Biomechanical characteristics of the horizontal mattress stitch: implication for double-row and suture-bridge rotator cuff repair

Background

We investigated the effects of bite-size horizontal mattress stitch (distance between the limbs passed through the tendon) on the biomechanical properties of the repaired tendon.

Methods

We anchored 20 bovine Achilles tendons to bone using no. 2 high-strength suture and 5-mm titanium suture anchors in a mattress–suture technique. Tendons were allocated randomly into two groups of ten each to receive stitches with a 4- or 10-mm bite. Specimens underwent cyclic loading from 5 to 30 N at 1 mm/s for 30 cycles, followed by tensile testing to failure. Gap formation, tendon strain, hysteresis, stiffness, yield load, ultimate load, energy to yield load, and energy to ultimate load were compared between groups using unpaired t tests.

Results

The 4-mm group had less (p < 0.05) gap formation and less (p < 0.05) longitudinal strain than did the 10-mm group. Ultimate load (293.6 vs. 148.9 N) and energy to ultimate load (2,563 vs. 1,472 N-mm) were greater (p < 0.001) for the 10-mm group than the 4-mm group. All tendons repaired with 4-mm suturing failed at the suture–tendon interface, with sutures pulling through the tendon, whereas the suture itself failed before the tendon did in seven of the ten specimens in the 10-mm group.

Conclusions

Whereas a 4-mm bite fixed the tendon more tightly but at the cost of decreased ultimate strength, a 10-mm bite conveyed greater ultimate strength but with increased gap and strain. These results suggest that for the conventional double-row repair, small mattress stitches provide a tighter repair, whereas large stitches are beneficial to prevent sutures from pulling through the tendon after surgery. For suture-bridge rotator cuff repair, large stitches are beneficial because the repaired tendon has a higher strength, and the slightly mobile medial knot can be tightened by lateral fixation.     

Comparison of Four Methods for Percutaneous Achilles Tendon Lengthening: A Cadaveric Study

Percutaneous Achilles tendon lengthening can result in Achilles tendon rupture. This complication has been controversially linked to torsion effects in the Achilles tendon. Routine percutaneous triple-hemisection techniques (group A), rotary triple-hemisection (group B), distal double-hemisection (group C), and proximal double-hemisection (group D) were compared in cadaveric specimens to provide insights into the mechanism of uneven incision lengthening and inadvertent Achilles tendon rupture. The degree of Achilles tendon torsion on various planes was measured in 20 lower limb pairs from fresh cadavers. The increase in postoperative maximum ankle joint dorsiflexion degree and the length of the lengthened Achilles tendon were greater in group B (p < .05) and group C (p < .05) compared with the routine percutaneous triple-hemisection technique (group A). The width of the tensile gap of the distal incision was significantly greater in group B (p < .05) and group C (p < .05) compared with that in group A. Rotary triple-hemisection was shown to eliminate the effect of Achilles tendon torsion on percutaneous Achilles tendon lengthening. Because proximal double-hemisection is performed away from the distal Achilles tendon where the fibers rotate sharply, the technique results in more even extension of the incisions and achieves a greater increase in the maximum degree of ankle joint dorsiflexion. Uneven incision lengthening was observed with the routine percutaneous triple-hemisection and distal double-hemisection techniques. Achilles tendon torsion affected the surgical outcomes. Rotary triple-hemisection and proximal double-hemisection techniques resulted in more even extension of the incisions and achieved a greater increase in the degree of maximum ankle joint dorsiflexion.     

