Transosseous Repair Research Articles

Degradable magnesium alloy suture promotes fibrocartilaginous interface regeneration in a rat rotator cuff transosseous repair model

Despite transosseous rotator cuff tear repair using sutures is widely accepted for tendon-bone fixation, the fibrocartilaginous enthesis regeneration is still hardly achieved with the traditional sutures. In the present work, degradable magnesium (Mg) alloy wire was applied to suture supraspinatus tendon in a rat acute rotator cuff tear model with Vicryl Plus 4–0 absorbable suture as control. The shoulder joint humerus-supraspinatus tendon complex specimens were retrieved at 4, 8, and 12 weeks after operation. The Mg alloy suture groups showed better biomechanical properties in terms of ultimate load to failure. Gross observation showed that hyperplastic response of the scar tissue at the tendon-bone interface is progressively alleviated over time in the both Mg alloy suture and Vicryl suture groups. In the histological analysis, for Mg alloy suture groups, chondrocytes appear to proliferate at 4 weeks postoperatively, and the tendon-bone interface showed an orderly structural transition zone at 8 weeks postoperatively. The collagenous fiber tended to be aligned and the tendon-bone interlocking structures apparently formed, where transitional structure from unmineralized fibrocartilage to mineralized fibrocartilage was closer to the native fibrocartilaginous enthesis. In vivo degradation of the magnesium alloy wire was completed within 12 weeks. The results indicated that Mg alloy wire was promising as degradable suture with the potential to promotes fibrocartilaginous interface regeneration in rotator cuff repair.

Transosseous Meniscus Root Repair in Pediatric Patients and Association With Durable Midterm Outcomes and High Rates of Return to Sports

Background: Injuries to the meniscus root attachments result in extrusion of the meniscus, impaired distribution of hoop stresses, and progressive degenerative articular wear. As a result of these deleterious effects, there has been increasing emphasis on repairing meniscus root injuries to restore structure and function. Purpose: To describe meniscus root tear patterns, associated injuries, and outcomes of transosseous meniscus root repair in a series of pediatric patients. Study Design: Case series; Level of evidence, 4. Methods: A single-institution retrospective review approved by the institutional review board was performed on consecutive adolescent patients aged <19 years with a meniscus posterior root tear treated with transosseous root repair over 4 years. All patients had a minimum 24-month clinical follow-up. The primary outcomes were revision meniscal surgery, and Lysholm, patient satisfaction, and Tegner activity scores. Results: A total of 20 patients (11 male and 9 female patients), with a mean age of 15.6 years (range, 13-18 years), met the inclusion criteria. There were 14 lateral meniscus root tears and 6 medial meniscus root tears. Seventeen patients (85%) had an associated ligament tear: 12 anterior cruciate ligament (ACL) tears and 5 posterior cruciate ligament tears. Two root tears occurred in isolation and both were the posterior root of the medial meniscus. The majority of meniscus root tears (n = 14 patients; 70%) were root avulsions (type 5). The mean follow-up was 42 months (range, 25-71 months). One patient underwent secondary surgery on the affected meniscus after a new injury 4 years postoperatively. Patient-reported outcomes were obtained for 16 patients (80%) at a mean 54-month follow-up. The median Lysholm score was 95 (interquartile range [IQR], 90-100). The median patient satisfaction score was 10 (IQR, 8-10). Thirteen of 16 patients (81%) reported returning to the same or higher level of sports after surgery. Conclusion: Meniscus root tears most commonly occur in pediatric patients as root avulsions of the posterior root of the lateral meniscus and in association with ACL tears. This is unique compared with the adult population, in which the medial meniscus posterior root is often injured in isolation from a radial tear adjacent to the root. In our pediatric case series, transosseous root repair resulted in successful outcomes in the majority of patients, with durable results at the midterm follow-up.

