Suture Slippage Research Articles

A modified orthotopic left lung transplantation model in rats

To enhance the operability of the rat orthotopic left lung transplantation model, we implemented several improvements and meticulously detailed the procedure. One hundred and thirty-one healthy male Sprague Dawley rats, weighing between 250 and 300 g, were utilized, with 64 serving as donors, 64 as recipients, and 3 as sham controls. We employed a modified three-cuff technique for the orthotopic left lung transplantation. Notably, our modified perfusion method could prevent donor lung edema, while waist-shaped cuffs minimized suture slippage during anastomosis. Additionally, positioning the recipient rat in a slightly left-elevated supine position during anastomosis reduced tension on the lung hilum, thus mitigating the risk of vascular laceration. The introduction of a unique two-person anastomosis technique significantly reduced operation time and substantially improved success rates. Furthermore, maximizing inflation of donor lungs both during preservation and surgery minimized the occurrence of postoperative atelectasis. Various other procedural refinements contributed to the enhanced operability of our model. Sixty-four rat orthotopic left lung transplantations were performed with only one surgical failure observed. The acquisition time for donor lungs averaged (19 ± 4) minutes, while (11 ± 1) minutes were allocated for donor lung hilum anatomy and cuff installation. Recipient thoracotomy and left lung hilar anatomy before anastomosis required (24 ± 8) minutes, with anastomosis itself taking (31 ± 6) minutes. Remarkably, the survival rate at the 4-h postoperative mark stood at 96.7 %. Even six months post-operation, transplanted left rat lungs continued to exhibit proper inflation and contraction rhythms, displaying signs of chronic pathological changes. In summary, our modified rat model of orthotopic left lung transplantation demonstrates robust operability, significantly reducing surgical duration, improving operation success rates, and enhancing postoperative survival rates. Furthermore, its long-term survival capacity enables the simulation of acute and chronic disease processes following lung transplantation.

Comparison of Biomechanical Failure Loads Between Tape-Type and Conventional Sutures in Internal Knotless Anchor-Based Constructs.

Background:Despite the increasing prevalence of tape-type sutures, whether internal knotless anchors can consistently affix tape-type sutures has not been thoroughly investigated.Purpose:To evaluate whether substituting tape-type sutures for conventional sutures influences the suture-holding strength of internal knotless anchors.Study Design:Controlled laboratory study. Level of evidence, 5.Methods:A total of 3 internal knotless anchors were tested: a spiral core clamping anchor (Footprint Ultra PK), a winged clamping anchor (PopLok), and a spooling anchor (ReelX STT). Four constructs were compared for each type of anchor, with the anchor double or quadruple loaded with tape-type sutures or conventional sutures. The testing protocol comprised preloading suture tension to 10 N; cyclic loading, in which tension increased in increments of 10 N from 10 to 90 N; and a load-to-failure stage set at a speed of 0.5 mm/s. The clinical failure load (CFL) was defined as suture slippage of ≥3 mm. Also, 1-way analysis of variance and power analysis were used to compare the CFLs of the constructs.Results:For the quadruple-loaded spiral core clamping anchors, a significant reduction in CFLs was seen with conventional sutures over tape-type sutures (138.10 ± 4.73 vs 80.00 ± 12.25 N, respectively; P < .001). This reduction was not observed under the double-loaded condition (conventional vs tape type: 76.00 ± 5.48 vs 80.00 ± 10.00 N, respectively). Substitution of the suture materials did not significantly reduce the CFLs for the winged clamping anchors (conventional vs tape type: 40.00 ± 10.00 vs 30.00 ± 7.07 N for double loaded, respectively, and 64.00 ± 13.41 vs 50.00 ± 10.00 N for quadruple loaded, respectively) or the spooling anchors (conventional vs tape type: 62.00 ± 19.23 vs 56.32 ± 20.20N for double loaded, respectively, and 72.00 ± 21.68 vs 84.00 ± 13.42 N for quadruple loaded, respectively).Conclusion:Substituting tape-type sutures for conventional sutures increased the CFLs of some internal knotless anchors. With specific suture-anchor combinations, quadruple-loaded conventional suture anchors had CFLs higher than those of double-loaded conventional suture anchors.Clinical Relevance:When multiple tape-type sutures are used in conjunction with a clamping anchor, clinicians should note a possible reduction in CFLs and resultant early suture slippage.