Assessment of the Resistance of Several Suture Techniques in Human Cadaver Achilles Tendons

Many treatments are available for acute Achilles tendon ruptures, conservative and surgical, with none superior to another. For surgical treatment, one can use various techniques. Recent studies have shown that double stitches are superior to simple sutures. Therefore, in the present study, we sought to determine the suture technique that is the most resistant to rupture. We performed an experimental anatomic study with 27 fresh-frozen human cadaveric Achilles tendons obtained through the body donation program of the University of Barcelona, testing the maximum strength. We simulated a rupture by performing resection in the middle portion of the tendon, 4 cm proximal to the calcaneus insertion. We then evaluated the double Kessler, double Bunnell, Krackow, and percutaneous Ma and Griffith technique. We used absorbable suture (polydioxanone no. 1) with all the techniques. Traction was performed using a machine that pulls the tendon at 10 to 100 N in 1000 repetitive cycles. Statistical analysis was performed using the χ² test and analysis of variance, with the 95% confidence intervals (p < .05). All repairs failed at the site of the suture knots, with none pulling out through the substance of the tendon. We found no significant differences among the different open suture techniques (p > .05). The Krackow suture presented with superior resistance, with a rupture rate 16.70% but with a mean elongation of 7.11 mm. The double Bunnell suture had the same rupture rate as the Krakow suture (16.70%) but with an inferior mean elongation of 4.53 mm. The Krackow and Bunnell suture were superior in endurance, strength of failure, and primary stability compared with the other suture types. However, the former presented with greater tendon elongation, although the difference was not statistically significant. Therefore, according to our findings and the published data, we recommend double Bunnell sutures for the surgical treatment of acute Achilles tendon rupture.     

Biomechanical analysis of knotless flexor tendon repair using large-diameter unidirection barbed suture

Purpose

In traditional flexor tendon repairs, suture knots can be sites of weakness, impair tendon healing, stimulate an inflammatory response, and increase the bulk of the tendon repair. Because of this, there has been an increased interest in knotless flexor tendon repair using barbed suture. Since knots are not required, it may be possible to increase the strength of the tendon repair by using a large-diameter barbed suture. The purpose of this study was to biomechanically compare a traditional four-strand tendon repair using 3-0 braided polyester with a similar knotless four-strand tendon repair using 0 unidirectional barbed suture.

Methods

Twenty-two matched cadaveric flexor digitorum profundus tendons were lacerated and assigned to repair by a four-strand modified Kirchmayr–Kessler technique using 3-0 braided polyester (n = 11) or knotless four-strand modified Kirchmayr–Kessler repair using 0 unidirectional barbed suture (n = 11). Repaired tendons were linearly distracted to failure at 20 mm/min after 1 N preload. Maximum load and load at 2-mm gap formation were recorded. Maximum load and load at 2-mm gap formation were compared with the Student’s t test, and p values ≤ 0.05 were considered significant.

Results

The mean maximum load of the barbed, knotless suture repair was higher than that of the traditional repair (52 vs. 42 N). There was no difference between the two groups in the mean load required to produce a 2-mm gap.

Conclusions

The four-strand knotless tendon repairs using a large-diameter unidirectional barbed suture were stronger than the traditional four-strand repairs using 3-0 braided polyester, and had similar 2-mm gap resistance.     

Comparison of Suture-Based Anchors and Traditional Bioabsorbable Anchors in Foot and Ankle Surgery

We compared the pullout strength of a suture-based anchor versus a bioabsorbable anchor in the distal fibula and calcaneus and evaluated the relationship between bone mineral density and peak load to failure. Eight paired cadaveric specimens underwent a modified Broström procedure and Achilles tendon reattachment. The fibula and calcaneus in the paired specimens received either a suture-based anchor or a bioabsorbable suture anchor. The fibular and calcaneal specimens were loaded to failure, defined as a substantial decrease in the applied load or pullout from the bone. In the fibula, the peak load to failure was significantly greater with the suture-based versus the bioabsorbable anchors (133.3 ± 41.8 N versus 76.8 ± 35.3 N; p = .002). No significant difference in load with 5 mm of displacement was found between the 2 groups. In the calcaneus, no difference in the peak load to failure was found between the 2 groups, and the peak load to failure with 5 mm of displacement was significantly lower with the suture-based than with the bioabsorbable anchors (52.2 ± 9.8 N versus 75.9 ± 12.4 N; p = .003). Bone mineral density and peak load to failure were significantly correlated in the fibula with the suture-based anchor. An innovative suture-based anchor had a greater peak load to failure compared with a bioabsorbable anchor in the fibula. In the calcaneus, the load at 5 mm of displacement was significantly lower in the suture-based than in the bioabsorbable group. The correlation findings might indicate the need for a cortical bone shelf with the suture-based anchor. Suture-based anchors could be a viable alternative to bioabsorbable anchors for certain foot and ankle procedures.     

