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Jain G, Datt R, Krishna A, Patro BP, Morankar R. No Clear Difference in Clinical Outcomes Between Knotted and Knotless Arthroscopic Bankart Repair: A Systematic Review. Arthroscopy 2024:S0749-8063(24)00464-X. [PMID: 38942097 DOI: 10.1016/j.arthro.2024.05.036] [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: 12/31/2023] [Revised: 05/19/2024] [Accepted: 05/28/2024] [Indexed: 06/30/2024]
Abstract
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.
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Affiliation(s)
- Gunjar Jain
- Department of Orthopaedics, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Rameshwar Datt
- Department of Orthopaedics, ESI-PGIMSR, Basaidarapur, New Delhi, India.
| | - Anant Krishna
- Department of Orthopaedics, Maulana Azad Medical College & Lok Nayak Jai Prakash Narayan Hospital, New Delhi, India
| | - Bishnu Prasad Patro
- Department of Orthopaedics, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Rahul Morankar
- Division of Pedodontics and Preventive Dentistry, Centre for Dental Education and Research, All India Institute of Medical Sciences, Delhi, India
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Wilke AJ, Martin R, Bates NA, Jastifer JR, Martin KD. Technique Variation in the Surgical Treatment of Lateral Ankle Instability. Foot Ankle Spec 2024; 17:259-263. [PMID: 37823588 DOI: 10.1177/19386400231202029] [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] [Indexed: 10/13/2023]
Abstract
INTRODUCTION Lateral ankle sprains are the most common type of injury to the ankle and can lead to ankle instability. There are many described techniques for the surgical treatment of lateral ankle instability. The purpose of this study is to quantify the variation in surgeon technique for lateral ankle instability treatment. METHODS Surveys were sent to 62 orthopaedic foot and ankle surgeons regarding surgical technique for the treatment of lateral ankle instability. Clinical agreement was defined as greater than 80% agreement to assess the cohesiveness of surgical methods as described by Marx et al. Results. Response rate was 49/62 (79%). There was clinical agreement for not using bone tunnels and not using metal anchors. All other factors lacked clinical agreement. A greater average number of throws and knots (4.2 for each, range 1-6 throws, range 2-12 knots) were used by surgeons that do not believe knots cause pain compared to an average of 3.9 (range, 1-6) throws and 4.0 (range, 2-15) knots by surgeons who do believe knots cause pain. The association that surgeon who believed knots do cause pain and thus used fewer knots and throws was not statistically significant (P > .05). The preferred material by surgeons in our study are as follows: nonabsorbable braided suture (26/49, 53%), suture tape (15/49, 31%), and fiber tape (4/49, 8%). Among surgeons who use absorbable suture (34/49, 69%), there was no significant difference (P > .05) between surgeons who believe knots cause pain (23/34, 68%) and those who do not (11/34, 32%). DISCUSSION AND CONCLUSION Among this small sample of orthopaedic foot and ankle surgeons, there is wide variation in surgical technique for lateral ankle instability treatment and little agreement on the clinical standard of care. This disagreement highlights the need for comparative outcome studies in the treatment of ankle instability. LEVEL OF EVIDENCE Level III: Retrospective cohort study.
