Transosseous Repair Research Articles

Arthroscopic Transosseous Rotator Cuff Repair

Open transosseous rotator cuff repair (RCR) was the original benchmark surgical technique for RCR. The advent of arthroscopic and suture anchor technology shifted the paradigm from open to arthroscopic surgery. Although technological advances have progressed, they come at a cost. Suture anchor technology is expensive, optimal constructs have yet to be determined, and the technology may lead to challenging complications and revision scenarios. In more recent years, a return to transosseous bone tunnels has been described with new arthroscopic techniques, eliminating the need for suture anchors. The purpose of this article is to review the historical, biomechanical, clinical, and economic literature surrounding arthroscopic transosseous RCR.

Patellar Tendon Rupture with Transosseous Tunnel Repair

Background: Patellar tendon rupture is an injury most often occurring in adults and commonly caused by tensile overload to the extensor mechanism of the knee or direct trauma to the tendon. Early diagnosis and timely surgical repair lead to good functional outcomes and high rates of return to activity. Indications: In patients with impaired knee extensor mechanisms, inability to perform a straight leg raise, or evidence of complete tendon rupture on imaging, surgical tendon repair is indicated. Technical Description: The surgical technique demonstrated here presents a standard patellar tendon repair with transosseous tunnels of a 32-year-old man. Briefly, dissection was performed down to the retinacular layer, and the patellar tendon stump was identified. Any devitalized soft tissue was removed from the inferior pole of the patella and the proximal tendon stump by a rongeur. Two locking Krackow sutures were placed along the medial and lateral aspect of the patellar tendon. Then, a drill bit was used to create 3 transosseous tunnels in the patella and a nitinol basket was used to pass sutures through each tunnel. The retinacular layer was closed by figure-of-eight stiches, followed by layered closure of the subcutaneous layer, and finally, the skin. Results: Early surgical repair of the patellar tendon leads to good functional outcomes and return to sport rates. In a retrospective study of 38 knees, at average of 9.3 years follow-up, 96% of patients reported they were satisfied/very satisfied, with a 100% returning to work. High rates of return to sports have been reported from a retrospective study, with a 94.4% and 83.3% rate of return to sport and rate of return to sport at the same level, respectively. Discussion: In this surgical technique video, we review the common presentation, indications of surgical repair, key steps and technique pearls for a case of a ruptured patellar tendon. Furthermore, we review complications and postoperative rehabilitation guidelines, postoperative clinical outcomes, and return-to-sport rates existing in the literature. Finally, we assess key differences between 2 commonly used surgical techniques, knotless suture anchors versus transosseous tunnels, in patellar tendon 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 of approval from the patient(s) with this submission for publication.

Comparison of cost, surgical time, and clinical results between arthroscopic transosseous rotator cuff repair with lateral cortical augmentation and arthroscopic transosseous equivalent suture bridge: A propensity score-matched analysis

BackgroundTo reduce the healthcare burden, the clinical results of arthroscopic rotator cuff repair and the cost of the implants used have recently been focused upon. This study compared implant cost, surgical time, short-term clinical results, and cuff repair integrity 2 years postoperatively between arthroscopic transosseous rotator cuff repair using lateral cortical augmentation (TOA) and arthroscopic transosseous-equivalent suture bridge (TOE). MethodsThis study included 220 patients with rotator cuff repairs performed by a single surgeon between December 2013 and December 2018. Overall, 70 TOA and 68 TOE cases met the inclusion criteria. The same surgeon performed the procedures at two different hospitals, and the techniques differed between the facilities. A total of 42 TOA patients were matched with 42 TOE patients. The patients were matched using a propensity score analysis by gender, age, and cuff tear size. The minimum follow-up period was 2 years. Implant cost and surgical time were compared between the two methods. The range of motion, clinical outcomes, and visual analog scale were evaluated. Magnetic resonance imaging was performed to examine cuff repair integrity 2 years postoperatively. ResultsThe follow-up rate was 81% (112/138 patients). Implant cost was significantly lower with TOA ($1,396 vs. $2,165; p < 0.001) than with TOE. The average surgical time in the TOA method was significantly shorter than that in the TOE method (82 vs. 109 min; p = 0.001). At a minimum 2-year follow-up, the mean active elevation, abduction, and clinical outcomes improved with both methods, although no improvements in external and internal rotations were observed with either method. There were no significant differences in the postoperative variables and retear rate (TOA, 12%; TOE, 19%; p = 0.548) between the two methods. ConclusionsTOA and TOE achieved comparable clinical results; however, TOA was more cost-effective and had a shorter surgical time than TOE. Level of evidenceLevel Ⅲ, retrospective matched control study.

