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Malik SS, Hart D, Gustafson S, Peeler J, McRae S, MacDonald P. Assessment of formalin preserved and fresh frozen quadriceps tendon graft-suture constructs for load to failure testing: a biomechanical cadaveric study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024:10.1007/s00590-024-03976-w. [PMID: 38958725 DOI: 10.1007/s00590-024-03976-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 04/29/2024] [Indexed: 07/04/2024]
Abstract
PURPOSE Fresh-frozen specimen availability and cost may be a barrier for initiation of biomechanical studies where soft tissue is used in a construct with other medical devices. The impact of soft tissue preservation method on the outcomes of biomechanical studies in the specific case of graft-suture constructs is relatively unexplored. This study aimed to observe peak loads and failure modes in biomechanical testing of fresh-frozen (FF) versus formalin embalmed (FE) quadriceps tendon (QT) graft-suture constructs for soft tissue fixation in ACLR and assess suitability of FE QT graft constructs for load-to-fail testing. METHODS Twenty QT grafts were harvested from human cadaver specimens. Ten grafts came from fresh-frozen donors and 10 from embalmed donors. All grafts were prepared with the modified Prusik knot using a braided composite suture and subjected to tensile loading. Comparisons between the biomechanical properties of the graft-suture constructs were made with unpaired t tests with α = 0.05. RESULTS FE and FF constructs displayed similar peak loads and failure modes. FF constructs had greater elongation after pre-tensioning than FE (7.3 vs. 5.5 mm, p = 0.02) and greater elongation after cyclic loading than FE constructs (17.5 vs. 10.5 mm, p = 0.01). Hysteresis was greater for FF constructs at the 50th, 100th, 150th, and 200th cycle (p = 0.02, p = 0.07, p < 0.001, p = 0.004, respectively). FE constructs were stiffer than fresh-frozen (103 vs. 84 N/mm, p < 0.001). CONCLUSION FE constructs were significantly stiffer but displayed similar peak load and failure mode to FF which was reflective of the strength of the suture material. FE grafts can offer an alternative to FF grafts in graft-suture constructs for biomechanical studies where load at failure and knot security and strength is of main interest.
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Affiliation(s)
- Shahbaz S Malik
- Worcestershire Acute Hospital NHS Trusts, Charles Hastings Way, Worcester, WR5 1DD, UK
| | - Darren Hart
- Pan Am Clinic Foundation, 75 Poseidon Bay, Winnipeg, MB, R3M 3E4, Canada.
| | - Sara Gustafson
- Orthopaedic Innovation Centre, 320-1155 Concordia Avenue, Winnipeg, MB, R2K 2M9, Canada
| | - Jason Peeler
- Max Rady College of Medicine, University of Manitoba, 102-745 Bannatyne Avenue, Winnipeg, MB, R3E 0J9, Canada
| | - Sheila McRae
- Pan Am Clinic Foundation, 75 Poseidon Bay, Winnipeg, MB, R3M 3E4, Canada
| | - Peter MacDonald
- Pan Am Clinic, 75 Poseidon Bay, Winnipeg, MB, R3M 3E4, Canada
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Olivos-Meza A, Hernández-Espinoza EM, Domínguez-Hernández VM, Araujo-Monsalvo VM, Estrada-Villaseñor EG, Pichardo-Bahena R, Murguía-González LÁ, Rodríguez-Reinoso JD, de Jesus Hernández-León J, Landa-Solis C. Biomechanical and histological comparison of two suture configurations for soft tissue grafts: speedtrap™ versus krackow stitch. Cell Tissue Bank 2024; 25:705-712. [PMID: 38724712 DOI: 10.1007/s10561-024-10133-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 01/30/2024] [Indexed: 06/01/2024]
Abstract
To compare 2 different graft preparation techniques to determine biomechanical strength and resultant tissue trauma evaluated by histology. Twelve common flexors of the finger's tendons were prepared with either tubulization (SpeedTrap™) or transtendon stiches (Orthocord™). The stiffness, resistance and energy at maximum load were tested for biomechanical assessment in both groups. After load testing, Samples were stained with hematoxylin and eosin (HE) to evaluate histological damage. We observe that the time to prepare tendons with SpeedTrap™ was 8.3 times faster (1:25 min) than traditional ones (15:02 min). In all cases, the mean values for SpeedTrap™ were higher in terms of strength, stiffness and energy at maximum load than for traditional suture but without significant difference (p > 0.05). The Krackow stitch produces greater structural damage to the collagen fibers while SpeedTrap™ maintains better organized arrangement of the fibers after tubulization preparation. With the results obtained, we can conclude that the tubulization technique allows faster graft preparation with less structural damage to the manipulated tissue without altering the biomechanical resistance provided by the transtendon suture technique.
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Affiliation(s)
- Anell Olivos-Meza
- Orthopedics and Traumatology, Hospital Medica Sur, Mexico City, Mexico
| | - Edgar Manuel Hernández-Espinoza
- Orthopedic Sports Medicine and Arthroscopy Department, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Mexico City, Mexico
| | | | - Víctor Manuel Araujo-Monsalvo
- Head of the Biomechanics Laboratory, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Mexico City, Mexico
| | | | - Raúl Pichardo-Bahena
- Head of Pathological Anatomy Laboratory, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Mexico City, Mexico
| | - Luis Ángel Murguía-González
- Orthopedic Sports Medicine and Arthroscopy Department, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Mexico City, Mexico
| | - Juan Diego Rodríguez-Reinoso
- Orthopedic Sports Medicine and Arthroscopy Department, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Mexico City, Mexico
| | - Jonatan de Jesus Hernández-León
- Orthopedic Sports Medicine and Arthroscopy Department, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Mexico City, Mexico
| | - Carlos Landa-Solis
- Investigator, Tissue Engineering, Cell Therapy and Regenerative Medicine Unit, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Calzada México Xochimilco 289, 14389, Mexico City, Mexico.
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Arakawa T, Hiraoka H, Kuribayashi S, Okinaga S. Graft Suturing Method Affects on Graft Diameter in Hamstring-Based Anterior Cruciate Ligament Reconstruction. Cureus 2024; 16:e61054. [PMID: 38916006 PMCID: PMC11196011 DOI: 10.7759/cureus.61054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2024] [Indexed: 06/26/2024] Open
Abstract
INTRODUCTION Various benefits of needleless suture loop techniques in anterior cruciate ligament reconstruction graft preparation have been discussed, yet their impact on graft diameter remains unexplored. We hypothesized that the suture loop technique would reduce the graft diameter compared to the conventional locking suture technique. METHODS Fifty-seven patients whose grafts were made with the Krackow stitch (group K) and 54 patients with the suture loop (group SL) were analyzed retrospectively. (1) The distal (sutured side) diameter of each anteromedial bundle and posterolateral bundle was compared to the proximal (non-sutured side) diameter, and (2) the average of the proximal and distal graft diameters in each group was calculated. RESULTS In group K, 78.9% of anteromedial bundles and 40.3% of posterolateral bundles exhibited a larger distal diameter than the proximal, while in group SL, 42.6% of anteromedial bundles and 3.7% of posterolateral bundles showed a larger distal diameter. In both bundles, there were significantly fewer grafts with larger distal diameters in group SL (p < 0.001). The mean distal diameter of anteromedial bundles was smaller in group SL (6.33 ± 0.43 mm vs. 6.07 ± 0.43 mm, p < 0.005). Consequently, the distal cross-sectional area of anteromedial bundles in group SL was 8% smaller than that in group K. CONCLUSION The use of the suture loop technique resulted in a significantly smaller distal diameter of the anteromedial bundle. This reduces the size of the tibial tunnel and may contribute to a reduction in potential damage to adjacent structures.
