Transosseous Repair Research Articles

Retrospective Evaluation of Clinical and Radiological Results of Patients Treated With Arthroscopic Transosseous Repair for Rotator Cuff Tear.

Surgical repair is recommended for symptomatic full-thickness rotator cuff tears to restore muscle function and alleviate pain. Advances in arthroscopic techniques and new implant designs have led to more reliable repair methods. The choice of technique is crucial for achieving favorable clinical outcomes. This study evaluates the short-term clinical and radiological outcomes of patients treated with the arthroscopic transosseous technique (ATO). Data from 43 patients who underwent full-thickness rotator cuff (RC) repair using the arthroscopic transosseous technique between February 2014 and April 2016 were prospectively collected and retrospectively reviewed. Included patients had medium-sized (1-3 cm) full-thickness supraspinatus tears extending to the infraspinatus and underwent tenotomy or biceps tenodesis. Functional outcomes were assessed using the Visual Analog Scale (VAS), American Shoulder and Elbow Surgeons (ASES) score, and constant score at their final follow-up appointment. Radiological evaluation included postoperative MRI to assess re-tear development. The mean follow-up period was 26.52±8.14 months. Postoperative VAS, ASES, and constant scores significantly improved compared to preoperative values (3.14±1.20, 88.4±8.12, and 88.9±10.6, respectively). The ATO technique provides strong mechanical and biological repair, yielding good functional outcomes for full-thickness rotator cuff tears (RCTs). It is an effective method for early recovery of shoulder joint range of motion (ROM) and pain reduction.

Arthroscopic Centralization of the Medial Meniscus Reduces Load on a Posterior Root Repair Under Dynamic Varus Loading: A Biomechanical Investigation

Background: In addition to the integrity of the meniscal hoop function, both the anterior and posterior meniscus roots as well as the meniscotibial and meniscofemoral ligaments are crucial in restraining meniscal extrusion. However, the interaction and load sharing between the roots and these peripheral attachments (PAs) are not known. Purposes: To investigate the influence of an insufficiency of the PAs on the forces acting on a posterior medial meniscus root repair (PMMRR) in both neutral and varus alignment and to explore whether meniscal centralization reduces these forces. Study Design: Controlled laboratory study. Methods: In 8 fresh-frozen human cadaveric knees, an arthroscopic transosseous root repair (step 1) was performed after sectioning the posterior root of the medial meniscus. The pull-out suture was connected to a load cell to allow measurement of the forces acting on the root repair. A medial closing-wedge distal femoral osteotomy was performed to change the mechanical axis from neutral to 5° of varus alignment. The meniscus was completely released from its PAs (step 2), followed by transosseous arthroscopic centralization (step 3). Each step was tested in both neutral and varus alignment. The specimens were subjected to nondestructive dynamic varus loading under axial compression of 300 N in 0°, 15°, 30°, 45°, and 60° flexion. The changes in force acting on the PMMRR were statistically analyzed using a mixed linear model. Results: Axial loading in neutral alignment led to an increase of the force of root repair of 3.1 ± 3.1 N (in 0° flexion) to 6.3 ± 4.4 N (in 60° flexion). In varus alignment, forces increased significantly from 30° (3.5 N; 95% CI, 1.1-5.8 N; P = .01) to 60° (7.1 N; 95% CI, 2.7-11.5 N; P = .007) flexion, in comparison with neutral alignment. Cutting of the PAs in neutral alignment led to a significant increase of root repair forces in all flexion angles, from 7.0 N (95% CI, 1.0-13.0 N; P = .02) to 9.1 N (95% CI, 4.1-14.1 N; P = .003), in comparison with the intact state. Varus alignment significantly increased the forces in the cut states from 4.8 N (95% CI, 1.0-8.5 N; P = .02) to 11.1 N (95% CI, 4.2-18.0 N; P = .006) from 30° to 60° flexion, in comparison with the neutral alignment. Arthroscopic centralization led to restoration of the native forces in both neutral and varus alignment, with no significant differences between the centralized and intact states. Conclusion: An insufficiency of the PAs of the medial meniscus, as well as varus alignment, led to increased forces acting on a PMMRR. These forces were reduced via an arthroscopic meniscal centralization. Clinical Relevance: Performing arthroscopic meniscal centralization concomitantly with PMMRR may reduce failure of the repair by reducing the load of the root.

