Transosseous Tunnels Research Articles

A comparison of distal triceps tendon repair outcomes by surgical technique

Distal triceps tendon ruptures are an uncommon injury with several reported repair techniques. Outcomes research between the repair techniques is complicated by the rarity of the injury as most published materials are based on small sample sizes and specific surgical techniques. This study compared surgical complications, reoperations, and range of motion between all suture transosseous tunnel only (TT), suture anchor only (SA), and transosseous tunnel plus suture anchor (TTSA) repair techniques. We retrospectively identified patients who underwent a distal triceps repair at our tertiary-care institution from 2011 to 2021. The electronic medical record was reviewed for patient demographics, triceps rupture characteristics, repair technique, and postoperative complications. This study includes 199 patients who underwent a repair by TT (82), SA (69), or TTSA (48) techniques. No differences were identified between groups with regards to demographics and medical comorbidities. Patients treated by SA technique were more likely to have a loss of elbow extension (SA: 14 [26.4%], TT: 6 [8.57%], TTSA: 4 [10.0%], P= .014) postoperatively with an average loss of 9° for the patients in all groups. However, no differences were identified between the groups with regards to postoperative complications (TT: 15.9%, SA: 17.4%, TTSA: 18.8%, P= .911), including triceps rerupture (TT: 6.10%, SA: 4.35%, TTSA: 12.5%, P= .260), and reoperation (TT: 11.0%, SA: 11.6%, TTSA: 14.6%, P= .822) rates. Regardless of repair technique, distal triceps tendon repair surgery has a relatively high complication and reoperation rate. However, given the similarities between the various methods of repair, surgeons can be confident in repairing this type of injury by whichever modality they deem appropriate.

Arthroscopic-Assisted Fixation of Tibial Spine Fractures

Tibial spine fractures (TSF) are an avulsion injury of the anterior cruciate ligament (ACL) at the insertion on the tibial plateau. These injuries predominantly affect the pediatric population and are important to treat appropriately as they act similarly to complete ACL injuries. The decision to pursue surgical management is dictated mostly by fracture displacement, but also by various factors such as concomitant injuries, age and level of activity. Multiple fixation strategies are available, ranging from transosseous suture and suture anchors to the use of screws, staples or absorbable nails.This technique paper describes the author's preferred technique involving an arthroscopic assisted reduction of the tibial spine fracture and transosseous suture fixation. High tensile non-absorbable sutures are passed through the base of the ACL which are then passed through two 2.4mm transosseous tunnels tied over a bone bridge on the anterior medial tibia.An arthroscopic approach has been reported to have similar positive outcomes when compared to open reductions. Furthermore, the transosseous suture construct has been described to be advantageous biomechanically and to yield satisfactory results when compared to alternative fixation options.

SpeedBridge Technique for Open Distal Triceps Tendon Repair

Background: Distal triceps tendon ruptures occur most commonly in middle-aged males, with possible rupture locations including the musculotendinous junction, mid-tendon, or most commonly, at the tendinous insertion. This surgical technique video demonstrates a hybrid distal triceps tendon repair construct utilizing transosseous sutures, SpeedBridge compression, and knotless suture anchor fixation. Indications: Indications for this procedure include an acute injury with complete avulsion of the distal triceps tendon from the olecranon and extension weakness. The goals of surgical repair include restoration of the tendon footprint on the olecranon and the creation of a strong fixation construct that balances tension to optimize healing and restore functional range of motion. Technique Description: The proximal avulsed tendon is prepared with two number 2 suture tapes placed in a locking Krackow fashion. The locking stitch exit point is determined at a distance proximal to the distal end of the tendon to optimize tension after the reduction of the tendon to the footprint. Two looped sutures are then passed through the tendon at the same exit level as the locking stitch, 1 on the medial and lateral sides of the locking stitch, respectively. Two transosseous tunnels are drilled obliquely, from proximal to distal, through the olecranon. A 4.75-mm suture anchor is then drilled and tapped in the proximal ulna, in between 2 transosseous tunnel exit points, for lateral placement. The medial and lateral locked stitches are passed through the medial and lateral transosseous tunnels, respectively. The SpeedBridge construct is formed by passing one suture from each locking stitch limb back through the tendon using the previously placed looped sutures as shuttling devices. After appropriate tensioning, the sutures are secured into the previously drilled 4.75-mm suture anchor in a specific fashion. Results: Current literature suggests that the SpeedBridge technique for triceps tendon repair demonstrates good functional and clinical outcomes with high satisfaction rates, elbow functional scores, and rates of returning to work/activity, coupled with low complication rates. Conclusion: The hybrid SpeedBridge construct is an effective technique for acute distal triceps 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.

