Transosseous Suture Technique Research Articles

Transosseous Suture Fixation of Proximal Humeral Fractures

The optimal treatment of displaced fractures of the proximal part of the humerus remains controversial. We evaluated the long-term functional and radiographic results of transosseous suture fixation in a series of selected displaced fractures of the proximal part of the humerus. Over an eleven-year period, a consecutive series of 188 patients with a specifically defined displaced fracture of the proximal part of the humerus underwent open reduction and internal fixation with transosseous sutures. Twenty patients were lost to follow-up and three died before the time of follow-up, leaving a cohort of 165 patients (ninety-four women and seventy-one men; mean age, fifty-four years) available for the study. Forty-five (27%) of the injuries were four-part fractures with valgus impaction; sixty-four (39%) were three-part fractures; and fifty-six (34%) were two-part fractures of the greater tuberosity, thirty-six (64%) of which were associated with anterior dislocation of the shoulder. All fractures were fixed with transosseous, nonabsorbable, number-5 Ethibond sutures. Associated rotator cuff tears detected in fifty-seven patients (35%) were also repaired. Over a mean follow-up period of 5.4 years, functional outcome was assessed with the Constant score. Follow-up radiographs were assessed for fracture consolidation, malunion, nonunion, heterotopic ossification, and signs of impingement, humeral head osteonecrosis, and degenerative osteoarthritis. All fractures, except for two three-part fractures of the greater tuberosity, united within four months. The quality of fracture reduction as seen on the first postoperative radiograph was regarded as excellent/very good in 155 patients (94%), good in seven (4%), and poor in three (2%). Malunion was present in nine patients (5%) at the time of the last follow-up; six of the nine had had good or poor initial reduction and three, excellent/very good reduction. Humeral head osteonecrosis was seen in eleven (7%) of the 165 patients; four demonstrated total and seven, partial collapse. Fifteen patients had heterotopic ossification, but none had functional impairment. Four patients had signs of impingement syndrome, and two had arthritis. At the time of the final evaluation, the mean Constant score was 91 points, and the mean Constant score as a percentage of the score for the unaffected shoulder, unadjusted for age and gender, was 94%. The clinical and radiographic results of this transosseous suture technique were found to be satisfactory at an average of 5.4 years postoperatively. Advantages of this technique include less surgical soft-tissue dissection, a low rate of humeral head osteonecrosis, fixation sufficient to allow early passive joint motion, and the avoidance of bulky and expensive implants.

The Effect of Double-Row Fixation on Initial Repair Strength in Rotator Cuff Repair: A Biomechanical Study

The purpose of this study was to compare the initial mechanical strength of 3 rotator cuff repair techniques. A total of 30 fresh-frozen cadaveric shoulders were prepared, and full-thickness supraspinatus tears were created. Specimens were randomized and placed into 3 groups: (1) transosseous suture technique (group I: TOS, n = 10, 6F/4M), (2) single-row suture anchor fixation (group II: SRSA, n = 10, 6F/4M), and (3) double-row suture anchor fixation (group III: DRSA, n = 10, 6F/4M). Each specimen underwent cyclic load testing from 5 N to 180 N at a rate of 33 mm/sec. The test was stopped when complete failure (repair site gap of 10 mm) or a total of 5,000 cycles was attained. Group I (TOS) failed at an average of 75.3 +/- 22.49 cycles, and group II (SRSA) at an average of 798.3 +/- 73.28 cycles; group III (DRSA) had no failures because all samples were stopped when 5,000 cycles had been completed. Fixation strength of the DRSA technique proved to be significantly greater than that of SRSA (P < .001), and both suture anchor groups were significantly stronger than the TOS group (P < .001). Suture anchor repairs were significantly stronger than transosseous repairs. Furthermore, double-row suture anchor fixation was significantly stronger than was single-row repair. Therefore, double-row fixation may be superior to other techniques in that it provides a substantially stronger repair that could lead to improved biologic healing. A high incidence of incomplete healing occurs in rotator cuff repair. Use of double-row fixation may help the clinician to address some deficiencies in current methods by increasing the strength of the repair, potentially leading to improved healing rates.

