Simple Stitch Research Articles

High-Tensile Strength Tape Versus High-Tensile Strength Suture: A Biomechanical Study

To determine which suture design, high-tensile strength tape or high-tensile strength suture, performed better at securing human tissue across 4 selected suture techniques commonly used in tendinous repair, by comparing the total load at failure measured during a fixed-rate longitudinal single load to failure using a biomechanical testing machine. Matched sets of tendon specimens with bony attachments were dissected from 15 human cadaveric lower extremities in a manner allowing for direct comparison testing. With the use of selected techniques (simple Mason-Allen in the patellar tendon specimens, whip stitch in the quadriceps tendon specimens, and Krackow stitch in the Achilles tendon specimens), 1 sample of each set was sutured with a 2-mm braided, nonabsorbable, high-tensile strength tape and the other with a No. 2 braided, nonabsorbable, high-tensile strength suture. A total of 120 specimens were tested. Each model was loaded to failure at a fixed longitudinal traction rate of 100 mm/min. The maximum load and failure method were recorded. In the whip stitch and the Krackow-stitch models, the high-tensile strength tape had a significantly greater mean load at failure with a difference of 181 N (P = .001) and 94 N (P = .015) respectively. No significant difference was found in the Mason-Allen and simple stitch models. Pull-through remained the most common method of failure at an overall rate of 56.7% (suture = 55%; tape = 58.3%). In biomechanical testing during a single load to failure, high-tensile strength tape performs more favorably than high-tensile strength suture, with a greater mean load to failure, in both the whip- and Krackow-stitch models. Although suture pull-through remains the most common method of failure, high-tensile strength tape requires a significantly greater load to pull-through in a whip-stitch and Krakow-stitch model. The biomechanical data obtained in the current study indicates that high-tensile strength tape may provide better repair strength compared with high-tensile strength suture at time-zero simulated testing.

Suturing the myotendinous junction in total hip arthroplasty: A biomechanical comparison of different stitching techniques

BackgroundThe repair of the myotendinous junction following total hip arthroplasty is challenging as this region is the weakest part of the muscle structure. This study investigated the mechanical behaviour and the mode of failure of different suturing techniques of the myotendinous junction. A new asymmetrical stitch was compared to two widely used techniques, i.e. the simple stitch (two loops in parallel) and the figure-of-eight stitch. MethodsThe ovine triceps brachii myotendinous junction was selected as the experimental model. Each technique was sewn in muscle belly on one side and in a polyester belt (no-tendon configuration) or in thin tendon (full configuration) on the other side. The former was chosen to determine the grasping power of the stitch on the muscle despite the tendon quality, the latter to simulate a very thin gluteus medius tendon. FindingsThe new stitch showed a higher ultimate strength (+40%) compared to the two controls in the no-tendon configuration. In the full configuration, no significant increase was observed, although failure of the new stitch always occurred at the tendon side. Furthermore, the new stitch does not alter the stiffness of repair. InterpretationThe new stitch has a higher grasping power on muscle belly than the single passing-through stitches thanks to the multiple fixation points, which better distribute the load in the tissue. However, such performance can be fully exploited only in the presence of good quality tendons.

Arthroscopic Labral Reconstruction of the Hip Using Semitendinosus Allograft

The labrum of the hip is recognized as being important to the stability of the hip and a major cause of hip pain. Damage to the labrum may result in increased joint stress and articular damage. Labral damage is often treated through various methods, among them simple stitch repair, base refixation, and debridement. Labral reconstruction becomes necessary when the labrum is too damaged to salvage, which renders labral repair improbable and labral debridement ineffective. In contrast to other methods that have been described for this treatment, our technique uses a semitendinosus allograft as a graft source, allowing for arthroscopic hip labral reconstruction. This technique has many advantages and is easily reproducible. It has shown promising results in patients with labral damage. The purpose of this article is to detail the step-by-step surgical technique of labral reconstruction using a semitendinosus allograft, in addition to the indications, pearls, and pitfalls of the technique.