Acute Patellar Tendon Ruptures: An Update on Management.

Patellar tendon ruptures can be debilitating injuries. When incomplete, partial tears can be managed nonsurgically with immobilization and progressive rehabilitation. Although complete ruptures remain a relatively uncommon injury, they portend a high level of morbidity. Ruptures typically result from an acute mechanical overload to the extensor mechanism, such as with forced quadriceps contraction and knee flexion. However, chronically degenerated tendons are also predisposed to failure from low-energy injuries. Diagnosis can often be made clinically with recognition of a palpable defect to the tendon, localized patellar tendon tenderness, and inability to actively extend the knee. Diagnosis and surgical planning can be established with radiograph, ultrasonography, or magnetic resonance imaging. Surgical repair is the mainstay of treatment, and there have been many recent advances in repair technique, optimal reconstruction strategies, and supplemental fixation. Time to surgery for complete tears remains the most important prognosticator for success. Direct primary repair can be completed with transosseous tunnels, suture anchor repair, or end-to-end repair. Tendon reconstruction can be achieved with or without mechanical or biologic augments. Rehabilitation programs vary in specifics, but return to sport can be expected by 6 months postoperatively.

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

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

Risk Factors Associated With Poor Outcomes After Quadriceps Tendon Repair.

Ruptures of the quadriceps tendon present most frequently in older adults and individuals with underlying medical conditions. To examine the relationship between patient-specific factors and tear characteristics with outcomes after quadriceps tendon repair. Case-control study; Level of evidence, 3. A retrospective review was conducted on all patients who underwent quadriceps tendon repair between January 1, 2016, and January 1, 2021, at a single institution. Patients <18 years and those with chronic quadriceps tendon tears (>6 weeks to surgery) were excluded. Information was collected regarding patient characteristics, presenting symptoms, tear characteristics, physical examination findings, and postoperative outcomes. Poor outcome was defined as a need for revision surgery, complications, postoperative range of motion of (ROM) <110° of knee flexion, and extensor lag of >5°. A total of 191 patients met the inclusion criteria. Patients were aged 58.5 ± 13.2 years at the time of surgery, were predominantly men (90.6%), and had a mean body mass index (BMI) of 32.2 ± 6.3 kg/m2. Patients underwent repair with either suture anchors (15.2%) or transosseous tunnels (84.8%). Postoperatively, 18.5% of patients experienced knee flexion ROM of <110°, 11.3% experienced extensor lag of >5°, 8.5% had complications, and 3.2% underwent revision. Increasing age (odds ratio [OR], 1.03 [95% CI, 1.004-1.07]) and female sex (OR, 3.82 [95% CI, 1.25-11.28]) were significantly associated with postoperative knee flexion of <110°, and increasing age (OR, 1.08 [95% CI, 1.04-1.14]) and greater BMI (OR, 1.14 [95% CI, 1.05-1.23]) were significantly associated with postoperative extensor lag of >5°. Current smoking status (OR, 15.44 [95% CI, 3.97-65.90]) and concomitant retinacular tears (OR, 9.62 (95% CI, 1.67-184.14]) were associated with postoperative complications, and increasing age (OR, 1.05 [95% CI, 1.02-1.08]) and greater BMI (OR, 1.08 [95% CI, 1.02-1.14]) were associated with risk of acquiring any poor outcome criteria. Patient-specific characteristics-such as increasing age, greater BMI, female sex, retinacular involvement, and current smoking status-were found to be risk factors for poor outcomes after quadriceps tendon repair. Further studies are needed to identify potentially modifiable risk factors that can be used to set patient expectations and improve outcomes.