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Affiliation(s)
- Takahiro Arakawa
- Department of Orthopaedic Surgery, The University of Tokyo, Tokyo, JPN
- Department of Orthopaedic Surgery, Tokyo Teishin Hospital, Tokyo, JPN
| | - Hisatada Hiraoka
- Department of Orthopaedic Surgery, Tokyo Teishin Hospital, Tokyo, JPN
| | - So Kuribayashi
- Department of Orthopaedic Surgery, Tokyo Teishin Hospital, Tokyo, JPN
| | - Shuji Okinaga
- Department of Orthopaedic Surgery, Tokyo Teishin Hospital, Tokyo, JPN
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Diaz MA, Branch EA, Dunn JG, Brothers A, Jordan SE. Whip-Lock Stitch Is Biomechanically Superior to Whipstitch for Semitendinosus Tendons. Arthrosc Sports Med Rehabil 2024; 6:100853. [PMID: 38304466 PMCID: PMC10830526 DOI: 10.1016/j.asmr.2023.100853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 11/18/2023] [Indexed: 02/03/2024] Open
Abstract
Purpose To assess the biomechanical performance of different stitching methods using a suturing device by comparing the elongation, stiffness, failure load, and time to stitch completion in cadaveric semitendinosus tendons (STs) and quadriceps tendons (QTs). Methods A total of 24 STs and 16 QTs were harvested from cadaveric knee specimens (N = 40). Samples were randomly divided into 2 groups: whipstitch (WS) and whip-lock (WL) stitch. Both tendon ends were clamped to a graft preparation stand, and a 2-part needle was used to place 5 stitches, each 0.5 cm apart. Stitching time was recorded. Samples were preconditioned and then underwent cyclic loading from 50 to 200 N at 1 Hz for 500 cycles, followed by load-to-failure testing at 20 mm/min. Stiffness (in newtons per millimeter), ultimate failure load (in newtons), peak-to-peak displacement (in millimeters), elongation (in millimeters), and failure displacement (in millimeters) were recorded. Results Completion of the WS was significantly faster than the WL stitch in the ST (P < .001) and QT (P = .004). For the ST, the WL stitch exhibited higher ultimate failure loads and construct stiffness than the WS. Regarding the QT, the WL stitch showed higher stiffness and displacement than the WS; however, the ultimate failure load was higher for the WS in the QT. The ultimate failure load in the QT was higher than that in the ST for both stitches. In the ST, only 25% of WSs and 100% of WL stitches failed due to suture breakage. In the QT, suture breakage led to the failure of 100% of both the WL stitches and WSs. Conclusions In the ST, the WL stitch resulted in improved biomechanical performance through higher ultimate load and fewer failures from tissue damage compared with the WS. In the QT, both the WS and the WL stitch showed similar biomechanical performance with ultimate failure loads above established clinical failure thresholds. Clinical Relevance Various types of ligament and tendon injuries require suturing to enable repair or reconstruction. The success of ligament or tendon surgery often relies on soft-tissue quality. It is important to investigate the biomechanical properties of stitching techniques that help preserve soft-tissue quality as a step to determining their clinical suitability.
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Affiliation(s)
- Miguel A. Diaz
- Foundation for Orthopaedic Research and Education, Tampa, Florida, U.S.A
| | - Eric A. Branch
- Tallahassee Orthopedic Clinic, Panama City, Florida, U.S.A
| | - Jacob G. Dunn
- St. Francis Orthopaedic Institute, Columbus, Georgia, U.S.A
| | - Anthony Brothers
- Andrews Research & Education Foundation, Gulf Breeze, Florida, U.S.A
| | - Steve E. Jordan
- Andrews Research & Education Foundation, Gulf Breeze, Florida, U.S.A
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Li Y, Beaudry E, Besada N, Chan R, Westover L. Biomechanical Comparison of Distal Radioulnar Joint Reconstruction Graft Preparation Techniques. J Wrist Surg 2024; 13:38-43. [PMID: 38264137 PMCID: PMC10803139 DOI: 10.1055/s-0043-1769909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 05/09/2023] [Indexed: 01/25/2024]
Abstract
Background Graft preparation techniques for the Adams-Berger distal radioulnar joint (DRUJ) reconstruction vary among surgeons with insufficient evidence to support any specific technique. Questions/Purposes We compared survival with cyclic loading, absolute elongation, elongation rate, and modes of failure of four graft preparation techniques. Methods Fifteen porcine extensor tendons were divided into three equal groups: tendon only; tendon augmented along its full length with nonlocking 2-0 FiberLoop suture spaced at 6 mm intervals; and tendon with suture at 12 mm intervals. Suture only was also tested. Samples were woven through custom radius- and ulna-simulating jigs mounted on a mechanical testing machine. Samples underwent a staircase cyclic loading protocol and were then inspected visually for the mode of failure. Survival with cyclic loading, absolute elongation, and elongation rate was compared. Results Average survival with cyclic loading of suture-augmented tendon was significantly higher than tendon only. All tendon groups had significantly higher survival compared with suture only. Absolute elongation was subject to variability due to initial nonlinear elongation behavior of samples. The elongation rate was significantly lower with suture compared with all tendon groups. Modes of failure included rupture of the tendon and/or suture at the simulated graft-bone interface and elongation of the entire construct without rupture. Conclusions In this biomechanical study, augmentation of porcine tendons with suture spaced at either 6 or 12 mm for DRUJ reconstruction significantly increased survival to a staircase cyclic loading protocol Clinical Relevance For the Adams-Berger reconstruction, tendon grafts augmented along their entire length by nonabsorbable braided suture are biomechanically superior to tendon alone.