Ulnar positive variance associated with TFCC foveal tear.

The ulnar positive variance (UPV) can be observed on simple radiography due to a triangular fibrocartilage complex (TFCC) foveal tear. This study investigated to identify how much radiographic UPV occurs due to a TFCC foveal tear, which may be misdiagnosed as an ulnar impaction syndrome (UIS). One hundred forty patients who underwent arthroscopic transosseus TFCC foveal repair from March 2013 to March 2019 in our institution were enrolled in this study. Ulnar variances were measured in preoperative, postoperative 6weeks, 1-year follow-up wrist posteroanterior (PA) radiograph, and power grip PA radiograph of the affected wrist and were compared with those of the same patient's unaffected wrist. In the neutral wrist PA radiograph, ulnar variance increased by 0.56mm (p < 0.001) after TFCC foveal tear compared to the unaffected side. In the power grip view, ulnar variance also increased by 0.39mm (p < 0.001) in the affected wrist. The preoperative ulnar positive variance was reduced after an arthroscopic transosseous TFCC foveal repair from 0.56 to 0mm (p < 0.001). No significant statistical difference was observed between an Atzei class 2 and 3 TFCC tear (0.56mm vs. 0.41mm, p = 0.263). This study revealed that TFCC foveal tear induces 0.56mm of radiologic UPV, which was successfully corrected after arthroscopic transosseous TFCC foveal repair. Therefore, UPV associated with TFCC foveal tear should not be misdiagnosed as an UIS. Also, when ulnar shortening osteotomy is planned in case of UIS combined with TFCC foveal tear, the amount of UPV induced by TFCC foveal tear should be considered to prevent over-shortening.

Transosseous Repair With Nice Knot Augmentation Versus Knotless Suture Anchor Repair With Suture Tape for Quadriceps Tendon Rupture: A Cadaveric Study.

Quadriceps tendon rupture is typically repaired using either transosseous tunnels or suture anchors. Recent literature has suggested that suture anchor repair is biomechanically superior to the use of transosseous tunnels. Augmentation of the transosseous technique with Nice knots may result in improved biomechanical properties as compared with a suture anchor construct. To compare biomechanical properties of a novel transosseous quadriceps tendon repair technique with Nice knot augmentation to those of knotless suture anchor repair, an artificial quadriceps tendon rupture was created in 10 matched pairs of cadaveric knees (n=20). Each cadaver was subjected to biomechanical testing to calculate the average ultimate load to failure, repair site gapping after early and late cyclic loading, and stiffness. Transosseous repair augmented with Nice knots as compared with knotless suture anchor repair had greater load to failure (mean±SD, 1489.5±297.6 N vs 717.7±191.4 N, P<.001), decreased gapping after early and late cyclic loading (cycles 1-20: mean±SD, 0.59±0.4 mm vs 2.1±1.2 mm, P=.008; cycles 21-250: mean±SD, 1.2±0.7 mm vs 3.9±1.7 mm, P=.002), and greater construct stiffness (mean±SD, 80.7±15.7 N/mm vs 44.4±13.4 N/mm, P=.001). The transosseous quadriceps tendon repair technique with Nice knot augmentation is biomechanically better than knotless suture anchor repair with regard to ultimate load to failure, gap formation after cyclic loading, and construct stiffness in cadaveric specimens. [Orthopedics. 2023;46(3):135-140.].