Robot-assisted transosseous repair of triangular fibrocartilage complex: a cadaver study.

The feasibility and accuracy of robot-assisted bone tunnel construction in the transosseous repair of the triangular fibrocartilaginous complex (TFCC) were compared with those of freehand arthroscopic repair. A total of 20 cadaveric specimens were randomized into robotic-assisted and arthroscopy-guided groups. Three bone tunnels were constructed in the ulnar foveal region in each specimen. The discrepancy between the planned and actual tunnel exits was determined in the robot-assisted group by merging images. The success rate of tunnel construction, time consumption and number of drilling attempts were compared between groups. The median planned/actual exit discrepancy was 0.8 mm in the robot-assisted group, with 90% of tunnel exits successfully placed in the footprint region, compared to 63.3% in the arthroscopy-guided group. The robot-assisted group spent less time and required fewer drilling attempts to construct bone tunnels. These results indicated that the robot-assisted technique can accurately construct multiple bone tunnels in the foveal region and reduce the difficulty of TFCC transosseous repair.Level of evidence: III.

Unicortical Button Fixation Provide Higher Strength Compared with Transosseous Repair for Subscapularis Tendon in Total Shoulder Arthroplasty

Subscapularis tendon (SSc) dysfunction following total shoulder arthroplasty (TSA) results in poor functional outcomes. There have been numerous SSc repair constructs tested biomechanically and clinically, however, none has been demonstrated as superior. Newer techniques and implants have emerged, but have not been fully tested. We hypothesized that the unicortical button (UB) fixation will provide significantly improved restoration of the anatomic footprint and biomechanical properties when compared to transosseous (TO) repair of the SSc. A digital footprint of SSc humeral insertion was obtained in 6 pairs of fresh-frozen cadaveric shoulders using a three-dimensional (3-D) digitizer. A complete SSc tear was created, and each pair of shoulders was randomized to either SSc repair with UB or TO repair. Each specimen underwent a cyclic loading protocol followed by pull-to-failure. The failure load, elongation at failure, gapping failure, number of cycles until failure, the load at key gapping points (1 mm, 3 mm, 5 mm, and 10 mm) and the failure mode were recorded using high-resolution video recording. 3-D surfaces of the insertion footprint and repair site were obtained, and surface areas were calculated using a custom MATLAB script and laser scanner. Paired t-tests were conducted to compare differences between two repair groups. Failure load was significantly higher in the UB group (382.4 N ± 56.5 N) than in the TO group (253.6 N ± 103.4 N, p=0.005). TO repair provided higher gapping at failure (28.8 mm ± 8.2 mm) than UB repair (10.4 mm ± 6.8 mm, p=0.0017). UB repair had significantly higher load at the 1-mm, 5-mm, and 10-mm gapping compared with TO repair with p=0.042, p=0.033, and p=0.0076, respectively. There were no significant differences between elongation failure, the difference in footprint area from native to repair states, or the percentage of restored footprint area between groups. (p=0.26, p=0.18 and p=0.21 respectively) CONCLUSION: The UB fixation showed a significantly lower gap at failure, higher failure load and number of cycles until failure, and higher gap loads compared with the traditional TO repair for SSc. Although more clinical research is necessary, the UB fixation that utilizes cortical bone presents promising results.

“In My Experience…Development of Novel Transosseous Rotator Cuff Repair Techniques and Technologies”

The author reviews his experience with transosseous rotator cuff repair techniques and technologies

Satellite myoblast and mesenchymal stem cell injections decrease fatty degeneration after rotator cuff tear in rats.