The Simple Cow Hitch Stitch Technique for Arthroscopic Rotator Cuff Repair and Stabilization Using Knotless Suture Anchors

The tissue-suture interface is the most vulnerable and challenging part of adequate restoration and fixation in rotator cuff repair. We describe a simple stitch technique for arthroscopic rotator cuff repair using knotless suture anchors based on the cow hitch. The simple cow hitch stitch technique is easy to perform, especially under difficult conditions, and provides excellent initial fixation strength as required for integration of the reinserted cuff and for shoulder stabilization.

Load to Failure and Stiffness: Anchor Placement and Suture Pattern Effects on Load to Failure in Rotator Cuff Repairs.

Background:Rotator cuff tendinopathy is a frequent cause of shoulder pain that can lead to decreased strength and range of motion. Failures after using the single-row technique of rotator cuff repair have led to the development of the double-row technique, which is said to allow for more anatomical restoration of the footprint.Purpose:To compare 5 different types of suture patterns while maintaining equality in number of anchors. The hypothesis was that the Mason-Allen–crossed cruciform transosseous-equivalent technique is superior to other suture configurations while maintaining equality in suture limbs and anchors.Study Design:Controlled laboratory study.Methods:A total of 25 fresh-frozen cadaveric shoulders were randomized into 5 suture configuration groups: single-row repair with simple stitch technique; single-row repair with modified Mason-Allen technique; double-row Mason-Allen technique; double-row cross-bridge technique; and double-row suture bridge technique. Load and displacement were recorded at 100 Hz until failure. Stiffness and bone mineral density were also measured.Results:There was no significant difference in peak load at failure, stiffness, maximum displacement at failure, or mean bone mineral density among the 5 suture configuration groups (P < .05).Conclusion:According to study results, when choosing a repair technique, other factors such as number of sutures in the repair should be considered to judge the strength of the repair.Clinical Relevance:Previous in vitro studies have shown the double-row rotator cuff repair to be superior to the single-row repair; however, clinical research does not necessarily support this. This study found no difference when comparing 5 different repair methods, supporting research that suggests the number of sutures and not the pattern can affect biomechanical properties.

Integrating Satins Strips with Manual Embroidery for Enhancing Ladies Evening Wear Aesthetics

Women always need to distinguish themselves and individuals and appear in the elegant elegant appearance is striking and the most special occasions in which a woman can shine are special occasions, weddings and birthdays, and the woman incurs a lot of money to buy this type of clothing because these pieces of decorations and embroidery with lobes and ornament and beads and strings, Therefore, many women found it difficult to appear in the elegant appearance on those special occasions due to the high cost of these models, in addition to the spread of clothes with the traditional appearance of embroidery with beads, sequins, wali ... ...... Hence the idea of ​​the research by the researcher Whose primary goal was to decorate and develop evening wear for women, by combining simple stitches of work with satin ribbons with manual embroidery represented by beads, pearls, serma threads, and so on. It is a method that the researcher considered a new way to develop evening wear, so that it meets the needs of women, and was the most important The results of the study showed that female consumers consumed this idea and accepted it with admiration, and they considered these tapes a new idea that must be applied and tried, and the results showed after the statistical analysis that the The designs implemented with the technique of embroidery with satin ribbons with manual embroidery have brought about a great development in the evening wear for women and according to the opinions of the consumers, and the statistical results also showed that the designs implemented with this technology have created an improvement in the aesthetic value of the evening wear for women in accordance with the opinions of specialists in clothes and fabric.

A new anatomic technique for type II SLAP lesions repair.

A new and more anatomical technique for SLAP II lesions repair is described. It consists in the reattachment of the medial aspect of the biceps anchor to the superior glenoid neck with a mattress stitch posterior and medial to the biceps anchor and a simple stitch placed anteriorly to the biceps. From 2011 to 2012, 14 patients matching the inclusion criteria were selected for the study. A visual analogic scale, ROWE, UCLA, ASES and Constant scores were used to make evaluation. The passive ROM before surgery, at final follow-up, and the resumption of sports activities were analysed. The Constant, ASES, UCLA and ROWE scores passed from 64.6 (SD 13.9), 76.9 (SD 22.4), 28.4 (SD 23.8) and 53.6 (SD 20.6) to, respectively, 92.6 (SD 11.8), 108.3 (SD 8.5), 33.6 (SD 2.7) and 96.5 (SD 7.2) at final follow-up. Of the four patients who had participated in agonistic overhead athletics preoperatively, all of them were able to return to their preinjury level. No complications were observed in the present study. In our technique, the anatomy is respected leaving the articular aspect of the superior labrum loose and reinforcing the medial side. The clinical relevance of this work is that probably this technique could improve clinical results, giving a better mobility of the shoulder and a return to the same preoperative level in overhead athletes.