Suture Slippage During Anterior Cruciate Ligament Graft Passage Is Significantly Lower Using a Krackow Suture

PurposeTo compare the suture slippage on a hamstring tendon graft prepared with a modified finger-trap device (SPEEDTRAP) with one prepared with Krackow stitch during graft passage through the tibial tunnel in ACL reconstruction.MethodsThirty-eight patients underwent anatomic triple-bundle anterior cruciate ligament reconstruction with 2 femoral and 3 tibial tunnels. After semitendinosus tendon was cut in half to make 2 grafts, the free ends of the proximal membranous portion (posterolateral [PL] graft) were prepared together with 2 sutures: (1) one SPEEDTRAP and one Krackow stitch for 20 cases (group A) and (2) double Krackow stitches on both sides for 18 cases (group B). Then, the PL graft was dye-marked at the proximal suture of SPEEDTRAP in group A and Krackow suture in group B and was inserted into the joint via tibial tunnel ahead of the loop side. The distance between the mark on the graft and the proximal suture of SPEEDTRAP or Krackow stitch was measured under arthroscopy after graft fixation at femur. Slippage was defined as 1 mm and more of distance between the mark and the proximal suture.ResultsSlippage was observed in 16 cases for SPEEDTRAP and in 2 for Krackow suture in group A, whereas one case showed slippage in group B. The slippage distance was 4.0 ± 2.9 mm for SPEEDTRAP and 0.2 ± 0.5 mm for Krackow stitch in group A (P < .001), whereas it was 0.1 ± 0.2 mm for double Krackow stitch in group B, showing a significant difference from SPEEDTRAP suture (P < .001).ConclusionsAt the time of PL graft passage through the tibial tunnel in anterior cruciate ligament reconstruction, there was significantly less slippage observed with the Krackow stitch compared with the SPEEDTRAP stitch.Level of EvidenceLevel IV, therapeutic case series.

Suture Slippage After Arthroscopic Cuff Repair: Medial Displacement of Suture Knots on Follow-up Ultrasonography

Background:Compared with the single-row technique, the double-row rotator cuff repair technique is known to have a higher load to failure and a lower frequency of gap formation, leading to a lower retear rate. There are some patients with poor clinical outcomes or poor muscle strength without radiologic retear.Purpose/Hypothesis:To assess the postoperative position of suture knots via serial ultrasonography in patients who had undergone arthroscopic rotator cuff repair with the suture-bridge technique. Our hypothesis was that the suture would pull out of the lateral anchor (suture slippage), changing the positions of the medial suture knots during healing.Study Design:Case series; Level of evidence, 4.Methods:This study included 53 patients (55 shoulders) who underwent arthroscopic suture-bridge repair and were evaluated for a minimum of 24 months. On serial ultrasonography, a straight line was drawn between the top of the greater tuberosity and the medial cortex of the anchor hole. The distances between the knots of the medial rows and the perpendicular line through the center of the anchor hole were measured in longitudinal plane images of the supraspinatus. Follow-up ultrasonography was performed at 2, 3, and 6 months postoperatively as well as at the final visit. The visual analog scale, the American Shoulder and Elbow Surgeons score, the Constant score, and the University of California, Los Angeles shoulder score were recorded preoperatively and on the final follow-up.Results:Of the 55 shoulders, 6 developed retears at repaired sites. The mean follow-up duration was 37.5 months (range, 24-65 months). Slippage distance increased significantly over time (P < .001). The slippage at the final visit did not differ between patients with retear and no retear (13.4 mm for retear group; 10.6 mm for no retear group [P = .096]).Conclusion:Suture knots of the medial row migrated medially via a suture pullout from the lateral row anchor of suture-bridge technique. Suture slippage distance did not differ significantly between retear and no retear groups.

How to tie dangerous surgical knots: easily. Can we avoid this?

ObjectiveSecure knots are essential in all areas of surgical, medical and veterinary practice. Our hypothesis was that technique of formation of each layer of a surgical knot was important to...