Rotator cuff (RC) tears cause fatty degeneration, aggravated by delayed treatment. Surgical repair alone cannot reverse fatty degeneration. It was aimed to test if local injections of satellite cell-derived myoblasts or satellite myoblasts (SM) from the deltoid region and mesenchymal stem cells (MSCs) from the subcutaneous abdominal fat pad would stimulate myogenesis and decrease adipogenesis in the rat model of fatty degenerated RC tear. A standardized RC tear surgery was performed on both shoulders of 24 Wistar albino rats at t = 0, and rats were followed for 8 weeks to create a chronic degeneration model. The animals were randomly divided into repair + SM and MSC (n = 12) or repair only (n = 12) groups. Transosseous repair with or without stem cell-based injection was performed on the right shoulder of all rats on week 8, with additional injections on weeks 9 and 10. The left shoulders were used as control. The animals were followed until week 14 for recovery. Histological and histomorphometric analyses were performed in week 14. The repair + SM and MSC group had a significantly greater supraspinatus muscle mass than the repair only and control groups. The adipose tissue ratio was significantly lower in the repair + SM and MSC groups versus the repair only and control groups. Histologically, the repair + SM and MSC group had improved muscle and tendon organization. In treating chronically degenerated RC tear in a rat model, surgical repair combined with injections of SM and MSC improved fatty degeneration, tendon healing and myogenesis. Level III.

A modified partial wedge-shaped metaphyseal ulnar osteotomy for the treatment of ulnar impaction syndrome with reverse oblique sigmoid notch.

We describe a modified metaphyseal ulnar osteotomy to treat ulnar impaction syndrome with a reverse oblique sigmoid notch. Based on a computational analysis of radiographs, a modified wedge metaphyseal ulnar osteotomy was devised with its apex positioned at the ulnar styloid base to avoid impaction between the sigmoid notch and ulnar head. Subsequently, nine patients with ulnar impaction syndrome and a reverse oblique sigmoid notch underwent this operation, combined with arthroscopic exploration and transosseous triangular fibrocartilage complex repair. The mean follow-up was 14 months. All patients achieved bone union within 5 weeks, with no degenerative changes being observed during the follow-up assessments. The final follow-up assessments revealed decreases in ulnar variance and in the scores for Visual Analogue Scale, Quick Disabilities of the Arm, Shoulder and Hand questionnaire and the Patient-Rated Wrist Evaluation. All patients achieved excellent or good grades on the Modified Mayo Wrist Score. This technique is effective in treating the ulnar impaction syndrome with a reverse oblique sigmoid notch.Level of evidence: IV.

Biomechanical strength of triceps tendon repairs: systematic review and meta-regression analysis of human cadaveric studies.

It is unclear which triceps tendon repair constructs and techniques produce the strongest biomechanical performance while minimizing the risk of gap formation and repair failure. We aimed to determine associations of construct and technique variables with the biomechanical strength of triceps tendon repairs. PubMed, Embase, Cochrane Library, Web of Science, Scopus, and ClinicalTrials.gov were systematically searched for peer-reviewed studies on biomechanical strength of triceps tendon repairs in human cadavers. 6 articles met the search criteria. Meta-regression was performed on the pooled dataset (123 specimens). Outcomes of interest included gap formation, failure mode, and ultimate failure load. Covariates were fixation type; number of implants; and number of sutures. Stratification by covariates was performed. We found no association between fixation type and ultimate failure load; however, suture anchor fixation was associated with less gap formation compared with transosseous direct repair (β = - 1.1; 95% confidence interval [CI]:- 2.2, - 0.04). A greater number of implants was associated with smaller gap formation (β = - 0.77; 95% CI: - 1.3, - 0.28) while a greater number of sutures was associated with higher ultimate failure load ( β= 3; 95% CI: 21, 125).In human cadaveric models, the number of sutures used in triceps tendon repairs may be more important than the fixation type or number of implants for overall strength. If using a transosseous direct repair approach to repair triceps tendon tears, surgeons may choose to use more sutures in their repair in order to balance the risk of larger gap formation when compared to indirect repair techniques. Level III.

