0 monofilament nylon sutures were used for core sutures and 6-0 monofilament nylon sutures for circumferential running sutures. Cyclic testing was performed using 20 N with 600 cycles at 1 Hz. ResultsFive out of eight specimens in the MK group ruptured during cyclic testing. Thus, this group was excluded from analysis. On the other hand, all tendons in the TLS and Y1 groups tolerated cyclic testing. Average gaps of the TLS and Y1 groups were 0.5 ± 0.8 mm and 1.9 ± 2.2 mm, respectively. All tendons in the TLS group and six out of nine tendons in the Y1 group formed gaps less than 2 mm. Two tendons in the Y1 group formed a gap of 3.8 and 6.6 mm had breakage of peripheral sutures at the first cycle. Mean ultimate tensile force of the TLS and Y1 group measured after cyclic tensing, were 66.2 ± 9.0 N and 65.9 ± 13.1 N, respectively. No statistical difference between the two groups was found in gap and ultimate tensile forces. ConclusionsThis study suggested that the TLS and Y1 techniques have tensile properties to allow early active mobilization. None of tendons repaired with the TLS technique had gaps more than 2 mm.

Concomitant Medial Meniscal Root Repair with Extrusion Repair (Centralization Technique).

Concomitant Medial Meniscal Root Repair with Extrusion Repair (Centralization Technique).

"Flipped Lid" Fracture of the Lateral Tibial Plateau with Dislocated Lateral Meniscus: A Case Report.

We present a rare "flipped lid" type of fracture of the lateral tibial plateau with dislocation of the lateral meniscus into the notch with intact roots. This was fixed using headless screws through arthrotomy and peripheral suturing of the meniscus. At the 1-year follow-up, although there was terminal restriction of 10° flexion with redislocation of the lateral meniscus, the patient was able to perform all daily activities and declined further surgery. Flipped lid-type fracture is rare and results in good outcome when fixed early. Meniscal dislocation repair requires close monitoring to detect failure.

Effects of a Q Suture Technique as a Core Suture on Resistance to Gap Formation and Tensile Strength in an Ex Vivo Porcine Flexor Tendon Model

The Q suture has been reported to be an effective alternative to conventional peripheral sutures in tendon repair. Whether the Q method can be used as a core suture rather than a peripheral suture by adjusting the purchase length is unknown. We tested a double Q suture technique with variable purchase length and studied its effects on gap formation and tensile strength using an exvivo model. Forty pig flexor tendons were repaired using the double Q sutures with purchase lengths of 2, 4, 6, and 8 mm. Twenty tendons repaired using the double Tsuge and double Kessler sutures with an 8-mm purchase length were used as controls. The tendons were subjected to cyclic loading and load-to-failure. The number of tendons that formed an initial or 2-mm gap between the tendon ends, gap distance at the repair site, stiffness, and ultimate strength were recorded. During cyclic loading, the double Q suture with a 4-8-mm purchase had fewer tendons form an initial or 2-mm gap and a smaller gap size at the repair site than the Tsuge and Kessler sutures. The stiffness of the double Q suture with a 6-8-mm purchase length and Tsuge suture was greater than those of the double Kessler suture. The double Q suture with a 2-mm purchase length had smaller ultimate strength than the other sutures. The Q suture may be an effective tendon repair method whose role can be converted between peripheral and core sutures via adjusting the suture purchase length. With an optimal suture length of 4-6 mm, the double Q method had tensile resistance superior to 4-strand core sutures. The double Q suture may be a viable option as a core suture in flexor tendon repair when the purchase length is appropriately adjusted.

Biomechanical Analysis of a New Eight-Strand Suture for Flexor Tendon Repair.

Background The placement of multistrand sutures during flexor tendon repair requires complicated surgical skills; such suturing is difficult. We developed a new, simpler eight-strand suture, which we term the Yoshizu cross-lock. This reduces the numbers of suture passages through the tendons, as well as the numbers of knots. Methods Fourteen porcine flexor tendons were transected and repaired using the Yoshizu cross-lock system; no peripheral sutures were placed. Our system is a modification of the published, exposed cross-lock repair method that employs a 4-0 monofilament nylon two-strand line and two needles. The repaired tendons were subjected to linear, noncyclic load-to-failure tensile testing. The initial gap, the 2-mm gap force, and the ultimate strength were measured. Results The initial gap force was 12.6 ± 5.6 Newtons (N), the 2-mm gap force was 33.9 ± 10.9 N, and the ultimate strength was 70.1 ± 17.0 N. All tendons subjected to Yoshizu cross-lock repair failed due to suture rupture rather than pullout. Conclusions Our biomechanical study revealed that Yoshizu cross-lock repair had sufficient tensile strength but was associated with wide variation in the 2-mm gap load (standard deviation = 10.9 N). This study is clinically relevant, showing that the Yoshizu cross-lock repair combined with peripheral suturing may allow a repaired flexor tendon to withstand the stresses encountered during early active mobilization. This simple eight-strand technique will be particularly useful to surgeons who commonly employ the cross-lock stitch for primary flexor tendon repair following early mobilization.