Rotator cuff repair: The effect of double-row fixation on three-dimensional repair site

There is a high rate of recurrent and residual tears after rotator cuff repair surgery. Recent cadaveric studies have provided surgeons with new knowledge about the anatomy of the supraspinatus tendon insertion. Traditional repair techniques fail to reproduce the area of the supraspinatus insertion, or footprint, on the greater tuberosity anatomically. Double-row suture anchor (DRSA) fixation is a new technique that has been developed to restore the supraspinatus footprint better. In this study, 3-dimensional mapping was used to determine the area of the footprint recreated with 3 different repair methods: a transosseous simple suture technique, fixation with a single row of suture anchors, and DRSA fixation. The DRSA fixation technique consistently reproduced 100% of the original supraspinatus footprint, whereas the single-row suture anchor fixation and transosseous simple suture techniques reproduced only 46% and 71% of the insertion site, respectively. Therefore, the footprint area of the DRSA fixation technique was significantly larger (P < .05) than that of the other 2 techniques. Furthermore, double-row fixation may provide a tendon-bone interface better suited for biologic healing and restoring normal anatomy.

Biomechanical comparison of double-loaded suture anchors using arthroscopic Mason–Allen Stitches versus traditional transosseous suture technique and modified Mason–Allen stitches for rotator cuff repair

In recent studies objective evaluations have demonstrated that arthroscopic rotator cuff repairs can have higher failure rates than open repairs. Thus, there is a need for a stronger tissue-holding stitch for arthroscopical repair. The purpose of this study was to compare the biomechanical properties of traditional open transosseous suture technique and modified Mason-Allen stitches versus double-loaded suture anchors and arthroscopic Mason-Allen stitches in rotator cuff repair. In 20 sheep shoulders the infraspinatus tendons were dissected from their insertion and were randomized to 2 repair groups: (1) repair with transosseous suture and modified Mason-Allen stitches, (2) repair with double loaded bioabsorbable suture anchors and arthroscopic Mason-Allen stitches: Both groups were coupled with braided, nonabsorbable polyester (Ethibond) suture sized USP No. 2. All repairs were cyclically loaded from 10 to 180N with the use of a materials testing machine. The number of cycles to gap formation of 5 and 10mm at the repair site and the mode of failure were recorded. The number of cycles to 5-mm gap was mean 634 (SD 106) for group 1 and mean 750 (SD 107) for group 2 (P<0.026). The corresponding values to 10-mm gap were mean 1573 (SD 161) for group 1, and mean 1789 (SD 183 cycles) for group 2 (P<0.012). In group 2 the mode of failure occurred by tissue pull-out, whereas in group 1 the failure occurred by a mixture of suture breakage and pull-out. This time-zero study demonstrates that the combination of bioabsorbable suture anchors and arthroscopic Mason-Allen stitches provides strength superior to that of the modified Mason-Allen transosseous suture technique under isometric cyclic loading conditions. However, additional evaluation is needed to examine the effects on the sustained strength of the repair throughout the healing process.

Experimental evaluation of biological samples impact response

The optimal method for rotator cuff repair of the shoulder is not yet known. The aim of this study was to compare the time-dependent biomechanical properties of the traditional open transosseous suture technique and modified Mason-Allen stitches (group 1) versus the double-loaded suture anchors technique and so-called arthroscopic Mason-Allen stitches (group 2) in rotator cuff repair.Eighteen adult female sheep were randomized into two groups: in an open approach in which the released infraspinatus tendon was repaired with group 1, and with group 2. Animals were sacrificed at 6, 12, or 26 weeks; shoulders were harvested and magnetic resonance imaging was performed. Eight untreated contralateral shoulders served as controls. Tendons of 16 additional unpaired cadaver shoulder joints of adult female sheep were identically treated for analysis at time zero. In a biomechanical evaluation all specimens were loaded to failure at a constant displacement rate using a standard universal testing machine. The load-to-failure and stiffness of the healed bone-tendon interface were calculated.Magnetic resonance imaging analysis showed cuff integrity in all cases, and no evidence of foreign body reaction to the anchors. Load-to-failure and stiffness data did not indicate any significant difference between the two treatment groups, neither at 6 weeks nor at 12 or 26 weeks. However, at time zero the group 2 had a higher load-to-failure in comparison to the group 1 (P < 0.010), but there was no difference for the stiffness (P < 0.121).This in vivo study showed that, postoperatively, the group 2 technique provides superior stability and after healing would gain strength comparable to the group 1 technique.