Rates of medial and lateral row failure and risk factors for Re-tear in arthroscopic double row rotator cuff repair

A common postoperative complication after rotator cuff repair is re-tear requiring a secondary procedure. Double row and trans-osseous equivalent repair techniques have become increasingly popular in recent years, however repair failure remains a relatively common complication after primary rotator cuff repair. A retrospective observational study of 389 consecutive patients undergoing arthroscopic double-row rotator cuff repair from February 1, 2014 to March 31, 2020 was conducted. Univariate and multivariate statistics were used to assess differences in demographics, comorbidities, and tear characteristics between patients who experienced re-tear and those who did not. Repair failures were confirmed by plain MRI or intraoperatively during repeat surgical treatment. A subgroup analysis of patients who experienced re-tear due to medial row failure was conducted. The overall re-tear rate was 8.2% (32 patients). Six patients (1.5%) experienced medial row failure, while 26 patients (6.7%) experienced lateral row failure. The average time to re-tear was 279.3 ± 291.2 days. On multivariate analysis, patients with Goutallier Classification ≥3 (OR: 4.274, p = 0.046) and 3 anchor repair (OR: 5.387, p = 0.027) were at significantly increased risk for any re-tear after controlling for other tear characteristics. No statistically significant independent risk factors for medial row failure were identified after controlling for confounding variables. Goutallier classification greater than 3 and a primary repair with 3 anchors are significant risk factors for re-tear after double row rotator cuff repair, however they are not associated with increased occurrence of medial row failure. Further evaluation of risk factors for medial row failure is required to avoid this rare but serious re-tear pattern.

Risk Factors and Corresponding Management for Suture Anchor Pullout during Arthroscopic Rotator Cuff Repair.

Due to the aging of the population, the incidence of rotator cuff tears is growing. For rotator cuff repair, arthroscopic suture-anchor repair has gradually replaced open transosseous repair, so suture anchors are now considered increasingly important in rotator cuff tear reconstruction. There are some but limited studies of suture anchor pullout after arthroscopic rotator cuff repair. However, there is no body of knowledge in this area, which makes it difficult for clinicians to predict the risk of anchor pullout comprehensively and manage it accordingly. The literature search included rotator cuff repair as well as anchor pullout strength. A review of the literature was performed including all articles published in PubMed until September 2021. Articles of all in vitro biomechanical and clinical trial levels in English were included. After assessing all abstracts (n = 275), the full text and the bibliographies of the relevant articles were analyzed for the questions posed (n = 80). Articles including outcomes without the area of interest were excluded (n = 22). The final literature research revealed 58 relevant articles. Narrative synthesis was undertaken to bring together the findings from studies included in this review. Based on the presented studies, the overall incidence of anchor pullout is not low, and the incidence of intraoperative anchor pullout is slightly higher than in the early postoperative period. The risk factors for anchor pullout are mainly related to bone quality, insertion depth, insertion angle, size of rotator cuff tear, preoperative corticosteroid injections, anchor design, the materials used to produce anchors, etc. In response to the above issues, we have introduced and evaluated management techniques. They include changing the implant site of anchors, cement augmentation for suture anchors, increasing the number of suture limbs, using all-suture anchors, using an arthroscopic transosseous knotless anchor, the Buddy anchor technique, Steinmann pin anchoring, and transosseous suture repair technology. However, not many of the management techniques have been widely used in clinical practice. Most of them come from in vitro biomechanical studies, so in vivo randomized controlled trials with larger sample sizes are needed to see if they can help patients in the long run.