Dynamic Tendon Grip (DTG\u2122) novel knot array compared to traditional sutures for zone two flexor tendon injury \u2013 a biomechanical feasibility study

BackgroundFlexor tendon injuries pose many challenges for the treating surgeon, the principal of which is creating a strong enough repair to allow early active motion, preserving a low-profile of the repair to prevent buckling and subsequent pulley venting. A main concern is that a low-profile repair is prone to gap formation and repair failure. The Dynamic Tendon Grip (DTG™) all suture staple device claims to allow a strong and low-profile repair of the flexor tendon. The purpose of this study is to test the effects of the DTG™ device in early active motion simulation on range of motion, load to failure and gap formation and to compare it to traditional suturing technique.MethodsTwelve fresh-frozen cadaveric fingers were assigned to two groups: DTG™ device (n = 9) and traditional suturing (double Kessler 4-core suture and a peripheral suture, n = 3). The deep flexor was incised and repaired in zone 2, and active motion simulation was carried out with a cyclic flexion–extension machine. Finger range of motion and gap formation were measured, as well as load to failure and method of repair failure.ResultsFollowing motion simulation, ROM decreased from 244.0 ± 9.9° to 234.5 ± 5.8° for the DTG™ device compared to 234.67 ± 6.51° to 211.67 ± 10.50° for traditional suturing. The DTG™ repair demonstrated gap formation of 0.93 ± 0.18 mm in 3 of 8 specimens after applying 1 kg load, which negated after load removal. Load to failure averaged 76.51 ± 23.15 N for DTG™ and 66.31 ± 40.22 N for the traditional repair. Repair failure occurred as the suture material broke for the DTG™ array and at the knot level for the traditional repair.ConclusionsThe DTG™ all-suture stapling concept achieved a strong low-profile repair in zone 2 flexor tendon injury after active motion simulation. Further clinical studies will be needed to determine the effectiveness of this device compared to traditional techniques.

Comparison of 4 Different 4-Strand Core Suturing Techniques for Flexor Tendon Laceration: An Ex Vivo Biomechanical Study.

Forces applied to the repaired flexor tendon should not exceed its yield force during early postoperative rehabilitation to prevent gapping and rupture. We aimed to biomechanically compare the tensile strengths and the 2-mm gapping of 4 different 4-strand core suturing techniques for flexor tendon repair. Fifty-six goat deep digital flexor tendons were repaired with the 4-strand double-modified Kessler, the 4-strand augmented Becker, the 4-strand Savage, and the 4-strand modified Tang techniques. All tendons were repaired with 4-0 polyester for core suture and 5-0 polyester for continuous epitendinous running suture. The specimens were subjected to static linear tensile testing by applying a single linear load-to-failure pull. After the linear load testing, the yield load, the ultimate strength of the repaired tendons, and the force exerted to yield a 2-mm gap were measured. All peripheral sutures ruptured near the yield point. All core suture techniques were similar regarding the yield force. The augmented Becker 4-strand technique had the greatest ultimate strength (98.7 [82-125.3] N). The modified double Kessler technique was the weakest in resisting a 2-mm gap formation. The 4-strand modified Tang repair had the shortest (11.3 [7-15] minutes), while the 4-strand augmented Becker had the longest operative time (29 [23-33] minutes). All 4 techniques demonstrated similar yield force, with differences in operative time, ultimate strength, and resistance to gapping. Future clinical studies can further elucidate their appropriateness for early active motion protocols.

The consistency and reliability of six-strand and four-strand flexor tendon repairs: a comparative porcine cadaveric study.

The aim of this study was to compare the consistency and reliability of the six-strand Gan modification of the Lim-Tsai flexor tendon repair with the four-strand Adelaide repair, both with 3-0 sutures and with eight to ten runs of simple 5-0 running peripheral suture as well as the influence of the surgeons' level of experience on the strength of the repair in a cadaveric animal setup. Thirty-nine surgeons repaired 78 porcine flexor digitorum profundus tendons with either the Adelaide technique (39 tendons) or the modified Lim-Tsai technique (39 tendons). Each repaired tendon was tested in a material testing machine under a single cycle load-to-failure test. The forces were recorded when the gap between the two tendon stumps reached 1 and 2 mm and when irreversible elongation or total rupture occurred. We found no significant differences in gap formation force and yielding strength of the tendons between the two methods. The surgeon's previous experience in tendon repairs did not improve the consistency, reliability or tensile strength of the repairs. We conclude that if a strong peripheral suture is added, the modified Lim-Tsai repair has the same technical reliability and consistency as the Adelaide repair in term of ultimate loading strength in this test setup.