Transosseous Multiple Finger Flexor Tendon Pulley Reconstruction

Background: Closed finger flexor tendon pulley injuries occur most frequently in rock climbing but also during other heavy finger strength work or exercises. While single pulley injuries receive a conservative therapy, multiple pulley injuries often require a surgical repair, as otherwise they will lead to contracture and loss of range of motion and functionality. While established surgical techniques, which use bone encircling tendon graft techniques, were found to produce osteonecrosis of the phalanx, our new transosseous technique avoids this problem. Indications: All triple pulley injuries (A2,3,4) (grade-4b injuries) and double pulley injuries (A2,3 or A3,4) (grade-4a injuries) are indicated, if the injury is older than 10 days at the point of therapy start or the flexor tendons bowstringing is either not redressable in the ultrasound or extended. Also, grade-4a injuries are indicated, if a secondary contracture starts to build. Technique Description: Standard palmar-sided incision, followed by debridement of the tendon sheath, pulley flap, and, if applicable, scare tissue in between the flexor tendons and the bone is performed. Wire-guided 3.0-mm drill holes at the base phalanx at the level of the former distal portion of the A2 pulley are completed. Passing of the palmaris longus tendon through the drill hole and interlacing it as a “loop and a half” follows. Distal continuation through lacing the transplant through the remaining rims of the former pulleys and the flexor tendon sheath is then performed. Securing the repair after tendon gliding control to itself is completed. Postsurgically, the splint is immobilized for 2 weeks, followed by the use of a thermoplastic pulley support ring for 4 weeks with active mobilization. Results: No complications occurred during or after the surgery. In few cases, a restricted range of motion in the proximal interphalangeal (PIP) joint of the respective finger of up to 3 to 5 grade occurred. One patient, who had a presurgical PIP extension deficit of 30°, which was released during the surgery, developed over time again a 20° extension deficit. The functional outcome score ranged between good and excellent, with one case being only satisfactory. The sport-specific outcome score was either good or excellent for all patients, with one patient with contracture where it was satisfactory. No osteonecrosis of the phalanx was recorded. Discussion: For multiple pulley ruptures, various surgical techniques are described. We favored a modified “loop and a half” technique with a distal continuation to the A3 pulley. This combines the advantages of the “loop and a half” technique, as the strongest, and the Weilby repair, as the most functional repair. We recently noticed some cases with osseous necrosis of the phalanx following this repair, likely due to the high pressure of the circulation of the tendon graft onto the bone and its blood vessels. Therefore, we have modified our procedure into a transosseous repair, which is presented in this article. This approach was first evaluated in a cadaver study to exclude a potential risk of osseous failure (fracture) during stress caused by the drill hole. After ruling out this risk, the transosseous technique became our standard approach, as it combines the advantages of the “loop and a half” technique with those of the Weilby repair and decreases the pressure onto the dorsal cortex of the fingers base phalanx and thus the risk of osteonecrosis.

Surgical Technique of Arthroscopic Transosseous Implant-Less Rotator Cuff Repair Using “Arthrocuff” System

Rotator cuff tears remain one of the most common causes of shoulder pain and disability. Although many repair techniques like single-row, double-row, and transosseous equivalent repair have become popular, transosseous repair still remains the gold standard.Arthroscopic transosseous repair is a safe and affordable alternative to suture anchors. Considering this fact, a reusable instrumentation “ArthroCuff”, was developed by SpowerN Medical Equipment (Chennai, India) in collaboration with the National Hub for Healthcare Device Development, India. Arthrocuff system not only aids a robust transosseous rotator cuff repair, but it is also cost-effective. We present the video technique of Arthrocuff for rotator cuff repair.

Transosseous repair with a cortical implant for greater tubercle cyst-related rotator cuff tear results in good clinical outcomes, but significant implant migration.

