高强度聚酯纤维缝线减张治疗陈旧性髌腱断裂

目的 探讨陈旧性髌腱断裂的临床特点,介绍采用高强度聚酯纤维缝线减张治疗陈旧性髌腱断裂的手术方法 和术后康复方法 .方法 2002年1月至2007年2月,收治陈旧性髌腱断裂6例,手术切断超长的瘢痕愈合髌腱组织.恢复长度后重新吻合,并在胫骨结节和髌骨两端钻骨孔,采用4根高强度聚酯纤维缝线经骨孔减张保护.术后对患者采用积极的康复锻炼方案:术后第1天即町下地直立行走及被动屈膝90°,休息和睡眠时不须支具石膏固定保护;术后3周起开始练习主动抬腿;术后6周后开始练习快走,负重2 kg直腿抬高;术后12周后开始练习上下楼梯和下蹲;术后6个月后开始正常运动以及蹬跳运动.结果 术后随访1～5年,平均3.2年.患者早期即可以活动并可以下床直立行走,所有患者均未出现再断裂.手术6个月以后,患者均恢复正常的平地行走、跑步能力等,屈膝基本达到对侧的水平,股四头肌力量良好.Lysholm评分均能达到100分.结论 高强度聚酯纤维缝线减张治疗陈旧性髌腱断裂,创伤小,方法 简单,不须外加牵引,不须石膏固定,不须二次手术取内固定.积极的康复训练允许患者早期行走,效果可靠.     

Recurrent and Chronic Complete Ruptures of the Proximal Origin of the Hamstring Muscles Repaired With Fascia Lata Autograft Augmentation

Hamstring injuries are common, especially among athletes. A complete rupture of the proximal hamstring muscles requires surgical intervention. In this report we describe a reconstruction method for a complete proximal hamstring rupture using fascia lata autograft augmentation in addition to suture anchors. This method can be advocated in cases in which the primary repair has failed or in chronic injuries where a large defect between the distally retracted tendons and the ischial tuberosity prevents anatomic reinsertion. In our technique, a muscle-tendon flap is first created from the retracted tendon stump, turned proximally, and fixed to the ischial tuberosity by suture anchors. The fascia lata graft is then fixed from the midpart to the ischial tuberosity via the same sutures. The other sleeve of the graft is folded on the ventral side of the ruptured tendon stump and fixed by use of absorbable sutures. Then the other sleeve is folded on the dorsal side and fixed in the same manner. Finally, the fixation can still be reinforced with additional absorbable sutures passing through both sleeves of the graft, as well as the muscle-tendon bridge and the tendon stump.     

A mechanical comparison of gluteus medius attachment methods in a canine model

Seven techniques of gluteus medius attachment were compared in vitro in a canine model. Four methods were used for tendon to tendon attachment: (a) two modified Bunnell-Mayer stutures, (b) two Kessler locking loop sutures, (c) two horizontal mattress sutures, and (d) two sutures with a looped suture technique. The two methods of tendon to bone attachment were repair with a 1 cm spiked staple and repair with a spiked washer and screw, and the method of bone to bone attachment involved two figure-eight cerclage wires. The colitralateral limb served as a control. Compared with the bone to bone attachment, the four tendon to tendon attachments and the two tendon to bone attachments had significantly less strength (31 and 30% of the ultimate load for bone to bone repair, respectively) and tensile stiffness (24 and 39% of the tensile stiffness for bone to bone attachment, respectively) (p ≤ 0.0001). The control specimens were significantly stronger and stiffer than all specimens (p ≤ 0.05) except those that had bone to bone fixation. There were no significant differences among the four tendon to tendon suture repairs with regard to either strength or stiffness; the values ranged from 28–45% of those of the controls. Among the tendon to bone repairs, fixation with a spiked washer and screw was significantly stronger than that with a spiked staple (p = 0.032), but there was no difference between these two techniques with regard to stiffness.     