Arthroscopic Anchorless Transosseous Rotator Cuff Repair Produces Equivalent Clinical Outcomes and Imaging Results as a Standard Suture Bridge Technique with Anchors

To compare the clinical and imaging outcome of arthroscopic transosseous (TO)-equivalent rotator cuff repair (RCR) with anchors with arthroscopic anchorless TO RCR at a minimum of 2 years postoperatively. The study population included patients who underwent RCR using either an anchorless TO technique with a TO suture passing device (group A) and those who were matched for tear size and underwent RCR using suture anchors for repair (group B). The inclusion criterion was an easily reducible rotator cuff tear with a sagittal extension of 2 to 4 cm. After a minimum of 2 years, clinical outcome scores and magnetic resonance imaging were obtained. Tendon quality and footprint integration were evaluated using the Sugaya classification. Seventy patients were included. A total of 45 were in group A and 25 were in group B. Group A had 2 bone tunnels and 4 sutures using an X-box configuration, and group B had a suture bridge construct of 4 anchors. Group A and B had identical anteroposterior tear size and were comparable for age. The Constant score improved from 50 ± 17.4 to 88 ± 8.6 in group A versus 48 ± 14.5 to 87 ± 7.2 in B. The SubjectiveShoulder Value rose from 47 ± 19.1 to 95 ± 7.4 in group A vs from 47 ± 19.4 to 95 ± 7.6 in B. Neither the preoperative (P ≥ .502) nor postoperative scores (P ≥ .29) showed a significant difference. Magnetic resonance imaging showed 2 small retears in group A and one in B, resulting in an identical 4% retear rate. The mean Sugaya type was 2.02 versus 2.24 (P= .206) for groups A versus B. Anchorless TO RCR is a valid alternative to suture anchor techniques. Clinical outcome data showed comparable results for both techniques after a follow-up of 2 years. The healing results as observed on magnetic resonance imaging were also equivalent for both groups. Level III, retrospective comparative study.

Suture Bridge Transosseous Quadriceps Tendon Repair for Spontaneous Quadriceps Tendon Rupture in Patients With End-Stage Renal Disease

End-stage renal disease with spontaneous quadriceps tendon rupture (QTR) is a specific condition that differs from classic QTR. The tissue quality of the quadriceps tendon (QT), the rupture site, the mechanism of injury, and the pathophysiology of the rupture mechanism all have an effect on conventional QT repair procedures, with a higher likelihood of rerupture or failed repair construction. We believe that our technique provides repair-site stability, strong repair construction, increased contact surface healing, and a reduced chance of rerupture after QT repair. Furthermore, in most patients who have end-stage renal disease with QTR, misdiagnosis and/or underestimation occurs, resulting in proximal retraction of the QT and poor results; however, this technique can be performed with alternative procedures such as augmentation or QT lengthening. The suture bridge transosseous QT repair technique relies on biomechanics knowledge for better stability. Suture bridge repair concept can achieve better healing of all layers of the QT until returning to normal activity with no disability and an improved quality of life.

Transtibial Repair of Lateral Meniscus Posterior Root Tears Improves Contact Biomechanics in Pediatric Cadavers

A paucity of data exists on the treatment of pediatric lateral meniscus root tears (LMPRTs). This study aims to characterize the biomechanics of the lateral knee joint in pediatric cadavers following LMPRT and root repair. Our hypotheses were: (1) compared with the intact state, LMPRT would be associated with decreased contact area; (2) compared with the intact state, LMPRT would be associated with increased contact pressures; and (3) compared with LMPRT, root repair would restore contact area and pressures toward intact meniscus values. Eight cadaver knees (ages 8-12 years) underwent contact area and pressure testing of the lateral compartment. Tekscan pressure mapping sensors covering the tibial plateau were inserted underneath the lateral meniscus. Appropriate pressure load equivalents were applied by a robot at degrees of flexion: 0, 30, 60. Three meniscus conditions were tested: (1) intact, (2) complete root tear, and (3) repaired root tear. Root repairs were performed with transtibial pullout sutures. Statistical analysis was performed. Root tear significantly decreased mean contact area at 30° (P= .0279) and 60° (P= .0397). Root repair increased mean contact area and did not significantly differ from intact states. Differences in contact pressures between meniscus states were not statistically significant. Relative to the intact state. the greatest increase in contact pressures occurred between 0° and 30°. Root repair decreased mean contact pressures at 0° and 30°. At 60°, mean contact pressures of the repair state were closer in magnitude to the tear state than the intact state. Conclusions: LMPRT decreases contact area and increases contact pressures in the lateral knee compartment. Repair of LMPRT improves tibiofemoral contact area at high (>30°) degrees of flexion and contact pressures at low (<30°) degrees of flexion. Transosseous pullout repair is a clinically validated treatment for LMPRT. This study provides baseline biomechanics data of transtibial pullout repair of pediatric LMPRTs.