To evaluate whether an arthroscopic transosseous technique (ATO) with cortical implants is effective for rotator cuff tear (RCT) repair in patients with cysts of the greater tuberosity (GTC). Patients treated with the ATO technique between January 2013 and October 2017 were evaluated. Inclusion criteria were patients treated for both cyst-related and non-cyst-related RCTs and patients with a moderate-sized tear (1-3cm) according to the DeOrio and Cofield classification. A total of 39 patients were separated into two groups: Group 1 (n = 16) patients with cyst-associated RCT, and Group 2 (n = 23) patients with no cyst. Implant pull-out and migration were evaluated radiologically on standard antero-posterior shoulder radiographs and rotator cuff re-tear was assessed on magnetic resonance images at the final follow-up examination. Group 1 patients were separated into two subgroups according to cyst size (cyst < 5mm and cyst ≥ 5mm) and subgroup analysis was performed. Clinical assessment was performed using a visual analog scale, the Constant score and Oxford shoulder score. The mean follow-up time was 33.7 ± 11.7months. The mean cyst size was 5.4 ± 1.5mm. There was no significant difference in re-tear rates between the cystic and non-cystic groups. The mean implant migration distance was 3.0 ± 2.2mm in patients with a RCT -related cyst and 0.7 ± 0.8mm in those without a cyst. A statistically significant difference was found between the groups (p = 0.002). There was no statistically significant difference between the groups in respect of clinical scores. No implant failure was observed. The ATO method performed with a cortical implant in RCTs resulted in satisfactory recovery and clinical outcomes in the short to medium term with low failure rates. While no implant failures were observed, implant migration was associated with cyst presence. Therefore, judicious use is advocated in the choice of transosseous fixation for cyst-related RCTs and patients should be informed of the possibility of implant migration. III.

Clinical Outcomes of the Arthroscopic Transosseous Suture Repair of the Rotator Cuff Using Absorbable Thread for the Medial Mattress Suture

We performed arthroscopic transosseous suture repair of the rotator cuff (ATOS) using absorbable threads for the medial mattress suture to prevent re-tear of the cuff at the medial mattress suture. This study aimed to evaluate the clinical outcomes of this procedure.

Arthroscopic-Assisted Foveal Reattachment of Triangular Fibrocartilage Complex Tears With Distal Radioulnar Joint Instability: A Comparison of Suture Anchors and Transosseous Sutures

To compare the clinical outcomes of arthroscopically-assisted suture anchor repair and transosseous sutures for repair of foveal triangular fibrocartilage complex tears in patients with distal radioulnar joint (DRUJ) instability. Sixty patients with triangular fibrocartilage complex foveal detachment associated with DRUJ instability were prospectively recruited and randomized into 2 equal groups-the anchor repair group and the transosseous repair group. The primary outcome was DRUJ function after 2 years, which was assessed by the DRUJ evaluating system. The secondary outcomes were grip strength, visual analog scale for pain, Mayo Modified Wrist ScorePatient-Rated Wrist Evaluation score, and the Disabilities of the Arm, Shoulder, and Hand score. There were no significant differences between the groups for any of the outcome measures. Good-to-excellent outcomes (according to the DRUJ evaluation system) were achieved in 27 (90%) patients in the anchor repair group and 26 (86.7%) patients in the transosseous repair group. Fewer complications were observed in the anchor repair group. Both techniques yielded good and comparable outcomes with a lesser incidence of early complications in the anchor repair group. Therapeutic II.

Arthroscopic transosseous foveal footprint repair of the triangular fibrocartilage complex.

Foveal disruption of the triangular fibrocartilage complex contributes to the instability of distal radioulnar joint. We have developed an arthroscopic transosseous foveal footprint repair technique, which maximizes the contact between the disrupted triangular fibrocartilage complex and its foveal footprint for better healing by using four sutures in a divergent configuration through a 1.6-mm bone tunnel. Twelve patients with triangular fibrocartilage complex foveal injuries who had undergone this repair technique were reviewed with a mean follow-up of 53months. All patients achieved significant improvement in the modified Mayo wrist score and the Disabilities of the Arm, Shoulder and Hand score. All patients had stable distal radioulnar joints with comparable ranges of motion and grip strengths between the operated and contralateral wrists. There was no significant difference in functional score in those who were treated more than 6months after injury.Level of evidence: IV.

The Transosseous Internal Four Strand Technique: A New All-Inside Technique for Zone 1 Flexor Tendon Repairs.

Multiple techniques for the repair of flexor tendon injuries in zone 1 have been proposed over time. While pull-out suture techniques and bone anchor seem to be stronger than internal suture techniques, they are associated with a higher complication rate. We therefore developed an alternative internal suture repair with similar biomechanical stability to those of pull-out sutures and bone anchors. Twenty porcine distal phalanges and deep flexor tendons were randomized to 2 groups of 10 each. The tendons were transsected at the level of the distal interphalangeal joint. In group 1, repairs were performed with a well-established intraosseous suture repair and in group 2 with our new multistrand technique. The repairs were biomechanically tested with linear distraction until failure. We recorded a significantly higher 2-mm gap force (2GF)-and thus higher stability-of the repairs in group 1 in comparison to group 2. With a 2GF of more than 50 N, our suture technique allows for a modern early active motion rehabilitation protocol. Breakage of the suture construct occurred at random places in the repair in both groups. No pull-outs were noted. This study presents a strong transosseous multistrand repair technique for flexor tendon repair in zone 1 that is simple and fast to perform and should have enough strength to withstand early active motion rehabilitation.