Achilles Tendon Open Surgical Treatment With Platelet-Rich Fibrin Matrix Augmentation: Biomechanical Evaluation

The relationship between surgical technique and ankle biomechanical properties after surgery for acute rupture of the Achilles tendon (ATR) has not yet been fully investigated. Platelet-rich fibrin (PRF) matrices seem to play a central role in the complex processes of tendon healing. Our aim was to analyze the biomechanical characteristics, stiffness, and mechanical work of the ankle during walking in patients who had undergone surgery after ATR with and without PRF augmentation. We performed a retrospective review of all consecutive patients who had been treated with surgical repair after ATR. Of the 20 male subjects enrolled, 9 (45%) had undergone conventional open repair of the Achilles tendon using the Krackow technique (no-PRF) and 11 (55%) had undergone surgery with PRF augmentation. An additional 8 healthy subjects were included as a control group. A gait analysis evaluation was performed at 6 months after surgery. The percentage of the stance time of the operated leg, double-support time of the healthy leg, and net work of the ankle during the gait cycle showed statistically significant differences between the no-PRF and the healthy group (p < .005). No differences were found between the PRF and healthy groups. Treatment with suture and PRF augmentation could result in significant functional improvements in term of efficiency of motion.     

Biomechanical comparison of the primary stability of suturing Achilles tendon rupture: a cadaver study of Bunnell and Kessler techniques under cyclic loading conditions

Introduction  Biomechanical studies investigating suture techniques for Achilles tendon repair used single load to failure tests in order to evaluate the maximal load capacity of the repaired construct. During early rehabilitation the repair is repetitively loaded such as exercise or daily living activities like walking. Cyclic loading seems to duplicate the physiological loading conditions more closely than single cycle failure tests. Aim of this study was to test the most commonly used Achilles tendon repair techniques (Bunnell and Kessler repair) under cyclic loading conditions. Materials and methods  Following tenotomy fresh human cadaveric tendons were sutured either with the Bunnell or Kessler technique. After repair, cyclic loading tests were performed with a uniaxial biomechanical testing machine Lloyd LR-5K Plus. Both groups were sutured with 0.7 mm PDS. Results  Except at maximum load we could not find significant differences between tendons sutured by Bunnell and Kessler techniques. During the cyclic testing there were no differences between both groups with respect to displacement. This applies also to the stiffness of the constructs, which we defined from the load to failure measurements. The failure modes in both groups differed; the tendons repaired by Kessler technique were cut by the tendons and in the Bunnell group the suture material tore in each specimen tested. Conclusion  In our study Bunnell and Kessler techniques showed similar biomechanical properties using the same suture material. The typical failure mode of the Bunnell technique shows potential to optimise biomechanical behavior by using stronger suture material.     

Pectoralis major transosseous equivalent repair with knotless anchors: Technical note and literature review

Introduction:Rupture of the pectoralis major (PM) tendon was initially described almost 2 centuries ago, but most of the reported injuries have occurred within the last 30 years. Options for repair have varied widely. The most common methods for repair depend on either transosseous sutures or suture anchors for fixation. Transosseous suture repair allows for docking the tendon into a trough at its anatomic insertion, but risks cortical breakage during suture passing. Our experience has confirmed the value and potential advantages of anchors for a secure fixation.Aims:To describe a variation of repair using knotless suture anchors and a burred trough to dock the tendon into its anatomic insertion.Conclusion:We describe a technique of a transosseous equivalent PM repair technique. To our knowledge, this is the first paper describing such a repair technique for PM rupture.     