Anchorless Arthroscopic Transosseous Rotator Cuff Repair.

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

An ovine knee simulator: description and proof of concept.

The ovine stifle is an established model for evaluation of knee treatments, such as meniscus replacement. This study introduces a novel ovine gait simulator for pre-testing of surgical treatments prior to in vivo animal trials. Furthermore, we describe a pilot study that assessed gait kinematics and contact pressures of native ovine stifle joints and those implanted with a novel fiber-matrix reinforced polyvinyl alcohol-polyethylene glycol (PVA-PEG) hydrogel meniscus to illustrate the efficacy of the simulator. The gait simulator controlled femoral flexion-extension and applied a 980N axial contact force to the distal tibia, whose movement was guided by the natural ligaments. Five right ovine stifle joints were implanted with a PVA-PEG total medial meniscus replacement, fixed to the tibia via transosseous tunnels and interference screws. Six intact and five implanted right ovine stifle joints were tested for 500k gait cycles at 1.55Hz. Implanted stifle joint contact pressures and kinematics in the simulator were compared to the intact group. Contact pressures were measured at 55° flexion using pressure sensitive film inserted sub-meniscally. 3D kinematics were measured optically across two 30-s captures. Peak contact pressures in intact stifles were 3.6 ± 1.0MPa and 6.0 ± 2.1MPa in the medial and lateral condyles (p < 0.05) and did not differ significantly from previous studies (p > 0.4). Medial peak implanted pressures were 4.3 ± 2.2MPa (p > 0.4 versus intact), while lateral peak pressures (9.4 ± 0.8MPa) were raised post medial compartment implantation (p < 0.01). The range of motion for intact joints was flexion/extension 37° ± 1°, varus/valgus 1° ± 1°, external/internal rotation 5° ± 3°, lateral/medial translation 2 ± 1mm, anterior/posterior translation 3 ± 1mm and distraction/compression 1 ± 1mm. Ovine joint kinematics in the simulator did not differ significantly from published in vivo data for the intact group, and the intact and implanted groups were comparable (p > 0.01), except for in distraction-compression (p < 0.01). These findings show correspondence of the ovine simulator kinematics with in vivo gait parameters. The efficacy of the simulator to evaluate novel treatments was demonstrated by implanting a PVA-PEG hydrogel medial meniscal replacement, which restored the medial peak contact pressures but not lateral. This novel simulator may enable future work on the development of surgical procedures, derisking subsequent work in live animals.

Reinsertion of Posterior Meniscal Root for Management of Hypermobile Lateral Meniscus: Description of a Surgical Technique

Lateral meniscus hypermobility is a special condition in which the posterior horn of the lateral meniscus exhibits excessive mobility. This condition can cause pain and locking in the knee, especially during kneeling, deep flexion, or squatting. In this article, we present a surgical technique for the reinsertion of the posterior root of the external meniscus in cases of hypermobility without detachment. The objective is to increase the tension of the meniscotibial and meniscal popliteal ligaments to achieve meniscal stability. The procedure involves suturing the meniscal root and fixation using a knotless implant through a transosseous tunnel. This technique has proven to be effective in stabilizing the lateral meniscus in patients with hypermobility.