Allogeneic Dermal Fibroblasts Improve Tendon-to-Bone Healing in a Rabbit Model of Chronic Rotator Cuff Tear Compared With Platelet-Rich Plasma

To compare the effects of allogeneic dermal fibroblasts (ADFs) and platelet-rich plasma (PRP) on tendon-to-bone healing in a rabbit model of chronic rotator cuff tear. Thirty-two rabbits were divided into 4 groups (8 per group). In 2 groups, the supraspinatus tendon was detached and was left as such for 6 weeks. At 6 weeks after creating the tear model, we performed transosseous repair with 5× 106 ADFs plus fibrin injection in the left shoulder and PRP plus fibrin in the right shoulder. The relative expression of the COL1, COL3, BMP2, SCX, SOX9, and ACAN genes was assessed at 4 weeks (group A) and 12 weeks (group B) after repair. Histologic and biomechanical evaluations of tendon-to-bone healing at 12 weeks were performed with ADF injection in both shoulders in group C and PRP injection in group D. At 4 weeks, COL1 and BMP2 messenger RNA expression was higher in ADF-injected shoulders (1.6 ± 0.8 and 1.0 ± 0.3, respectively) than in PRP-injected shoulders (1.0 ± 0.3 and 0.6 ± 0.3, respectively) (P= .019 and P= .013, respectively); there were no differences in all genes in ADF- and PRP-injected shoulders at 12 weeks (P > .05). Collagen continuity, orientation, and maturation of the tendon-to-bone interface were better in group C than in group D (P= .024, P= .012, and P= .013, respectively) at 12 weeks, and mean load to failure was 37.4 ± 6.2 N/kg and 24.4 ± 5.2 N/kg in group C and group D, respectively (P= .015). ADFs caused higher COL1 and BMP2 expression than PRP at 4 weeks and showed better histologic and biomechanical findings at 12 weeks after rotator cuff repair of the rabbit model. ADFs enhanced healing better than PRP in the rabbit model. This study could serve as a transitional study to show the effectiveness of ADFs in achieving tendon-to-bone healing after repair of chronic rotator cuff tears in humans.

Arthroscopic Foveal Repair of the Triangular Fibrocartilage Complex Improved the Clinical Outcomes in Patients With Persistent Symptomatic Distal Radio-Ulnar Joint Instability After Plate Fixation of Distal Radius Fractures: Minimum 2-Year Follow-Up

To investigate the longitudinal trend of symptomatic distal radioulnar joint (DRUJ) instability after plate fixation for distal radius fractures (DRFs), determine which factors are associated with persistent symptomatic DRUJ instability, and evaluate the postoperative outcomes of arthroscopic foveal repair of the triangular fibrocartilage complex (TFCC) in patients with persistent symptomatic DRUJ instability after plate fixation for DRF. All consecutive patients who underwent plate fixation for DRF between January 2014 and December 2017 and were followed up for a minimum of 1 year were included in this retrospective study. DRUJ instability was evaluated by subjective ulnar wrist pain and physical examination that included foveal sign and ballottement testing every 2 months after surgery. In patients with persistent symptomatic DRUJ instability lasting >6 months, arthroscopic transosseous foveal repair was performed with consent. Clinical outcomes were evaluated at a minimum of 2 years after surgery. The Generalized Estimating Equation model was used to analyze the incidence rate trend of symptomatic DRUJ instability. Overall, 204 patients were included. The incidence of symptomatic DRUJ instability decreased gradually with time after fixation for DRF until 6 months and was maintained thereafter. Thirty-four of 204 patients (16.6%) had persistent symptomatic DRUJ instability. In multivariable analysis, only high-energy injury was an independent risk factor for persistent symptomatic DRUJ instability (P= .003; odds ratio= 3.599). Seventeen patients underwent arthroscopic foveal repair. The mean follow-up period thereafter was 28.6 months. All clinical outcomes improved significantly compared with preoperative values, and no patient had residual DRUJ instability. In patients who had persistent symptomatic DRUJ instability for >6 months after plate fixation for DRFs, arthroscopic foveal repair of the TFCC is considered as a treatment option. Arthroscopic foveal repair of the TFCC to stabilize the DRUJ provided satisfactory clinical and functional outcomes and decreased ulnar-side pain. Level IV, retrospective case series.