How to overcome severed sutures of the tibial bone peg in anterior cruciate ligament reconstruction

We report a case of severed sutures of the tibial bone peg during anterior cruciate ligament reconstruction. The graft retracted proximally in the bone tunnel. We describe a simple and aesthetically acceptable method to salvage this rare complication by use of a small arthrotomy through the defect in the remaining patellar tendon.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 3 (March), 2002: E12     

A looping operation to restore the distally ruptured tendon of the bicipital muscle

Surgical Principles The ruptured end of the tendon is bisected. An oval bone trough is made through the proximal radius and one of the tendon halves is pulled through it from the ulnar side. The other half is looped around the radius and the ends are then sutured together. Thus an anatomical reinsertion of the distal tendon of the biceps brachii muscle is achieved. The transosseous fixation of the distal biceps tendon was described in 1927 by Bunnel [1] and 1931 by Platt [5]. Modifications were established in 1928 by Kerschner [3], in 1938 by Thomsen [6], and in 1962 by Lange [4]. These techniques also attempt to reinsert the tendon anatomically. Revised Version from: Operat. Orthop. Traumatol. 4 (1992), 185–193 (German Edition).     

Fixation of tendon grafts for collateral ligament reconstructions: a cadaveric biomechanical study

PURPOSE: To compare the biomechanical properties of 4 methods of fixation of tendon grafts to bone as used for ligament reconstructions. METHODS: Thirty-two metacarpals were harvested from fresh-frozen cadavers and stripped of soft tissue. Flexor tendons were harvested from the same cadavers and cut into 2-mm-wide strips. Each tendon was fixed to a metacarpal head at the site of origin of a collateral ligament. Four different methods of fixation were tested. In group 1 the tendon was fixed to the bone with a 4.0-mm Arthrex bio-tenodesis interference screw (Arthrex, Inc., Naples, FL). In group 2 the tendon was passed through a bone tunnel and fixed with a 3.2-mm mini-Acutrak screw (Acumed, LLC, Hillsboro, OR) that was inserted in interference mode. In group 3 the tendon was passed through a bone tunnel and fixed with sutures tied over a polyethylene button. In group 4 the tendon was fixed with a mini-Mitek bone suture anchor (Mitek Worldwide, Norwood, MA). All specimens were clamped into a linear loading machine and loaded until failure. Statistical analysis was performed by 1-way analysis of variance testing. RESULTS: The differences in maximal tensile strength and stiffness were statistically significant when comparing any 2 groups. The Arthrex biotenodesis interference screw was the strongest and stiffest fixation method, followed by the Acutrak screw inserted in interference mode. Next was the suture tied over a button method. The mini-Mitek bone suture anchor was the weakest. CONCLUSIONS: Interference screw fixation of tendons to bone has statistically significant higher pullout strength and stiffness than 2 other commonly used fixation methods. The use of interference screws for fixation of tendon grafts to bone for hand ligament reconstructions is a promising new surgical technique.     

Repair of Patellar Tendon Rupture With Suture Anchors

Repair of a ruptured patellar tendon is usually performed with the use of sutures that are passed through intraosseous tunnels within the patella. However, a number of caveats pertain to this method. The Beath pin may penetrate the articular surface or may unduly injure the quadriceps through multiple passes. The already injured patellar tendon may be overly shortened after debridement and insertion into bony tunnels, and loosening through the tunnels may occur. Obliquely oriented bony tunnels may cause abnormal patellar tilt, leading to uneven force distribution. This technical note reports the details of an alternative repair with 3 suture anchors that is incorporated into a 6-stranded Krackow technique, with additional mattress sutures as needed. Because of the low-profile nature of the anchors, this technique more accurately re-creates the footprint at the inferior pole of the patella and avoids articular cartilage penetration and injury to the surrounding soft tissue. The possibility of loosening through bony tunnels or creation of abnormal stresses is eliminated. A smaller incision is used, and operative (tourniquet) time is diminished. Although pullout of the anchors may be a logical concern, previous studies have suggested that this construct is more than sufficient to withstand the forces to which it is subjected.     