Clinical and Radiologic Evaluation of Arthroscopic Medial Meniscus Root Tear Refixation: Comparison of the Modified Mason-Allen Stitch and Simple Stitches

This study compared the clinical and radiologic outcomes of arthroscopic medial meniscus root refixation using the modified Mason-Allen stitch and simple stitches. The outcomes of 25 patients who underwent arthroscopic meniscus root refixation using the modified Mason-Allen stitch (M group) between June 2010 and January 2012 were compared with those of 25 matched control patients (S group) who underwent meniscus root refixation using simple stitches between March 2004 and August 2007. The Lysholm score, International Knee Documentation Committee Subjective Knee Form score, joint space narrowing, and Kellgren-Lawrence grade were assessed. Medial meniscal extrusion, progression of cartilage degeneration, and healing status of the refixed medial meniscus root were assessed on magnetic resonance images. No between-group difference was found in age, sex, body mass index, or preoperative patient characteristics. The mean follow-up times for the M and S groups were 24.1 and 25.9 months (P = .248), respectively. The Lysholm, International Knee Documentation Committee Subjective Knee Form, and Tegner activity scores improved significantly in both groups. The repaired root tended to heal better in the M group than in the S group (P = .065). Although the postoperative clinical outcomes did not differ between the groups, postoperative medial meniscal extrusion decreased -0.6 ± 0.9 mm in the M group and increased 1 ± 0.6 mm in the S group on magnetic resonance imaging (P < .001). The M group did not show significant progression in the Kellgren-Lawrence grade and cartilage degeneration (P = .083 and P = .317, respectively), whereas both measures increased significantly in the S group (P = .008 and P < .001, respectively). Compared with simple stitches, the modified Mason-Allen stitch improved the degree of meniscal extrusion, although the 2 different suture techniques showed no difference in clinical outcomes at short-term follow-up. Level III, retrospective comparative study.

Arthroscopic Single-Row Versus Double-Row Repair for Full-Thickness Posterosuperior Rotator Cuff Tears: A Critical Analysis Review.

Over the past two decades, arthroscopic rotator cuff repair has become one of the most popular orthopaedic surgical procedures because of its proven ability to diminish pain and improve function in patients with symptomatic rotator cuff tears. As a result of this increasing demand, arthroscopic techniques have evolved rapidly in an effort to improve structural integrity, biomechanical function, and, ultimately, clinical outcomes. With the increasing number of techniques available for the repair of full-thickness rotator cuff tears, debate has arisen regarding the clinical superiority of any one of these methods over the others. Specifically, this debate has centered on traditional single-row versus traditional double-row repair constructs (Fig. 1). Therefore, the purpose of this article is to present a critical review of the most relevant evidence and to provide clinical care recommendations regarding arthroscopic single-row versus double-row rotator cuff repair constructs. Fig. 1 Traditional single-row suture configuration utilizes two lateral anchors tied in a simple stitch pattern ( Fig. 1 , A ). Traditional double-row suture configuration utilizes an additional medial row of anchors with mattress stitches ( Fig. 1 , B ). The rotator cuff represents a confluence of four tendons that envelop the humeral …

The role played by a suspended external-internal suture in reducing marginal flap tension after bone reconstruction: a clinical prospective cohort study in the maxilla.