Collagen Ribbon Augmentation of Achilles Tendon Tears: A Biomechanical Evaluation

Early motion of a repaired Achilles tendon has been accepted to improve both clinical and biomechanical outcomes. It has been postulated that augmenting a primary Achilles tendon repair with a collagen ribbon will improve the repair construct's initial strength, thereby facilitating early motion. The purpose of the present study was to compare the failure load of Achilles tendon defects repaired with suture, with or without augmentation with a collagen ribbon. Ten matched pairs of cadaveric feet and tibiae underwent simulated Achilles tendon tear in the watershed area and were then repaired with 4-strand Krackow sutures only or were sutured and augmented with a box weave collagen ribbon xenograft. The specimens were prepared for testing by keeping the insertion of the Achilles to the calcaneus intact and dissecting the gastrocnemius at its origin, leaving the repair undisturbed. The mean load at failure for the augmented (suture plus collagen ribbon) specimens was 392.4 ± 74.9 N. In contrast, the mean load at failure for the suture-only (control) construct was 98.0 ± 17.6 N (p < .001). The augmented specimens demonstrated a greater mean strength of 4.1 ± 0.9 N (range 3.2 to 5.6). After cyclic loading, the mean gap across the Achilles repair was significantly smaller in the augmented group than in the control group (p = .006). We have concluded that box weave collagen ribbon augmentation of the primary suture Achilles tendon repairs can provide enhanced gap resistance and strength under cyclic loading and ramped tensile testing.     

Biomechanical Study of a Multifilament Stainless Steel Cable Crimp System Versus a Multistrand Ultra-High Molecular Weight Polyethylene Polyester Suture Krackow Technique for Achilles Tendon Rupture Repair

Currently, Achilles tendon rupture repair is surgically addressed with an open or minimally invasive approach using a heavy, nonabsorbable suture in a locking stitch configuration. However, these sutures have low stiffness and a propensity to stretch, which can result in gapping at the repair site. Our study compares a new multifilament stainless steel cable-crimp repair method to a standard Krackow repair using multistrand, ultra-high molecular weight polyethylene polyester sutures. Eight matched pairs of cadavers were randomly assigned for Achilles tendon repair using either Krackow technique with polyethylene polyester sutures or the multifilament stainless steel cable-crimp technique. Each repair was cyclically loaded from 10 to 50 N for 100 loading cycles, followed by a linear increase in load until complete failure of the repair. During cyclic loading, 4 of the 8 Krackow polyethylene polyester suture repairs failed, whereas none of the multifilament stainless steel cable crimp repairs failed. Load to failure was greater for the multifilament stainless steel cable crimp repairs (321.03 ± 118.71 N) than for the Krackow polyethylene polyester suture repairs (132.47 ± 103.39 N, p = .0078). The ultimate tensile strength of the multifilament stainless steel cable crimp repairs was also greater than that of the Krackow polyethylene polyester suture repairs (485.69 ± 47.93 N vs 378.71 ± 107.23 N, respectively, p = .12). The mode of failure was by suture breakage at the crimp for all cable-crimp repairs and by suture breakage at the knot, within the tendon, or suture pullout for the polyethylene polyester suture repairs. The multifilament stainless steel cable crimp construct may be a better alternative for Achilles tendon rupture repairs.     

Is There a Relation between AOFAS Ankle-Hindfoot Score and SF-36 in Evaluation of Achilles Ruptures Treated by Percutaneous Technique?