Simultaneous traumatic dislocation of the posterior tibial tendon and long peroneal tendon: a case report

BackgroundViewing the existing literature, one can find several documents about dislocation of the peroneal tendons. Clinical findings, diagnostics, and therapy are well described. Instead, the list of documents describing dislocations of the posterior tibial tendon is short. We found no case in which a dislocation of both long peroneal tendon and posterior tibial tendon is described.Case presentationWe present a case of a 29-year-old male patient who sustained an ankle injury after a fall at a boulder gym. He admitted himself with severe pain, tenderness, and swelling of his left ankle. Dislocation of the posterior tibial tendon and simultaneous dislocation of the long peroneal tendon was diagnosed using x-ray, computed tomography, and magnetic resonance imaging. Transosseous suture repair with periosteal augmentation of the flexor retinaculum was performed at the medial malleolus. At the lateral malleolus, transosseous suture was used to repair the superior retinaculum. The ankle was immobilized following surgery. The patient underwent physical therapy afterwards. The treatment resulted in good recovery, and the patient returned to the same level of performance at rock climbing.ConclusionOur novel finding is that simultaneously sustained dislocations of the posterior tibial tendon and the long peroneal tendon may occur and can be successfully treated as if each injury is treated individually. Level of evidence Level V, case report.

A Novel Arthroscopic Transosseous Procedure for Rotator Cuff Repair: An Economical Freehand Method

Open transosseous repair was historically considered the gold-standard surgical solution for rotator cuff tears; however, with advancements in arthroscopic surgery, this procedure was largely replaced by anchor-based techniques. Yet, the ability of anchor-based techniques to achieve similar biomechanical fixation remains uncertain.In this article, we describe a reproducible, economical, arthroscopic anchorless transosseous rotator cuff repair technique that uses an Omega configuration. This technique involves two bone tunnels and four high-strength polyethylene sutures and is suitable for medium-to-large rotator cuff tears that would alternatively need multiple anchors. This procedure not only maximizes the tendon-footprint contact area without using any implanted device but also theoretically lowers the bone laceration rate and is cost effective. In the current Technical Note, the procedure is described in detail along with several tips and tricks. ClassificationsLevel I, shoulder; Level II, rotator cuff.

Failure rates and outcomes after anatomic total shoulder arthroplasty are equivalent irrespective of subscapularis repair technique

BackgroundSubscapularis management during total shoulder arthroplasty (TSA) remains an area of debate. Although subscapularis-sparing techniques exist, most TSAs are performed through a deltopectoral interval with the subscapularis released and repaired. A paucity of literature exists comparing transosseous repair (TOR) with direct primary tendon repair (PTR) of a subscapularis tenotomy. Our study compared outcomes after TOR and PTR in patients undergoing anatomic TSA. MethodsThis retrospective study included patients who underwent primary anatomic TSA through a deltopectoral approach with subscapularis tenotomy using either PTR or TOR for repair. Outcome measures included subscapularis failure rates, visual analog scale (VAS) scores, American Shoulder and Elbow Surgeons (ASES) survey scores, internal rotation range of motion and strength, complications, and reoperation rates at 3 months, 1 year, and 2 years. ResultsInstitutional database query identified 306 patients who had primary anatomic TSA, 114 of whom had PTR and 192 TOR. Postoperative ASES and VAS scores were significantly improved at all time points in both groups compared with the preoperative scores (P < .001). Average active internal rotation was significantly improved at all time points in the PTR group (P < .001). In the TOR group, significant improvement was noted at 1 and 2 years but not at 3 months. Overall, subscapularis failure occurred in 13 patients, and complications that did not require surgery were noted in 28 patients. Reoperation was performed in 18 patients. However, subscapularis failures, complications not requiring surgery, and reoperations were not significantly different between the two groups. The difference in average internal rotation range of motion between the TOR and PTR groups was statistically significant at 3 months (P = .015) but not at 1 year (P = .265), although the difference trended toward significance again at the 2-year mark (P = .080). No significant differences were noted between the two groups in internal rotation strength, VAS scores, and ASES averages. ConclusionBoth transosseous and primary soft-tissue repair techniques after subscapularis tenotomy result in good outcomes after primary anatomic TSA. No differences were found between groups regarding clinical subscapularis failure rate, internal rotation range of motion or strength, VAS, or ASES scores at 2-year follow-up. Level of evidenceLevel III, Retrospective Comparative Study