To define the role played by a suspended external-internal (SEI) suture in reducing marginal flap tension after bone augmentation in the maxilla and in enhancing primary wound healing. Twenty partially edentulous patients requiring bone augmentation (either guided bone regeneration or autogenous bone block placement) before or simultaneous with implant insertion in the maxilla were enrolled in this clinical prospective cohort study. Flap tension was measured by a dynamometer, which was accurate to within 1 g. The force recorded was that needed to enable the vestibular extensible flap to reach the edge of the palatal nonextensible flap. Flap tension was recorded after the periosteum-releasing incision was made (before application of any suture; T1), and after the SEI suture was applied (T2). Final marginal flap adaptation was accomplished via horizontal mattress sutures and simple stitches. Wound healing was monitored at 1, 2, 4, and 16 weeks and classified as "obtained primary closure" or "compromised" as a result of dehiscence or marginal flap necrosis. The mean flap tension measured at T1 was 32.9 ± 7.7 g. After the SEI suture was applied, the mean marginal flap tension decreased to 4.1 ± 1.5 g. The marginal flap tension was reduced by 87.6% compared to the initial strain. All patients healed uneventfully, and no complications such as dehiscences or marginal flap necrosis were recorded. The application of the SEI suture reduced the tension on the margins of the flaps and played a decisive role in obtaining primary wound healing. In case of passive wound closure (strain < 5 g), the type of augmentation procedure (guided bone regeneration or autogenous block) was revealed to have no impact on the quality of wound healing.

Strength of Arthroscopic Meniscal Root Repair Constructs

Clinical study has illustrated the prevalence of meniscal root injury and potential for degenerative sequel without repair. Repair constructs have been presented by authors, and repair strengths determined. However, prior studies have evaluated constructs placed ex vivo without method to place the strongest construct in an arthroscopic fashion nor strength evaluation of constructs placed arthroscopically. We present two new meniscal root repair constructs with arthroscopic technique and strength evaluation of arthroscopically placed repair constructs. Pullout strength, stiffness, and time of suture construct for the different meniscal repair patterns was evaluated. This will aid the clinician in determining the best method for arthroscopic meniscal root repair and aid in the development of appropriate postoperative rehabilitation plans. The hypothesis of this study is that maximum failure load, stiffness, and repair execution time will vary based upon suture construct, with higher strengths and execution times with increased repair technique complexity. Twenty cadaveric knees were mounted in a simulated surgical position, and sutures were placed arthroscopically at the root of the medial and lateral menisci. Four repair constructs were tested including 2 novel repair constructs: 2 simple stitches, 1 inverted mattress stitch, 1 double locking loop stitch, and 2 double locking loop stitches. Arthroscopic placement of suture repair construct was timed. In total 40 posterior meniscal roots, both lateral and medial from 21 cadaveric specimens were tested, with 10 trials for each construct. Specimens were dissected, and the medial and lateral menisci harvested. Individual meniscus specimens were cycled and then tested to failure on an Instron machine with a custom baseplate mimicking the transosseous suture tunnel utilized in meniscal root repair. The Kruskal-Wallis Test was used to evaluate for statistical significance between groups. The mean maximum failure loads were: 2 simple stitches (2SS) 137±49 N, 1 inverted mattress stitch (1MS) 126±44 N, 1 double loop locking stitch (1DLS) 201±44 N, 2 double loop locking stitches (2DLS) 396±69 N. Inter-construct comparison revealed statistical difference between 2DLS (p < 0.01) and all three remaining constructs (< 0.01), and 1DLS when compared to 2SS and 1MS (p <0.01, <0.01). Statistical significance was not found between 2SS and 1MS (p=0.8). The average time for repair of the 4 fixation techniques were: 2SS 1.78 ± 0.87 minutes, 1MS 2.40 ± 1.90 minutes, 1DLS 4.67 ± 2.01minutes, 2DLS 5.38 ± 0.62 minutes. Constructs with four suture limbs within the simulated repair tunnel illustrated stiffer constructs. Arthroscopically placed locking loop repair constructs are stronger than current arthroscopic techniques with increase in time of repair. As complexity of the repair construct increases so does time for fixation and pullout strength. With this study, an arthroscopic technique is presented to produce stronger meniscal root repair constructs with little increase in surgical time.