Low Tensile Strength Suture With Transosseous Tunnels and Suture Anchors 5 mm in Diameter or Greater Are Associated With Higher Failure Rates in Primary Patellar Tendon Repair

To determine the rate of and risk factors for clinical failure and return to military duty following primary patellar tendon repair with either transosseous trunnel repair or suture anchor repair. The Military Health System Data Repository (MDR) was queried to identify all adult patients undergoing surgical treatment of a patellar tendon rupture in the Military Health System from 2014 to 2018. Patients who underwent either transosseous tunnel repair or suture anchor repair were included. Health records were examined to collect additional data. Univariate analysis and multivariate logistic regression models were used to determine independent risk factors for rerupture. A total of 450 knees in 437 patients were included. Transosseous tunnel repair was the most frequently used technique (314/450, 77%), followed by suture anchor repair (113/450, 25%). Rerupture occurred in 33 knees (7%). There was no difference in rerupture rate between transosseous tunnel repair and suture anchor repair (P= .15), and this result persisted within the multivariate logistic regression model. Among transosseous tunnel repairs, use of low tensile strength suture was an independent risk factor for repair failure (odds ratio [OR], 3.4; P= .016). Among suture anchor repairs, use of anchors 5.0 mm in diameter or greater (OR, 12.0; P= .027) was an independent risk factor for repair failure. There is no statistically significant difference in failure rate between transosseous tunnel repair and suture anchor repair in primary patellar tendon ruptures. However, the use of low tensile strength suture with transosseous tunnels and the use of suture anchors 5.0 mm in diameter or greater resulted in significantly higher failure rates. These data suggest that use of high tensile strength suture in transosseous tunnel repair and use of suture anchors less than 5.0 mm in diameter in suture anchor repair result in lower failure rate in primary patellar tendon repair. Level III, retrospective cohort study.

Anchorless Arthroscopic Transosseous Rotator Cuff Repair.

Rotator cuff repair techniques have evolved over time. The original techniques were open procedures, then surgeons adopted arthroscopic repair procedures with anchors and implants. Today, rotator cuff repair has evolved to be performed as an arthroscopic transosseous technique that is again performed without the use of anchors. In this video, the 5 essential steps of arthroscopic transosseous repair will be demonstrated. (1) Position the patient in either the beach chair or lateral decubitus position. (2) Utilize 4-portal arthroscopy, which allows a consistent vantage point while having 3 other portals for instrumentation. (3) Perform just enough bursectomy to expose the rotator cuff. (4) Anatomically reduce the rotator cuff anatomy where possible. (5) Triple-load the transosseous tunnels with high-strength sutures in order to maximize the biomechanical strength of the repair. Alternative surgical techniques include open rotator cuff repair and single and double-row rotator cuff repair using anchors. The goal of any rotator cuff repair is to anatomically restore the rotator cuff. The fundamental principles include a strong initial biomechanical fixation, cuff footprint anatomy restoration, and maximization of biological factors to promote healing of the rotator cuff. Rotator cuff repair was originally performed as an open procedure, which allows for direct visualization of the tear and repair; however, open repair requires some level of deltoid splitting, which can potentially affect postoperative early mobilization. Single-row and double-row cuff repairs can both be performed arthroscopically. Proponents of the double-row procedure prefer that technique for its footprint restoration and stronger biomechanical fixation; however, the double-row procedure can result in overtensioning of the repair and can lead to medial-based rotator cuff failures. Proponents of the single-row procedure prefer that technique for its ease of operation, fewer implants, lower cost, and low repair tension; however, the single-row procedure fixes the tendon at a single point, limiting the repaired footprint, and can be associated with lower fixation strength. The arthroscopic transosseous rotator cuff repair achieves all of the above goals as it provides strong initial fixation and anatomic footprint restoration, which allows maximal patient biology for healing. There are numerous studies that can attest to the success of arthroscopic transosseous repair. Some of the benefits include decreased health-care costs and postoperative pain levels. In a 2016 study of 109 patients undergoing arthroscopic transosseous rotator cuff repair, Flanagin et al. reported a mean American Shoulder and Elbow Surgeons (ASES) score of 95 and a failure rate of 3.7% at mid-term follow-up1. Similarly, in a study comparing transosseous repair to transosseous equivalent repair, Srikumaran et al. reported that patients undergoing transosseous repair had a mean ASES score of 92 and a failure rate of 14%, with no significant differences between treatment groups2. Finally, in a study assessing the results of arthroscopic transosseous rotator cuff repair at >10 years postoperatively, Plachel et al. reported a mean ASES score of 92 and a failure rate of 27%3. Compared with conventional rotator cuff with anchors, the transosseous cuff repair can lead to cut-out of the repair sutures from the bone.Use a 4-portal arthroscopy technique, which will help the surgeon visualize all tear configurations while instrumenting them.Perform just enough bursectomy, in order to preserve the growth factors for cuff healing.Take care to minimize tuberosity trauma as a result of burring.Prepare the transosseous tunnels with a wide bone bridge.Load each tunnel with 3 high-strength sutures in order to maximize repair strength.Restore the rotator cuff footprint to facilitate tissue healing. ASES = American Shoulder and Elbow SurgeonsRCR = rotator cuff repairATRCR = arthroscopic transosseous rotator cuff repairARCR = arthroscopic rotator cuff repairPDS = polydioxanone sutureROM = range of motionSSV = Subjective Shoulder ValueFF = forward flexionOR = operating roomFU = follow-up.