Arthroscopic Transosseous Repair of a Medial Meniscal Posterior-Root Tear.

(1) Preoperative evaluation, including patient history, examination, and imaging (i.e., radiographs and magnetic resonance imaging). (2) Preparation and positioning. The patient is placed in the supine position, and anteromedial and anterolateral portals are created. (3) Placement of sutures. Two simple cinch sutures are placed into the posterior horn, within approximately 5 mm of each other. (4) Footprint decortication. Remove articular cartilage from the native root insertion site. (5) Drilling of the transosseous tibial tunnel. Introduce a tibial tunnel guide over the decorticated base, set guide to 45° to 50°, place a 2-cm vertical incision over an anteromedial tibial guide footprint, advance a 2.4-mm guide pin through the guide, and overream to 5 mm. (6) Passing of the sutures with use of a looped suture passer introduced retrograde through the tibial tunnel to retrieve sutures. (7) Anchor placement and fixation. Apply maximum suture traction, drill a second aperture 0.5 to 1.0 cm distal to the original aperture on the anteromedial aspect of the tibia, pass the suture ends through the anchor, and fix the anchor into the aperture. (8) Repair evaluation and closure. Note the position and stability of the meniscal root relative to the native footprint. Standard closure in layers is performed. If the patient experiences no relief from nonoperative treatment, an MMPRT can be treated operatively via partial meniscectomy or repaired via direct suture-anchor repair or indirect transosseous (transtibial) repair. Direct repair utilizes a suture anchor inserted at the root site5. Variations of the present technique include different suture configurations or numbers of tunnels. Although several suture configurations have been described, the simple cinch stitch (utilized in the present procedure) has been shown to be better at resisting displacement than the locking loop stitch6. Moreover, it has been suggested that simple stitches are less technically difficult and more able to resist displacement because they require less tissue penetration than other stitches7. Lastly, procedures that utilize a single versus a second transtibial tunnel have been shown to be equivalent in cadaveric studies8. The desired results of MMPRT repair include anatomic reduction, preservation of meniscal tissue and knee biomechanics, and preservation of hoop stress, which improve activity, function, and symptoms and mitigate degenerative changes and the risk of progression to total knee arthroplasty. At a minimum of 2 years after transosseous repair, the Lysholm, Western Ontario and McMaster Universities Osteoarthritis Index, 12-Item Short Form, and Tegner activity scale were significantly improved8,9. Previous studies have shown significant improvement in the Hospital for Special Surgery and Lysholm scores without radiographic osteoarthritis progression at the same minimum follow-up10. Lastly, in the longest-term follow-up study to date, transosseous repair survivorship was reported to be 99% at 5 years and 92% at 8 years, with failure defined as conversion to total knee arthroplasty11. Pearls○ Decorticate the native meniscal root down to bleeding bone.○ Consider fenestration or percutaneous release of the medial collateral ligament in order to further open a tight medial compartment.○ A self-retrieving suture passer allows the use of standard arthroscopy portals.○ A multiuse variable-angle tibial tunnel drill guide allows point-to-point placement over the native meniscal root insertion.○ A guide with a tip may be easier and more accurate to control.○ Consider different guides when drilling the tibial tunnel, according to the anatomy of the patient.○ A low-profile guide may provide better clearance along the condyles.○ Utilize a cannula when shuttling sutures through the tibial tunnel in order to prevent a soft-tissue bridge.○ With anchor fixation, consider drilling over a guide pin and tapping when the bone is hard.○ Study preoperative imaging to evaluate the amount of arthritis present. Evaluate all compartments on magnetic resonance imaging for additional pathology.Pitfalls○ Obliquity of the tibial tunnel can cause the guide pin and reamer to enter too anteriorly.○ Patient failure to adhere to postoperative rehabilitation and restrictions can lead to unfavorable outcomes.○ The use of lower-strength sutures may increase the risk of fixation failure.