Artificial chordae in the setting of complex mitral valve repair: early outcomes using the folding leaflet technique

Neochordal repair is particularly limited in case of large prolapse with absence of a reference point on a nearby segment. Our aim was to overcome these limitations by means of a simple technique: the 'Folding Leaflet'. Ninety-six patients underwent this technique between January 2009 and August 2012 from a global mitral valve (MV) repair group of 384 patients. A subgroup of 68 patients with complex lesions, bileaflet, commissural or multisegment prolapse, was selected. These more challenging patients were considered as the study group in order to assess the efficacy of our technique. The neochordae were fixed to the papillary muscle with a simple stitch and then were passed through the free margin of the prolapsing leaflet. Free-edge remodelling was achieved weaving this suture and surpassing the coaptation line. Then, the leaflet was folded and its free margin was temporarily approximated edge-to-edge to the adjacent annulus. This was used as the reference point while the neochordae were tied without the need for adjacent healthy chordae or use of callipers. Complete echocardiographic follow-up was obtained at 6-month intervals. All patients had ≥ 2 prolapsed segments: posterior leaflet (40 patients), anterior leaflet (13 patients) or both leaflets (15 patients). Annuloplasty was routinely used and the mean number of neochordae per patient was 4.1 ± 2.2 (2-13). Mean follow-up was 28 ± 14 months (5-49 months). There was only one in-hospital death. Another patient died by pneumoniae (15th postoperative month). At the first-month follow-up, 51 patients had no mitral regurgitation (MR) and 16 patients had Grade 1 MR. Only 1 patient had more than mild regurgitation at the 6-month follow-up. There was no evidence of Grade 3 or 4 MR in any patient. At the 2-year follow-up, 34 patients remained with no MR or trace MR and 7 patients had Grade 1 MR. MV repair for complex degenerative MR using this technique of neochordal repair results in excellent early and mid-term outcomes. This technique facilitates the extensive use of neochordae in case of large areas of prolapse.

Biomechanical Validation of Load-Sharing Rip-Stop Fixation for the Repair of Tissue-Deficient Rotator Cuff Tears

Background: Poor-quality tendon is one of the most difficult problems the surgeon must overcome in achieving secure fixation during rotator cuff repair. A load-sharing rip-stop construct (LSRS) has recently been proposed as a method for improving fixation strength, but the biomechanical properties of this construct have not yet been examined. Purpose: To compare the strength of the LSRS construct to that of single-row fixation for rotator cuff repair. Study Design: Controlled laboratory study. Methods: Rotator cuff tears were created in 6 cadaveric matched-pair specimens and repaired with a single row or an LSRS. In the LSRS repair, a 2-mm suture tape was placed as an inverted mattress stitch in the rotator cuff, and sutures from 2 anchors were placed as simple stitches that passed medial to the suture tape. The suture tape limbs were secured with knotless anchors laterally before sutures were tied from the medial anchors. Displacement was observed with video tracking after cyclic loading, and specimens were loaded to failure. Results: The mean load to failure was 371 ± 102 N in single-row repairs compared with 616 ± 185 N in LSRS repairs (P = .031). There was no difference in displacement with cyclic loading between the groups (3.3 ± 0.8 mm vs 3.5 ± 1.1 mm; P = .561). In the single-row group, 4 of 6 failures occurred at the suture-tendon interface. In the LSRS group, only 1 failure occurred at the suture-tendon interface. Conclusion: The ultimate failure load of the LSRS construct for rotator cuff repair was 1.7 times that of a single-row construct in a cadaveric model. Clinical Relevance: The LSRS rotator cuff repair construct may be useful in the repair of difficult tears such as massive tears, medial tears, and tears with tendon loss.