A PROSPECTIVE STUDY OF FUNCTIONAL OUTCOME AFTER ROTATOR CUFF REPAIR FOR LARGE ROTATOR CUFF TEARS FOLLOWING ARTHROSCOPIC DOUBLE ROW -TRANSOSSEOUS EQUIVALENT REPAIR V/S SINGLE ROW ROTATOR CUFF REPAIR

Tears of the rotator cuff tendons remain a common source of pain and disability among the adult population. Age appears to be the most common aetiology, with 25% of individuals in their 60's and in 50% of individuals in their 80's being found to have rotator cuff tears. Prevalence of partial thickness rotator cuff tears ranges from 15 to 32% in the general population, and is higher (40%) in the dominant arm. Arthroscopic Adequate Initial xation plays a key role in achieving successful healing with rotator cuff tears. A number of surgical techniques have been described for the repair of rotator cuff injuries. These include xation both single- and double-row suture anchor techniques, transosseous Equivalent Repair. Much debate exists over the gold standard surgical technique, in particular with regards to Single Vs Double row methods.

The imaging features of tape suture: a contemporary surgical material.

To offer an adjunctive imaging tool to MRI for evaluating tape suture related rotator cuff repairs. A two-part pilot study was performed to assess visibility of tape suture following imaging with various modalities. Institutional research ethics board approval was obtained prior to cadaveric studies. Two tape sutures, FiberTape® and TigerTape®, were evaluated in each experiment. The first experiment assessed the tape suture's presence in a gelatin mold following exposure to X-ray, ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) without contrast. The second experiment assessed tape suture's visibility in a cadaveric shoulder model following a standard of care, double-row, transosseous equivalent rotator cuff repair. The same imaging protocols and equipment were used for each part of the study with the addition of MR arthrography-tailored images on the cadaveric specimen. All images were assessed by a musculoskeletal trained radiologist. The gelatin study demonstrated that the tape suture was visible via ultrasound only. X ray, CT, and MRI did not show tape suture material. In the ultrasound component of the cadaveric study, distinct echogenic textural detail of the tape suture was easily identified, compatible with the simulated rotator cuff repair. X ray and unenhanced CT did not show the tape suture material or the rotator cuff. MRI without intraarticular gadolinium contrast did not adequately image the suture tape; however, faint artifact in the repair region was visualized. MRI with intra-articular contrast did not show the tape suture material in detail; however, the intraarticular gadolinium did provide an advantageous background of high T1 signal that contrasted with the cuff/suture construct. Ultrasound proved to be an effective imaging modality to visualize tape suture in both the gelatin and cadaveric parts of the pilot study. Ultrasound may be a useful tool to evaluate post-operative tape suture-related repairs in patients that cannot obtain MRIs or when the MRI findings are equivocal.

The incidence of hip dislocation after posterior approach primary total hip arthroplasty: comparison of two different posterior repair techniques.