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Affiliation(s)
- Yibo Li
- Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Eric Beaudry
- Department of Mechanical Engineering, Faculty of Engineering, University of Alberta, Edmonton, Alberta, Canada
| | - Nader Besada
- Department of Civil and Environmental Engineering, Faculty of Engineering, University of Alberta, Edmonton, Alberta, Canada
| | - Robert Chan
- Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Lindsey Westover
- Department of Mechanical Engineering, Faculty of Engineering, University of Alberta, Edmonton, Alberta, Canada
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Lamplot JD, Smith BL, Slone HS, Hauck OL, Wijdicks CA. Tape-Reinforced Graft Suturing and Retensioning of Adjustable-Loop Cortical Buttons Improve Quadriceps Tendon Autograft Biomechanics in Anterior Cruciate Ligament Reconstruction: A Cadaveric Study. Arthroscopy 2024; 40:136-145. [PMID: 37355187 DOI: 10.1016/j.arthro.2023.06.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 04/13/2023] [Accepted: 06/12/2023] [Indexed: 06/26/2023]
Abstract
PURPOSE To investigate the biomechanical effects of tape-reinforced graft suturing and graft retensioning for all-soft tissue quadriceps tendon (ASTQT) anterior cruciate ligament reconstruction (ACLR) in a full-construct human cadaveric model. METHODS Harvested cadaveric ASTQT grafts were assigned to either (1) double-suspensory adjustable-loop cortical button device (ALD) fixation in which both graft ends were fixed with a suspensory fixation device with (n = 5) or without (n = 5) tape-reinforced suturing or (2) single-suspensory distal tendon fixation in which only the patellar end was fixed with an ALD (n = 5) or fixed-loop cortical button device (FLD) (n = 5). All specimens were prepared using a No. 2 whipstitch technique, and tape-reinforced specimens had an integrated braided tape implant. Graft preparation time was recorded for double-suspensory constructs. Samples were tested on an electromechanical testing machine using a previously published protocol simulating rehabilitative kinematics and loading. RESULTS Tape-reinforced graft suturing resulted in greater graft load retention after cycling (11.9% difference, P = .021), less total elongation (mean [95% confidence interval (CI)], 5.57 mm [3.50-7.65 mm] vs 32.14 mm [25.38-38.90 mm]; P < .001), greater ultimate failure stiffness (mean [95% CI], 171.9 N/mm [158.8-185.0 N/mm] vs 119.4 N/mm [108.7-130.0 N/mm]; P < .001), and less graft preparation time (36.4% difference, P < .001) when compared with unreinforced specimens. Retensioned ALD constructs had less cyclic elongation compared with FLD constructs (mean total elongation [95% CI], 7.04 mm [5.47-8.61 mm] vs 12.96 mm [8.67-17.26 mm]; P = .004). CONCLUSIONS Tape-reinforced graft suturing improves time-zero ASTQT ACLR construct biomechanics in a cadaveric model with 83% less total elongation, 44% greater stiffness, and reduced preparation time compared with a whipstitched graft without tape reinforcement. ALD fixation improves construct mechanics when compared with FLD fixation as evidenced by 46% less total elongation. CLINICAL RELEVANCE Tape-reinforced implants and graft retensioning using ALDs improve time-zero ACLR graft construct biomechanics in a time-zero biomechanical model. Clinical studies will be necessary to determine whether these implants improve clinical outcomes including knee laxity and the incidence of graft rupture.
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Affiliation(s)
| | - Benjamin L Smith
- Department of Orthopedic Research, Arthrex, Naples, Florida, U.S.A
| | - Harris S Slone
- Department of Orthopedic Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Oliver L Hauck
- Department of Orthopedic Research, Arthrex, Naples, Florida, U.S.A
| | - Coen A Wijdicks
- Department of Orthopedic Research, Arthrex, Naples, Florida, U.S.A
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Kanayama T, Nakase J, Kimura M, Yoshimizu R, Yanatori Y, Ishida Y, Tsuchiya H. Speed whip ripstop technique during anterior cruciate ligament reconstruction using quadriceps tendon results in higher fixation strength. Knee Surg Sports Traumatol Arthrosc 2023; 31:4068-4075. [PMID: 37318561 DOI: 10.1007/s00167-023-07482-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 06/06/2023] [Indexed: 06/16/2023]
Abstract
PURPOSE To compare the biomechanical strength of different fixation configurations using a suspensory button in a soft-tissue quadriceps tendon graft for Anterior Cruciate Ligament (ACL) reconstruction. METHODS Thirty fresh-frozen bovine Achilles tendons (10 mm wide, 50 mm long, and 4 mm thick) were used in this study. Tendons were assigned to three groups (n = 10 per group) with different suture configurations using adjustable loops with a suspensory button: group A, with the threads of an adjustable loop fixed by crossing at the tip of the loop and the entire loop; group B, continuous loops with hanging buttons were directly sutured to the tendon with eight simple sutures; group C, fixation was performed using the speed whip ripstop technique. Tensile tests with five cycles of preloading were performed at 50 N, held at 50 N for 1 min, and load-to-failure testing was conducted until rupture at 5 mm/min. The difference in the elongation and the maximum load-to-failure force were measured. RESULTS The average elongation was significantly larger in group B (16.6 ± 2.2 mm) than in groups A (10.3 ± 2.4 mm) and C (10.0 ± 1.0 mm), (p < 0.001). The average load-to-failure force varied significantly between the three groups, 157.5 ± 33.4 N in group A, 253.4 ± 45.5 N in group B, and 337.7 ± 21.0 N in group C, (p < 0.001). CONCLUSION Fixation using the speed whip ripstop technique to fix the suspensory button and soft-tissue transplant tendon resulted in minimal elongation and higher fixation strength. Simple devices that use this method have already been developed. Since it can be fixed using a relatively simple method, speed whip ripstop technique was shown to be advantageous for femoral fixation in ACL reconstruction using soft-tissue quadriceps tendon. The findings of this study could help surgeons reduce graft re-tear rates in ACL reconstruction using quadriceps tendons. LEVEL OF EVIDENCE N/A, laboratory control study.
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Affiliation(s)
- Tomoyuki Kanayama
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa-city, 920-8641, Japan
| | - Junsuke Nakase
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa-city, 920-8641, Japan.