The percutaneous technique of Achilles tendon repair seems to offer satisfactory clinical and functional results, although these results have been evaluated mainly using objective rating scales. Recently, some “subjective” rating scales have been combined to evaluate the results of various surgical treatments. The purpose of the present study was to compare the results of a percutaneous Achilles tendon repair evaluated objectively using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and subjectively using the Medical Outcomes Study, short-form, 36-item questionnaire (SF-36) questionnaire. A total of 17 consecutive patients were treated for acute Achilles tendon rupture using the modified percutaneous Ma and Griffith technique. We reviewed all patients with a follow-up of 24 to 64 months (mean 45.5). At the final follow-up visit, the AOFAS ankle-hindfoot score of each patient was compared with each 1 of the 8 domains of the SF-36 questionnaire, using the parametric Pearson correlation coefficient and the equivalent nonparametric Spearman rho correlation coefficient. The relation between the objective (AOFAS) and subjective (SF-36) results showed a significant correlation (Pearson's correlation coefficient) between the physical functioning (r = 0.597, p = .011) and bodily pain (r = 0.663, p = .004) SF-36 domains, and a nonstatistically significant correlation with the other SF-36 domains. Very similar results were found using the nonparametric Spearman rho correlation coefficient. These results suggest that regarding pain and function, the AOFAS ankle-hindfoot score and SF-36 provide complementary information; therefore, we believe that the SF-36 questionnaire should be used with the AOFAS ankle-hindfoot score for a more complete evaluation of the outcome.     

Biomechanical Comparison of Knotless Suture Anchor Versus Percutaneous End-to-End Technique for Mid-Substance Achilles Tendon Rupture Repair

Percutaneous Achilles tendon repairs can be performed with 2 distal fixation techniques: knotless suture anchor repair (KL) or percutaneous end-to-end repair (ETE). There is a paucity of literature comparing the biomechanical strength of these 2 distal fixation techniques. The aim of this study was to compare the strength of KL and ETE repairs using flat-braided suture for mid-substance Achilles tendon rupture during simulated progressive rehabilitation. Nine matched pairs of fresh-frozen below-knee cadaveric extremities were randomly assigned into these 2 repair groups. Each specimen was tested in 2 parts sequentially; Part I simulating passive ankle range of motion (cyclic: 20N-100N), and Part II simulating ambulation in a walking boot (cyclic: 20N-190N). The number of cycles, gap displacement, and the mode of failure were recorded for each repair. Achilles tendon repairs using the percutaneous methods of ETE and KL techniques showed no significant difference in the number of cycles to clinical failure, mean gap displacement, or overall failure rate. During Part I, the survival rate in terms of clinical failure for KL and ETE groups was 8 of 9 repairs and 7 of 9 repairs, respectively. During Part II, all repairs experienced clinical failure in both groups. Five repairs in the KL group experienced suture anchor pull out from the calcaneus, and 3 repairs failed at suture-tendon interface. Four repairs in the ETE group failed due to knot slippage and 5 repairs failed at suture-tendon interface. Both techniques are viable options in treating acute mid-substance Achilles tendon ruptures.     

Association Between Knee Osteoarthritis and Functional Changes in Ankle Joint and Achilles Tendon

Increasing evidence has shown that biomechanical forces often drive the progression of knee osteoarthritis (OA). Attention should be given to the changes in adjacent joints and their relation to knee OA. The purpose of the present study was to examine the changes in Achilles tendon thickness of individuals with knee OA and to evaluate the correlation between Achilles tendon thickness and knee OA severity in a case-control prospective observational study. A total of 93 participants with no previous ankle injuries were recruited. Of the 93 participants, 63 had knee OA of the medial compartment and 30 served as controls. The subjects underwent a clinical examination that included measurements of weight, height, Achilles tendon thickness, and 1-leg heel rise. The subjects also underwent a computerized gait test and completed the Hebrew version of the Western Ontario and McMaster Osteoarthritis Index and 36-item short-form (SF-36) health survey. Significant difference was found in Achilles tendon thickness between the subjects with knee OA and the healthy controls (17.1 ± 3.4 versus 15.1 ± 3.1; p = .009). Significant differences were also found between the 2 groups in the 1-leg heel rise test, Western Ontario and McMaster Osteoarthritis Index scores, SF-36 scores, and all gait measures. Significant correlations were found between the Achilles tendon thickness and the following measures: weight (r = 0.46), body mass index (r = 0.55), Kellgren and Lawrence OA severity grade (r = 0.25), 1-leg heel rises (r = ?0.50), and SF-36 score (r = ?0.25). Subjects with knee OA presented with a thicker Achilles tendon compared with the healthy controls. Furthermore, a significant correlation between Achilles tendon thickness and knee OA severity was found. A comprehensive assessment of the Achilles tendon and ankle joint should be a part of the knee OA evaluation process.     