P1078 - Laparoscopic staged management of high Intrabdominal testis: A prospective randomized study

Abstract Objective To prospectively compare outcomes and complications of both staged laparoscopic techniques used in management of high intrabdominal testis (IAT). Materials and Methods Forty five patients were included in the study in whom unilateral high IAT were identified and were subjected to two-stage laparoscopic orchiopexy. Patients were prospectively randomized into two groups according to laparoscopic technique in use; either two stage Fowler-Stephens laparoscopic orchiopexy (FSLO) or staged laparoscopic traction orchiopexy (SLTO). Intraoperative evaluation for the distance of the testis from the internal ring, state of the internal ring (closed or open), operative time (min), intraoperative and early postoperative complications were recorded after first stage. Surgical outcomes of both techniques included operative time, intraoperative complications, success rate, final scrotal site position, testicular size and vascularity, and these were recorded within 48h of the second stage procedure and at 6 month follow-up. Results Staged FSLO was performed on 25 testes. Four cases were lost during follow up. Out of these 21 cases, one child had an atrophic testis before the second stage based on previously recorded operative size. SLTO was done on 20 testes. We had 2 cases of fixation suture slippage rendering a total of 18 patients who underwent second stage operation. No patients converted from laparoscopic to open surgery. At 6 month follow-up visits, 27 testes were found on examination to have a low scrotal position, (14 in the FSLO group and 13 in the SLTO group), 9 testes in high scrotal position (5 in the FSLO group and 4 in the SLTO group). Testicular ascent occurred in one patient in each group. Testicular atrophy was identified in 3 cases among the FS group, while no case of testicular atrophy occurred in the traction group of patients (p = 0.048). Conclusions Both staged laparoscopic techniques had comparable success rates as regard final scrotal position for high undescended IAT in children, and were associated with no intra or post operative complications. SLTO had a better outcome as it was not associated with any testicular atrophy compared to FSLO at 6 months follow up.

Laparoscopic staged management of high intrabdominal testis: A prospective randomized study

ObjectiveTo prospectively compare outcomes and complications of both staged laparoscopic techniques used in management of high intrabdominal testis (IAT). Materials and MethodsForty five patients were included in the study in whom unilateral high IAT were identified and were subjected to two-stage laparoscopic orchiopexy. Patients were prospectively randomized into two groups according to laparoscopic technique in use; either two stage Fowler-Stephens laparoscopic orchiopexy (FSLO) or staged laparoscopic traction orchiopexy (SLTO).Intraoperative evaluation for the distance of the testis from the internal ring, state of the internal ring (closed or open), operative time (min), intraoperative and early postoperative complications were recorded after first stage.Surgical outcomes of both techniques included operative time, intraoperative complications, success rate, final scrotal site position, testicular size and vascularity, and these were recorded within 48h of the second stage procedure and at 6 month follow-up. ResultsStaged FSLO was performed on 25 testes. Four cases were lost during follow up. Out of these 21 cases, one child had an atrophic testis before the second stage based on previously recorded operative size. SLTO was done on 20 testes. We had 2 cases of fixation suture slippage rendering a total of 18 patients who underwent second stage operation. No patients converted from laparoscopic to open surgery.At 6 month follow-up visits, 27 testes were found on examination to have a low scrotal position, (14 in the FSLO group and 13 in the SLTO group), 9 testes in high scrotal position (5 in the FSLO group and 4 in the SLTO group). Testicular ascent occurred in one patient in each group. Testicular atrophy was identified in 3 cases among the FS group, while no case of testicular atrophy occurred in the traction group of patients (p = 0.048). ConclusionsBoth staged laparoscopic techniques had comparable success rates as regard final scrotal position for high undescended IAT in children, and were associated with no intra or post operative complications. SLTO had a better outcome as it was not associated with any testicular atrophy compared to FSLO at 6 months follow up.

Adjustable 6-0 polypropylene flanged technique for scleral fixation, part 2: repositioning of subluxated IOLs.