Complications after arthroscopic triangular fibrocartilage complex (TFCC) surgery.

Wrist arthroscopy is a valuable and widely utilized tool in the treatment of triangular fibrocartilage complex (TFCC) injuries. These procedures include synovectomy alone, peri-capsular or transosseous repair, and arthroscopic-assisted reconstruction, and each are associated with specific complications. This review describes the types of complications and their rates in different types of arthroscopic TFCC surgery reported in the literature and in our centre. Across the spectrum of arthroscopic TFCC surgery, complication rates and the learning curve increase with surgical complexity. Relevant anatomy, prevention and management of complications including nerve injury and irritation, extensor tendon injury and tendinitis, fracture, stiffness, and persistence of symptoms or instability are discussed. Vigilance to anatomical details and careful dissection can help to reduce complications that may result in disturbing pain and functional loss.

Primary Arthroscopy-Assisted Foveal Repair of Triangular Fibrocartilage Complex Associated with Acute Distal Radius Fractures in Young Adults

Abstract Background In distal radius fractures (DRFs) occurring in nonosteoporotic age groups, it is known that triangular fibrocartilage complex (TFCC) injuries are frequently combined, with some experiencing persistent symptomatic instability. However, a gold standard treatment for these associated lesions has not yet been established. Purpose Our purpose was to investigate the outcomes of primary arthroscopy-assisted transosseous foveal repair of the TFCC associated with DRFs in young adults. Methods Fifteen patients aged <65 years who underwent open reduction and internal fixation for DRF and arthroscopy-assisted repair for foveal tear of the TFCC were included. Those patients were observed to have complete peripheral TFCC tear on preoperative wrist magnetic resonance imaging and intraoperative distal radioulnar joint (DRUJ) stability tests. This was confirmed with an arthroscopic examination. The transosseous technique was used to repair the TFCC after firm fixation of the DRF. The patients were immobilized with the long-arm splint in a neutral position for 2 weeks postoperatively and a removable short-arm splint was applied for another 2 weeks. DRUJ stability, grip strength, and patient-reported outcomes, including disabilities of the arm, shoulder, and hand (DASH) and Patient-Rated Wrist Evaluation scores, were evaluated as primary outcomes at 3, 6, and 12 months postoperatively. Results All patients showed a stable DRUJ throughout the follow-up period. The average grip strength ratio compared to the unaffected side was 69, 83, and 90% at 3, 6, and 12 months after surgery, respectively. The mean DASH score was 26.9, 18.4, and 6.7 at 3, 6, and 12 months postoperatively, respectively. Conclusion Primary arthroscopy-assisted transosseous foveal repair of the TFCC with internal fixation of the distal radius resulted in early recovery and good clinical outcomes in young patients. Level of evidence Therapeutic, level IV.