A novel repair method for the treatment of acute Achilles tendon rupture with minimally invasive approach using button implant: A biomechanical study

BackgroundMinimally invasive Q3 repair has been proposed for acute Achilles tendon rupture with low rate of complications. However there are still controversies about optimal technique. In this study we aimed to describe Endobutton-assisted modified Bunnell configuration as a new Achilles tendon repair technique and evaluate its biomechanical properties comparing with native tendon and Krackow technique.Methods27 ovine Achilles tendons were obtained and randomly placed into 3 groups with 9 specimens ineach. The Achilles tendons were repaired with Endobutton-assisted modified Bunnell technique in group 1, Krackow suture technique in group 2 and group 3 was defined as the control group including native tendons. Unidirectional tensile loading to failure was performed at 25 mm/min. Biomechanicalproperties such as peak force to failure (N), stress at peak (MPa), elongation at failure, and Young'smodulus (GPa) was measured for each group. All groups were compared with each other using one-wayANOVA followed by the Tukey HSD multiple comparison test (a = 0.05).ResultsThe average peak force (N) to failure of group 1 and group 2 and control group was 415.6 ± 57.6, 268.1 ± 65.2 and 704.5 ± 85.8, respectively. There was no statistically significant difference between native tendon and group 1 for the amount elongation at failure (p > 0.05).ConclusionsRegarding the results, we concluded that Endobutton-assisted modified Bunnell technique provides stronger fixation than conventional techniques. It may allow early range of motion and can be easily applied in minimally invasive and percutaneous methods particularly for cases with poor quality tendon at the distal part of rupture.Level of evidenceLevel II, Biomechanical research study.     

Foreign body granulomatous reaction associated with polyethelene ‘Fiberwire®’ suture material used in Achilles tendon repair

Repair of acute Achilles tendon rupture is a common procedure. There are many accepted surgical techniques; suture selection is largely due to surgeon preference.We present a case report of a granulomatous reaction to suture material following Achilles tendon repair. ‘Fiberwire^®’ is an increasingly popular suture material for the repair of tendons and ligamentous structures; the polyethelene braided structure with silicone and polyester coating provides high tensile strengths and good handling characteristics.Eight months following uneventful Achilles tendon repair surgery in an otherwise fit and well patient, pain, swelling and loss of function was noted. She required revision surgery with debridement and reconstruction of the tendo Achillis with flexor hallucis longus tendon transfer. Histology revealed a granulomatous reaction with giant cell response surrounding sections of the suture.Both the silicone coating of Fiberwire^® and polyethylene core have the potential to cause a severe granulomatous reaction. We would advise caution in the use of this suture for tendo Achillis repair, and use the readily available alternatives.     

Jigless Knotless Internal Brace Versus Other Minimal Invasive Achilles Tendon Repair Techniques in Biomechanical Testing Simulating the Progressive Rehabilitation Protocol

The jigless knotless internal brace surgery (JKIB), an alternative method for minimal invasive surgery (MIS) repair of acute Achilles tendon rupture, has advantages of preventing sural-nerve injury in MIS and superficial wound infection in open surgery, as previous clinical research demonstrates. However, no comparative study on the biomechanical performance between JKIB and other MIS techniques has been reported until now. In this study, 50 fresh porcine Achilles tendons were used to compare the JKIB with open surgery (two-stranded Krachow suture) with other MIS techniques, including Percutaneus Achilles Repair System (PARS), Speedbridge (SB), and Achillon Achilles Tendon Suture System (ACH), using a biomechanical testing with cyclic loading at 1 Hz. This test was used to simulate a progressive rehabilitation protocol where 20 to 100 N was applied in the first 250 cycles, followed by 20 to 190 N in the second 250 cycles, and then 20 to 369 N in the third 250 cycles. The cyclic displacement after 10, 100 and 250 cycles were recorded. The survived cycles were defined as a sudden drop in measured load. In survived cycles, the JKIB group (552.3 ± 72.8) had significantly higher cycles than the open, PARS, and ACH groups (204.3 ± 33.3, 395.9 ± 96.0, and 397.1 ± 80.9, respectively, p < .01) as analyzed by post hoc analysis, but no significant difference as compared with the SB group (641.6 ± 48.7). In cyclic displacement after 250 cyclic loadings, the JKIB group (11.29 ± 1.29) showed no significant difference as compared with PARS, SB, and ACH groups (12.21 ± 1.18, 9.80 ± 0.80, and 11.57 ± 1.10 mm, respectively) and significant less displacement than the open group (14.50 ± 1.85, p < .01). These findings suggest that JKIB could be an option for acute Achilles tendon repair in the MIS fashion due to no larger cyclic elongation compared with other MIS techniques.     