Treatment of acute achilles tendon rupture with the panda rope bridge technique

IntroductionAlthough nonsurgical methods and many surgical techniques have been developed for repairing a ruptured Achilles tendon, there is no consensus on its best treatment. In this article, a novel minimally invasive technique called the Panda Rope Bridge Technique (PRBT) is described.MethodsPatient with acute Achilles tendon rupture was operated on in the prone position. The PRBT begin with making the proximal bridge anchor (Krackow sutures in the myotendinous junction), the distal bridge anchor (two suture anchors in the calcaneus bone) and the ropes (threads of the suture anchors) stretched between the anchor sites. Then a small incision was made to debride and reattach the stumps of ruptured tendon. After the surgery, no cast or splint fixation was applied. All patients performed enhanced recovery after surgery (ERAS), which included immediate ankle mobilisation from day 1, full weight-bearing walking from day 5 to 7, and gradually take part in athletic exercises from 8 weeks postoperatively.ResultsPBRT was performed in 11patients with acute Achilles tendon rupture between June 2012 and June 2015. No wound infection, fistula, skin necrosis, sural nerve damage, deep venous thrombosis or tendon re-rupture was found. One year after the surgery, all patients reported 100 AOFAS ankle-hindfoot score points and the mean ATRS was 96.6.ConclusionThe PRBT is a simple, effective and minimally invasive technique, with no need for immobilisation of the ankle, making possible immediate and aggressive postoperative rehabilitation.     

Quadriceps and patellar tendon ruptures

Ruptures of the quadriceps as well as the patellar tendon occur in low frequency, but cause major functional deficits of the leg. These injuries usually require operative treatment. Acute quadriceps tendon ruptures are treated by suture repair, using heavy sutures guided through bone tunnels in the patella. Chronic defects and neglected cases require a local tendon transfer, either by a quadriceps tendon turn-down or by a V-Y-plasty of the quadriceps tendon. Ruptures of the patellar tendon are treated by suture of the tendon stumps plus an reinforcement procedure protecting the tendon and avoiding secondary patella alta. Patello-tibial fixation may be achieved by a cerclage technique using wire or an autologous tendon strip, alternatively a patello-tibial external fixator can be applied. In chronic and neglected cases, patellar tendon reconstruction is performed with autologous tendon grafts or with soft tissue allografts. The graft must be protected by a patello-tibial fixation for the first weeks.     

A New Technique to Improve Tissue Grip: “The Lasso-Loop Stitch”

In the chain of reattachment of the rotator cuff, links extend from the tendon to the anchor within the bone. Passage of the suture through the tendon is noted at the start of the chain, but as shown before, this is most vulnerable, depending on the quality of the tendon. We present a new technique of suture placement designed to improve tissue grip: “The lasso-loop stitch.” One side of the wire is passed through the edge of the tendon, which is ruptured by the wire in the middle—not at the end. The wire is not pulled through completely. Through this process, a loop is created at the upper side of the tendon. The end of the wire, at the same side used to make the loop, is passed through the loop with a grasp. The wire is passed through the loop, and the end of the wire is brought extra-articularly. Through this technique, the reduction force of a suture is augmented, and a constricting factor is added. We have not changed the location of the anchors. So far, we have used the technique in rotator cuff repair, biceps tenodesis, and the Bankart procedure.     

Tensile strength of the medial patellofemoral ligament before and after repair or reconstruction

The tensile strength of the medial patellofemoral ligament (MPFL), and of surgical procedures which reconstitute it, are unknown. Ten fresh cadaver knees were prepared by isolating the patella, leaving only the MPFL as its attachment to the medial femoral condyle. The MPFL was either repaired by using a Kessler suture or reconstructed using either bone anchors or one of two tendon grafting techniques. The tensile strength and the displacement to peak force of the MPFL were then measured using an Instron materials-testing machine. The MPFL was found to have a mean tensile strength of 208 N (SD 90) at 26 mm (SD 7) of displacement. The strengths of the other techniques were: sutures alone, 37 N (SD 27); bone anchors plus sutures, 142 N (SD 39); blind-tunnel tendon graft, 126 N (SD 21); and through-tunnel tendon graft, 195 N (SD 66). The last was not significantly weaker than the MPFL itself.     