Total hip arthroplasty (THA) remains one of the most successful orthopedic surgical procedures. The posterior approach is associated with a higher incidence of post-operative dislocations than others. Adequate posterior soft tissue repair techniques, including capsulorrhaphy and transosseous bone sutures in the greater trochanter effectively reduce the dislocation rate. Post-operative "posterior hip precautions" were historically believed to reduce dislocation risks, although not clearly proven. The first protocol consists of capsulorrhaphy with the prescription of post-operative posterior hip precautions (TT) and the second, transosseous bone sutures without precautions (TB). This study aims to determine the optimal protocol to decrease the dislocation rate following posterior approach primary THA. A 10-year retrospective case-control chart review analyzed demographic, pre-, intra-, and post-surgical parameters. Primary outcomes were the difference in dislocation and revision surgery rates between protocols. Secondary outcomes included the incidence of recurrent dislocations and the identification of predictors of dislocation. 2,242 THAs were reviewed and 26 (1.2%) resulted in dislocation. Increased age (p = 0.04) ASA score (p = 0.03) and larger acetabular cup size (p < 0.001) were associated with heightened risk. Tendon to tendon (TT) repair saw a 1.62% dislocation rate versus 0.98% for tendon-to-bone (TB) repair, although statistically insignificant (p = 0.2). Transosseous repair resulted in recurrent dislocations for 8/16 (50%) patients compared to 6/10 (60%) in the suture group (p ≤ 0.001). No significance was found for prescription of posterior hip precautions. To our knowledge, this is the first study to perform a direct comparison of TT repair with posterior precautions to TB repair without posterior precautions. Similarity in dislocation rate, decreased recurrent events and the alleviated patient burden from precautions leads the authors to recommend the TB repair without precautions for a successful THA.

Effect of Poly-L-Lactic Acid Mesh Augmentation on Cyclic Gap Formation in Transosseous Patellar Tendon Repair: A Biomechanical Study.

No previous study has investigated poly-L-lactic acid (PLLA) surgical mesh augmentation in the repair of inferior pole patellar tendon rupture. We compared the biomechanical properties of transosseous patellar tendon repair with PLLA surgical mesh augmentation to transosseous repair without augmentation. Ten matched pairs of cadaveric knees were used. Specimens in each pair were randomized to undergo the transosseous technique alone or the transosseous technique augmented with a PLLA surgical mesh. An inferior pole patellar tendon rupture was simulated and the repair procedure was performed. Specimens were cyclically loaded for 500 cycles. Gap formation was measured using two sensors placed medial and lateral to the repair site. After cyclic loading, load to failure was determined by pulling the tendon at a constant rate until a sudden decrease in load occurred. The primary outcome measure was cyclic gap formation at the medial and lateral sensors. Compared with controls, specimens that underwent PLLA mesh-augmented repair had significantly lower medial gap formation at all testing intervals up to 500 cycles (p < 0.05) and significantly lower lateral gap formation at all testing intervals from 10 to 500 cycles (p < 0.05). Transosseous patellar tendon repair augmented with a PLLA woven mesh device provided significantly greater resistance to gap formation compared with transosseous repair alone. These results suggest that PLLA mesh augmentation of the transosseous technique is biomechanically effective for patellar tendon repair.

Hybrid Knot and Knotless Suture Anchor Repair for Patellar Tendon Rupture

Background: Patellar tendon ruptures are the third-most common injury involving the knee extensor mechanism. They typically occur in men under 40 years old as a result of eccentric quadriceps contraction while the knee is flexed and the foot is planted.1 The optimal treatment is surgical repair within 2 weeks of injury to prevent scar formation, degeneration, and loss of tendon excursion. Indications: Operative management is generally indicated for patellar tendon ruptures. In this case, a physically active, healthy 24-year-old man presented with acute pain, extensor lag, and patella alta related to a basketball injury. He was diagnosed with acute patellar tendon rupture/extensor mechanism disruption and indicated for surgery. Technique description: We describe a technique for primary patellar tendon repair which uses both knot-based and knotless suture anchor fixation. Using a pulley effect, sutures in the inferior patellar anchors are used to reduce and repair the patellar tendon back to its bony origin. Patellar anchor-based tapes and a suprapatellar traction suture are affixed with knotless anchors to the proximal tibia to reinforce the repair. Anchor-based suture limbs are used to repair the medial and lateral retinacula. Results: The senior authors’ experience with this technique has been excellent restoration of extensor mechanism function, with rehabilitation permitting early range of motion and no major complications or failures. This patient returned to unassisted activities of daily living between 8 and 12 weeks and had returned to gym workouts and recreational sports at 12 months. Discussion/conclusion: Biomechanical studies have demonstrated that compared with transosseous repair, suture anchor repair decreases gap formation and improves ultimate load to failure. Advantages of suture anchor repair include smaller incision, less tissue dissection, shorter operative time, and improved repair biomechanics. Our technique follows a principle of tendon repair using a high number of suture and tape limbs to span the repair. In addition, this technique incorporates a “double row” of suture anchors and spans the primary repair with a suture and tape “internal brace.” 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.