Osteoarticular Open Flake Fracture Refixation: The “Parachute” Technique

Osteochondral fractures of the patella, also known as “flake fractures,” frequently occur after patellar dislocation. In such fractures, a piece of patellar cartilage with subchondral bone breaks off due to patellar dislocation or subsequent reposition. Various surgical techniques have evolved for surgical therapy with the goal of realigning the patellar cartilage. This article presents a cost-effective surgical technique for achieving stable refixation of large osteochondral fragments in patellar flake fractures. The proposed technique entails creating transosseous tunnels in a confluent fashion at the margins, exactly between the fragment and the natural cartilage. Sutures are passed through the established tunnels for flake refixation. This refixation method ensures evenly distributed pressure without penetration of the fragment itself, resulting in the formation of a characteristic parachute configuration composed of confluent bone tunnels and absorbable sutures. The suitability of flake refixation is assessed through an algorithm, allowing for appropriate patient selection. The described technique offers several advantages, including its simplicity and cost-effectiveness, a flexible configuration of the sutures, and the ability to provide stable refixation for large osteochondral fragments.

Biomechanical Comparisons of Different Reconstructive Techniques for Scapholunate Dissociation: A Cadaveric Study.

There are many techniques for the treatment of chronic scapholunate dissociation. The three-ligament tenodesis (3LT) is used most widely, but reconstruction of the dorsal ligament alone may not provide sufficient stability. The Mark-Henry technique (MHT) compensates for the insufficient stability of 3LT by additional reconstruction of the volar ligament, but the procedure is complex. The SwiveLock technique (SWT), a recently introduced method, provides stability by using autologous tendons with synthetic tapes, but lacks long-term clinical results. To perform biomechanical comparisons of different reconstructive techniques for scapholunate dissociation using a controlled laboratory cadaveric model. Eleven fresh-frozen upper-extremity cadaveric specimens were prepared. The scapholunate distance, scaphoid rotation, and lunate rotation of the specimens were measured during continuous flexion-extension and ulnar-radial deviation movements. The data were collected using a wrist simulator with a linear guide rail system (tendon load/motion-controlled system) and a motion capture system. Results were compared in five conditions: (1) intact, (2) scapholunate dissociation, (3) SWT, (4) 3LT, and (5) MHT. Paired t-test was employed to compare the biomechanical characteristics of intact wrists to those of scapholunate dissociated wrists, and to those of wrists after each of the three reconstruction methods. SWT and MHT were effective solutions for reducing the widening in scapholunate distance. According to the radioscaphoid angle, all three reconstruction techniques were effective in addressing the flexion deformity of the scaphoid. According to the radiolunate angle, only SWT was effective in addressing the extension deformity of the lunate. In terms of scapholunate angle, only the results after SWT did not differ from those of the intact wrist. The SWT technique most effectively improved distraction intensity and rotational strength for the treatment of scapholunate dissociation. Taking into account the technical complexity of 3LT and MHT, SWT may be a more efficient technique to reduce operating time and minimize complications due to multiple incisions, transosseous tunnels, and complicated shuttling.

"Biological Fixation" of Flexor Digitorum Longus: A New Modification of Tendon Transfer for Treatment of Posterior Tibialis Tendon Dysfunction.

Numerous surgical procedures for the treatment of posterior tibialis tendon (PTT) dysfunction have been developed, including tendon transfers, osteotomies, and arthrodesis. Among these methods, foot and ankle surgeons most frequently use flexor digitorum longus (FDL) tendon transfer in conjunction with medial translational osteotomy of the calcaneus. Formerly, some less invasive techniques have been described to reduce surgical-related complications after FDL tendon transfer. Herein, we introduced a new modification of short-stump FDL tendon fixation to the navicular bone and reported the functional outcomes of the current technique in a patient with PTT dysfunction. In the current technique, the FDL tendon was fixed to the navicular bone via a trans-osseous tunnel using a split PTT stump. This method does not require any kind of fixation devices, such as an interference screw or anchor suture.Level of Evidence: V.

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

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

Stabilization of Recurrent Elbow Instability in the Presence of Hyperlaxity in Children Using a Nonanatomic Soft Tissue Reconstruction.