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Affiliation(s)
| | | | | | | | - Kevin D Martin
- The Ohio State University Wexner Medical Center, Columbus, Ohio
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3
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Nicolay RW, Jahandar A, Retzky JS, Kontaxis A, Verma NN, Fu MC. Biomechanical properties of suprapectoral biceps tenodesis with double-anchor knotless luggage tag sutures vs. subpectoral biceps tenodesis with single-anchor whipstitch suture using all-suture anchors. JSES Int 2023; 7:2393-2399. [PMID: 37969507 PMCID: PMC10638590 DOI: 10.1016/j.jseint.2023.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023] Open
Abstract
Background As the use of all-suture anchors continues to increase, limited biomechanical data on the use of these anchors in various configurations for tenodesis of the long head biceps tendon (LHBT) exists. The aim of this study was to compare the biomechanical properties of a 2-anchor luggage tag suprapectoral biceps tenodesis (Sup-BT) vs. a single-anchor whipstitch subpectoral biceps tenodesis (Sub-BT) using all-suture anchors. The hypothesis was that the Sub-BT will have a higher ultimate load to failure and less creep relative to the Sup-BT construct. Methods Eighteen fresh frozen cadaveric humeri were used. The specimens were randomly divided into 2 groups of 9; i) The Sup-BT were performed with 2 1.8 mm knotless all-suture anchors using a luggage-tag fixation configuration, ii) The Sub-BT were performed using a single 1.9 mm all-suture anchor and a whipstitch suture configuration with a tied knot. The humeri were tested on a hydraulic MTS machine where the specimens were preloaded at 5 N for 2 minutes and then cyclically loaded from 5 to 50 N for 1000 cycles at 1 Hz while maximum displacement was recorded with a motion system and markers attached to the bone and bicep tendon. The tendon was then tensioned at a rate of 1 mm/s to obtain the ultimate load to failure. CT scans of the specimens were used to calculate the bone mineral density at the site of the anchor/bone interface and video recordings were captured during load to failure to document all modes of failure. Results There was no significant difference in the average load to failure of the Sup-BT and Sub-BT groups (197 N ± 45 N (SD), 164 N ± 68 N (SD) respectively; P = .122) or creep under fatigue between the Sup-BT vs. Sub-BT specimens (3.1 mm, SD = 1.5 vs. 2.2 mm, SD = 0.9; P = .162). The bone mineral density was statistically different between the 2 groups (P < .001); however, there were no observed failures at the anchor/bone interface and no correlation between failure load and bone mineral density. Conclusion The ultimate load to failure and creep between a Sup-BT with 2 knotless all-suture anchors using a luggage tag suture configuration was equivalent to a Sub-BT with 1 all-suture anchor using a whipstitched suture configuration and a tied knot. Surgeons can perform either technique confidently knowing that they are biomechanically equivalent in a cadaver model at time zero, and they offer similar strength to other fixation methods cited in the literature.
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Affiliation(s)
- Richard W. Nicolay
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, NY, USA
| | - Amirhossein Jahandar
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, NY, USA
| | - Julia S. Retzky
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, NY, USA
| | - Andreas Kontaxis
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, NY, USA
| | - Nikhil N. Verma
- Section of Shoulder and Elbow Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Michael C. Fu
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, NY, USA
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4
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Hsu JC, Wilhelm CV. Endoscopic Proximal Hamstring Tendon Repair With Knotless Suture-Bridge Technique. Arthrosc Tech 2023; 12:e1737-e1745. [PMID: 37942091 PMCID: PMC10627846 DOI: 10.1016/j.eats.2023.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 05/28/2023] [Indexed: 11/10/2023] Open
Abstract
Symptomatic proximal hamstring tendon tears are typically repaired surgically, with open incision and knot-tying technique. An endoscopic, knotless, suture-bridge repair technique is presented. Potential advantages include knotless simplicity, compression over a broad zone to improve tendon-bone healing, and decreased pain secondary to elimination of knots and the open incision and approach.
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Affiliation(s)
- Jim C. Hsu
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, U.S.A
| | - Christopher V. Wilhelm
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, U.S.A
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Moroski N, Eskew J, Cole A. Subpectoral Biceps Tenodesis Using an All-Suture Knotless Anchor. Arthrosc Tech 2023; 12:e937-e942. [PMID: 37424659 PMCID: PMC10323911 DOI: 10.1016/j.eats.2023.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/12/2023] [Indexed: 07/11/2023] Open
Abstract
The long head of the biceps tendon is a common pain generator in the anterior shoulder and is concomitantly seen with other shoulder pathology including subacromial impingement, as well as rotator cuff and labral tears. This Technical Note describes a mini-open onlay biceps tenodesis technique using all-suture knotless anchor fixation. This technique is easily reproducible, is efficient, and offers the unique benefits of providing a consistent length-tension relation and mitigating the risk of peri-implant reaction and fracture without sacrificing strength of fixation.
