Movement-induced knot migration after anterior stabilization in the shoulder

No Clear Difference in Clinical Outcomes Between Knotted and Knotless Arthroscopic Bankart Repair: A Systematic Review

PURPOSE

To analyze whether the arthroscopic Bankart repair using a knotless suture anchor has a better functional outcome than the conventional knot-tying Bankart repair.

METHODS

A comprehensive literature search was done in the PubMed, Scopus, Embase, and Cochrane databases in May 2023. Studies comparing the clinical outcome of Bankart repair using knotless and knot-tying techniques were included in the study. In vitro, animal, and Level IV and V studies were excluded. The risk of bias in randomized controlled trials was calculated according to the RoB 2 tool, and for nonrandomized studies, Methodological Index for Non-Randomized Studies criteria were used. Statistical analysis was done using RevMan software.

RESULTS

A total of 9 studies, including 2 randomized controlled trials and 7 nonrandomized comparative studies involving 720 patients, were included in the systematic review. The ROWE score ranged from 81.7 to 94.3 in the knot-tying group and 86 to 96.3 in the knotless group. Visual Analog Scale scores at the final follow-up ranged from 0.1 to 1.7 in the knot-tying group and 0.7 to 2.5 in the knotless group. The rate of redislocation, subluxation, and revision surgery in the knot-tying group ranged from 0% to 14.7%, 16.7% to 29.7%, and 1.6% to 17.6%, respectively, whereas that in the knotless group ranged from 2.4% to 23.8%, 7.4% to 22.2%, and 2.4% to 19%, respectively. The mean external rotation was 54° to 65° in the knot-tying group and 61° to 99° in the knotless group. The mean forward-flexion was 164 to 172 in the knot-tying group and 165 to 174 in the knotless group. Our subjective synthesis does not reveal any difference in the outcome between the 2 groups.

CONCLUSIONS

The available literature does not demonstrate a clear difference in functional outcomes, residual pain, and rate of complications as redislocation, subluxation, and revision surgery between Bankart repairs performed with knotted and knotless anchors.

LEVEL OF EVIDENCE

Level III, systematic review of Level I to III studies.

Knotless Bioabsorbable Anchors Placed on the Glenoid Face for Arthroscopic Bankart Repair

BACKGROUND

Quantitative analysis of the glenoid face knotless-type anchor placement for arthroscopic Bankart repair has not been reported.

PURPOSE

To evaluate the clinical and radiologic outcomes after arthroscopic Bankart repair using knotless bioabsorbable anchors depending on the anchor location.

STUDY DESIGN

Case series, Level of evidence, 4.

METHODS

A total of 124 patients (113 men and 11 women; age, 25.6 ± 7.5 years; follow-up time, 46.5 ± 18.2 months [range, 6.2-75.5 months]) who underwent arthroscopic Bankart repair with the bioabsorbable knotless anchor between 2017 and 2021 were included in this study. Among them, 118 patients were observed for >2 years (mean, 48.2 ± 16.8 months [range, 24-75.5 months]) and were analyzed for final clinical and radiologic outcomes. Using postoperative 6-month magnetic resonance imaging, remnant glenoid (%) and labral height were measured. Shoulder range of motion (ROM), radiographic osteoarthritic change, dislocation, apprehension test, and return to sports were recorded. Three groups were established based on the remnant glenoid, which represented the percentage of the exposed glenoid anteroposterior diameter to the original diameter using the best-fit circle method-group A: lower quartile; group B: interquartile; and group C: upper quartile-and variables were analyzed.

RESULTS

Overall, the remnant glenoid was 57% ± 6.4% (range, 41.5%-75%) after the surgery. Osteoarthritic change, dislocations, and positive apprehension tests were observed in 5 (4.2%), 4 (3.4%), and 12 (10.2%) patients, respectively. A total of 34 (28.8%) and 64 (54.2%) patients could return to sports without and with restrictions, respectively. Comparing groups A, B, and C, postoperative labral height (7 ± 1, 7 ± 2, and 7 ± 1 mm; P = .623), final osteoarthritic change (1, 4, and 0; P = .440), positive apprehension tests (5, 5, and 2; P = .387), and return to sports (complete/restricted/unable, 6/18/5, 19/29/11, 9/17/4; P = .769) were not different. All ROM were similar across the groups (all P > .054), except for external rotation (ER) at postoperative 6 months (41.3°± 12.8°; 50.2°± 18.5°; and 49.8°± 15.2°; P = .050). However, ER after 1 year was similar across the groups (all P > .544). In further analysis, patients with positive apprehension tests had lower labral height compared with others (5 [4-6] mm and 7 [6-8] mm; P < .001).