Meniscal Root Repair in Pediatric Patients: Minimum 2-Year Outcomes (196)

Objectives:The medial and lateral menisci function to optimize force transmission across the knee by increasing contact area between the femur and tibia, absorbing shock, and transmitting loads. The anterior and posterior meniscus roots anchor the meniscus to bone. Injuries to the meniscus root attachments result in extrusion of the meniscus, impaired distribution of hoop stresses, and progressive degenerative articular wear. As a result of these deleterious effects, there has been increasing emphasis on repair of meniscus root injuries to restore structure and function. The purpose of this study is to describe meniscus root tears, associated injuries, and minimum 2-year treatment outcomes in a series of pediatric patients.Methods:A single-institution, IRB approved, retrospective review was performed of consecutive pediatric patients less than 19 years of age with a meniscus root tear treated with transosseous root repair over a 4-year period. All patients had minimum 24-month clinical follow-up. Partial root tears treated with partial meniscectomy or irreparable root tears were excluded. All meniscus root tears were classified arthroscopically based on the tear types described by LaPradeADDIN EN.CITE 9. The primary outcomes were revision meniscus surgery and patient reported outcome scores (PROs) (Lysholm, Patient Satisfaction, and Tegner activity).Results:Twenty-one patients, 11 males and 10 females with a mean age of 15 years (range 7 – 18 years), met inclusion criteria. There were 15 lateral meniscus root tears and 6 medial meniscus root tears. The tears occurred in the posterior root in 20 patients (95%). The most common injury pattern was a lateral meniscus posterior root tear (14 patients, 67%). 18 patients (86%) had an associated ligament tear: 13 ACL tears and 5 PCL tears. Two root tears occurred in isolation, and both were the posterior root of the medial meniscus. The majority of meniscus root tears (15 patients, 71%) were root avulsions (type 5). Mean follow-up was 42 months (range 25 – 71 months). Three patients had a second surgery on the affected knee. In two patients, one with revision ACL reconstruction and one treated with chondroplasty of the patella, the meniscus root repair was noted to be well healed. A third patient sustained a new injury to the knee 4 years following medial meniscus posterior root repair and underwent partial medial meniscectomy. At final follow-up, PROs were obtained for 17 patients (81%). Mean Lysholm score was 91 (range 51 – 100). Mean patient satisfaction score was 8.7 (range 5 – 10). Fourteen of 16 patients (88%) reported returning to the same or higher level of activity following surgery.Conclusions:Meniscus root tears occur in pediatric patients, most commonly as root avulsions of the posterior root of the lateral meniscus and in association with ACL tears. This is unique as compared to the adult population, in which the medial meniscus posterior root is often injured in isolation and radial tears adjacent the root are the most commonly described injury pattern. In our case series, transosseous root repair resulted in successful outcomes in the majority of patients with durable results at midterm follow-up.

Quadriceps Tendon Repair Using Double-Row Suture Anchor Fixation

Quadriceps tendon ruptures compromise the knee extensor mechanism and cause an inability to ambulate and significant functional limitations. Therefore, the vast majority of quadriceps tendon ruptures are indicated for operative intervention to restore patient mobility and function. Although these injuries were traditionally repaired using a transosseous repair technique, recent literature has shown that suture anchor repair may offer biomechanical advantages. Additionally, research in other areas of orthopaedics has found that a double-row suture anchor construct can offer additional biomechanical strength to tendinous repair. This technical note describes a safe and effective quadriceps tendon repair using a double-row suture anchor construct.

Clinical and Radiological Outcomes of Rotator Cuff Repairs Using All-Suture Anchors as Medial Row Anchors.