Quadriceps Tendon Repair Using Cadaveric Fascia Lata Allograft: A Novel Technique for Repair of Chronic Quadriceps Tendon Rupture

Rupture of the quadriceps tendon, although rare, is associated with impaired stability of the knee joint and therefore requires surgical repair. Although several techniques provide excellent clinical results for acute ruptures, treatment of chronic ruptures remains clinically challenging. We describe a novel technique for reconstruction of a large quadriceps tendon rupture by transosseous repair with a cadaveric facia lata allograft as reinforcement in a 78-year-old man.

Knotted and knotless double row transosseous equivalent repair techniques for arthroscopic rotator cuff repair demonstrate comparable post-operative outcomes.

To compare failure rates and outcomes after transosseous equivalent (TOE) double row (DR) knotted suture bridge versus knotless suture tape bridge repair techniques for rotator cuff tears. A consecutive series of 272 shoulders in 256 patients who underwent arthroscopic, double row, TOE repair for full-thickness tears of the supraspinatus tendon were reviewed. Eighty-four shoulders were repaired using knotted suture bridge (KSB) technique, and 188 shoulders were repaired using all knotless suture tape bridge (KTB) technique. Revision procedures and concomitant subscapularis tendon repairs were excluded from analysis. The minimum follow-up was 12months. Primary outcome was failure of surgical repair, defined as either confirmed retear on MRI and/or need for revision surgery. Secondary clinical outcome measures were assessed including range of motion, strength, visual analog scale (VAS), operative time, subjective shoulder value (SSV), Patient-Reported Outcomes Measurement Information System (PROMIS) mental and physical health, American Shoulder and Elbow Surgeons Shoulder Score (ASES), Brophy shoulder activity scores, and need for manipulation under anesthesia (MUA). A total of 127 shoulders (38 KSB and 89 KTB) met inclusion criteria for the study. No significant difference in demographic variables were present between the groups at baseline. Supraspinatus tear size and average follow-up time did not differ significantly between groups. Failure rates were similar between the KSB and KTB repairs (13.1 vs 7.9%, n.s.). There was no significant difference in functional outcomes including strength, range of motion in forward flexion and external rotation, as well as patient reported outcomes including VAS, SSV, PROMIS, ASES, and Brophy scores between the groups. There was also no difference in post-operative stiffness requiring MUA. Both KSB and KTB repair techniques demonstrate low retear rates with excellent functional outcomes when compared to pre-operative examination. Both KSB and KTB techniques are viable options for achieving a successful rotator cuff repair. Level III.

Clinical Outcomes of Arthroscopic One-Tunnel Triangular Fibrocartilage Complex Transosseous Suture Repair Are Not Diminished in Cases of Ulnar Styloid Process Fracture Nonunion