Tendon-Bone Interface Motion in Transosseous Suture and Suture Anchor Rotator Cuff Repair Techniques

Background Although many studies involving rotator cuff repair fixation have focused on ultimate fixation strength and ability to restore the tendon's native footprint, no studies have characterized the stability of the repair with regard to motion between the tendon and repair site footprint. Hypothesis Suture anchor fixation for rotator cuff repair has greater interface motion between tendon and bone than does transosseous suture fixation. Study Design Controlled laboratory study. Methods Twelve fresh-frozen human cadaveric shoulders were tested in a custom device to position the shoulder in internal and external rotations with simulated supraspinatus muscle loading. Tendon motion relative to the insertional footprint on the greater tuberosity was determined optically using a digital camera rigidly connected to the humerus, with the humerus positioned at 60° of internal rotation and 60° of external rotation. Testing was performed for the intact tendon, a complete supraspinatus tear, a suture anchor repair, and a transosseous tunnel repair. Results Difference in tendon-bone interface motion when compared with the intact tendon was 7.14 ± 3.72 mm for the torn rotator cuff condition, 2.35 ± 1.26 mm for the suture anchor repair, and 0.02 ± 1.18 mm for the transosseous suture repair. The transosseous suture repair demonstrated significantly less motion when compared with the torn rotator cuff and suture anchor repair conditions (P <. 05). Conclusion Transosseous suture repair compared with suture anchor repair demonstrated superior tendon fixation with reduced motion at the tendon-to-tuberosity interface. Clinical Relevance Development of new fixation techniques for arthroscopic and open rotator cuff repairs should attempt to minimize interface motion of the tendon relative to the tuberosity.

Tendon-to-Bone Pressure Distributions at a Repaired Rotator Cuff Footprint Using Transosseous Suture and Suture Anchor Fixation Techniques

Background Interface contact pressure between the tendon and bone has been shown to influence healing. This study evaluates the interface pressure of the rotator cuff tendon to the greater tuberosity for different rotator cuff repair techniques. Hypothesis The transosseous tunnel rotator cuff repair technique provides larger pressure distributions over a defined insertion footprint than do suture anchor techniques. Study Design Controlled laboratory study. Methods Simulated rotator cuff tears over a 1 × 2-cm infraspinatus insertion footprint were created in 25 bovine shoulders. A transosseous tunnel simple suture technique (n = 8), suture anchor simple technique (n = 9), and suture anchor mattress technique (n = 8) were used for repair. Pressurized contact areas and mean pressures of the repaired tendon against the tuberosity were determined using pressure-sensitive film placed between the tendon and the tuberosity. Results The mean contact area between the tendon and tuberosity insertion footprint was significantly greater for the transosseous technique (67.7 ± 5.8 mm2) compared with the suture anchor simple (34.1 ± 9.4 mm2) and suture anchor mattress (26.0 ±5.3 mm2) techniques (P < .05). The mean interface pressure exerted over the footprint by the tendon was also greater for the transosseous technique (0.32 ± 0.05 MPa) compared with the suture anchor simple (0.26 ± 0.04 MPa) and suture anchor mattress (0.24 ± 0.02 MPa) techniques (P < .05). Conclusion The transosseous tunnel rotator cuff repair technique creates significantly more contact and greater overall pressure distribution over a defined footprint when compared with suture anchor techniques. Clinical Relevance Stronger and faster rotator cuff healing may be expected when beneficial pressure distributions exist between the repaired rotator cuff and its insertion footprint. Tendon-to-tuberosity pressure and contact characteristics should be considered in the development of improved open and arthroscopic rotator cuff repair techniques.