The Rotator Cuff Repair Mess

To the Editor: I reached orthopaedic surgery led by the hand of my father, Jose M. Palomo, as well as Lorenz Bohler (The Treatment of Fractures) and Sir Reginald Watson-Jones (Fractures and Joint Injuries). Soon afterward, at the faculty ofmedicine, I learnedabout Sir JohnCharnley (The Closed Treatment of Common Fractures). Until that moment, a bony fracture meant some kind of cast and traction, as well as the dictum, “Close open fractures but don’t open the closed ones.” I had to give up that knowledge to closely and religiously follow, in a successive and exclusive way, the immovable principles of Maurice Muller (AO plates and screws), Gerhard Kuntscher and Josef Ender (intramedullary nails), R. Hamilton Russell (balanced suspension skeletal traction), Augusto Sarmiento (functional casts), Klaus Klemm and Dieter Schellman (locked nails), AO LISS plates, and nowadays, MIPO locked plates. Shall theydlocked platesdremain forever or will any of the previously abandoned “obsolete” techniques return to the present time, the sameway theFoucault pendulumalways returns to its starting point? It is now nearly 30 years since I started performing arthroscopic surgery of the knee, and although it has quite progressed, that development has maintained a certain predominant direction without too many bends except for extra-articular techniques and double-bundle ACL reconstruction. Shoulder arthroscopy has evolved quite differently. For rotator cuff repair, I started my training following Gary Gartsman, and so my metallic anchors went to the lateral aspect of the humerus to send their threads in an inverted mattress stitch configuration, in a single row, to push the cuff against its footprint. I then shifted to simple stitches from doubleloaded metallic anchors inserted at the top of the footprint (a la Stephen Snyder) and to absorbable top and medial anchors (a la Stephen Burkhart) to configure double-everted mattress stitches brought to a second single row of PEEK anchors distal to the lateral edge of the greater tuberosity. Then came the triple-loaded metallic anchors, just to fight the SutureBridge configuration, polyester suture-based anchors, not to mention all the transosseous-equivalent constructs, which were followed by the anchorless real transosseous device. Modified Mason-Allen stitches and rip-stop constructs, as well as reconstructive tissue matrices, then came to close the loop.up to a few months ago. I have now returned, very much in the way the Foucault pendulum

179 * ARTIFICIAL CHORDAE IN THE SETTING OF COMPLEX MITRAL VALVE REPAIR: EARLY OUTCOMES USING THE FOLDING LEAFLET TECHNIQUE

Objectives: Neochordal repair is particularly limited in the case of large prolapse with absence of a reference point on a nearby segment. Our aim was to overcome these limitations by means of a simple technique, the “folding leaflet”. Methods: Ninety-six patients underwent this technique between January 2007 and August 2012. A subgroup of 68 patients with bileaflet, commissural or multisegment prolapse was selected. The neochordae were fixed to the papillary muscle with a simple stitch and then were passed through the free margin of the prolapsing leaflet. Free-edge remodelling was achieved, weaving this suture and surpassing the coaptation line. Then the leaflet was folded and its free margin was temporarily approximated edge-to-edge to the adjacent annulus. This was used as the reference point while the neochordae were tied without the need for adjacent healthy chordae or the use of callipers. Complete echocardiographic follow-up was obtained at 6-month intervals. Results: All patients had ≥2 prolapsed segments: posterior leaflet (40 patients), anterior leaflet (13 patients) or both leaflets (15 patients). Annuloplasty was routinely used and the mean number of neochordae per patient was 4.1 ± 2.2 (range 2-13). Mean follow-up was 28 ± 14 months (range 5-49 months). One patient died from pneumonia (15th postoperative month). At last follow-up, 42 patients remained with no or trace mitral regurgitation (MR), 23 patients had grade 1 MR and only one patient had grade 2 MR. Conclusions: Mitral valve repair for complex degenerative MR using this technique of neochordal repair results in excellent early and mid-term outcomes. This technique facilitates the extensive use of neochordae in the case of large areas of prolapse.

Biomechanical Evaluation of Different Suture Techniques for Arthroscopic Transtibial Pull-out Repair of Posterior Medial Meniscus Root Tears

Background: A tear of the posterior medial meniscus root (PMMR) is increasingly recognized as a serious knee joint injury. Several suture techniques for arthroscopic transtibial pull-out repair have been described; however, only limited data about the biomechanical properties of these techniques are currently available. Hypothesis: There are significant differences between the tested suture techniques, with more complex suture configurations providing superior biomechanical properties. Study Design: Controlled laboratory study. Methods: A total of 40 porcine medial menisci were randomly assigned to 1 of 4 groups (10 specimens each) according to suture technique: two simple stitches (TSS), horizontal mattress suture (HMS), modified Mason-Allen suture (MMA), and two modified loop stitches (TLS). Meniscus-suture constructs were subjected to cyclic loading followed by load-to-failure testing in a servohydraulic material testing machine. Results: During cyclic loading, the HMS and TLS groups showed a significantly higher displacement after 100, 500, and 1000 cycles compared with the TSS and MMA groups. After 1000 cycles, the highest displacement was found for the TLS group, with significant differences compared with all other groups. During load-to-failure testing, the highest maximum load and yield load were observed for the MMA group, with statistically significant differences compared with the TSS and TLS groups. With regard to stiffness, the TSS and MMA groups showed significantly higher values compared with the HMS and TLS groups. Conclusion: The MMA technique provided the best biomechanical properties with regard to cyclic loading and load-to-failure testing. The TSS technique seems to be a valuable alternative. Both the HMS and TLS techniques have the disadvantage of lower stiffness and higher displacement during cyclic loading. Clinical Relevance: Using a MMA technique may improve healing rates and avoid progressive extrusion of the medial meniscus after transtibial pull-out repair of PMMR tears. The TSS technique may be used as an alternative that is easier to perform, but a more careful rehabilitation program is possibly necessary to avoid early failure.