Endoscopic-assisted repair of acute Achilles tendon rupture with Krackow suture: An anatomic study

PurposeTo study the feasibility of applying Krackow locking stitches in the endoscopic-assisted repair of acute Achilles tendon rupture and the possible complications encountered.Type of studyAnatomic study.MethodsTwelve Achilles tendons in six cadavers were cut at 6 cm from its insertion and endoscopic-assisted repair of Achilles tendon was performed. These legs were then cut open in midline to study (i) the locking stitches formed and (ii) the relation of the sural nerve to the locking stitches.ResultWith endoscopic-assisted technique, Krackow-type locking stitches can be formed in eight legs. In four legs, the stitches fell into the ruptured gap and lie deep to the tendon. The tendon rupture end was grasped by the suture rather than forming a Krackow-type locking stitch when the suture was tightened. There was no sural nerve laceration noted. However, in two legs, the sural nerves were found trapped in the sutures at around the proximal portal.ConclusionsKrackow locking stitches can be formed by the minimally invasive technique. However, there are risks of stitches falling into the ruptured gap and lie deep to the tendon and risk of sural nerve entrapment at the proximal medial portal. The original technique is not suitable for clinical application. Modification of the technique by grasping the tendon end with Allis tissue forceps before passing the suture may prevent the suture from falling into the ruptured tendon gap.     

Fibrous connection to bone after immediate repair of the canine infraspinatus: the most effective bony surface for tendon attachment

The purpose of this histologic study was to identify the most effective bony surface for fibrous connection to bone after immediate repair of the canine infraspinatus. Light microscopic views were used to evaluate collagen fiber development. The left infraspinatus tendon of 15 dogs was transected and repaired to 3 different bone surfaces: a tendon end adjacent to the tendon insertion (group 1, n = 5), a calcified fibrocartilage layer (group 2, n = 5), and a cancellous surface (group 3, n = 5). Tendon repair to distal tendon ends restored the 4-layered enthesis in the healing period, whereas tendon repair to the calcified fibrocartilage layer considerably delayed fiber development into bone. Fiber connection to cancellous surface developed according to the remodeling of trabecular bone. Secure fiber connection into the thickened trabecular bone developed by 16 postoperative weeks. On the basis of these results, in clinical settings, ruptured tendon ends should be attached to the remaining distal tendon end or to a cancellous surface; they should not be attached to a calcified fibrocartilage layer.     

Flexor tendon repair in zone II with 6-strand techniques and early active mobilization

PURPOSE: There are many biomechanic studies of 6-strand suture techniques for active mobilization, but few reports have described the clinical outcome in zone II flexor tendon lacerations. We discuss the clinical results of zone II flexor tendon repair using 2 of these techniques followed by controlled early active mobilization. METHODS: Six-strand sutures using the number 1 technique by Yoshizu or a triple-looped suture technique were used to repair flexor tendons in 27 fingers from 21 consecutive patients. Fingers were mobilized by combining active extension and passive or active flexion in a protective splint for the first 3 weeks after surgery. The follow-up period averaged 13 months. RESULTS: Based on the original Strickland criteria, the results were excellent in 17 fingers, good in 9, and fair in 1. The average flexion was 62 degrees for distal interphalangeal joints and 91 degrees for proximal interphalangeal joints. None of the repaired tendons ruptured. CONCLUSIONS: The 6-strand flexor tendon suture technique followed by controlled active mobilization protected with a dorsal splint is safe, produces no ruptures, and achieves very good results in zone II flexor tendon laceration repair. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level II.     