Rotator cuff repair: the effect of double-row fixation versus single-row fixation on three-dimensional repair site (SS-03)

In rotator cuff surgery, increasing emphasis is being placed on maximizing the repair site contact area, thereby increasing the tendon-bone interface to potentially enhance more complete healing. Previous studies have demonstrated that traditional repairs using a single row of suture anchors or trans-osseous sutures fail to reproduce the area of the native supraspinatus tendon insertion or “footprint” on the greater tuberosity. The purpose of this study was to demonstrate the superiority of a double-row fixation technique in restoring the normal area of the supraspinatus footprint. Materials and Methods: A cadaveric study was performed using 7 fresh frozen shoulders. Rotator cuff tears were created and then repaired using several techniques: single-row suture anchor fixation (SRSA) using Mitek Fastin RC anchors (Mitek Worldwide, Norwood, MA), double-row suture anchor fixation (DRSA), and trans-osseous suture technique (TOS). The repair footprint area was determined for each technique by three-dimensional digitation, using a MicroScribeG2X digitizer (Immersion Corp, San Jose, CA). The area of the original tendon insertion site was also assessed for comparison. The data was processed using Rhinoceros NURBS modeling software (McNeal and Associates, Seattle, WA) and the repair site areas were compared for the different repair techniques. Appropriate power analysis was performed to insure adequate sample size and a 2 tailed paired Student t test was performed to reveal statistical significance of detected differences. Results: The footprint area of the DRSA technique was larger than that of the other two techniques. These findings were statistically significant (P < .05). Furthermore, the DRSA technique consistently reproduced 100% of the original supraspinatus footprint area. Both the SRSA and TOS technique failed to do so. On average, the TOS technique reproduced only 71% of the original insertion site and the SRSA technique reproduced 46%. The differences between the area of the original footprint, TOS and SRSA were all statistically significant (P < .05). Conclusions: Double-row fixation in rotator cuff repair reproduces 100% of the supraspinatus footprint while traditional single-row techniques fail to do so. Double-row fixation may be a superior technique by providing a tendon-bone interface better suited for biologic healing and restoring normal anatomy. In rotator cuff surgery, increasing emphasis is being placed on maximizing the repair site contact area, thereby increasing the tendon-bone interface to potentially enhance more complete healing. Previous studies have demonstrated that traditional repairs using a single row of suture anchors or trans-osseous sutures fail to reproduce the area of the native supraspinatus tendon insertion or “footprint” on the greater tuberosity. The purpose of this study was to demonstrate the superiority of a double-row fixation technique in restoring the normal area of the supraspinatus footprint. Materials and Methods: A cadaveric study was performed using 7 fresh frozen shoulders. Rotator cuff tears were created and then repaired using several techniques: single-row suture anchor fixation (SRSA) using Mitek Fastin RC anchors (Mitek Worldwide, Norwood, MA), double-row suture anchor fixation (DRSA), and trans-osseous suture technique (TOS). The repair footprint area was determined for each technique by three-dimensional digitation, using a MicroScribeG2X digitizer (Immersion Corp, San Jose, CA). The area of the original tendon insertion site was also assessed for comparison. The data was processed using Rhinoceros NURBS modeling software (McNeal and Associates, Seattle, WA) and the repair site areas were compared for the different repair techniques. Appropriate power analysis was performed to insure adequate sample size and a 2 tailed paired Student t test was performed to reveal statistical significance of detected differences. Results: The footprint area of the DRSA technique was larger than that of the other two techniques. These findings were statistically significant (P < .05). Furthermore, the DRSA technique consistently reproduced 100% of the original supraspinatus footprint area. Both the SRSA and TOS technique failed to do so. On average, the TOS technique reproduced only 71% of the original insertion site and the SRSA technique reproduced 46%. The differences between the area of the original footprint, TOS and SRSA were all statistically significant (P < .05). Conclusions: Double-row fixation in rotator cuff repair reproduces 100% of the supraspinatus footprint while traditional single-row techniques fail to do so. Double-row fixation may be a superior technique by providing a tendon-bone interface better suited for biologic healing and restoring normal anatomy.