Acute Achilles Tendon Rupture Repair in Athletically Active Patients: Results on 188 Tendons

We report on the outcome of acute Achilles tendon ruptures by a single surgeon using open and percutaneous techniques was performed. This prospective study included 186 patients with 188 ruptured Achilles tendons. A traditional open technique was primarily performed on patients from January 2001 to December 2011. From January 2012 to January 2018, a percutaneous repair was primarily performed. Outcome measures included the Roles and Maudsley (RM) score, ability to perform a single leg heel raise, calf atrophy and return to activity. There were 149 males (average age 42.5 ± 12.7 years) and 39 females (average age 41.7 ± 11.4 years). Of the 188 ruptured tendons (92 repairs on the right Achilles and 96 on the left), 103 were repaired percutaneously and 85 had open repairs. There were 18 (9.6%) complications. Three re-ruptures occurred, one following open and two following percutaneous repairs, all within 12 weeks of the original repair. Two patients developed a Venousthromboembolism (1.0%). Thirteen patients had suture reactions; three infections (1.6%), 11 wound complications (5.8%), and 3 required surgical excision of the suture material (1.6%). Non-absorbable sutures were associated with more wound complications and were more frequently used in open repairs (p = .003). Patients who underwent open repair experienced more wound complications (p = .0001). Patients who underwent percutaneous repair using absorbable suture experienced a lower rate of overall complications (p = .0007). Basketball (n = 29) was the most common sport during which ruptures occurred. Return to activity (RTA) was 8.2 ± 2.9 months. There was no difference for RTA between males and females (p = .54) and RM scores (p= .69), nor surgical technique, and no difference for RTA based on the desired activity (p = .47). 123 of the 188 patients returned to their desired activity (65.5%). There was a statistically significant evidence of a positive association between inability to perform heel-raises and decreased activity (p = .01).     

Achilles Impingement Tendinopathy on Magnetic Resonance Imaging

Haglund's syndrome is impingement of the retrocalcaneal bursa and Achilles tendon caused by a prominence of the posterosuperior calcaneus. Radiographic measurements are not sensitive or specific for diagnosing Haglund's deformity. Localization of a bone deformity and tendinopathy in the same sagittal section of a magnetic resonance imaging scan can assist with the diagnosis in equivocal cases. The aim of the present cross-sectional study was to determine the prevalence of Haglund's syndrome in patients presenting with Achilles tendinopathy and note any associated findings to determine the criteria for a diagnosis of Haglund's syndrome. We reviewed 40 magnetic resonance imaging scans with Achilles tendinopathy and 19 magnetic resonance imaging scans with Achilles high-grade tears and/or ruptures. Achilles tendinopathy was often in close proximity to the superior aspect of the calcaneal tuberosity, consistent with impingement (67.5%). Patients with Achilles impingement tendinopathy were more often female (p < .04) and were significantly heavier than patients presenting with noninsertional Achilles tendinopathy (p = .014) or Achilles tendon rupture (p = .010). Impingement tendinopathy occurred medially (8 of 20) and centrally (10 of 20) more often than laterally (2 of 20) and was associated with a posterior prominence or hyperconvexity with a loss of calcaneal recess more often than a superior projection (22 of 27 versus 8 of 27; p < .001). Haglund's deformity should be reserved for defining a posterior prominence or hyperconvexity with loss of calcaneal recess because this corresponds with impingement. Achilles impingement tendinopathy might be more appropriate terminology for Haglund's syndrome, because the bone deformity is often subtle. Of the 27 images with Achilles impingement tendinopathy, 10 (37.0%) extended to a location prone to Achilles tendon rupture. Given these findings, insertional and noninsertional Achilles tendinopathy are not mutually exclusive and impingement might be a subtle, unrecognized cause of Achilles tendinopathy and subsequent rupture.     