CONCLUSION

In arthroscopic Bankart repair, the placement of knotless bioabsorbable anchors on the glenoid face, combined with the remplissage procedure or rotator interval closure, resulted in a low recurrence rate and moderate return to sports. However, most patients had some restrictions in returning to sports. Moreover, this technique was not associated with postoperative arthritis and shoulder stiffness, including ER deficit, which was not affected by the position of the anchor on the glenoid face for a minimum 2-year follow-up.

Disabled Throwing Shoulder: 2021 Update: Part 2-Pathomechanics and Treatment

The purpose of this paper is to provide updated information for sports healthcare specialists regarding the disabled throwing shoulder (DTS). A panel of experts, recognized for their experience and expertise in this field, was assembled to address and provide updated information on several topics that have been identified as key areas in creating the DTS spectrum. Each panel member submitted a concise presentation on one of the topics within these areas, each of which were then edited and sent back to the group for their comments and consensus agreement in each area. Part two presents the following consensus conclusions and summary findings regarding pathomechanics and treatment, including (1) internal impingement results from a combination of scapular protraction and humeral head translation; (2) the clinically significant labral injury that represents pathoanatomy can occur at any position around the glenoid, with posterior injuries most common; (3) meticulous history and physical examination, with a thorough kinetic chain assessment, is necessary to comprehensively identify all the factors in the DTS and clinically significant labral injury; (4) surgical treatment should be carefully performed, with specific indications and techniques incorporating low profile implants posterior to the biceps that avoid capsular constraint; (5) rehabilitation should correct all kinetic chain deficits while also developing high-functioning, throwing-specific motor patterns and proper distribution of loads and forces across all joints during throwing; and (6) injury risk modification must focus on individualized athlete workload to avoid overuse. LEVEL OF EVIDENCE: V, expert opinion.

Comparison of Biomechanical Failure Loads Between Tape-Type and Conventional Sutures in Internal Knotless Anchor–Based Constructs

Background:

Despite the increasing prevalence of tape-type sutures, whether internal knotless anchors can consistently affix tape-type sutures has not been thoroughly investigated.

Purpose:

To evaluate whether substituting tape-type sutures for conventional sutures influences the suture-holding strength of internal knotless anchors.

Study Design:

Controlled laboratory study. Level of evidence, 5.

Methods:

A total of 3 internal knotless anchors were tested: a spiral core clamping anchor (Footprint Ultra PK), a winged clamping anchor (PopLok), and a spooling anchor (ReelX STT). Four constructs were compared for each type of anchor, with the anchor double or quadruple loaded with tape-type sutures or conventional sutures. The testing protocol comprised preloading suture tension to 10 N; cyclic loading, in which tension increased in increments of 10 N from 10 to 90 N; and a load-to-failure stage set at a speed of 0.5 mm/s. The clinical failure load (CFL) was defined as suture slippage of ≥3 mm. Also, 1-way analysis of variance and power analysis were used to compare the CFLs of the constructs.

Results:

For the quadruple-loaded spiral core clamping anchors, a significant reduction in CFLs was seen with conventional sutures over tape-type sutures (138.10 ± 4.73 vs 80.00 ± 12.25 N, respectively; P < .001). This reduction was not observed under the double-loaded condition (conventional vs tape type: 76.00 ± 5.48 vs 80.00 ± 10.00 N, respectively). Substitution of the suture materials did not significantly reduce the CFLs for the winged clamping anchors (conventional vs tape type: 40.00 ± 10.00 vs 30.00 ± 7.07 N for double loaded, respectively, and 64.00 ± 13.41 vs 50.00 ± 10.00 N for quadruple loaded, respectively) or the spooling anchors (conventional vs tape type: 62.00 ± 19.23 vs 56.32 ± 20.20N for double loaded, respectively, and 72.00 ± 21.68 vs 84.00 ± 13.42 N for quadruple loaded, respectively).