Primary fixation strength of rotator cuff repair techniques: a comparative study

Purpose: The goal of the study was to compare the primary fixation strength of transosseous suture, suture anchor, and hybrid repair techniques for rotator cuff repair. Type of Study: Animal model experiment. Methods: Thirty-two sheep shoulders were divided into 4 homogeneous groups, according to bone density and tendon dimensions. Infraspinatus tendons were transected from their insertions and reattached using 4 different techniques. Group 1 was repaired with a single Mason-Allen stitch and 2 transosseous tunnels for each end of the suture, knotted on the lateral cortex of proximal humerus; group 2 was repaired with double Mason-Allen stitches and 2 transosseous tunnels; group 3 was repaired with 2 Corkscrews (Arthrex, Germany); and group 4 was repaired with 2 Corkscrews combined with a single Mason-Allen transosseous suture. All specimens were tested for their fixation strengths with a material testing system. Results: The mode of failure in group 1 was mainly suture breakage. In groups 3 and 4, the tendons pulled out from the sutures. In group 2, sutures broke the bony bridge between the 2 tunnels. The mean load to failure value was 160.31 ± 34.59 N in group 1, 199.36 ± 11.73 N in group 2, 108.32 ± 15.98 N in group 3, and 214.24 ± 28.52 N in group 4. Anchor fixation was significantly weaker compared with other groups ( P <.001). Combination of a transosseous suture and anchor fixation (group 4) was significantly stronger than the single transosseous suture (group 1) and double anchor techniques (group 3) ( P <.001). Conclusions: Hybrid technique was the strongest among the tested rotator cuff repair techniques. With the addition of one transosseous suture to two anchors, the strength of the repair could be doubled.

Bone loss following tendon laceration, repair and passive mobilization

Little is known about the localized changes in bone mass that occur following tendon or ligament injury. Interruption of normal load transfer at the insertion site will presumably lead to a localized loss of bone, although few data exist to support this claim. To test this hypothesis, we transected the canine flexor digitorum profundus (FDP) tendon from its insertion, and either repaired it using a trans-osseous suture technique or left it unrepaired (laceration only). Post-operatively, forelimbs in the repair group were cast immobilized except for 10 min of daily passive mobilization rehabilitation, whereas in the laceration only group dogs were allowed full weight bearing. At 5–42 days post-injury, we assessed bone mineral density (BMD) using pQCT and osteoclast surface by histomorphometry. We measured significant bone loss in the distal phalanx after combined FDP tendon laceration, repair, and post-operative passive mobilization, with BMD decreases of 20%, 40%, and 41% at 10, 21, and 42 days ( p<0.01). Moreover, we observed that passive mobilization and tendon laceration each contributed independently to the observed bone loss. At 42 days, BMD was reduced by 21% in bones that were not injured but were subjected to the post-operative passive mobilization protocol, while BMD was reduced by 28% in bones subjected to tendon laceration and full weight bearing ( p<0.01). In both the passive mobilization and laceration specimens, we counted significantly increased osteoclasts after only 7–10 days, and these increases persisted through 42 days ( p<0.05). We conclude that rapid and sustained bone resorption leads to significant bone loss in the 6-week period following flexor tendon injury and repair. This bone loss may impact healing by impeding the restoration of a strong tendon–bone interface.