Can capsular plication compensate the lack of one suture anchor in an arthroscopic three suture anchor Bankart repair? A comparative study

ObjectiveThe aim of this study was to compare the complication rates and clinical results of labral repair with two suture anchors and capsular plication, and labral repair with three suture anchor fixation in artroscopic Bankart surgery.MethodsSixty-nine patients (60 males, 9 females; mean age: 28.2 ± 7.8 years (range: 16–50)) who had undergone arthroscopic repair of a labral Bankart lesion were evaluated. Group A underwent an arthroscopic Bankart repair with three knotless suture anchors, while group B underwent a modified arthroscopic Bankart repair with two knotless suture anchors and an additional capsular plication procedure. The mean follow-up was 52.5 months. Constant Shoulder Score (CSS), Rowe Score (RS), modified UCLA Shoulder Score (mUSS) and range of motion (ROM) were used as outcome measures.ResultsIn both groups, a significant improvement was detected in functional outcomes at postoperative last follow-up compared to the preoperative period. No statistically significant difference was found (p > 0.05) in clinical scores (CSS; Group A: 89.7, Group B: 80.2) (RS; Group A: 88.2, Group B: 80.2) (mUSS; Group A: 26.3, Group B: 25.7) external rotation loss (At neutral; Group A: 4.5°, Group B: 5.2°. At abduction; Group A: 4.3°, Group B: 5.7°) and recurrence rates (Group A: 13.3%, Group B: 20.8%). Although the difference was not statistically significant, the recurrence rate was higher in group B (20.8%), compared to group A (13.3%), despite the shorter average follow-up time of group B (p = 0.417).ConclusionsArthroscopic repair of labral Bankart lesions with both techniques showed good functional outcomes and stability at the latest follow-up. Higher recurrence rate despite the shorter average follow-up of group B suggests that two anchor usage might not be sufficient for Bankart repair in terms of better stability and less recurrence risk.Level of evidenceLevel III, Therapeutic Study.     

Biomechanical Comparison of Tape Versus Suture in Simulated Achilles Tendon Midsubstance Rupture

As sutures have progressed in strength, increasing evidence supports the suture tendon interface as the site where most tendon repairs fail. We hypothesized that suture tape would have a higher load to failure versus polyblend suture due to its larger surface area. Eleven matched pairs of cadaveric Achilles tendons were sutured with 2 mm wide braided ultrahigh molecular weight polyethylene tape (Tape) or 2 mm wide braided ultrahigh molecular weight polyethylene suture (Suture) using a Krackow repair method. All Achilles repair constructs were cyclically loaded, after which they were loaded to failure. Change in suture footprint height, clinical and ultimate load to failure, and location of failure was recorded. Clinical loads to failure for Tape and Suture were 290.4 ± 74.8 and 231.7 ± 70.4 Newtons, respectively (p= .01). Ultimate loads to failure for Tape and Suture were 352.9 ± 108.1 and 289.8 ± 53.7 Newtons, respectively (p = .11). Cyclic testing resulted in significant changes in footprint height for both Tape and Suture, but the 2 sutures did not differ in terms of the magnitude of change in footprint height (p = .52). The suture tendon interface was the most common site of failure for both Tape and Suture. Our results suggest that Tape may provide added repair strength in vivo for Achilles midsubstance rupture.