Flexor tendon repair: recent changes and current methods.

The current clinical methods of flexor tendon repair are remarkably different from those used 20 years ago. This article starts with a review of the current methods, followed by presentation of past experience and current status of six eminent hand surgery units from four continents/regions. Many units are using, or are moving toward using, the recent strong (multi-strand) core suture method together with a simpler peripheral suture. Venting of the critical pulleys over less than 2 cm length is safe and favours functional recovery. These repair and recent motion protocols lead to remarkably more reliable repairs, with over 80% good or excellent outcomes achieved rather consistently after Zone 2 repair along with infrequent need of tenolysis. Despite slight variations in repair methods, they all consider general principles and should be followed. Outcomes of Zone 2 repairs are not dissimilar to those in other zones with very low to zero incidence of rupture.

Up to five-week delay in primary repair of Zone 2 flexor tendon injuries: outcomes and complications.

We report the outcomes of delayed primary repair of flexor tendons in Zone 2 in 31 fingers and thumb (28 patients) averaging 15days (range 4-37) after injury in 2020. The delay was longer than usual due to the COVID-19 pandemic. The tendons were repaired with a 6-strand core suture (M-Tang method) or a double Tsuge suture and a peripheral suture. This was followed by an early, partial-range, active flexion exercise programme. Adhesions in four digits required tenolysis. These patients were not with longest delay. Outcomes of two improved after tenolysis. The other two patients declined further surgery. One finger flexor tendon ruptured in early active motion. This was re-repaired, and final outcome was good. Overall excellent and good results using the Tang criteria were in 27 out of 31 fingers and thumbs (87%). The time elapsed between the injury and surgery is not an important risk factor for a good outcome, rather it depends on proper surgical methods, the surgeon's experience and early mobilization, properly applied. Adhesions may occur, but they can be managed with tenolysis.Level of evidence: IV.

Transosseous Sutures in Tendon-to-Bone Repairs: the Role of the Epitendinous Suture

Background: Numerous transosseous fixation techniques for flexor tendon injuries in Zone 1 of the hand have been described in the literature. While relatively high maximal loads to failure are documented in different biomechanical experiments, several tests revealed a low 2 mm gapping resistance of the tendon-to-bone repairs. We therefore aimed to investigate the effect on gap formation adding a peripheral suture to an established transosseous fixation technique. In addition, we analyzed the influence of different suture materials (braided vs. non-braided) on the stability of the core suture. Method: A total of 30 porcine flexor digitorum profundus tendons were divided into 3 groups (n = 10 each) and repaired using the transverse intraosseous loop technique (TILT). In group 1 and group 2 the repairs were performed using PDS 3-0 or Ethibond 3-0, respectively. In group 3, a peripheral suture was added to the core suture (PDS 3-0) consisting of two figure-of-eight stitches with PDS 5-0. The biomechanical performance of the repaired tendons was analyzed using a standardized protocol. Results: The suture material and peripheral suture showed no effect on the ultimate failure load in our testing. However, the addition of a peripheral suture led to a statistically significantly higher 2 mm gap force when compared with the repair with a core suture only. Conclusion: In conclusion, addition of a palmar epitendinous suture to the transosseous core suture significantly increases the load to 2 mm gap formation in Zone 1 flexor tendon repairs and thus allows an immediate controlled mobilization.

Surgeon-innovator and physician-humanist ahead of his time (to the 145th anniversary of the birth of academician A.V. Vishnevsky)

The main scientific and practical activities of A.V. Vishnevsky took place in Kazan and Moscow. This paper presents little-known facts from the creative life of A.V. Vishnevsky, with a focus on his contribution to the development of local anesthesia and novocaine blockade in our country. Vishnevsky graduated from the Astrakhan gymnasium in 1894 and from the Kazan University in 1899. From 1899 to 1912, he was an assistant dissector at the departments of normal anatomy, topographic anatomy, and operative surgery of Kazan University. During the First World War, he mostly performed surgery to wounded individuals with gunshot injuries that involved peripheral nerves, producing neurolysis or suturing of the nerves. To treat brain abscesses, he used oil-balsamic drainage, which gave better results than other therapeutic methods. From 1914 to 1934, he managed first the hospital and then the faculty surgical clinics in Kazan. With the emerging problems in surgery, he paid much attention to neurosurgery, local analgesia, suppurative processes, nervous tropism, and gunshot wounds. His original theoretical works were devoted to neural trophy. His proposed methods of nerve block, in particular, pericardial novocainic and vago-sympathetic blockages, were widely accepted. As regards his contribution to the field of military surgery, he promoted proper surgical treatment of wounds, justified secondary treatment of wounds, and suggested methods to combat traumatic shock, secondary bleeding, etc. In 1947, A.V. Vishnevsky was appointed as the Director of the Institute of Surgery of the USSR Academy of Medical Sciences in Moscow. He was the founder of the great national school of surgeons.