Biomechanical evaluation of different suture materials for arthroscopic transtibial pull-out repair of posterior meniscus root tears

To evaluate the biomechanical properties of four different suture materials for arthroscopic transtibial pull-out repair of posterior meniscus root tears, with special focus on the meniscus-suture interface. Forty fresh-frozen lateral porcine menisci were used. The posterior meniscus root was sutured in a standardized fashion with a simple stitch using four different suture materials: group A, No. 2 PDS™; group B, No. 2 Ethibond™; group C, No. 2 FiberWire™; and group D, 2-mm Fibertape™. Meniscus-suture constructs were subjected to cyclic loading followed by load-to-failure testing using a servo-hydraulic material testing machine. During cyclic loading, group D showed a significantly higher displacement after 100, 500, and 1,000 cycles compared to group A (p < 0.001, p = 0.001, and p = 0.001), and a significantly higher displacement after 100 and 500 cycles compared to group B (p = 0.010 and p = 0.045). Group C showed a significantly higher displacement compared to group A after 100 cycles (p = 0.008). The highest maximum load was observed in group D, with significant differences compared to group A (p = 0.013). Group B showed a significantly higher stiffness compared to group A (p = 0.023), and both group C and group D showed a significantly higher stiffness compared to group A and group B (p < 0.001). None of the evaluated suture materials provided clearly superior properties over the others during both cyclic loading and load-to-failure testing. Based on the results of this study, FiberWire™ may be the preferred suture material for transtibial pull-out repair of posterior meniscus root tears because of comparably low displacement during cyclic loading and high values for maximum load and stiffness. In the clinical setting, FiberWire™ may improve healing rates and avoid progressive extrusion of the meniscus after transtibial pull-out repair of posterior meniscus root tears.

The Effect of Sliding Knots on the Suture-Tendon Interface Strength

Background: The tissue-suture interface remains the most common site of failure in rotator cuff repairs. It is currently unknown if arthroscopic sliding knots injure the tissue and weaken the suture-tendon interface. Purpose: To evaluate the effect sliding knots have on the strength of the suture-tendon interface. Study Design: Controlled laboratory study. Methods: A total of 32 sheep infraspinatus tendons were randomized among 4 groups of stitches (n = 8): simple-static, simple-sliding, mattress-static, and mattress-sliding. All high-strength, No. 2 suture stitch-knot combinations were created in an arthroscopic simulated environment, and sliding knots were tied with shortening of the suture and sliding of the knot down to the tissue interface to simulate surgical technique. Each graft was cyclically loaded on a mechanical testing system from 5 to 20 N for 20 cycles and then loaded to failure. A least squares analysis of variance model was used to test significance of sliding stitches upon cyclic elongation, peak-to-peak displacement, and ultimate load. Estimated means and standard deviations are reported from the regression model. Results: A mattress-static stitch (116 N) was significantly stronger than a mattress-sliding stitch (70 N; P < .001). The ultimate loads for the simple-static (46 N) and sliding (50 N) stitches were not statistically different. For cyclic elongation, the only difference was the mattress-sliding stitch (0.95 mm) having a greater elongation than the simple-static (0.61 mm; P = .01) and simple-sliding (0.68 mm; P = .04) stitches. Both mattress stitches had significantly less peak-to-peak displacement (0.39 and 0.41 mm) than the simple stitches (0.47 and 0.46 mm; P < .001). Conclusion: Sliding suture through tissue weakens the suture-tendon interface in mattress stitch constructs but not in simple stitch constructs. Mattress stitches have superior holding strength compared with simple stitches. Clinical Relevance: Clinical relevance is uncertain. In situations with poor tissue quality or concern regarding tension across the repair, consideration should be given to using static knots as opposed to sliding knots when placing mattress stitches.