Conclusion:

Substituting tape-type sutures for conventional sutures increased the CFLs of some internal knotless anchors. With specific suture-anchor combinations, quadruple-loaded conventional suture anchors had CFLs higher than those of double-loaded conventional suture anchors.

Clinical Relevance:

When multiple tape-type sutures are used in conjunction with a clamping anchor, clinicians should note a possible reduction in CFLs and resultant early suture slippage.

Arthroscopic Bennett Lesion Resection and Posterior Labral Repair Using All-Suture Anchors

The Bennett lesion is an extra-articular ossification at the posteroinferior glenoid rim that is common among overhead-throwing athletes. While the majority of these exostoses are asymptomatic, some may cause posterior shoulder pain during throwing motion and frequently have concomitant posterior labral tears. Multiple approaches to Bennett lesion resection have been described, and there is debate regarding the need for capsulotomy, posterior labral repair, and capsular repair. The purpose of this article is to describe our preferred surgical technique for arthroscopic Bennett lesion resection and posterior labral repair using knotless all-suture anchors.

Knotless anchor repair produced similarly favourable outcomes as knot anchor repair for anterior talofibular ligament repair

PURPOSE

To compare clinical function after knot anchor versus knotless anchor repair of the anterior talofibular ligament (ATFL) in patients with chronic lateral ankle instability.

METHODS

All patients who underwent arthroscopic surgical ATFL repair using knot or knotless suture anchors were included in this study. Functional scores (American Orthopedic Foot and Ankle Society (AOFAS), Karlsson score and Tegner activity scores) and magnetic resonance imaging (MRI) were used to evaluate the ankle with a follow-up of at least 2 years.

RESULTS

A total of 52 patients with chronic ankle instability were included in this study. Among these patients, 23 patients underwent one knot anchor repair procedure (Group A), and the other 29 patients underwent one knotless anchor repair procedure (Group B). At the final follow-up, there were no significant differences between Group A and Group B regarding the AOFAS score (89 ± 9 vs 84 ± 11; ns), Karlsson score (82 ± 14 vs 75 ± 18; ns), or Tegner activity score (4 ± 1 vs 4 ± 2; ns). There also were no significant differences in the mean ATFL signal-noise ratio (SNR) value (7.5 ± 4.4 vs 7.3 ± 2.9; ns) or ATFL angle (82° ± 7° vs 84° ± 9°; ns) between the groups.

CONCLUSION

When compared with knot repair, knotless repair of the lateral ankle ligament produced similar functional outcomes.

LEVEL OF EVIDENCE

III.

The Arthroscopic Bankart Repair: State of the Art in 2020: Decision-making and Operative Technique

Traumatic anterior shoulder instability is prevalent among young athletes, and recurrent dislocations can result in compromised upper extremity function, increasing glenohumeral bone loss, and ultimately, posttraumatic arthritis. Although management algorithms have evolved in response to contemporary data and technical innovation, the arthroscopic Bankart repair continues to be a mainstay for the primary surgical management of first-time or recurrent anterior shoulder instability with marginal attritional glenoid bone loss (ie, <10% to 15%) and/or "on track" Hill-Sachs defects. The advantages of arthroscopic stabilization include its minimally invasive technique, high cost effectiveness, and relatively low recurrence rates and propensity for perioperative complications. The current article reviews contemporary indications/contraindications, management of the first-time dislocator, critical glenoid bone loss, surgical technique, and reported clinical outcomes of the arthroscopic Bankart repair.

Arthroscopic Knotless Rotator Cuff Repair With Decellularized Dermal Allograft Augmentation: The "Canopy" Technique

Repairability and clinical outcomes of full-thickness rotator cuff tears rely on tendon mobility, tissue quality, and subsequent tension on a repair. While repair of rotator cuff tears tend to yield excellent clinical results, poor tissue quality has been an important factor that has hampered successful outcomes. This Technical Note describes a double-row rotator cuff repair using a SpeedBridge configuration with dermal allograft "canopy" augmentation to bolster the repairable but thinned rotator cuff tissue. This technique employs a unique graft fixation strategy to simplify the procedure. This approach could provide surgeons with a great option when faced with mobile but thinned rotator cuff tissue.