| | - Mitsuhiro Kimura
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa-city, 920-8641, Japan
| | - Rikuto Yoshimizu
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa-city, 920-8641, Japan
| | - Yusuke Yanatori
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa-city, 920-8641, Japan
| | - Yoshihiro Ishida
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa-city, 920-8641, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa-city, 920-8641, Japan
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Muscatelli S, Walley KC, Daly-Seiler CS, Greenstein JA, Sciascia A, Patterson DP, Freehill MT. Biomechanical Comparison of a Novel Multiplanar, Perpendicular Whipstitch With the Krackow Stitch and Standard Commercial Whipstitch. Orthop J Sports Med 2022; 10:23259671221107034. [PMID: 35982831 PMCID: PMC9380225 DOI: 10.1177/23259671221107034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 04/05/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Using alternating orthogonal suture throws with the looped whipstitch
technique may allow enhanced suture fixation. Hypothesis: It was hypothesized that this novel multiplanar, perpendicular looped
whipstitch (MP) technique would have improved biomechanical properties
compared with the standard looped whipstitch (WS) and Krackow stitch
(KS). Study Design: Controlled laboratory study. Methods: A total of 30 cadaveric tibialis anterior tendons were randomly assigned into
3 groups of 10. Tendons were secured to a custom clamp, and the other end
was sutured using 1 of 3 techniques: the KS, WS, or novel MP. The MP was
performed with alternating orthogonal throws starting right to left, then
front to back, left to right, and back to front. Each technique used 4
passes of No. 2 FiberWire spaced 5 mm apart and ending 10 mm from the tendon
end. Tendons were preloaded to 5 N, pretensioned to 50 N at 100 mm/min for 3
cycles, returned to 5 N for 1 minute, cycled from 5 to 100 N at 200 mm/min
for 100 cycles, and then loaded to failure at 20 mm/min. Elongation was
recorded after pretensioning and cycling and was measured both across the
suture-tendon interface and from the base of the suture-tendon interface to
markings on the suture limbs (construct elongation). One-way analyses of
variance were performed, with Bonferroni post hoc analysis when
appropriate. Results: There were no differences in cross-sectional area or stiffness among the 3
techniques. The ultimate load for WS (183.33 ± 57.44 N) was less compared
with both MP (270.76 ± 39.36 N) and KS (298.90 ± 25.94 N)
(P ≤ .001 for both). There was less construct
elongation for KS compared with WS and MP for total displacement, measured
from pretensioning to the end of cycling (P < .001). All
3 techniques saw a decrease in length (shortening) at the suture-tendon
interface during testing. There was more shortening at the suture-tendon
interface for WS compared with KS (P = .006). Conclusion: The KS appears superior, as it maximized strength while minimizing construct
elongation or graft shortening. The ultimate load of the MP technique was
greater than that of the standard technique but not significantly different
from that of the KS technique. Clinical Relevance: The KS is preferred. If using a WS, multiplanar, perpendicular passes should
be considered.
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Affiliation(s)
| | | | | | | | | | - David P Patterson
- University of Michigan Health System, Ann Arbor, Michigan, USA.,Ann Arbor VA Healthcare System, Ann Arbor, Michigan, USA
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9
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Direct suturing quadriceps tendon to a continuous loop with a suspensory button provides biomechanically superior fixation in ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2022; 30:2307-2313. [PMID: 34807305 DOI: 10.1007/s00167-021-06805-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 11/11/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE To compare the biomechanical strength of different fixation configurations using suspensory buttons in a soft-tissue quadriceps tendon (QT) grafts in anterior cruciate ligament (ACL) reconstruction. METHODS Forty bovine QTs, 6-cm long and 10-mm wide, were allocated into four groups with different suture configurations using suspensory buttons (n = 10 in each group): Group A, a baseball suture with a knot tied to the continuous loop with a suspensory button; Group B, same configuration as in Group A but with the knot tied at the opposite end of the baseball suture; Group C, a continuous loop with a suspensory button stitched directly to the QT with simple sutures, and Group D, a baseball suture tied directly to a suspensory button. Biomechanical testing was performed by preloading followed by cyclic loading for 500 cycles between 10 and 100 N. The length of elongation (mm) and maximum load to failure (N) were recorded, and compared among the four groups. RESULTS Group C showed significantly smaller elongation (4.1 mm [95% CI 3.1-5.2]) than Group A (8.2 mm [95% CI 7.0-9.4]), Group B (10.5 mm [95% CI 7.7-13.3]), and Group D (8.5 mm [95% CI 7.0-9.9]) (A-C; P = 0.004, B-C; P = 0.0001, C-D; P = 0.0018). The maximum load to failure in Group C (386 N [95%CI 306-466]) was significantly higher than that in Group A (196 N [95% CI 141-251]), Group B (226 N [95% CI 164-289]), and Group D (212 N [95%CI 171-253]) (A-C; P = 0.0001, B-C; P = 0.0009, C-D; P = 0.0002). No significant differences were observed between Group A, B, and D in terms of elongation and maximum load to failure. CONCLUSION The soft-tissue QT graft fixation configuration stitched directly to a continuous loop with suspensory button using simple sutures exhibits small elongation and high maximum load to failure among the four configurations. Regarding clinical relevance, direct suturing of the soft-tissue QT to a continuous loop with a suspensory button may be advantageous for femoral fixation in ACL reconstruction from a biomechanical perspective, and warrant future development of a novel fixation device using this principle.
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Malik SS, Hart D, Parashin S, Peeler J, McRae S, MacDonald P. Does the Nice Knot Offer Less Elongation Than the Modified Prusik Knot? An In Vitro Study in Cadaver Quadriceps Tendons. Clin Orthop Relat Res 2022; 480:1403-1410. [PMID: 35238847 PMCID: PMC9191388 DOI: 10.1097/corr.0000000000002153] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 02/04/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND ACL graft-suture fixation can be constructed with needle or needleless techniques. Needleless techniques have the advantage of decreased injury, preparation time, and cost. The Nice knot is common among upper extremity procedures, and has been shown to have higher load to failure and less elongation compared with other double loop knots; however, there are no studies that have looked at its use for ACL graft-suture construct to determine whether it offers less elongation relative to other needleless techniques. QUESTIONS/PURPOSES In a cadaver quadriceps tendon model, we asked: (1) Does the Nice knot have less elongation than the Prusik knot? (2) Does the Nice knot have increased peak load and stiffness compared with the Prusik knot? (3) What were the modes of failure of each knot? METHODS Sixteen quadriceps tendon grafts were harvested from 16 cadaver knee specimens. The median (range) age of the donors was 80 years (70 to 96) and included three male and five female donors. Eight grafts were prepared with the Prusik knot and eight with the Nice knot using a braided polyblend suture. The graft-suture constructs were mounted in a materials testing machine and subjected to a tensile loading protocol beginning with pretensioning of three cycles from 0 to 100 N at 1 Hz followed by a constant load of 50 N for 1 minute then cyclic loading of 200 cycles from 50 to 200 N at 1 Hz. The constructs were loaded to failure as the final step of the loading protocol. Elongations of the construct after each loading step, peak load, stiffness, and graft cross-sectional area were compared. RESULTS Construct elongations (median [IQR]) for the Nice knot were lower than that of the Prusik knot after pretensioning (4.4 mm [0.8] versus 5.7 mm [1.4]; p = 0.02), preloading (0.6 mm [0.3] versus 1.0 mm [0.3]; p = 0.005), and cyclic loading (7.4 mm [1.4] versus 10.9 mm [2.1]; p = 0.005). Peak load was not different for the Prusik knot construct compared with the Nice knot (334 N [43] versus 312 N [13]; p = 0.08). Stiffness of the Prusik knot construct (103 N/mm [17]) was no different than the Nice knot construct (110 N/mm [13]; p = 0.13). Graft cross-sectional area of the Prusik knot constructs (85 mm2 [35]) were similar to the grafts of the Nice knot constructs (97 mm2 [31]; p = 0.28). Failure mode of the constructs did not differ between groups; it was caused by suture rupture near the knots that secured the free suture ends to the machine and was seen in all 16 tests. CONCLUSIONS The results of this biomechanical study show that the Nice knot construct has similar or greater biomechanical properties compared with the Prusik knot in the graft suture construct, although the magnitude of the differences are not likely to the level of clinical importance. CLINICAL RELEVANCE The Nice knot offers an attractive alternative option for needleless ACL graft preparation technique. Future studies should consider comparison to established needle techniques such as Krackow or whipstitch and testing in an intraarticular component in an in vivo model.