Anchorless Transosseous Rotator Cuff Repair: A Technical Note

Background: Transosseous rotator cuff repair provides robust fixation and broad footprint compression without the risk of foreign body reaction that may be seen with suture anchors. We present our technique for anchorless transosseous repair using a modern device to efficiently create bone tunnels and assist in suture passage. Indications: Tears of the supraspinatus tendon, with or without extension to the infraspinatus, in patients with acute or chronic tears, with good bone quality, and who fail appropriate nonoperative management. Technique: The beach-chair position with an articulating arm holder is preferred for this procedure. A glenohumeral diagnostic arthroscopy is performed, and intra-articular pathology is addressed as needed. The arthroscope is brought into the subacromial space, and a lateral viewing portal is established. A thorough bursectomy with or without acromioplasty is performed to attain visualization of the cuff. After the tear is identified, the tendon edges are debrided. It is critical to determine the tear pattern, the reduction maneuvers necessary, and the number of bone tunnels that are warranted. The desired location of the bone tunnel is marked with a pilot hole. The device is positioned over the pilot hole and a power drill is advanced through the lateral cortex. The device assists in creating a bone tunnel through the greater tuberosity and passes a nitinol loop through the tunnel. The loop is retrieved by the device and is brought to the lateral portal. Sutures are loaded into the loop and are brought through the bone tunnel. The sutures are then passed through the tendon using a curved retrograde suture passer in simple fashion and are tied to secure the tendon to the footprint. For larger tears, 2 or 3 tunnels may be used to widen the area for footprint compression. The specific configuration used will depend on the tear size, pattern, and surgeon preference. Results: Arthroscopic transosseous repairs have yielded promising results. Healing rates are comparable to anchor-based techniques, with the benefit of avoiding foreign bodies at the footprint. Discussion: Anchorless transosseous rotator cuff repair may be reproducibly performed with the use of a modern device for bone tunnel creation and suture passage. However, this technique should be used with caution in patients with osteoporosis or poor bone quality due to theoretical concerns of greater tuberosity fracture or suture pullout through the tunnels. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Comparative Study of Inferior Pole of Patella Fracture Treated with Transosseous Technique using Modified Krackow's Technique Versus Traditional Anterior Tension Band Wiring.

The inferior pole of patella constitutes around 9.3-22% of all the patella fractures presenting to the hospital. The management of inferior pole fractures has been debated since a long from early day of partial or full patellectomy to the current dictum of open reduction and fixation because of the importance of extensor mechanism of the knee. There are various modalities of management of the inferior pole of patella fracture. The use of braided polyester wire has shown to have a higher load to failure and less implant fatigue, leading to the use of trams osseous repair technique with fiber wire as an alternative to tension ban wiring. Twenty patients were divided into two groups of 10 each: Group A comprised of patients operated with tension band wiring (TBW) and Group B with patient operated with transosseous repair. Both groups underwent the same physiotherapy postoperatively and the results were compared. Radiological outcomes and the WOMAC score of the patients are comparable in both groups. The return to full range of motion is also similar in both groups with similar physiotherapy given in both groups. This shows that with careful patient selection transosseous repair can be used as an alternative to TBW.

Revision Transtibial Medial Meniscal Root Repair With Concomitant Medial Opening-Wedge Proximal Tibial Osteotomy

Background: Complete meniscal root tears disrupt dispersion of axial loading forces through hoop stresses. This increases point-loading on tibiofemoral cartilage and leads to chondromalacia and accelerated osteoarthritis (OA). Posterior root tears may be treated successfully with a transtibial pullout repair. Varus malalignment also leads to increased medial compartment pressures, increasing the risk of early OA and putting increased stress on the meniscus and stabilizing knee ligaments. In particular, revision medial meniscal root repairs without correction of varus malalignment are at increased risk of failure. Genu varum may be corrected with a medial opening-wedge proximal tibial osteotomy (OW PTO). Indications: Meniscal root repairs are indicated for acute or chronic tears in active patients with healthy cartilage. OW PTO is indicated for varus malalignment in ambulatory patients with healthy cartilage, or who are at risk for failure of meniscal or ligamentous procedures. Technique Description: After exposure of the osteotomy site, arthroscopy is performed through the incision and the revision posterior meniscus root repair is performed via a double-tunnel transtibial pullout technique. The positioning of these tunnels is modified superiorly so as to not cross the planned osteotomy site. The osteotomy is then performed by drilling 2 guide pins under fluoroscopy to delineate the plane of the cut. An OW plate is placed, and the root repair is tensioned last. Results: Double-tunnel transtibial pullout repairs increase meniscal fixation contact surface and have been shown to be biomechanically superior to all-inside fixation techniques. Medial OW PTO restores knee alignment and reduces supra-anatomic stresses in the medial compartment, additionally decreasing the risk of a revision medial meniscus repair failure. Discussion: Biomechanical studies have shown that meniscal root tears are functionally equivalent to complete meniscectomy. Varus malalignment increases the risk of medial meniscal tears, and reduces the risk of a successful long-term repair. We describe a technique for a revision transosseous posterior root repair with concomitant proximal tibial osteotomy, with discussion of surgical pearls and pitfalls. This technique restores anatomic position and native function of the medial meniscus while correcting tibiofemoral malalignment that could jeopardize the repair. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form.