The aim of our study is to report the clinical and radiological outcomes of a series of prospectively enrolled patients who have had double-row transosseous equivalent rotator cuff repairs, where all-suture anchors were used as medial-row anchors, with a minimum follow-up of 1 year. Twenty-two consecutive patients underwent arthroscopic transosseous equivalent double-row rotator cuff repair using all-suture anchors as medial-row anchors. Oxford Shoulder Score, Constant Score and Visual Analogue Scale pain score, together with shoulder range of motion, were used preoperatively and at 3 months, 6 months and final follow-up. Radiological evaluation was performed with magnetic resonance imaging at one-year post surgery to assess the structural integrity of the repair and the rate of cyst formation in greater tuberosity. The patient mean age was 61 years (range 46-75). Minimum follow-up was 1 year, and the mean final follow-up was 15 months (range 12-24). Healing failure in our patients was less than 5% (1/22 patients). There were significant improvements in shoulder function outcome scores at final follow-up. The Constant and Oxford scores were 78 and 44 at final follow-up respectively. There were similar magnitudes of improvement in range of motion (combined abduction and rotation), pain score and supraspinatus strength at final follow up. The improvements in outcome scores were already statistically significant at 3 months (P<.001). Using Kim's classification for cyst formation on T2-weighted MRI images, we observed no fluid or minimal fluid collection in 85% of the patients (17/22 patients). There were no correlations between the grade of bone changes and the clinical outcomes. It is safe to use all-suture anchors as medial-row anchors when performing double-row anchor transosseous equivalent rotator cuff repairs. The purported advantages of all-suture anchors may outweigh their perceived disadvantages in rotator cuff repair surgery.

Durability of transosseous repair of posterior soft tissues after primary total hip arthroplasty: a prospective randomized controlled trial.

Posterior soft tissue repair is one of the methods for preventing dislocation after total hip arthroplasty (THA). This study aimed to evaluate durability of two separate suture materials in THA patients who underwent posterior soft tissue repair. 42 THA patients were included in the study. The patients were randomly divided into two groups, where braided nonabsorbable suture was used in group A (n = 22), while braided absorbable suture was used in group B (n = 20). While repairing the posterior soft tissues, the piriformis and triceps coxae tendons together with the capsule were reattached to the greater trochanter via pull out sutures. Two hemoclips were attached as distance markers to both pull out sutures on the medial and lateal sides of the greater trochanter. Anteroposterior radiographs were taken one day, 15days, 3months and 6months after operation. Distances between the hemoclips medial and lateral to the greater trochanter were measured on the radiographs, and the closest distances were recorded. The repair was considered a failure if the difference of distances between the first and any of the follow-up measurements exceeded 15mm. No statistically significant difference was observed between the groups. In both groups, elongation magnitudes in all time intervals were statistically significant while the results obtained from measurements taken 15days after operation were more significant (p < 0.01). No dislocations were observed. We conclude that for transosseous posterior soft tissue repair in THA, both absorbable and nonabsorbable sutures are similarly durable and can be routinely performed.

Considerations in spontaneous quadriceps tendon rupture repair in end-stage renal disease patients: A case report

IntroductionSpontaneous quadriceps tendon rupture (SQTR) is a rare injury to the knee extensor mechanism that is usually associated with systemic diseases such as end stage renal diseases (ESRD) and it is more prevalent in the elderly. Due to the underlying pathology, quadriceps tendon rupture warrants special considerations and management in its repair.Case reportWe present two cases of quadriceps tendon rupture in end-stage renal disease (ESRD) patients. The first case; a 57 years old female who had bilateral SQTR and is undergoing hemodialysis. The second patient, a 26 years old male had unilateral quadriceps tendon rupture caused by minimal trauma.The first patient had a trans-osseous repair by direct suturing the quadriceps tendon stump to the proximal pole patella. The second patient was repaired with a modified Bunnel suture and anchor placement on the proximal pole patella. The first case had a re-rupture of the right quadriceps tendon and the second case has recovered with improved outcomes.DiscussionSpontaneous quadriceps tendon rupture is usually underlined by degenerative changes of the tendons. Special care is needed to address the pathologic tendon underlying SQTR. The current surgical literature still lacks the statistical data that shows which surgical approach is most optimal for SQTR in ESRD patients.ConclusionSQTR rupture is generally an injury of brittle tendons caused by underlying diseases. A multidisciplinary and comprehensive approach including a proper surgical approach and postoperative managements are crucial for good functional outcomes of the extensor mechanism.