To determine whether clinical outcomes of arthroscopic one-tunnel wrist triangular fibrocartilage complex (TFCC) transosseous suture repair are not diminished in cases of ulnar styloid process fracture nonunion (USPFN). Patients who underwent arthroscopic 1-tunnel transosseous suture repair of Palmer 1B foveal TFCC tear (with/without superficial fiber tear; Atzei class 2 or 3 TFCC tear) from 2015 to 2020 were retrospectively reviewed. Group I was the TFCC foveal tear repair group with USPFN. Group II was the TFCC foveal tear repair group without USPFN. In group I, no additional treatment for USPFN was made. Functional preoperative and postoperative outcomes were compared by Modified Mayo Wrist Score (MMWS); Quick Disabilities of the Arm, Shoulder, and Hand (Quick-DASH) score; grip strength; pain visual analog scale (VAS); and distal radioulnar joint (DRUJ) stability. Wrist posteroanterior, lateral, and both oblique views of the wrist were used to assess the ulnar styloid process before and after operation. This study consisted of 66 patients: group I (n= 22) and group II (n= 44). No differences were found between the 2 groups preoperatively in MMWS, Quick-DASH, grip strength, and VAS (MMWS: P= .94, Quick-DASH: P= .23, grip strength: P=.69, VAS: P= .45). No differences were found between the 2 groups with respect to outcome measures postoperatively in MMWS, Quick-DASH, grip strength, and VAS (MMWS: P= .59, Quick DASH: P= .82, grip strength: P= .15, VAS: P= .84). All of the enrolled patients achieved restored function with negative ballottement test and maintained DRUJ stability on follow-up. Of the 22 USPFN cases in group I, 11 (50%) showed spontaneous union after transosseous TFCC foveal repair without any additional USPFN treatment. The proportion of patients achieving a minimal clinically important difference for the Quick-DASH was similar between the 2 groups. Although this current study has insufficient statistical power, the available data suggest that patients with TFCC foveal tear combined with USPFNs treated with arthroscopic transosseous repair surgery could experience similar functional improvement compared with those with TFCC foveal tear without USPFNs. The presence of USPFN accompanied by Palmer 1B type TFCC foveal tear may not affect the clinical results, including MMWS, Quick-DASH, grip strength, VAS, and DRUJ stability of patients who undergo arthroscopic 1-tunnel transosseous suture repair. Level III, retrospective comparative study.

Biomechanical Outcomes of Surgically Repaired TFCC Palmer Type 1B Tears: A Systematic Review of Cadaver Studies.

Palmer type 1B triangular fibrocartilage complex (TFCC) tears are a common cause of distal radioulnar joint (DRUJ) instability. Unfortunately, the best surgical technique for TFCC reinsertion is still unknown, and up to a quarter of patients report instability after repair. The purpose of this systematic review of cadaver studies was to compare the biomechanical outcomes of different surgical techniques used for Palmer 1B TFCC tears. A systemic review of all cadaver studies published before January 2022 was performed using the PubMed and EMBASE databases. Only cadaver studies on reinsertion techniques for Palmer type 1B lesions were included. Biochemical outcome parameters evaluated were stability of the DRUJ and strength of the repair. A total of 248 articles were identified. Five articles fulfilled the inclusion criteria. Four different surgical techniques were identified. In 3 studies, transosseous tunnel repair was tested and resulted in the most stable DRUJ and strongest TFCC repair compared with the suture anchor repair, the peripheral capsular repair, and the outside-in repair. These results suggest that the transosseous tunnel repair might be a good technique for restoring DRUJ stability. However, more cadaver studies are needed to identify the most optimal technique.

Application of suture anchors for a clinically relevant rat model of rotator cuff tear.

Current rat model of rotator cuff (RC) tear could not mimic the suture anchor (SA) repair technique in the clinical practice. We designed a novel SA for RC repair of rats to establish a clinically relevant animal model. Small suture anchors that fit the rat shoulder were assembled. 60 rats were assigned to the transosseous (TO) repair group or SA repair group (n = 30/group). Micro‐computed tomography (Micro‐CT) scanning, biomechanical test and histological analysis were implemented at 2, 4, and 8‐week post‐repair. The failure load and stiffness in the SA group were significantly higher than those of TO group at 4‐week post‐repair. Micro‐computed tomography analysis showed the bone mineral density and trabecular thickness of the SA group were significantly lower than those of TO group. The SA group showed a better insertion continuity at 4‐week post‐repair compared to TO group. No significant difference in gait parameters was found between groups. Therefore, SA repair is applicable for the rat model of RC tears. The SA repair achieved superior RC tendon healing, but more extensive initial bone damage compared to TO repair, while the shoulder function was comparable. This model could replicate the current repair technique in the clinical situation and be considered for future preclinical studies on healing enhancement for RC tears. Statement of Clinical Significance: With high clinical relevance, this model may facilitate the translation from an animal study into clinical trials.