Transosseous Fixation with Suspensory Fixation System on Medial Meniscus Root Tears

Medial meniscal root injury is known to cause an increase in the tibiofemoral contact pressure and results in early osteoarthritis. Several techniques have been described for transosseous suture repair. Typically, the sutures are passed through the meniscus, pulled out through a transtibial tunnel, and tied over a bone bridge, a suture button, or a screw at the anterior tibial cortex. Desired meniscus root tension may not be achieved in transosseous fixation with a suture button. The suspensory fixation technique is aimed to prevent secondary looseness in the knot attached to the button implant in the tibia and to provide the desired tension in the fixation of the button implant in different degrees of flexion of the knee.

Similar Outcomes Are Found Between Quadriceps Tendon Repair With Transosseous Tunnels and Suture Anchors: A Systematic Review and Meta-Analysis

To evaluate the clinical outcomes and biomechanical performance of transosseous tunnels compared with suture anchors for quadriceps tendon repair. In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic search was performed in April 2021 in the following databases: Cochrane Database of Systematic Reviews, PubMed (1980-2021), MEDLINE (1980-2021), Embase (1980-2021), and CINAHL (1980-2021). Level I-IV studies were included if they provided outcome data for surgical repair of the quadriceps tendon using transosseous tunnels or suture anchors with minimum 1-year follow-up. Biomechanical studies comparing transosseous tunnels and suture anchors were separately analyzed. The systematic search yielded 1,837 citations, 23 of which met inclusion criteria (18 clinical, 5 biomechanical). In total, 13 studies reported results for transosseous repair and 7 studies reported results for repair with suture anchors. There were results for 508 patients from clinical studies. The average postoperative Lysholm score ranged from 88 to 92 for suture anchor repairs and 72.8 to 94 for transosseous repairs with range of motion ranging from 117° to 138° and 116° to 135°, respectively. Synthesis of the biomechanical data revealed the mean difference in load to failure was not significant between constructs (137.21; 95% confidence interval -10.14 to 284.57 N; P= .068). Transosseous and suture anchor techniques for quadriceps tendon repair result in similar biomechanical and postoperative outcomes. No difference between techniques in regard to ultimate load to failure among comparative biomechanical studies were observed. Level IV, systematic review level III-IV studies.

Arthroscopic repair with transosseous sling-suture technique for acute and chronic bony Bankart lesions