Despite growing concordance of opinion in the adult setting, pediatric elbow instability and its management are poorly represented in the literature due to its low prevalence and often unique circumstances. The authors present a case of posttraumatic recurrent posterior pediatric elbow instability in a patient with joint hypermobility. Our patient, a 9-year-old girl, sustained a right-sided supracondylar fracture of the humerus in April 2019. Having been managed operatively, the elbow remained unstable and dislocated posteriorly in extension. Definitive surgical management was designed to provide a stable functional elbow. The principle of the surgery was to create a checkrein of tissue, not changing in length in extension and flexion, and to prevent further posterior elbow instability. A 3mm slip of the central triceps tendon was dissected, leaving its attachment to the olecranon tip. Gracilis allograft was sutured to the strip of the triceps tendon to increase the tensile properties of the native tendon graft using a braided nonabsorbable suture. The tendon construct was then passed through a window made in the olecranon fossa and a transosseous tunnel in the ulna from the coronoid tip to the dorsal cortex. The tendon was tensioned and secured to the radial-dorsal aspect of the ulna with a nonabsorbable suture anchor in 90 degrees of flexion. At one year follow-up, the patient has a stable and pain-free elbow joint with no functional limitations.

OVINE KNEE KINEMATICS AND CONTACT PRESSURES OF A NOVEL FIBRE MATRIX-REINFORCED HYDROGEL TOTAL MENISCUS REPLACEMENT

No proven long-term joint-preserving treatment options exist for patients with irreparable meniscal damage. This study aimed to assess gait kinematics and contact pressures of novel fibre-matrix reinforced polyvinyl alcohol-polyethylene glycol (PVA-PEG) hydrogel meniscus implanted ovine stifle joints against intact stifles in a gait simulator.The gait simulator controlled femoral flexion-extension and applied a 980N axial contact force to the distal end of the tibia, whose movement was guided by the joint natural ligaments (Bartolo; ORS 2021;p1657- LB). Five right stifle joints from sheep aged &gt;2 years were implanted with a PVA-PEG total medial meniscus replacement, fixed to the tibia via transosseous tunnels and interference screws. Implanted stifle joint contact pressures and kinematics in the simulator were recorded and compared to the intact group. Contact pressures on the medial and lateral condyles were measured at 55° flexion using Fujifilm Prescale Low Pressure film inserted under the menisci. 3D kinematics were measured across two 30 second captures using the Optotrak Certus motion-tracking system (Northern Digital Inc.).Medial peak pressures were not significantly different between the implanted and intact groups (p&gt;0.4), while lateral peak pressures were significantly higher in the implanted group (p&lt;0.01). Implanted stifle joint kinematics in the simulator did not differ significantly from the intact baseline (p&gt;0.01), except for in distraction-compression (p&lt;0.01).Our findings show that the fibre-matrix reinforced PVA-PEG hydrogel meniscal replacement restored the medial peak contact pressures. Similar to published literature (Fischenich; ABE 2018;46(11):1–12), the lateral peak pressures in the implanted group were higher than the intact. Joint kinematics were similar across groups, with slightly increased internal-external rotation in the implanted group. These findings highlight the effectiveness of the proposed approach and motivate future work on the development of a total meniscal replacement.

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.

Anterior Cruciate Ligament Reconstruction With Transtibial Medial Meniscus Root Repair