Posterior Glenohumeral Instability: Diagnosis and Management

Posterior glenohumeral instability can manifest as posterior shoulder pain and dysfunction, particularly among athletes. Repetitive, posteriorly-directed axial loads, as commonly encountered by contact athletes (American football linemen, rugby players), result in microtrauma that can induce posteroinferior labral tears. Alternatively, SLAP tears commonly seen in throwing athletes may propagate in a posteroinferior direction (i.e., a type VIII SLAP tear), owing to a complex pathologic cascade involving glenohumeral capsular contracture and imbalances among the dynamic stabilizing muscles of both the glenohumeral joint and shoulder girdle. The diagnosis of posterior glenohumeral instability is elucidated by a thorough history and physical examination. Posterior shoulder pain is oftentimes insidious in onset. The throwing athlete with posterior glenohumeral instability may complain of diminished control, accuracy, and generalized shoulder discomfort. A number of provocative physical examination maneuvers have been described (Kim test, Jerk test), which load the humeral head against the labral lesion and recreate patients' symptoms. Magnetic resonance imaging and magnetic resonance arthrography can be of value in demonstrating avulsions of the labrum from the posteroinferior glenoid, and computed tomography is useful for quantifying the location and amount of attritional glenoid bone loss, although in contradistinction to anterior glenohumeral instability, clearly defined thresholds that would otherwise guide treatment have not been established. In the absence of substantial bone loss, arthroscopic posterior capsulolabral repair remains the gold standard for the surgical management of symptoms refractory to nonoperative treatment, and excellent clinical outcomes have generally been reported. However, high rates of return to play at the previous level of participation, particularly among throwing athletes, have been less consistently observed. Risk factors for the need for revision stabilization include surgery on the dominant extremity, female sex, and capsulolabral repairs involving either anchorless techniques or the use of less than 4 anchors.

Arthroscopic Low-Profile Knotless Repair of SLAP Tears With Suture Tape

SLAP tears have been a controversial topic in shoulder surgery for decades. The indications for repair of SLAP tears, as well as the methods of repair, have undergone a recent evolution. The use of intra-articular knots for SLAP repair has fallen out of favor because of potential abrasive damage to the rotator cuff and glenohumeral articular cartilage due to knot migration and prominence. In response to this potential iatrogenic injury, arthroscopic techniques have undergone an evolution using advanced techniques with low-profile knotless repairs. We describe our preferred low-profile knotless technique for SLAP repair using LabralTape (Arthrex) in a horizontal mattress configuration.

Differences in Failure Mode Between Simple and Mattress Suture Configuration in Arthroscopic Bankart Repairs: A Cadaveric Study

Background

Traumatic anterior shoulder dislocations disrupt the anteroinferior labrum (Bankart lesion), leading to high rates of instability and functional disability, necessitating stabilization.

Purpose

To investigate modes and locations of repair failure between simple and horizontal mattress suture configurations after arthroscopic Bankart repair using suture anchors in a cadaveric model.

Study Design

Controlled laboratory study.

Methods

A total of 48 fresh-frozen human cadaveric shoulders from 48 specimens underwent creation of Bankart lesions from either the 3:00 to 6:00 o'clock position on the right glenoid or the 6:00 to 9:00 o'clock position on the left glenoid. Shoulder laterality between specimens was alternated and randomized to either simple or mattress suture repair configurations. In each shoulder, anchors were placed on the glenoid at the 3:00, 4:30, and 6:00 o'clock positions on the right or 6:00, 7:30, and 9:00 o'clock positions on the left and were secured via standard arthroscopic knot-tying techniques. Specimens were tested in the supine anterior apprehension position using a servohydraulic testing machine that was loaded to failure, simulating a traumatic anterior dislocation. After dislocation, open inspection of specimens was performed, and failure mode and location were documented. Differences in failure mode and location were compared using nominal multivariate generalized estimating equations.

Results

Simple suture repairs most frequently failed at the labrum, while mattress suture repair failed at the capsule. Regardless of configuration, repairs failed most commonly at the 3:00 o'clock position on the right shoulder and 9:00 o'clock position on the left shoulder. Compared with mattress suture repairs, simple suture repairs failed at a significantly higher rate at the 6:00 o'clock position.