Robust Suture Combination for Rat Flexor Tendon Repair Model

PurposeWe aimed to develop a rat flexor tendon repair model that could be applied to experiments in similar clinical settings.MethodsWe prepared 3 different combinations of sutures in rat flexor tendons: group A had 3 single peripheral sutures plus a 2-strand core suture; group B had 3 figure-of-eight peripheral sutures alone; and group C had 3 figure-of-eight peripheral sutures plus a 2-strand core suture. We examined the in vitro tensile strength of the repaired tendons by a biomechanical test, the rerupture rate within 3 weeks, and histological findings in vivo.ResultsGroup C displayed the greatest ultimate strength by the mechanical test. The flexor tendons in group C did not rerupture within 3 weeks after surgery, whereas many of those in groups A and B reruptured. Fibrous scar tissue was observed in the gap of the tendon stumps in groups A and B, but not in group C.ConclusionsThe combination of figure-of-eight peripheral sutures and a 2-strand core suture provided the repaired rat flexor tendon with enough strength to prevent rerupture without cast fixation or immobilization after surgery.Clinical relevanceThis combination of sutures is useful to reproduce flexor tendon repair similar to that performed in clinical settings and will contribute to various translational experiments in vivo.

Using Q Suture to Enhance Resistance to Gap Formation and Tensile Strength of Repaired Flexor Tendons.

Peripheral epitendinous sutures are believed to enhance core suture strength in tendon repair and decrease the risk of gapping between tendon ends. Here Q suture, an alternative to peripheral sutures, is presented for the use in tendon repair. Its effects on gap formation and tensile strength of the repaired tendons were compared with conventional running peripheral sutures. Three 2-strand sutures and three 4-strand sutures were used in repairing porcine tendons. The time required for performing 2Q and running sutures were recorded. The repaired tendons were subjected to a cyclic loading test, and the cycle number, during which a 2-mm gap was formed, was determined. After the cyclic loading, the gap size at the tendon ends and the ultimate strength of the repaired tendons were measured. Augmentation with the Q sutures reduced the number of tendons showing 2-mm gaps at tendon ends during cyclic loading. With addition of Q sutures 2-strand sutures significantly increased the ultimate strength of the repaired tendons and 4-strand sutures decreased the gap distance at the repair site of tendons. The time required for performing 2Q sutures was significantly less than that for running sutures. Therefore, we conclude that the Q suture is efficient in enhancing the tensile resistance and tendon repair strength and can be an alternative to conventional peripheral sutures.

Meniscal Allograft Transplantation: Indications, Techniques, Outcomes

AbstractMeniscal allograft transplantation (MAT) has become an acceptable surgical treatment for select symptomatic and relatively young (<50 years of age) patients with a meniscal deficiency. MAT may also be considered in meniscal-deficient patients undergoing anterior cruciate ligament reconstruction and/or articular cartilage repair procedure in the ipsilateral compartment. Contraindications to MAT include asymptomatic patients, severe osteoarthritis, uncorrectable malalignment or instability, irreparable chondral damage, active infection, or inflammatory arthropathy. Most institutions prefer the use of fresh-frozen allografts, whereas the use of fresh-viable grafts is limited by their availability, and the use of cryopreserved and lyophilized grafts has gone out of favor. Donor allografts are size-matched to the recipient using x-rays or magnetic resonance imaging measurements. To date, no particular surgical technique has demonstrated superiority. Therefore, there are several used approaches (mini-open or arthroscopic), horns-fixation techniques (soft-tissue, bone-plugs, or bone-bridge), and peripheral suture techniques (inside-out or all-inside). Ipsilateral malalignment, instability, and/or chondral defects should be corrected or repaired if MAT is being performed. MAT survival rates are estimated at 73.5% at 10 years and 60.3% at 15 years. Mean time-to-failure is ∼8.2 and ∼7.6 years for a medial and lateral meniscus transplant, respectively. Significant improvement in patient-reported outcomes is expected following MAT, and 90% of patients will attest they will undergo the procedure again. Reoperation rates are estimated at 32%, with the most common complication being a tear of the meniscal allograft. Many studies reporting on outcomes of MAT are flawed because of low-quality, the use of non-fresh-frozen preservation techniques, and heterogeneity of patients and concomitant procedures. As our knowledge regarding patient selection, graft preparation, and techniques continue to develop, we expect MAT outcomes to improve much further.