To describe the technique of modified adjustable flange scleral fixation using 6-0 polypropylene sutures for repositioning of subluxated intraocular lenses (IOLs). Center for Applied Eye Research, Meir Medical Center, and the Ein-Tal Eye Center, Israel. Case series. Subluxated capsular-fixated posterior chamber IOLs are secured to the sclera using 6-0 polypropylene sutures looped around the IOL haptics. This method can be performed for any type of IOL: hydrophobic, hydrophilic, silicone, or poly(methyl methacrylate); 1-piece or 3-piece; and with either closed-loop or open-loop haptics. It can also be used in conjunction with capsular stabilizing devices. In the 18 cases performed, successful repositioning with stable and central fixation of the IOLs was achieved. One eye required a repeated surgery due to suture slippage. The eyes recovered relatively quickly with noted quiescence as early as 1 week postoperatively. Patients did not complain of ocular irritation from the subconjunctival flange up to the 6-month follow-up period. In 1 case, a flange was exposed postoperatively but the patient refused additional intervention and developed intraocular infection 7 months postoperatively. The adjustable 6-0 polypropylene flanged technique for IOL repositioning and scleral fixation was a relatively quick and simple method for management of subluxated IOLs. Complete coverage of the flange by conjunctiva and Tenon layer must be confirmed at the end of surgery.

Scleral Fixation of Single-Piece Foldable IOL Using Double-Flanged Technique.

PurposeTo describe the efficiency and visual results of a new method of transconjunctival intrascleral fixation of single-piece foldable IOL using double-flanged 6/0 prolene suture.Materials and MethodsSeventeen aphakic eyes of 17 patients without adequate capsular support were involved in this study. Lens was prepared by passing the 6/0 prolene suture in a track in the haptic of single-piece foldable IOL created by 31 g needle. The 6/0 prolene suture was retrieved through a 30 g needle transconjunctivally to outside the globe; then, IOL was implanted and a terminal bulb was created at the outer end of the prolene suture.ResultsAll cases were aphakic after complicated phacoemulsification. In 10 cases hydrophilic IOLs were used and in 7 cases hydrophobic IOLs were used. There is clear statistically significant difference between pre-UCVA and post- UCVA. Complications included suture slippage in 2 cases and prolene bulb exposure in one case. There was no significant difference in endothelial cell count and IOP before and after 3 months.ConclusionTransconjunctival intrascleral fixation of foldable single-piece IOLs is a safe efficient method for correcting aphakia.

Using Interconnected Knotless Anchor for Suprapectoral Biceps Tenodesis Could Offer Improved Biomechanical Properties in a Cadaveric Model

To compare the biomechanical characteristics of the interconnected knotless anchor (IKA) fixation with the double knotless anchor (DKA) and interference screw (IS) fixation in the suprapectoral biceps tenodesis. In total, 24 fresh-frozen human cadaveric shoulders (mean age, 67.3 ± 6 years) were used for the study. All the specimens were randomly divided into 3 experimental biceps tenodesis groups (n= 8): IKA, DKA, and IS. After tenodesis, each specimen was preloaded at 5 N for 2 minutes, followed by a cyclic loading test from 5 to 70 N for 500 load cycles. Finally, a destructive axial load to failure test (1 mm/s) was performed. All the values, including ultimate failure load, stiffness, cyclic displacement, and mode of failure were evaluated. The IKA provided the highest construct stiffness (38.9 ± 7.7 N/mm) and ultimate failure load (288.3 ± 47.6 N), the results for which were statistically better than the corresponding results in the IS and DKA groups. In terms of cyclic displacement, there were no statistical differences among the 3 fixation constructs. The most common failure mode was biceps tendon tearing in IS group (7/8) and IKA group (8/8). In the contrast, suture slippage accounted for the most common failure mode in DKA. In suprapectoral bicep tenodesis, IKA fixation appears to offer improved construct stiffness and ultimate failure load while maintaining comparable suture slippage as compared with IS fixation or DKA fixation in the current biomechanical study. The IKA fixation compares favorably with other techniques and could be an alternative clinical option for suprapectoral biceps tenodesis.

Biomechanical Evaluation of Knotless and Knotted All-Suture Anchor Repair Constructs in 4 Bankart Repair Configurations