Conclusion

Traumatic anterior shoulder dislocation after arthroscopic Bankart repair in a cadaveric model resulted in simple suture configuration repairs failing most commonly via labral tearing compared with capsular tearing in mattress repairs. Both repair configurations failed predominately at the anterior anchor position, with simple suture repairs failing more commonly at the inferior anchor position.

Clinical Relevance

Horizontal mattress suture configurations create a larger area of repair, decreasing the risk of repair failure at the labrum. The extra time required for mattress suture placement at the inferior anchor position is used effectively, resulting in lower biomechanical failure rates.

Posterior Labral Injury and Glenohumeral Instability in Overhead Athletes: Current Concepts for Diagnosis and Management

Posterior glenohumeral instability in overhead athletes presents a unique set of challenges for both diagnosis and treatment. Although a great deal of attention has been focused on the management of injuries to the biceps-labrum complex and rotator cuff in throwers, comparatively less has been written about posterior glenohumeral instability within this unique cohort. Historically, posterior instability has been observed secondary to either acute trauma or repetitive microtrauma, usually among collision athletes, weight lifters, and rowers. However, posterior glenohumeral instability resulting from pathology of the posterior capsulolabral tissues in throwers is a different entity, and the clinical assessment begins with an accurate differentiation between adaptive capsular laxity and labral injury with pathologic instability. Some posterior capsule labrum tears confirmed on arthroscopy will require nothing more than débridement. However, for more extensive lesions, surgical treatment must balance the necessity to repair torn capsulolabral tissues with the tendency to over constrain the shoulder. The literature provides mixed results regarding the likelihood of overhead athletes with posterior glenohumeral instability and labral injury treated surgically returning to their preinjury level of sport performance.

Sliding or Nonsliding Arthroscopic Knots for Shoulder Surgery: A Systematic Review

Background

Knot tying is a crucial component of successful arthroscopic shoulder surgery. It is currently unknown whether sliding or nonsliding techniques result in superior clinical outcomes.

Purpose

To assess the clinical outcomes of arthroscopic sliding knot (SK)- versus nonsliding knot (NSK)-tying techniques during arthroscopic shoulder surgery, including rotator cuff repair, Bankart repair, and superior labral anterior-posterior (SLAP) repair.

Study Design

Systematic review; Level of evidence, 4.

Methods

A systematic search of the PubMed, Embase, and Cochrane Library databases was performed using PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. All English-language literature published between 2000 and 2018 reporting clinical outcomes utilizing SK- or NSK-tying techniques during rotator cuff repair, Bankart repair, and SLAP repair with a minimum 24-month follow-up was reviewed by 2 independent reviewers. Information on type of surgery, knot used, failure rate, patient satisfaction, and patient-reported outcomes was collected. Patient-reported outcome measures included the Constant-Murley score, Rowe score, and visual analog scale for pain. Study quality was evaluated using the modified Coleman Methodology Score.

Results

Overall, 9 studies (6 level 3 and 3 level 4) with a total of 671 patients (mean age, 52.8 years [range, 16-86 years]; 65.7% male; 206 SK and 465 NSK) were included. There were 4 studies that reported on Bankart repair in 148 patients (63 SK and 85 NSK), 3 on SLAP repair in 59 patients (59 SK), and 2 on rotator cuff repair in 464 patients (84 SK and 380 NSK). Also, 6 studies compared knot-tying with knotless techniques (3 Bankart repair studies and 3 SLAP repair studies), while the studies reporting the outcomes of SLAP repair evaluated SK-tying techniques only. The failure rate for Bankart repair was 3.2% (2/63) for SKs and 4.7% (4/85) for NSKs. The failure rate for rotator cuff repair was 2.4% (2/84) for SKs and 6.3% (24/380) for NSKs. The failure rate for SLAP repair was 11.9% (7/59). Because of inconsistencies in outcomes and procedures, no quantitative analysis was possible. The mean modified Coleman Methodology Score for all studies was 65.1 ± 8.77, indicating adequate methodology.

Conclusion

The literature on clinical outcomes using SKs or NSKs for shoulder procedures is limited to level 4 evidence. Future studies should be prospective and focus on comparing the use of SKs and NSKs for shoulder procedures to elucidate which arthroscopic knot results in superior clinical outcomes.