Arthroscopic revision Bankart repair: A prospective outcome study

Purpose: The clinical outcome of the revision surgery for the failed Bankart repair is not well known. The purpose of this study was to prospectively analyze a series of patients with recurrent instability after primary Bankart repair that were revised arthroscopically using a suture-anchor technique. Type of Study: Prospective, nonrandomized outcome study. Methods: Twenty-three patients with failed Bankart repair were treated with arthroscopic surgery and were followed up for a mean of 36 months (range, 24-52 months; SD, 9 months). There were 21 men and 2 women with the mean age of 24 years (range, 17-34 years; SD, 4.4 years). Eight patients had previously received an open Bankart repair (5 transosseous-suture technique, 3 suture-anchor technique), and 15 had received an arthroscopic repair (10 transglenoid multiple-suture technique, 5 suture-anchor technique). The revision surgery included repair of the anterior labrum using suture anchors and nonabsorbable sutures, capsular plication, and proximal shift of the inferior capsule with or without closure of the rotator interval. The characteristics of the patients, possible modes of failure, surgical findings, shoulder scores (University of California at Los Angeles [UCLA] scale, Simple Shoulder Test, and Rowe score), and clinical outcome were evaluated. Results: Recurrent instability developed at a mean of 21 months (range, 11-39 months; SD, 8 months) after the initial stabilization. A possible cause of failure in 5 patients was a nonanatomic repair, with the labral tissue fixed proximal or medial to the glenoid margin. At the follow-up, 15 patients had excellent results, 4 good, 3 fair, and 1 poor, according to the UCLA scale. The mean Rowe score improved from 87.3 (range, 30-100; SD, 12.6) to 91.2 (range, 40-100; SD, 14.2) (P =.023). The Simple Shoulder Test responses improved from 8 yes responses preoperatively to 11 postoperatively. Eighteen patients achieved an activity return of more than 90% of preinjury level. Five patients had recurrence after revision surgery (1 frank dislocation, 2 subluxation, 2 positive anterior apprehension sign). Engagement in contact sports was correlated with the recurrence (r =.683, P =.003). With the number available, no significant difference could be detected in the outcome between the types of the primary surgery. Arthroscopic revision Bankart repair did not result in any additional loss of external rotation compared with the contralateral side (P =.723). The most predictable factor for the functional return was preoperative range of external rotation (r =.793, P =.001). Conclusions: Arthroscopic revision Bankart surgery using suture anchors can provide a satisfactory outcome, including a low recurrence rate and reliable functional return, in carefully selected patients.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 5 (May-June), 2002: pp 469–482

Recurrences after the open Bankart repair: A potential risk with use of suture anchors

Eighty-seven consecutive patients were treated with an open Bankart repair for traumatic, recurrent anterior instability of the shoulder. Forty-six of these patients underwent a transosseous suture technique. Forty-one patients were operated on with suture anchors. After follow-ups that ranged from 18 to 85 months, 7 of the 87 patients showed signs of recurrence and another 14 patients reported apprehension. Compared with the 66 patients without residual instability, these 21 patients were more likely to have been operated on with suture anchors (P < .05), had a greater incidence of hypermobility in joints other than the shoulder (P < .05), and had had a greater number of pre-operative episodes (P < .05). In light of this data we recommend the transosseous suture technique for open Bankart repairs. In addition, a cautious and extensive capsular repair may be required when a patient reports frequent subluxations preoperatively or has hypermobility in some joints, if not in the shoulder per se.

Efficacy and pitfalls of the STATAK soft-tissue attachment device for the Bankart repair

This report describes the results of Bankart repair with the use of a soft-tissue attachment device in 15 consecutive patients with traumatic, recurrent anterior instability of the shoulder. The mean operative time was 18 minutes shorter when compared with our previous series with the traditional transosseous suture technique. The surgical outcome was satisfactory in 12 patients and unsatisfactory in three. In two of these three patients, incomplete anchoring of the device seemed to have caused subluxation after the operation. Thus this device has the potential to shorten the operative time, but great care must be taken to securely position it below the cortical surface.