To evaluate the biomechanical performance of Bankart repair using 1.8-mm knotless all-suture anchors in comparison to 1.8-mm knotted all-suture anchors with both simple and horizontal mattress stitch configurations. Thirty fresh-frozen human cadaveric shoulders were dissected to the capsule, leaving the glenoid and humeral capsular insertions intact. A standardized anteroinferior labral tear was created and repaired using 3 anchors. A 2× 2 factorial design was implemented, with 6 matched pairs randomized between knotless and knotted anchor repairs and 6 matched pairs randomized into simple and horizontal mattress stitch configurations. In addition, 6 unpaired shoulders were used to evaluate the native capsulolabral state. First failure load, ultimate load, and stiffness were assessed. Linear mixed-effects modeling was used to compare endpoints. Digital image correlation was used to evaluate capsular strain throughout testing. Failure modes were reported qualitatively. The knotless all-suture anchor repair showed similar biomechanical strength to the knotted all-suture anchors for first failure load (coefficient, 142 N; 95% confidence interval [CI], -30 to 314 N; P= .12), ultimate load (coefficient, 11.1 N; 95% CI, -104.9 to 127.2 N; P= .847), and stiffness (coefficient, 3.4 N/mm2; 95% CI, -14.1 to 20.9 N/mm2; P= .697) when stitch configuration was held constant. No statistically significant differences were found on comparison of simple and mattress stitch configurations for first failure load (coefficient, -31 N; 95% CI, -205 to 143 N; P= .720), ultimate load (coefficient, 112 N; 95% CI, -321 to 97 N; P=.291), and stiffness (coefficient, -9.6 N/mm2; 95% CI, -27.3 to 8.1 N/mm2; P= .284) when anchor type was held constant. Specimens with knotless anchors and simple stitch techniques resulted in lower stiffness compared with the native state (P= .030). The knotless-mattress configuration resulted in significantly lower strain than the knotted-mattress (P= .037) and knotless-simple (P= .019) configurations and was the only configuration that did not result in a significant increase in strain compared with the intact specimens (P= .216). Fewer instances of suture slippage (loss of loop security) were observed with knotless anchors versus knotted anchors (11% vs 30%), and less soft-tissue failure was observed with the mattress stitch configuration versus the simple stitch configuration (36% vs 47%). Knotless and knotted all-suture anchor repairs with simple and mattress stitch configurations showed similar values of ultimate load, first failure load, and stiffness. However, the horizontal mattress stitch configuration proved to decrease capsular strain more similarly to the native state compared with the simple stitch configuration. Ultimate load and first failure load for all repairs were similar to those of the native state. Knotless all-suture anchors have a smaller diameter than solid anchors, can be inserted through curved guides, and preserve glenoid bone stock. This study presents knotless, tensionable all-suture anchor repair for labral tears that displays high biomechanical fixation strength, similar to the native capsulolabral state.

Revisability of polyetheretherketone suture anchors utilised in primary and revision Bankart repair

BackgroundPolyetheretherketone (PEEK) suture anchors are frequently used in Bankart shoulder stabilisation. This study analyzed the primary stability and revisability of PEEK anchors in-vitro in case of primary Bankart repair and revision Bankart repair after failed primary repair. MethodsTo simulate primary Bankart repair, 12 anchors (Arthrex PEEK PushLock® 3.5 mm) were implanted in 1, 3, 5, 7, 9 and 11 o'clock positions in cadaveric human glenoids and then cyclically tested. To simulate revision Bankart repair, 12 anchors were implanted in the same manner, over-drilled and 12 new anchors of the same diameter were implanted into the same bone socket as the primary anchors and then cyclically tested. The maximum failure loads (Fmax), system displacements, force at clinical failure and modes of failure were recorded. ResultsOne primary anchor failed prematurely due to a technical problem. Three out of 12 revision anchors (25%) dislocated while setting the 25 N preload. The Fmax, the displacement and clinical failure of the remaining 9 revision anchors were non-significant when compared to the 11 primary repair anchors. The main mode of failure in the primary and revision Bankart surgery group was suture slippage. Anchor dislocations were observed four times in the primary and once in the revision repair groups. ConclusionsRevision Bankart repair using PEEK anchors of the same diameter in a pre-existing bone socket is possible but bears high risk of premature anchor failure and can jeopardize the reconstruction. PEEK suture anchor in revision Bankart surgery should be implanted in a new bone socket if possible.