Operativer Zugang zum Schultergelenk

Osteotomy of the lesser tuberosity for the surgical delto-pectoral approach to the glenohumeral joint results in good visualization and overview and sufficient anatomical refixation of the insertion of the subscapularis muscle. However, clinical and biomechanical studies have not shown clearly significantly better results for osteotomy concerning ultimate load to failure, displacement after cyclic loading and outcome in patients compared with tenotomy and tenodesis of the subscapularis tendon. One advantage of osteotomy, however, is the potential radiological evaluation of the refixation with healing of the bony fragment. In the context of refixation, securing of the sutures behind the stem during implantation can be beneficial because it prevents sutures cutting through the bone. This benefit is increased in cemented stems by means of better suture fixation. With respect to the choice of osteotomy or tenotomy, the bony substance and tendon quality of the insertion of the subscapularis muscle should be evaluated.     

Die arthroskopische transossäre Reinsertion der Rotatorenmanschette

OBJECTIVE: Arthroscopic reinsertion of the supraspinatus and infraspinatus tendons by means of imitation of an open transosseous reinsertion technique. INDICATIONS: Tears in the tendon cuffs of the supraspinatus and infraspinatus muscles. Patients < 75 years of age. CONTRAINDICATIONS: Retracted tendons that cannot be sufficiently mobilized to provide a tension-free reinsertion. Tears of the tendon cuff of the subscapsularis muscle. SURGICAL TECHNIQUE: The free edges of the tendons are sparingly resected. The tendon attachment site on the greater tuberosity is freed of soft tissue and decorticated using an arthroscopic bone burr. A full-radius burr is used to drill insertion sites for the sutures in the tuberosity. A hollow needle is inserted percutaneously to puncture the free edges of the tendon for a single reinsertion suture. The hollow needle is then fed through the greater tuberosity to the lateral portal. The suture is guided through the needle and advanced via a working cannula. If the tear is > 2 cm in width, a mattress suture should be placed via another channel in the bone. This is to provide plane contact of the tendon to the reinsertion site. POSTOPERATIVE MANAGEMENT: Restriction of movement using a shoulder bandage for 6 weeks after the operation. RESULTS: In the 75 patients treated using a single suture, there was an improvement compared to the related Constant Score from 55.8% before the operation to 80.4% at the follow-up examination, after an average of 26.8 months. The average age in this group was 58.2 years (range 35-75 years). In the 21 patients treated with a mattress suture, there was an improvement compared to the related Constant score from 59% before the operation to 83% at 14.3 months after the operation. The average age in this group was 58 years (range 35-75 years).     

Mode of failure for rotator cuff repair with suture anchors identified at revision surgery

Rotator cuff tears are a common cause of shoulder pain and dysfunction. After surgical repair, there is a significant re-tear rate (25%-90%). The aim of this study was to determine the primary mode of mechanical failure for rotator cuffs repaired with suture anchors at the time of revision rotator cuff repair. We prospectively followed 342 consecutive torn rotator cuffs, repaired by a single surgeon using suture anchors and a mattress-suturing configuration. Of those shoulders, 21 (6%) subsequently underwent a revision rotator cuff repair by the original surgeon, and 1 underwent a second revision repair. Intraoperative findings, including the mode of failure, were systematically recorded at revision surgery and compared with the findings at the primary repair. In addition, 81 primary rotator cuff repairs had a radiographic and fluoroscopic evaluation at a mean of 37 weeks after repair to assess for any loosening or migration of the anchors. At revision rotator cuff repair, the predominant mode of failure was tendon pulling through sutures (19/22 shoulders) (P <.001). Two recurrent tears occurred in a new location adjacent to the previous repair, and one anchor was found loose in the supraspinatus tendon. The mean size of the rotator cuff tear was larger at the revision surgery (P =.043), the tendon quality ranked poorer (P =.013), and the tendon mobility decreased (P =.002), as compared with the index procedure. The radiographs and fluoroscopic examination showed that all 335 anchors in 81 patients were in bone. Rotator cuff repairs with suture anchors that underwent revision surgery failed mechanically by three mechanisms, the most common of which was tendon pulling through sutures. This suggests that the weak link in rotator cuff repairs with suture anchors and horizontal mattress sutures, as determined at revision surgery, is the tendon-suture interface.     