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Affiliation(s)
- Shahbaz S. Malik
- Department of Trauma and Orthopaedic Surgery, Worcestershire Acute Hospitals NHS Trust, Worcester, United Kingdom
| | - Darren Hart
- Pan Am Clinic Foundation, Winnipeg, Manitoba, Canada
| | - Sara Parashin
- Orthopaedic Innovation Centre, Winnipeg, Manitoba, Canada
| | - Jason Peeler
- Department of Human Anatomy & Cell Science, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Sheila McRae
- Pan Am Clinic Foundation, Winnipeg, Manitoba, Canada
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Peter MacDonald
- Pan Am Clinic, Winnipeg, Manitoba, Canada
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
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Fang C, Cheng R, Jiang J, Dimitriou D, Wang H, Jiang Z, Tsai TY, Cheng CK. An Efficient Needleless Grasping Suture Technique for Graft Preparation in Anterior Cruciate Ligament Reconstruction. Front Surg 2022; 9:863823. [PMID: 35647013 PMCID: PMC9133538 DOI: 10.3389/fsurg.2022.863823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 04/20/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveSeveral needleless techniques have been developed to outcome the inherent disadvantages of the traditional needle stitching technique for graft preparation, such as tendon damage through the needle, time consumption, and the potential risk of needlestick injury. The purpose of the present study is to compare the graft preparation time and the biomechanical performance between an efficient needleless technique and the traditional needle stitching technique for graft preparation in anterior cruciate ligament reconstruction (ACLR).MethodsThe time required to perform a complete suture on 20 hamstring tendons during ACLRs was measured. The grafts from one side were prepared using the needle stitching technique. The grafts from the other side used the needleless grasping suture technique. For the second part of the study, 12 fresh-frozen porcine flexor tendons were divided into two groups using two techniques and were mounted in an electric tensile test system. Each group was pretensioned to 100 N to simulate the maximum initial graft tension. The suturing state of sutures and graft (intact and damaged) and the load-elongation curve were recorded for each group. A Student’s t-test was used to compare the means of the two groups.ResultsIn operation, the needleless grasping suture technique group (19.8 ± 4.8, range: 13.5–32.9 s) was significantly faster (p < 0.05) than the needle stitching technique group (52.7 ± 12.7, range: 36.0–87.5 s). The state of sutures in each group was intact. The mean elongation was 11.75 ± 1.38 (range: 9.47–12.99) mm and 10.59 ± 1.02 (range: 9.12–11.76) mm in the needleless stitching technique group and the needle grasping suture technique group, respectively. There was no statistically significant difference in the elongation between the two groups (p > 0.05).ConclusionThe needleless grasping suture technique was a convenient and efficient method for graft preparation in ACLR.
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Affiliation(s)
- Chaohua Fang
- Department of Sports Medicine, Ningbo No. 6 Hospital, Zhejiang, China
- School of Biomedical Engineering and Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, China
- Engineering Research Center of Digital Medicine, Ministry of Education, Shanghai, China
| | - Rongshan Cheng
- School of Biomedical Engineering and Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, China
- Engineering Research Center of Digital Medicine, Ministry of Education, Shanghai, China
- Shanghai Key Laboratory of Orthopaedic Implants and Clinical Translation R&D Center of 3D Printing Technology, Department of Orthopaedic Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jian Jiang
- Department of Operating Room, Ningbo No. 6 Hospital, Zhejiang, China
| | - Dimitris Dimitriou
- Department of Orthopedics, Balgrist University Hospital, Zürich, Switzerland
| | - Huizhi Wang
- School of Biomedical Engineering and Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, China
- Engineering Research Center of Digital Medicine, Ministry of Education, Shanghai, China
- Shanghai Key Laboratory of Orthopaedic Implants and Clinical Translation R&D Center of 3D Printing Technology, Department of Orthopaedic Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ziang Jiang
- School of Biomedical Engineering and Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, China
- Engineering Research Center of Digital Medicine, Ministry of Education, Shanghai, China
- Shanghai Key Laboratory of Orthopaedic Implants and Clinical Translation R&D Center of 3D Printing Technology, Department of Orthopaedic Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tsung-Yuan Tsai
- School of Biomedical Engineering and Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, China
- Engineering Research Center of Digital Medicine, Ministry of Education, Shanghai, China
- Shanghai Key Laboratory of Orthopaedic Implants and Clinical Translation R&D Center of 3D Printing Technology, Department of Orthopaedic Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Correspondence: Cheng-Kung Cheng Tsung-Yuan Tsai
| | - Cheng-Kung Cheng
- School of Biomedical Engineering and Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, China
- Engineering Research Center of Digital Medicine, Ministry of Education, Shanghai, China
- Shanghai Key Laboratory of Orthopaedic Implants and Clinical Translation R&D Center of 3D Printing Technology, Department of Orthopaedic Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Correspondence: Cheng-Kung Cheng Tsung-Yuan Tsai
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12
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Marks JA, Zylka K, Copeland D’Agostino E. How a Human-Centered Design Process Transformed the User Experience of Graft Preparation in the Operating Room. ERGONOMICS IN DESIGN 2022. [DOI: 10.1177/10648046221074744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In this case study, the human-centered design process used by the Industrial Design and Human Factors (IDHF) team at Johnson & Johnson MedTech in developing the SPEEDTRAP™ Graft Preparation System is overviewed. This article describes three broad efforts to “Understand” needs within knee soft tissue repair procedures and potential opportunities; “Explore” possible solutions through conceptual development, prototyping, and usability testing; and “Materialize” the refinement and delivery of the SPEEDTRAP™ Graft Preparation System. The key results for each broad effort are described.