Vision-Based Surgical Suture Looping Through Trajectory Planning for Wound Suturing

Robot-assisted surgery has revolutionized the field of surgery over the past few decades. Despite many successes, achieving full automation in these surgeries remains a challenging task. In this paper, a dynamic approach is proposed to automate knot tying with an in-house robot vision system. Through efficient path planning and coordination between two grippers, the workspace required for constructing the suture loop can be reduced while issues such as suture slippage and collisions between instruments can be eliminated. Visual images were employed to monitor the two grippers in real time and their positions were evaluated using transformation matrices obtained experimentally. A linear quadratic control scheme was applied to optimize the tracking performance of the two grippers. From the experiments, this visual evaluation method can achieve a position accuracy of 1 mm in the workspace. The proposed algorithm was evaluated and automatic suture looping operation was successfully performed in all six trials. Different parameters in the control scheme were also examined by introducing external impulse disturbances during the knot-tying process. This proposed knot-tying approach demonstrates a simple and efficient way to construct a suture knot in a minimal workspace. Note to Practitioners —A surgical operation usually takes several hours to complete, which is a test of surgeon’s endurance. To better assist surgeons, several repetitive surgical tasks can be performed automatically with a robotic system. This paper presents a new method for robot-assisted surgical knot tying in a confined environment. Through simultaneous manipulation and trajectory planning of the two surgical grippers, suture loops were constructed while keeping the suture in tension. Images were employed to guide the gripers in completing the knot-tying process with high precision. Experiments were conducted to demonstrate the automated suture looping operation with the system and the proposed method. The robustness of the method was also examined by introducing impulse disturbances and occlusions during the experiments. This proposed method does not require complicated hardware setup, allowing easy implementations on various surgical systems.

Biomechanical properties of suprapectoral biceps tenodesis: double knotless screw fixation is superior to single knotless screw fixation.

The purpose of this study is to biomechanically evaluate a new technique of double knotless screw fixation for suprapectoral biceps tenodesis and compare the results with that of the single knotless screw fixation as well as the interference screw fixation. 24 fresh-frozen human cadaveric shoulders with a mean age of 68.3 ± 9years were studied. The specimens were randomly divided into three experimental biceps tenodesis groups (n = 8): single knotless screw, double knotless screw and interference screw. Each tenodesis specimen was mounted on a mechanical testing machine, preloaded for 2min at 5N, tested with cyclic loading from 5 to 70N for 500 load cycles and subjected to an axial load to failure test (1mm/s). The ultimate failure load, stiffness, cyclic displacement and mode of failure were evaluated. The interference screw fixation had the highest ultimate failure load (215.8 ± 43.1N) and stiffness (25.7 ± 5.2N/mm) which were significantly higher than the corresponding results for the single and double knotless screw groups (P = 0.0029). The double knotless screw group had the second highest ultimate failure load (162.8 ± 13.8N) and stiffness (15.1 ± 4.1N/mm) which were significantly higher than the corresponding results for the single knotless screw technique (P = 0.0002). The most common mode of failure was suture slippage for both the double (7/8) and single knotless screw (6/8) groups while biceps tendon tearing occurred most often for the interference screw group (6/8). In this biomechanical study, the double knotless screw fixation was found to have a significantly greater ultimate failure load and stiffness than the single knotless screw fixation but lower values than the interference screw fixation.

Mechanical properties of 6 finger-trap suture techniques.

To identify the most common methods used by surgeons to place finger-trap sutures (FTS), and determine their influence on the biomechanical properties of constructs. Questionnaire and experimental study. Six commonly used FTS methods (A-F) were identified from literature review and questionnaire. Constructs made with 3-metric nylon suture and 18-French polyurethane esophagostomy tubing were tested in axial loading to failure. Two patterns (B and D) selected based on common use and biomechanical performance were further tested, with 2, 4, and 8 repeats along the tube. Displacement, load, and energy at failure were compared between constructs, and failure mode was video recorded. Patterns E and F were susceptible to slipping (P < .001). Patterns A and D were stiffer than pattern E, and patterns A-D were stiffer than pattern F (P = .012). Patterns A and B had less extension than pattern E and F, and patterns A-D had less extension than pattern F (P = .002). 87.5% of FTS failed by breaking at the first suture knot. The number of repeats had no effect on FTS performance, but catastrophic failure occurred in 2 constructs with 2 repeats. The mechanical behavior of suture-tube constructs and failure mode is affected by the FTS pattern. Patterns E and F are not advocated due to suture slippage. The number of repeats may not affect the FTS performance, but a minimum of 4 repeats is recommended. Overall, patterns B, C, and D performed the best in axial loading.