Tackling technical skills competency: A surgical skills rating tool

BackgroundThe Accreditation Council for Graduate Medical Education common program requirements mandate a competency-based assignment of duties. To accomplish this, valid and reliable assessment tools must be developed to evaluate competence. This study evaluated a rating tool to assess competence in basic surgical suturing skills. MethodsA technical skills exercise consisting of the closure of three incisions, 3 cm long, was devised in 2006. The incisions were closed with simple stitches with two-handed knots, vertical mattress stitches with instrument knots, and a running stitch with one-handed knots. Fifteen min were allotted for completion. A rating instrument with 17 competency markers worth 1 point and a global 5-point Likert scale competency score was used to evaluate the performance. Twelve first-week post graduate year 1 surgical residents completed the exercise in 2006, and 16 final-month post graduate year 1 surgical residents completed it in 2011. All tasks were scored on video review by two independent raters. Statistical analysis included descriptive statistics, t-score analysis, rank sum analysis, Cohen's kappa coefficient, and Cronbach's alpha. ResultsThe mean total score (11.8 versus 13.9, P = 0.002) and median global competency rating (1 versus 3, P < 0.001) were lower for the first-week cohort. Cohen's kappa coefficient of inter-rater reliability was 0.77. Cronbach's alpha measure of internal consistency was 0.87. ConclusionThis rating form is a valuable tool to evaluate technical skill competency. Construct validity was demonstrated with improvement in total score and global rating. Excellent internal consistency and inter-rater reliability were also demonstrated. This form may be used to assess technical skill competency in an efficient skills exercise.

619 MODIFICATIONS IN TECHNIQUE LEADING TO IMPROVED SUCCESS OF ROBOTIC EXTRAVESICAL URETERAL REIMPLANATION

INTRODUCTION AND OBJECTIVES: While initial series have reported high failure rates, success of robotic assisted laparoscopic extravesical ureteral reimplantation (RALUR) has now approached that of open surgery. Improved success is often accredited to increased experience without indicating any improvement to technique. We review the outcomes of our first patients to have RALUR and analyze success based on changes in our technique that have occurred over time. METHODS: Between November 2008 and June 2011, a single surgeon, MSG, performed RALUR on a total of 22 patients (35 ureters) with vesicoureteral reflux (VUR). Retrospective analysis of our prospectively maintained database was performed. Only patients with successful completion of RALUR and postoperative voiding cystourethrogram (VCUG) were included in analysis. Success was defined as complete resolution of VUR on VCUG. The surgical technique for RALUR and subsequent modifications were placed into the following categories: Use of simple interrupted stitches and detrussoraphy length (DL) of 3 cm (1), Running stitch with DL of 4 cm (2), Running stitch, incorporation of ureteral adventitia with detrussoraphy closure, and DL of 5 cm (3) (Figure1). RESULTS: 20 patients (8 unilateral and 12 bilateral ureters) fit inclusion criteria. On preoperative VCUG, 12 ureters had grade 3 and 18 ureters grade 4 VUR. In patients with bilateral VUR, one had unilateral grade 1 and one had unilateral grade 2 VUR. Average age at surgery was 5.2 years (range 2.8 – 7.9 years). Mean operative time was 193 minutes for unilateral and 216 minutes for bilateral surgery. Average length of stay was 2.2 days (range 1 to 4 days). One patient was discharged with a catheter for transient urinary retention. No patient required readmission after discharge. Overall, resolution of VUR was seen in 25 of 32 ureters (78%). Resolution of VUR based on surgical technique was 8 of 13 ureters (62%), 6 of 8 ureters (75%), and 11 of 11 ureters (100%) for techniques 1, 2, and 3 respectively. Average follow up was 337 days (range 98 to 889 days). De novo postoperative hydronephrosis was seen in 9 ureters (28%) and resolved in all cases. CONCLUSIONS: Improvement in surgical technique including use of a running stitch, incorporation of ureteral adventitia into closure of detrussoraphy and increasing DL have helped in improving our success of RALUR.