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13
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Cheppalli N, Metikala S, Leung E, Richter DL. Failure of Primary Distal Biceps Repair After Cortical Button Fixation With Whipstitch Technique: A Root Cause Analysis. Cureus 2022; 14:e21254. [PMID: 35186539 PMCID: PMC8844290 DOI: 10.7759/cureus.21254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2022] [Indexed: 11/05/2022] Open
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14
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Mae T, Shimomura K, Ohori T, Hirose T, Taketomi S, Suzuki T, Nakata K. Suture Slippage During Anterior Cruciate Ligament Graft Passage Is Significantly Lower Using a Krackow Suture. Arthrosc Sports Med Rehabil 2021; 3:e1337-e1341. [PMID: 34712971 PMCID: PMC8527264 DOI: 10.1016/j.asmr.2021.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 06/21/2021] [Indexed: 11/30/2022] Open
Abstract
Purpose To compare the suture slippage on a hamstring tendon graft prepared with a modified finger-trap device (SPEEDTRAP) with one prepared with Krackow stitch during graft passage through the tibial tunnel in ACL reconstruction. Methods Thirty-eight patients underwent anatomic triple-bundle anterior cruciate ligament reconstruction with 2 femoral and 3 tibial tunnels. After semitendinosus tendon was cut in half to make 2 grafts, the free ends of the proximal membranous portion (posterolateral [PL] graft) were prepared together with 2 sutures: (1) one SPEEDTRAP and one Krackow stitch for 20 cases (group A) and (2) double Krackow stitches on both sides for 18 cases (group B). Then, the PL graft was dye-marked at the proximal suture of SPEEDTRAP in group A and Krackow suture in group B and was inserted into the joint via tibial tunnel ahead of the loop side. The distance between the mark on the graft and the proximal suture of SPEEDTRAP or Krackow stitch was measured under arthroscopy after graft fixation at femur. Slippage was defined as 1 mm and more of distance between the mark and the proximal suture. Results Slippage was observed in 16 cases for SPEEDTRAP and in 2 for Krackow suture in group A, whereas one case showed slippage in group B. The slippage distance was 4.0 ± 2.9 mm for SPEEDTRAP and 0.2 ± 0.5 mm for Krackow stitch in group A (P < .001), whereas it was 0.1 ± 0.2 mm for double Krackow stitch in group B, showing a significant difference from SPEEDTRAP suture (P < .001). Conclusions At the time of PL graft passage through the tibial tunnel in anterior cruciate ligament reconstruction, there was significantly less slippage observed with the Krackow stitch compared with the SPEEDTRAP stitch. Level of Evidence Level IV, therapeutic case series.
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Affiliation(s)
- Tatsuo Mae
- Department of Sports Medical Biomechanics, Osaka University Graduate School of Medicine, Osaka
| | - Kazunori Shimomura
- Department of Orthopaedics Surgery, Osaka University Graduate School of Medicine, Osaka
| | - Tomoki Ohori
- Department of Orthopaedics Surgery, Osaka University Graduate School of Medicine, Osaka
| | - Takehiko Hirose
- Department of Orthopaedics Surgery, Osaka University Graduate School of Medicine, Osaka
| | - Shuji Taketomi
- Department of Orthopaedic Surgery, The University of Tokyo, Tokyo
| | - Tomoyuki Suzuki
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo
| | - Ken Nakata
- Department of Sports and Performing Arts, Osaka University Graduate School of Medicine, Osaka, Japan
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15
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Le AH, Roach WB, Mauntel TC, Hendershot BD, Helgeson MD, Colantonio DF, Fredericks DR, Slaven SE, Pisano AJ, LeClere LE. A Biomechanical Comparison of High-Tensile Strength Tape Versus High-Tensile Strength Suture for Tendon Fixation Under Cyclic Loading. Arthroscopy 2021; 37:2925-2933. [PMID: 33901508 DOI: 10.1016/j.arthro.2021.04.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/16/2021] [Accepted: 04/14/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the biomechanical properties of high-tensile strength tape and high-tensile strength suture across 2 selected stitch techniques, the Krackow and whip stitch, in securing tendinous tissue during 5,000 cycles of nondestructive loading followed by a load to failure. METHODS Fourteen matched pairs each of cadaveric Achilles, quadriceps, and patellar tendons (n = 84) were randomly assigned to either Krackow or whip stitch and sutured with either 2-mm high-tensile strength tape or No. 2 high-tensile strength suture. Specimens were preloaded to 20 N, cyclically loaded from 20 to 200 N for 5,000 cycles at 2 Hz, and then loaded to failure at 200 mm/min. Linear mixed models evaluated the effects of suture material and stitch technique on cyclic normalized tendon-suture elongation, total normalized tendon-suture elongation at 5,000 cycles, and maximum load at failure. RESULTS Across all suture constructs, normalized elongation was greater during the initial 10 cycles, compared with all subsequent cycling intervals (all P < .001). There was less total normalized elongation (β = -0.239; P = .007) and greater maximum load at failure in tape (β = 163.71; P = .014) when used in the Krackow stitch compared with the whip stitch. CONCLUSIONS Our findings indicate that tape used in the Krackow stitch maintains the most favorable fixation strength after enduring cyclic loading, with greater maximum load at failure. In addition, overall normalized elongation during long-term cyclic loading was predominately affected by the stitch technique used, regardless of the suture material; however, tape allowed less normalized elongation during the initial loading cycles, especially when placed in the whip stitch. CLINICAL RELEVANCE Understanding the potential short- and long-term outcomes of suture material and stitch technique on securing tendinous tissue under repetitive stresses can help inform clinicians on optimal tendon fixation techniques for early postoperative activities.
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Affiliation(s)
- Anthony H Le
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Walter Reed National Military Medical Center, Bethesda.
| | - William B Roach
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda
| | - Timothy C Mauntel
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Walter Reed National Military Medical Center, Bethesda; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda
| | - Brad D Hendershot
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Walter Reed National Military Medical Center, Bethesda; Department of Rehabilitation Medicine, Uniformed Services University of the Health Science, Bethesda
| | - Melvin D Helgeson
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda
| | - Donald F Colantonio
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda
| | - Donald R Fredericks
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda
| | - Sean E Slaven
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda
| | - Alfred J Pisano
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda
| | - Lance E LeClere
- Department of Orthopaedic Surgery, Naval Health Clinic, United States Naval Academy, Annapolis, Maryland, U.S.A
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16
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Barber FA. Editorial Commentary: Suture Type or Technique Has Little Influence on Outcome After Acute Lower-Extremity Tendon Rupture. Arthroscopy 2021; 37:2934-2936. [PMID: 34481631 DOI: 10.1016/j.arthro.2021.05.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 05/16/2021] [Indexed: 02/02/2023]
Abstract
Operative repair of Achilles tendon rupture significantly decreases the rerupture rate, regardless of type of surgical suture technique. Likewise, regarding repair of either the quadriceps or patellar tendon, surgical repair technique does not significantly influence the generally excellent outcomes achieved, whereas too-early mobilization should be avoided. In terms of the use of suture versus suture tape, load to failure is similar. Many factors impact tendon rupture repair success, including postoperative care, the quality of the tendon, underlying medical issues, and patient compliance, but suture type or technique has little influence on outcome after acute lower-extremity tendon rupture.