Arthroscopic Knotless Remplissage for the Treatment of Hill-Sachs Lesions Using the PASTA Bridge Configuration

Recurrent glenohumeral dislocations can produce Hill-Sachs lesions-bony defects on the humeral head resulting from the humerus hitting the glenoid during dislocations. Some of these lesions can engage on the glenoid during motion, producing instability and potentially affecting the success of a labral repair. The remplissage was developed to address these Hill-Sachs lesions and improve stability. French for "filling," the goal of the remplissage is to fill the Hill-Sachs lesion with the infraspinatus tendon, preventing the margins of the lesion from engaging with the glenoid. Analogous to restoring the rotator cuff footprint during repair, a primary goal of the remplissage is to have the infraspinatus cover the Hill-Sachs lesion. The partial articular supraspinatus tendon avulsion (PASTA) bridge was originally developed for partial-thickness rotator cuff repair in situ, but additional uses have been found in other settings. The PASTA bridge uses a medial row horizontal mattress with a lateral anchor to create a linked construct to effectively distribute force and provide adequate coverage of the lesion. Knotless anchor technology used in this procedure prevents the need for arthroscopic knot tying and potentially damaging knot stacks. This Technical Note describes a remplissage technique using the PASTA bridge configuration to address Hill-Sachs lesions associated with recurrent glenohumeral instability.

Safety evaluation of a laxity-minimizing suture at 5 days and 6 weeks after repair of a sheep infraspinatus tendon

BACKGROUND

The ideal rotator cuff repair achieves high initial fixation strength and secure tendon-to-bone apposition until biological healing occurs. A suture that reacts to the local stress environment by minimizing suture laxity across the repair could theoretically maintain soft-tissue apposition to bone and therefore improve healing.

METHODS

By use of an in vivo ovine shoulder model, the infraspinatus tendon was transected and then repaired with either a laxity-minimizing suture or a traditional high tensile suture. The purpose of this study was to evaluate both sutures' safety at 5 days and 6 weeks after repair.

RESULTS

The macroscopic and microscopic analyses of the repair sites showed similar amounts of surgical trauma. There was no evidence of cheese wiring or tissue necrosis of the repaired tendons for either suture. There was no evidence of systematic toxicity in any animal. The maximum gap between cut edges of the tendon for repairs with the predicate suture was approximately twice the gap for the laxity-minimizing suture.

CONCLUSION

The laxity-minimizing suture was as safe at 5 days and 6 weeks as the predicate suture. Neither suture contributed to local tissue damage or particle generation leading to adverse systematic consequences. An additional observation was that the maximum gap between cut edges of the tendon for repairs with the predicate suture was approximately twice the gap for the laxity-minimizing suture.

Remplissage Using Interconnected Knotless Anchors: Superior Biomechanical Properties to a Knotted Technique?

PURPOSE

To evaluate the biomechanical fixation strength and gap formation of 2 different remplissage fixation methods (double pulley knotted construct and interconnected knotless repair construct) in cadaver specimens.

METHODS

Seven matched pairs of human cadaveric shoulders were used for testing (mean age, 56 ± 10 years). A shoulder from each matched pair was randomly selected to receive a Hill-Sachs remplissage using either a knotted (No. 2 FiberWire double pulley with 3.0-mm SutureTak anchors) or knotless (coreless No. 2 FiberWire interconnected between 3.9-mm knotless CorkScrew anchors) double mattress construct. The tendon was cycled between 10 and 100 N at 1 Hz for 100 cycles, followed by a single-cycle pull to failure at 33 mm/s. Cyclic displacement, load to clinical failure (5 mm), yield load, and mode of failure were recorded.

RESULTS

Neither construct demonstrated clinical failure under cyclic loading. Load to clinical failure was higher for the knotless repair than that of the knotted repair (788 ± 162 N vs 488 ± 227 N; P = .003). The yield load was higher for the knotless repair than that of the knotted repair (1,080 ± 298 N vs 591 ± 265 N; P = .008). The most common failure mode for the knotted repair was knot failure or tendon tearing, whereas the failure mode for the knotless repair was by anchor pull-out or tendon tear with no failures occurring via the interconnected suture construct mechanism.

CONCLUSIONS

In this biomechanical study comparing cyclic and ultimate loading for 2 double mattress remplissage repairs, the construct using interconnected, knotless sutures outperformed the knotted construct. No failure of the interconnected suture construct mechanism by slippage or breakage was observed in the knotless group.