Biomechanical evaluation of two arthroscopic techniques for biceps tenodesis: triple loop suture versus simple suture

Several techniques and procedures have been described to treat long head of the biceps pathology; however, tenodesis and tenotomy are the 2 most common procedures performed. This study evaluated the initial fixation strength of the biceps tenodesis triple loop suture (TLS) technique and compared it with that of the simple suture technique (SST). Twenty fresh frozen cadaveric human shoulders (humeral head and neck with attached biceps tendons) were harvested. The biceps tendon was tenotomized proximally before reattachment to the bicipital groove of the matching humerus using suture anchors. Tenodesis was performed using the SST or the TLS technique. Specimens were tested biomechanically for load to failure, stress, and stiffness. The mechanism of failure was evaluated and compared between the 2 suture techniques. Maximal load to failure was significantly greater using the TLS technique (122.2 ± 26.73 N) than the SST (46.12 ± 14.37 N, P < .001). There was no difference in the mean stiffness (SST: 7.33 ± 4.41 N/mm, TLS: 7.46 N/mm ± 2.67, P = .94). The failure mechanism in all SST samples occurred by suture cutout through the longitudinal fibers of the tendon. In all TLS samples, the failure occurred by suture slippage. This study demonstrated superior load to failure of the TLS compared with the SST technique for biceps tenodesis. Furthermore, this study provides the first description of the TLS technique as a possible application in biceps tenodesis. Clinical application of the TLS must be carefully considered, because although it achieved a superior biomechanical profile, experience with this stitch is limited.

Long-term follow-up of laparoscopic transcutaneous inguinal herniorraphy with high transfixation suture ligature of the hernia sac

BackgroundLaparoscopic transcutaneous inguinal hernia repair in children may reduce postoperative pain, improve cosmesis, allow for less manipulation of the cord structures, and offer easy access to the contralateral groin. However, there is concern for unacceptably high recurrence rates when the procedure is generalized. To address this increase in recurrence, in 2011 we described in this journal a modification of the laparoscopic transcutaneous technique that replicates high transfixation ligature of the hernia sac with the aim of inducing more secure healing, preventing suture slippage, and distributing tension across two suture passes. We now describe our long-term follow-up of this novel repair. MethodsAfter obtaining IRB approval, a retrospective chart review and phone follow-up were performed on all patients who underwent laparoscopic transfixation ligature hernia repair between October 2009 and August 2014 (including further follow-up of the 21 patients reviewed in the 2011 report of this technique). Data collection included demographics, laterality of hernia, evidence of recurrence, complications, and time to follow-up. ResultsMedian follow-up was 24months (range 2–52months). Three pediatric surgeons performed 216 laparoscopic transfixation ligature repairs on 166 patients. Demographics: mean age 29.5months (range 1–192months); male 67.2% and female 32.8%; 4.2% of patients were premature at operation. Repairs were bilateral in 42% of patients, right sided in 34%, and left sided in 24%. Three patients together experienced 4 recurrences, for an overall recurrence rate of 1.8%. Two of the recurrences occurred in a 2-month old syndromic patient with severe congenital heart disease who recurred twice after laparoscopic transfixation ligature repair then subsequently failed an attempt at open repair. Excluding this one outlier patient, the recurrence rate was 0.9%. The complication rate was 1.7% (3 hydroceles and 1 inguinal hematoma; all resolved spontaneously). ConclusionLaparoscopic high transfixation ligature hernia repair can be adopted by surgeons with basic laparoscopic skills, and result in excellent outcomes with acceptable recurrence rates.

Hamstring Graft Preparation Using a Modified Rolling Hitch Technique

Anterior cruciate ligament reconstruction using double-looped hamstring autograft is a common procedure in orthopaedic practice. However, during placement of the running, locking stitches at each end of the harvested tendons, the surgeon may face several potential obstacles, including the risk of damaging the tendon, predisposing the surgeon to needle-stick injury, and extended time consumption. We report a modified rolling hitch technique for hamstring graft preparation that is quick, cost-saving, and needleless as an alternative method. The original rolling hitch technique uses a traditional knot that attaches a rope to an object; the modified rolling hitch technique was created by adding 1 more turn before finishing with a half-hitch, which may prevent suture slippage off the tendon, thus providing sufficient fixation of the suture-tendon construct.