A biomechanical analysis of suture materials and their influence on a four-strand flexor tendon repair

PURPOSE: Flexor tendon repair strength depends on the suture technique and the suture material used. Configurations that incorporate locking loops prevent sutures from pulling through the tendon but typically fail because of suture breakage. The choice of suture material therefore influences repair strength. This study investigated the mechanical properties of 5 nonabsorbable 4-0 suture materials (monofilament nylon, monofilament polypropylene, braided polyester, braided stainless steel wire, and braided polyethylene) and evaluated their performance when used in a locking 4-strand flexor tendon repair configuration. METHODS: Five samples of 2 strands of each suture type were tested mechanically to determine the material stiffness and ultimate load. In addition, 50 fresh porcine flexor tendons were divided and repaired with each of the 5 suture materials using a 4-strand single-cross technique. Gap force, ultimate strength, and stiffness were measured to compare biomechanical performance. RESULTS: All repairs failed by suture rupture at the locking loop. Fibrewire and stainless-steel sutures and repairs were significantly stronger and stiffer than the other suture types. The results for Prolene and Ethibond were similar in the tendon repair groups with respect to gap and ultimate forces although Ethibond provided significantly increased repair stiffness. Nylon sutures and repairs consistently produced the poorest mechanical performance in all outcome measures. CONCLUSIONS: Suture material strongly influences the biomechanical performance of multistrand tendon repairs and is an important consideration for the surgeon. Fibrewire and stainless steel are the most biomechanically suitable suture materials for flexor tendon repair whereas nylon is the least suitable. Further developments in suture materials are important for advancements in flexor tendon repair strength.     

The effect of the EndoPearl on soft-tissue graft fixation

This study determined whether EndoPearl (Linvatec Corp, Largo, Fla) secondary fixation to an interference screw increased the fixation strength of a soft-tissue tendon graft. Ten-millimeter porcine patellar tendon grafts with attached patellae were harvested without a tibial bone plug and inserted into 9-mm tibial tunnels to test a nonlooped solid tendon graft. Twenty grafts were fixed with a BioScrew (Linvatec Corp, Largo, Fla) and 20 with BioScrew/EndoPearl combinations. These were tested with straight line destructive loads at 60 mm/min without cycling and after 500 cyclic loads. Tendons were secured with nonlocking (Bunnell) sutures along both edges and then passed through the central hole of the EndoPearl. A significant decrease in stretch at maximum force was noted between specimens that were cyclically loaded prior to testing and those that were not (P<.001); a significant increase in energy absorption between specimens with and without EndoPearl in the straight destructive test (P<.02); and a significant increase in stiffness with cyclic loading (P<.001). A positive correlation also was noted between failure force and insertion torque (P=.02). The EndoPearl increased energy absorption at failure. Solid tendon grafts consistently failed due to the sutures tearing out of the tendon and the tendon sliding by the interference screw. The Bunnell stitch was the weakest link and is not effective for this graft.     

Editorial Commentary: Causes of Failure After Arthroscopic Rotator Cuff Repair

Causes of failure after arthroscopic rotator cuff repair include patient factors, tear factors, and surgical factors. Failure may occur at the suture–tendon interface, the bone–tendon interface, or the bone–anchor interface. Low bone mineral density (BMD) in the greater tuberosity has been reported as a prognostic factor for recurrent tears following rotator cuff repair, and although most studies suggest the tendon-to-suture interface as the “weakest link,” patients with low BMD may have lower suture anchor pull-out strength. A potential alternative cause of failure is the suture cutting through the greater tuberosity bone in patients with low BMD. Knotless suture bridge constructs or single-row constructs may be more susceptible to a suture cutting through the bone. The knotted suture bridge technique, wherein the medial mattress sutures are tied, may to some extent “shield” against complete cut-through. When bone quality appears poor, a common response is to change the type of anchor, size of anchor, or the location of the anchor. Other factors, such as bone preparation, suture type, suture tensioning, and anchor type (e.g., internal vs external locking), may all potentially affect suture cutting through weak bone.