CLINICAL RELEVANCE

The use of the interconnected knotless suture technique might improve the biomechanical strength of arthroscopic remplissage repairs in treating shoulder instability.

Arthroscopic knotless anterior labral stabilization using labral tape and wide awake anaesthesia-short term results

BACKGROUND

The shoulder is the least constrained of all joints of the body and is more susceptible to injury including dislocation. The rate of recurrent instability following primary stabilization procedure at 10 years of follow-up ranged from 3.4 to 20%. There is a lack of evidence in the literature regarding use of labral tape and anchors for anterior stabilization despite the growing market for this product. We describe the outcomes of 67 patients who underwent knotless arthroscopic anterior stabilisation under awake anaesthesia using 1.5 mm LabralTape with 2.9 mm Pushlock anchors for primary anterior instability by a single surgeon.

METHODS

This was a retrospective analysis of prospectively collected outcome data for adult patients undergoing anterior stabilisation for primary traumatic anterior shoulder instability between 2013 and 2016 at two centres. Patients with > 25% glenoid bone loss, engaging Hill Sach's, and multidirectional instability were excluded. All cases underwent surgery using awake anaesthetic technique. The surgical technique and post-operative physiotherapy was standardized. Outcomes were measured at 6 months and 12 months.

RESULTS

Of the 74 patients in our study, 7 were lost to follow up. Outcomes were measured using the Oxford Instability Shoulder Score (OISS) and clinical assessment including the range of motion. The OISS showed statistically significant improvement from a mean score and standard deviation (SD) of 24.72 ± 2.8 pre-surgery to 43.09 ± 3.5 after the procedure at 12 months with good to excellent outcomes in 66 cases (98.5%). The mean abduction was 134.2 ± 6.32 and external rotation was 72.55 ± 5.42 at 60-90 position at 12 months. We report no failures due to knot slippage or anchor pull-out.

CONCLUSION

Our case series using the above technique has distinct advantages of combining a small non-absorbable implant with flat, braided, and high-strength polyethylene tape. This technique demonstrates superior medium term results to conventional suture knot techniques for labral stabilization thereby validating its use.

Arthroscopic Posterior Glenoid Fracture Fixation Using Knotless Suture Anchors

Shoulder instability after a posterior glenoid rim fracture is rare and potentially difficult pathology to treat. Operative techniques often involve a large dissection to view the fragments resulting in local soft tissue injury. Internal fixation is often achieved with interfragmentary screws; however, this may not be possible with small or multifragmentary fracture patterns. We describe an arthroscopic technique for posterior glenoid rim fracture fixation using knotless suture anchors. These anchors can be inserted without cannulas allowing easier access to the posterior glenoid. This procedure is simple, safe, and offers good visualization of the glenohumeral joint whilst avoiding the detrimental effects of larger surgical dissection.

The Oblique Mattress Lasso-Loop Stitch for Arthroscopic Capsulolabral Repair

Arthroscopic capsulolabral repair during shoulder stabilization surgery requires the use of suture anchors. Several arthroscopic suturing techniques for capsulolabral repair have been described, and each carries very specific advantages and disadvantages with regard to risk, patient satisfaction, and functional outcomes. The purpose of this report is to describe the oblique mattress lasso-loop stitch. This stitch (1) provides strong initial fixation of the labrum, (2) establishes labral height and allows for larger capsular plication if needed, (3) prevents the suture from cutting through the radial fibers of the glenoid labrum, (4) prevents knot migration to the articular side and loosening of the knot, and (5) requires fewer implants and preserves glenoid bone stock by increasing the amount of labrum and capsule that can be reattached to the glenoid with a single-loaded suture anchor.

Arthroscopic Repair of Inferior Labrum Anterior to Posterior Lesions of the Shoulder Using a Combined "Double-Pulley" Simple Knot Technique

Inferior labrum anterior to posterior lesions as an isolated injury or as part of an extensive traumatic labral tear are uncommon and may present as multidirectional instability of the shoulder. These lesions are hard to visualize radiographically and many times are diagnosed only during surgery. Arthroscopic repair of these lesions requires advanced arthroscopic skills and is required for restoration of glenohumeral stability. We report a combined double-pulley simple knot technique that anatomically reconstructs the inferior labrum while overcoming the typical technical challenges, providing a large footprint for healing along the inferior glenoid rim and minimizing the amount of suture material in direct contact with the articular cartilage and the risk of knot migration.