Background: The incidence of anterior cruciate ligament (ACL) injuries has rapidly increased. Patients with ACL injuries frequently present with concomitant meniscal pathologies. Posterior medial meniscal root tears (PMMR) are less commonly seen with acute ACL injuries as compared with lateral tears and are often degenerative in nature or more rarely in an acute setting. Clinical studies have demonstrated medial meniscal deficiency to be a significant risk factor for graft failure and poor postoperative clinical outcomes. As such, given its demonstrated efficacy, there has been growing interest in transtibial meniscal repair mechanisms in combination with an ACL reconstruction as a potential solution to this challenging pathology. Indication: Patients are indicated for surgery when presenting with symptomatic ACL deficiency verified on provocative testing and advanced imaging and objective insufficiency of the medial meniscal root. Contraindications for this procedure include advanced osteoarthritis (Kellgren–Lawrence grade ≥3) on weight-bearing x-rays, age &lt;50 years, and body mass index (BMI) &gt; 30 as well as poor-quality meniscal tissue and unrepairable chondral defects. Technique Description: The ACL stump is debrided and a burr hole is created. A femoral aiming guide is used to drill the femoral tunnel. Following medial collateral ligament (MCL) release, a healing bony bed is prepared with a curette and shaver at the anatomic tibial footprint. An aiming device is then used through the anterior medial portal to create 2 transosseous tibial tunnels. A vertical mattress suture and simple suture are placed through the meniscal root, shuttled through the posterior and anterior transosseous tunnels, respectively. The tibial ACL tunnel is placed using a standard guide to avoid tunnel convergence with the root tunnels and prevent graft tunnel mismatch. After graft passage, interference screws are inserted while maintaining graft tension. The sutures are then tied over a cortical button over the tibia. Results: Within 2 years postoperatively, patients are expected to have improved overall knee-specific quality of life, reduced pain, and a successful return to activities with low rates of graft failure. Discussion/Conclusion: Recent advancements in our understanding of the relationship between the medial meniscus and the ACL should prompt surgeons to continue considering such combined treatments in indicated patients. 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.

SIMULTANEOUS RUPTURE OF THE PATELLAR AND CONTRALATERAL QUADRICEPS TENDONS IN A NEPHROPATHY PATIENT.

In this case report, we describe the case of a 39-year-old woman with chronic renal failure on dialysis due to a previous history of eclampsia that caused the simultaneous rupture of the patellar and contralateral quadriceps tendons. Data were collected by interviews, direct observation, and medical examinations, and include information about the case history, the patient's characteristics, the former interventions, and the results obtained. The surgery to repair the patellar and contralateral quadriceps tendons was performed by transosseous tunnels and the Krackow technique with nonabsorbable sutures was used. The semitendinosus tendon was removed and used as reinforcement. Patient under follow-up with good functional results in both knees.Level of Evidence V, Expert Opinion.

No difference in load to failure or stiffness between transosseous tunnels, suture anchors, and cortical buttons for pectoralis major tendon repair: a systematic review & meta-analysis

PurposeSurgical options for pectoralis major tendon tears include primary repair, though there is no consensus as to which constructs are biomechanically superior for repair.MethodsA systematic review was performed by searching PubMed, the Cochrane library, and Embase using PRISMA guidelines to identify studies that analyzed the biomechanical properties of bone tunnels (BT), cortical buttons (CB) and suture anchors (SA) techniques for pectoralis major tendon repair. The search phrase implemented was ‘pectoralis major tendon repair biomechanics’. Studies that did not evaluate biomechanical outcome data, evaluated partial pectoralis major tendon tears, and non-English articles were excluded. Evaluated outcomes included ultimate load to failure (N) and stiffness (N/mm).ResultsSix studies met inclusion criteria, including a total of 124 cadaveric specimens, for pectoralis major tendon repair comparing BT with SA and CB. Pooled analysis from four studies reporting on ultimate load to failure between BT and SA failed to reveal a difference between BT and SA (p = 0.489). Pooled analysis from two studies reporting on stiffness failed to reveal a difference in favor of BT compared to SA (p = 0.705). Pooled analysis from four studies reporting on ultimate load to failure between BT and CB failed to reveal a difference between BT and CB (p = 0.567). Pooled analysis from two studies reporting on stiffness failed to reveal a difference in favor of BT compared to CB (p = 0.701).ConclusionsThere was no difference in load to failure or stiffness when using BT, CB, or SA in pectoralis major tendon repairs. This review reveals that clinical outcomes may better inform which fixation construct to implement in pectoralis major tendon repairs.Level of evidenceI.

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.].