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17
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Hong CK, Kuan FC, Hsu KL, Chen Y, Chuang HC, Chiang CH, Su WR. Does using high-tensile strength tape improve the fixation strength in tendon graft fixation with needleless suture wrapping techniques compared to a suture? J Orthop Surg (Hong Kong) 2021; 28:2309499020971865. [PMID: 33225808 DOI: 10.1177/2309499020971865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To compare the biomechanical properties of a high-tensile strength suture and high-tensile strength tape in tendon graft fixation using two needleless suture wrapping techniques, the modified Prusik knot and modified rolling hitch. METHODS Two needleless suture wrapping techniques, the modified rolling hitch (MR) and modified Prusik knot (MP), were utilized. Meanwhile, two kinds of suture materials, a No. 2 braided nonabsorbable high-strength suture (S) and a 1.3 mm high-tensile strength tape (T), were used. A total of 40 porcine tendons were used, which were randomly divided into four groups. Each group was assigned to one of the following groups: MRS, MRT, MPS, and MPT. Each specimen was pretensioned to 100 N for three cycles, cyclically loaded from 50 to 200 N for 200 cycles, and finally loaded to failure. RESULTS The MRT group (34.1 ± 3.5%) had a significantly higher value compared with the MRS (29.7 ± 2.3%), MPS (27.1 ± 3.6%) and MPT (29.5 ± 4.0%) groups in term of elongation after cyclic loadings (p = 0.002). In terms of ultimate failure load, there were no significant differences in the MRS (401 ± 27 N), MRT (380 ± 27 N), MPS (398 ± 44 N) and MPT (406 ± 49 N) values (p = 0.539). All specimens failed due to suture breakage at the knots. CONCLUSION Compared with the high-tensile strength suture, using the high-tensile strength tape lead to greater elongation after cyclic loading when the modified rolling hitch was used. No differences in terms of elongation after cyclic loading and load to failure were found between the high-tensile strength suture and tape using the modified Prusik knot.
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Affiliation(s)
- Chih-Kai Hong
- Department of Orthopaedic Surgery, 38026National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Fa-Chuan Kuan
- Department of Orthopaedic Surgery, 38026National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Biomedical Engineering, 38026National Cheng Kung University, Tainan, Taiwan
| | - Kai-Lan Hsu
- Department of Orthopaedic Surgery, 38026National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Biomedical Engineering, 38026National Cheng Kung University, Tainan, Taiwan
| | - Yueh Chen
- Department of Orthopaedic Surgery, 71587Sin Lau Hospital, Tainan, Taiwan
| | - Hao-Chun Chuang
- Department of Orthopaedic Surgery, 38026National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chen-Hao Chiang
- Department of Biomedical Engineering, 38026National Cheng Kung University, Tainan, Taiwan.,Department of Orthopaedics, 36597Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi, Taiwan
| | - Wei-Ren Su
- Department of Orthopaedic Surgery, 38026National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, 38026National Cheng Kung University Hospital, Tainan, Taiwan.,Musculoskeletal Research Center, Innovation Headquarter, 38026National Cheng Kung University, Tainan, Taiwan
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18
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Hong CK, Hsu KL, Kuan FC, Chen Y, Chiang CH, Yeh ML, Wen MJ, Su WR. The Biomechanical Properties of a High-Tensile Strength Tape for Tendon Graft Fixation Using the Krackow Configuration. Arthrosc Sports Med Rehabil 2020; 2:e347-e351. [PMID: 32875299 PMCID: PMC7451909 DOI: 10.1016/j.asmr.2020.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 05/05/2020] [Indexed: 11/27/2022] Open
Abstract
Purpose To compare the biomechanical properties of a high-tensile strength suture with the high-tensile strength tape for tendon graft fixation. Methods A total of 24 porcine tendons were used and were randomly divided into 2 groups. Two kinds of suture materials, a braided nonabsorbable high-strength suture (group S) and a high-tensile strength tape (group T), were used to complete 3 pairs of Krackow stitches on the tendons. Each specimen was pretensioned to 100 N for 3 cycles, cyclically loaded from 50 to 200 N for 200 cycles, and finally loaded to failure. Elongation after cyclic loading, ultimate failure load, and the mode of failure were recorded. Results The elongation after cyclic loading between group S (26% ± 5%) and group T (24% ± 5%) were not significantly different (P = .378). The ultimate failure loads in group T (400 ± 38 N) were significantly greater than those in group S (358 ± 21 N) (P = .010). All specimens failed because of suture material breakage. Conclusions Compared with the braided nonabsorbable high-strength suture, the high-tensile strength tape had similar elongation values after cyclic loading, but significantly greater ultimate failure load in this porcine in vitro biomechanical model. Clinical Relevance A secure suture-tendon construct is especially important when a post-tie fixation technique is used because the mitigating construct may potentially lead to graft loosening and affect graft healing.
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Affiliation(s)
- Chih-Kai Hong
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Kai-Lan Hsu
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Fa-Chuan Kuan
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Yueh Chen
- Department of Orthopaedic Surgery, Sin Lau Hospital, Tainan, Taiwan
| | - Chen-Hao Chiang
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan.,Department of Orthopedic Surgery, Chiayi Christian Hospital, Chiayi, Taiwan
| | - Ming-Long Yeh
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan.,Medical Device Innovation Center, National Cheng Kung University, Tainan, Taiwan
| | - Miin-Jye Wen
- Department of Statistics, National Cheng Kung University, Tainan, Taiwan
| | - Wei-Ren Su
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, College of Medicine, National Cheng Kung University
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19
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Taha ME, Schneider K, Clarke EC, O'Briain DE, Smith MM, Cunningham G, Cass B, Young AA. A Biomechanical Comparison of Different Suture Materials Used for Arthroscopic Shoulder Procedures. Arthroscopy 2020; 36:708-713. [PMID: 31727418 DOI: 10.1016/j.arthro.2019.08.048] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 08/18/2019] [Accepted: 08/20/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the viscoelastic properties of 4 commercially available cord-like sutures and 2 commercially available suture tapes when subjected to physiological loads, as well as to compare them with each other and to identify the clinically most desirable combination of suture material properties. METHODS Six suture materials (Ethibond, FiberWire, FiberTape, Orthocord, Ultrabraid, and Ultratape) underwent creep testing (n = 7, 60 N, 10 minutes) to determine specimen stiffness, initial elongation at 60 N of load, static creep (during 10 minutes of loading), and relaxed elongation (material recovery 3 minutes after removal of load). Furthermore, cyclic testing (n = 7, 10-45 N, 0.5 Hz, 500 cycles) was carried out to determine dynamic creep, peak-to-peak displacement, and relaxed elongation. Mechanical testing was conducted on a material testing machine in 37°C phosphate-buffered saline solution. RESULTS FiberTape showed the greatest stiffness (23.9 ± 3.2 N/mm, P < .001), the smallest amounts of static (0.38 ± 0.10 mm, P < .001) and dynamic (0.16 ± 0.09 mm, P = .003) creep, and the smallest peak-to-peak displacement (0.20 ± 0.02 mm, P < .001). FiberTape and FiberWire showed the smallest initial elongation (1.17 ± 0.17 mm and 1.63 ± 0.25 mm, respectively; P < .001). Ultrabraid showed the greatest relaxed elongation, both statically (4.73 ± 0.73 mm, P < .001) and dynamically (4.18 ± 0.83 mm, P = .002). CONCLUSIONS FiberTape consistently displayed less creep, greater stiffness, and less extensibility than the other suture types. Ultrabraid showed the largest amount of relaxed elongation on both static and dynamic testing. CLINICAL RELEVANCE When considering high stiffness in combination with low initial extension and low static creep to be ideal parameters to achieve optimal initial construct stability and considering low dynamic creep in combination with low peak-to-peak displacement to be ideal conditions for the repetitive loading of the construct during the healing process, tapes seem to be superior to cord-like sutures for performing rotator cuff repair.