BackgroundFailure to fix the fractured fragment can result in bony fragment resorption and consequent glenoid bone loss. Current arthroscopic repair techniques might lead to insecure fixation and refracture. The purpose of this study was to evaluate the effectiveness of the transosseous sling-suture technique for bony Bankart lesions, and to compare the clinical outcomes for acute and chronic bony Bankart lesions treated with this technique. MethodsA retrospective case series consisting of 46 patients with bony fracture of the glenoid rim following traumatic injury was identified from May 2015 to August 2020. The patients were divided into the acute lesion group and the chronic lesion group according to the time from first injury to surgery. The size of bone fragment was used to group the patients into the small and the medium sized fragment groups. All the patients underwent arthroscopic repairs using the transosseous sling-suture technique. Preoperative and postoperative evaluations including Rowe score, West Ontario Shoulder Instability Index (WOSI), Visual Analogue Scale (VAS) for pain scores, ROMs and number of dislocations were recorded. No significant differences were found in the comparisons of postoperative ROMs ang functional outcomes regarding between the small and the medium sized fragment groups. ResultsNo dislocations occurred for both groups postoperatively. At the last follow-up, all the ROMs (including anterior flexion, abduction, external rotation and internal rotation at the side), the Rowe score, the WOSI score and the VAS score for pain in the both groups were significantly improved compared to the preoperative evaluations (all Ps < 0.001). In the comparisons between the acute and the chronic lesion groups, significantly greater anterior flexion (158.9 ± 8.9° vs. 153.0 ± 6.4°, P = 0.037), abduction (167.7 ± 10.1° vs. 161.0 ± 7.0°, P = 0.035) and external rotation at the side (88.3 ± 6.4° vs. 83.5 ± 5.5°, P = 0.024) were found in the acute lesion group. The comparisons of the Rowe score (86.0 ± 7.5 vs. 87.5 ± 10.6, P = 0.319), the WOSI score (223.5 ± 56.3 vs. 185.0 ± 79.9, P = 0.062), the VAS score for pain (0.4 ± 0.2 vs. 0.3 ± 0.2, P = 0.324) and the internal rotation at the side (74.6 ± 13.2° vs. 80.5 ± 11.1°, P = 0.116) between these two groups did not demonstrate significant differences between the two groups. ConclusionThis arthroscopic transosseous sling-suture repair technique for shoulder anterior instability with acute and chronic bony Bankart lesion can restore joint stability, improve clinical outcomes and range of motion postoperatively. The acute bony Bankart lesion using the current technique can produce better range of motion compared to the chronic lesion. Study designRetrospective case series; Level of evidence, 4.

Arthroscopic transosseous anchorless rotator cuff repair reduces bone defects related to peri-implant cyst formation: a comparison with conventional suture anchors using propensity score matching.

The transosseous anchorless repair (ToR) technique was recently introduced to avoid suture anchor-related problems. While favorable outcomes of the ToR technique have been reported, no previous studies on peri-implant cyst formation with the ToR technique exist. Therefore, this study compared the clinical outcomes and prevalence of peri-implant cyst formation between the ToR technique and the conventional transosseous equivalent technique using suture anchors (SA). Cases with arthroscopic rotator cuff repair (ARCR) between 2016 and 2018 treated with the double-row suture bridge technique were retrospectively reviewed. Patients were divided into ToR and SA groups. To compare clinical outcomes, 19 ToR and 57 SA cases without intraoperative implant failure were selected using propensity score matching (PSM). While intraoperative implant failure rate was analyzed before PSM, retear rate, peri-implant cyst formation rate, and functional outcomes were compared after PSM. The intraoperative implant failure rate (ToR, 8% vs. SA, 15.3%) and retear rate (ToR, 5.3% vs. SA, 19.3%) did not differ between the two groups (all P>0.05). However, peri-implant cysts were not observed in the ToR group, while they were observed in 16.7% of the SA group (P=0.008). Postoperative functional outcomes were not significantly different between the two groups (all P>0.05). The ToR technique produced comparable clinical outcomes to conventional techniques. Considering the possibility of additional surgeries, the absence of peri-implant cyst formation might be an advantage of ToR. Furthermore, ToR might reduce the medical costs related to suture anchors and, thereby, could be a useful option for ARCR.

Biomechanical Comparison of Four- versus Six-Strand Transosseous Suture Repair for Patellar Tendon Rupture.

Surgical repair is indicated for patellar tendon ruptures that result in loss of knee extensor mechanism function. However, biomechanical studies report conflicting results when comparing transosseous suture versus suture anchor repair techniques. This discrepancy may be due to inconsistencies in experimental design as these studies use various numbers of suture strands. Therefore, the main objective of this study is to compare the ultimate load of four- versus six-strand transosseous suture repair. Secondary objectives are to compare gap formation after cyclical loading and mode of failure. Six pairs of fresh-frozen cadaveric specimen were randomly allocated to either four- or six-strand transosseous suture repair. Specimen underwent preconditioning cyclical loading and then load to failure. The six-strand repair had a significantly higher maximum load to failure compared with the four-strand repair (mean difference = 319.3 N [57.9%], p = 0.03). There was no significant difference in gap length after cyclical loading or at max load. There were no significant differences in mode of failure. Utilizing a six-stand transosseous patella tendon repair construct with one additional suture increases overall construct strength by over 50% compared with a four-strand construct.