Arthroscopic Knotless Repair of the Posterior Labrum Using LabralTape

Operative management of symptomatic labral tears of the shoulder has traditionally been the preferred treatment. Arthroscopic techniques and equipment continue to be refined and subsequent new recommendations for treatment are being developed. Contemporary techniques for arthroscopic knotless repair offer possible advantages over traditional arthroscopically tied knots. Although knotless repair of labral tears is well recognized, advancements continue to progress toward stronger fixation with reduced risks of cutting through the labrum and chondral abrasion. The suture tape used in the technique presented for arthroscopic knotless repair is stronger and flatter than traditional rounded suture and offers many potential benefits.

Arthroscopic Repair of Ankle Instability With All-Soft Knotless Anchors

In recent years, arthroscopic and arthroscopically assisted techniques have been increasingly used to reconstruct the lateral ligaments of the ankle. Besides permitting the treatment of several comorbidities, arthroscopic techniques are envisioned to lower the amount of surgical aggression and to improve the assessment of anatomic structures. We describe our surgical technique for arthroscopic, two-portal ankle ligament repair using an all-soft knotless anchor, which is made exclusively of suture material. This technique avoids the need for classic knot-tying methods. Thus it diminishes the chance of knot migration caused by pendulum movements. Moreover, it avoids some complications that have been related to the use of metallic anchors and some currently available biomaterials. It also prevents prominent knots, which have been described as a possible cause of secondary complaints.

Performance Comparison of a Pretied Suture Knot With Three Conventional Arthroscopic Knots

PURPOSE

To compare the knot characteristics of a pretied suture knot with 3 of the most commonly used arthroscopic knots tied with various high-strength sutures.

METHODS

Three commonly used arthroscopic knots (surgeon's knot, Seoul Medical Center, and Duncan loop) tied with no. 2 high-strength sutures were compared with a pretied knot secured with either 1, 2, or 3 reversed half hitches (RHAPS). An orthopaedic sports medicine surgeon and fellow tied a total of 120 knots. All knot combinations were tested for strength, knot bulk, cyclic loop elongation, ultimate loop elongation, and ultimate strength.

RESULTS

All pretied configurations had statistically significant improved strength (P = .048, P ≤ .001, and P < .001) versus all other knot groups with mean ± standard deviation loads of 206.3 ± 37.5, 285.6 ± 68.6, and 357.6 ± 61.1 N, respectively. The pretied knot with 1, 2, or 3 RHAPs has significantly smaller volume than the arthroscopic knots in all suture materials. All pretied knot configurations demonstrated no significant difference in cyclic loop elongation compared with standard arthroscopic knots; however, they had a statistically significant lower ultimate loop elongation (P = .001 for each pretied knot configuration).

CONCLUSIONS

Compared with other commonly tied arthroscopic knots using no. 2 high-strength suture, the pretied knot with doubled no. 1 high-tensile-strength suture tied with 1, 2, or 3 RHAPs results in a statistically significantly improved strength. The pretied knot has an equivalent cyclic loop elongation and lower ultimate loop elongation with all RHAP configurations. The pretied knot with 2 or 3 RHAPs has a significantly higher ultimate strength than all combinations of arthroscopic knots excluding one. The pretied knot with 1, 2, or 3 RHAPs has significantly less knot volume than all other knots tested and offers a more reproducible knot.

CLINICAL RELEVANCE

The pre-tied knot offers equivalent or improved strength while having a smaller knot volume.

Arthroscopic Posterior Stabilization of the Shoulder Using a Percutaneous Knotless Mattress Suture Technique

Posterior shoulder instability is far less common than anterior instability, and its arthroscopic treatment can be technically demanding. We describe a percutaneous arthroscopic technique for posterior shoulder stabilization using mattress sutures and knotless anchors. Spinal needles are used to pass the sutures percutaneously in a mattress fashion. Knotless anchors are used to secure the sutures under the labrum. These anchors can be used without cannulas, giving easier access to the posterior glenoid. This procedure is simple, cost-effective, and safe, avoiding the presence of both knots and suture strands in contact with the humeral head.