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Affiliation(s)
- Mohy E Taha
- Division of Orthopaedics and Trauma Surgery, Basel University Hospital, Basel, Switzerland
| | - Kerstin Schneider
- Department of Paediatric Orthopaedics, Schulthess Clinic Zurich, Zurich, Switzerland.
| | | | - David E O'Briain
- Department of Orthopaedic Service, University Hospital Waterford, Waterford, Ireland
| | - Margaret M Smith
- Raymond Purves Research Labs, University of Sydney, Sydney, Australia
| | - Gregory Cunningham
- Shoulder Center, Hirslanden Clinique la Colline, Geneva, Switzerland; Division of Orthopaedics and Trauma Surgery, University of Geneva, Geneva, Switzerland
| | - Benjamin Cass
- Sydney Shoulder Research Institute, Sydney, Australia
| | - Allan A Young
- Sydney Shoulder Research Institute, Sydney, Australia
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20
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Michel PA, Domnick C, Raschke MJ, Kittl C, Glasbrenner J, Deitermann L, Fink C, Herbort M. Soft Tissue Fixation Strategies of Human Quadriceps Tendon Grafts: A Biomechanical Study. Arthroscopy 2019; 35:3069-3076. [PMID: 31405619 DOI: 10.1016/j.arthro.2019.05.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 04/14/2019] [Accepted: 05/13/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the effects of different stitching methods and suture diameters on the graft fixation of soft tissue human quadriceps tendon grafts for anterior cruciate ligament (ACL) reconstruction. METHODS The Krackow locking stitch (K), whipstitch (W), and baseball stitch (B) were combined with either a 2× no. 2 (#2) or a 1× no. 5 (#5) braided composite suture for graft fixation of 36 human quadriceps tendons in 6 groups. Biomechanical testing was performed using a cyclic protocol with loads between 0 and 100 N. The maximum load until failure, cyclic elongation, and failure mode were recorded. RESULTS The highest mean maximum load to failure was observed in the 2 Krackow stitch groups. The K#2 group had significantly higher load to failure values compared with those of the W#2 and B#2 groups (K#2, 553 ± 82 N vs W#2, 392 ± 107 N, P = .0349; K#2 vs B#2 366 ± 118 N, P = .0129). The mean cyclic elongation was lowest in the Krackow groups (K#2, 10.59 ± 2.63 mm; K#5, 13.66 ± 2.3 mm). The regular failure mode was the rupture of the suture for the Krackow stitch (8 of 12) and suture pullout for the whipstitch (11 of 12) and baseball stitch groups (12 of 12). CONCLUSIONS The double Krackow stitch with no. 2 braided composite suture exhibits a high maximum load to failure combined with a low amount of elongation in a biomechanical study for human quadriceps tendon soft tissue graft fixation. Unlike the whipstitch and the baseball stitch, it can solidly prevent suture pullout. CLINICAL RELEVANCE A safe soft tissue graft fixation technique is especially important for quadriceps tendon grafts with their laminar anatomical structure and physiologically varying diameter. Unlike other grafts for ACL replacement, it fully relies on the soft tissue suture fixation to resist the pullout force.
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Affiliation(s)
- Philipp A Michel
- Department of Trauma, Hand and Reconstructive Surgery, Westfaelische Wilhelms University of Muenster, Muenster, Germany
| | - Christoph Domnick
- Department of Trauma, Hand and Reconstructive Surgery, Westfaelische Wilhelms University of Muenster, Muenster, Germany
| | - Michael J Raschke
- Department of Trauma, Hand and Reconstructive Surgery, Westfaelische Wilhelms University of Muenster, Muenster, Germany
| | - Christoph Kittl
- Department of Trauma, Hand and Reconstructive Surgery, Westfaelische Wilhelms University of Muenster, Muenster, Germany
| | - Johannes Glasbrenner
- Department of Trauma, Hand and Reconstructive Surgery, Westfaelische Wilhelms University of Muenster, Muenster, Germany
| | - Lucas Deitermann
- Department of Trauma, Hand and Reconstructive Surgery, Westfaelische Wilhelms University of Muenster, Muenster, Germany
| | - Christian Fink
- Gelenkpunkt Sports and Joint Surgery, Innsbruck, Austria; Research Unit for Orthopaedic Sports Medicine and Injury Prevention, Institute for Sports Medicine, Alpine Medicine and Health Tourism, Private University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | - Mirco Herbort
- Department of Trauma, Hand and Reconstructive Surgery, Westfaelische Wilhelms University of Muenster, Muenster, Germany; OCM Clinic, Munich, Germany.
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21
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McCabe MP. Editorial Commentary: Stronger and Faster Suture Configuration-But Is It Better? Challenges of Surgical Innovation in the Modern Era. Arthroscopy 2019; 35:1170-1171. [PMID: 30954110 DOI: 10.1016/j.arthro.2019.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 12/12/2018] [Accepted: 01/06/2019] [Indexed: 02/02/2023]
Abstract
When evaluating the characteristics of a new surgical technique, it is important to consider practical effects of the technique on clinical practice, as it would be inappropriate to advocate for cost-prohibitive or excessively time-consuming methods, even if biomechanically superior. The Krackow stitch has long been considered the gold standard for suture-graft fixation; potential limitations with this technique include the risk of needle sticks to the surgical team and the time required to perform the stitch. A new proprietary method (SpeedTrap, DePuy-Mitek, Raynham, MA) offers a significantly faster solution with equivalent or better biomechanics; however, elongation of the suture-graft construct is still a concern, and the cost effectiveness remains unclear. Regardless, we are fortunate to be practicing in an era when we can have great appreciation for the problem-solving innovations of surgeons who practiced in prior decades as well as witness the continued effort to optimize clinical outcomes now and in the future.
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