Femoral Suspension Devices for Anterior Cruciate Ligament Reconstruction

Background: Cortical suspension devices are commonly used for femoral graft fixation during anterior cruciate ligament (ACL) reconstructive surgery. Adjustable-length fixation devices provide technical advantages over fixed-length loops but may be more susceptible to lengthening during cyclic loading. Hypothesis: Both fixed-length and adjustable-length femoral cortical suspension devices would withstand ultimate loads greater than those normally experienced by the native ACL and would prevent clinically significant lengthening during prolonged cyclic loading. Study Design: Controlled laboratory study. Methods: Mechanical testing was performed on 3 ACL graft cortical suspensory devices by use of an extended cyclic loading (4500 cycles at 10-250 N) and pull-to-failure protocol. Two adjustable-length devices were additionally tested with the free suture ends tied. Results: Total displacement after 4500 cycles of tensioning at variable loads (expressed as mean ± SD) was 42.45 mm (±7.01 mm) for the Arthrex TightRope RT, 5.76 mm (±0.35 mm) for the Biomet ToggleLoc, and 1.34 mm (±0.03 mm) for the Smith & Nephew EndoButton CL Ultra (P < .001). The Arthrex TightRope reached clinical failure of 3 mm lengthening after fewer cycles (1349 ± 316) than the Biomet ToggleLoc (2576 ± 73) (P < .001). The Smith & Nephew EndoButton did not reach clinical failure during cyclic testing. With the free suture ends tied, after 4500 cycles, the Arthrex TightRope had a significant decrease in lengthening to 13.36 ± 1.86 mm (P < .037) There was also a significant difference in ultimate load between the TightRope (809.11 ± 52.94 N) and the other 2 constructs (P < .001). Conclusion: The ultimate load of all graft-fixation devices exceeded the forces likely to be experienced in a patient’s knee during the early postoperative rehabilitation period. However, the adjustable-length fixation devices experienced a clinically significant increase in loop lengthening during cyclic testing. This lengthening is partially caused by suture slippage into the adjustable-length loop. Clinical Relevance: Adjustable-length ACL graft cortical suspension devices lengthen under cyclic loads because free suture ends are pulled into the adjustable loop. This may allow for graft-fixation device lengthening during the acute postoperative period.

Anchoring strength of V-LOCTM barbed suture and Hem-o-lok clips: experimental comparison of nephro sparing surgery in porcine kidney model

Objective To compare anchoring capabilities and holding strength of Hem-o-lok clips and barbed sutures on porcine renal parenchyma.Methods An ex-vivo model was used for the study by using fresh porcine kidneys with intact renal capsule.A longitudinal incision was made on the renal capsule and parenchyma to a depth of 0.5 cm.The following sutures were tested:a 2-0 Vicryl (Covidien) with one and two Hem-o-lok clips (Weck),2-0 V-loc (Covidien),and 4-0 V-loc.An interrupted suture was placed through the renal capsule and parenchyma and attached to a hand-held force tester to quantify the holding strength.The tearing strength was also measured with the force tester using a horizontal mattress suture of 2-0 V-loc and 2-0 Vicryl secured with one Hem-o-lok clip (suture passing either through the middle or the far edge of the clip).Then,a Nephromax balloon catheter (Boston Scientific) was placed into the parenchymal incision,which was closed by a horizontal mattress suture with sliding-clip technique or by using a V-loc suture.The balloon was dilated and the incision of renal parenchyma was observed.Every procedure was repeated five times.Finally,the laparoscopy partial nephrectomy was performed with 2-0 V-loc suture in the living porcine model.Results The mean forces required for suture slippage are 2.52 N (2-0 V-loc suture ),3.26 N (2-0 Vicryl suture with one Hem-o-lok clip) and 4.10 N (2-0 Vicryl suture with two Hem-o-lok clips).And in the 2-0 V-loc suture group,the forces to violate the renal capsule was lower than in the two Hem-o-lok clips group.Unlike the renorrhaphy using the sliding clip technique,the horizontal mattress closure with the V-loc suture had withstand balloon dilation.However,in the living animal lab,the V-loc suture can facilitate renorrhaphy safely during partial nephrectomy.Conclusions The V-loc barbed suture can provide a similar holding strength with the same size Vicryl suture with one Weck clip anchor.However,we need more study to show enough safety due to the tissue tearing effect. Key words: Partial nephrectomy; Renorrhaphy; Warm ischemia; Safety