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Affiliation(s)
| | - Joshua Eskew
- Address correspondence to Joshua Eskew, M.D., Prisma Health Blue Ridge Orthopedics–Seneca, 10630 Clemson Blvd, Ste 100, Seneca, SC 29678, U.S.A.
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Johnson AH, Brennan JC, Lashgari CJ, Petre BM, Turcotte JJ, Redziniak DE. Clinical Results of Knot-tying Versus Knotless Suture Anchors in Arthroscopic Anteroinferior Labral Repair. Cureus 2023; 15:e40292. [PMID: 37448384 PMCID: PMC10337236 DOI: 10.7759/cureus.40292] [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: 06/11/2023] [Indexed: 07/15/2023] Open
Abstract
Background Arthroscopic repair of glenohumeral instability is becoming an increasingly common procedure. These repairs can be undertaken using knot-tying and knotless suture anchors; there is currently no clear consensus in the literature about what type of repair is most cost-effective and provides superior outcomes. The purpose of this study is to examine postoperative outcomes of patients undergoing arthroscopic anteroinferior labral repair (AALR) with either knot-tying or knotless anchors. Methods A single institution retrospective observational cohort study of 122 patients undergoing AALR from January 2014 to June 2021 was conducted. Univariate statistics were used to assess differences in demographics, operative characteristics, and postoperative outcomes between repair types; multivariate analysis was used to evaluate risk factors for recurrent instability and reoperation. Results Patients undergoing AALR with knotless anchors had a shorter case duration than those with knot-tying anchors (112.64 vs. 89.86 minutes, p<0.001). There were no significant differences between groups in the size of labral tear, presence of a glenoid bone defect, or Hill-Sachs lesion. After controlling for age, BMI, sex, glenoid bone defect, number of preoperative dislocations, and fixation type, only age (OR=0.896, p=0.010) and female sex (OR=5.341, p=0.008) were independent risk factors for recurrent instability and no factors were independent predictors of reoperation. Conclusion Patients undergoing AALR experienced similar rates of reoperation and recurrent instability regardless of whether a knot-tying or knotless repair was performed. The use of knotless suture anchors may improve cost-effectiveness due to decreased surgical time without diminishing postoperative outcomes.
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Affiliation(s)
| | - Jane C Brennan
- Orthopedic Research, Anne Arundel Medical Center, Annapolis, USA
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Hsu JC. Tensionable Distal Biceps Tendon Repair With Intramedullary Knotless All-Suture Anchors and FiberLoop w/FiberTag Suture. Arthrosc Tech 2022; 11:e2177-e2183. [PMID: 36632398 PMCID: PMC9826978 DOI: 10.1016/j.eats.2022.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/10/2022] [Indexed: 11/18/2022] Open
Abstract
Distal biceps tendon rupture is commonly repaired via bicortical drilling, extramedullary cortical button placement, and inlay tendon fixation. A retensionable technique with unicortical drilling, intramedullary knotless all-suture anchors placement, and onlay tendon fixation is presented, incorporating up-to-date advances in tendon-bone healing basic science, biceps tendon/radial tuberosity biomechanics, and knotless all-suture implant technology to facilitate radial tuberosity bone preservation, anatomic footprint restoration, improved suture-tendon connection security, and avoidance of drilling and implant-related injury to the posterior interosseous nerve.
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Affiliation(s)
- Jim C. Hsu
- Address correspondence to Jim C. Hsu, M.D., The Polyclinic, 904 7th Avenue, 4th Floor, Seattle, WA, 98104, U.S.A.
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Hsu JC. Knotless, Retensionable Posterior Meniscal Root Repair With Anterior Cruciate Ligament Repair TightRope and FiberRing Sutures. Arthrosc Tech 2022; 11:e2125-e2133. [PMID: 36632386 PMCID: PMC9826884 DOI: 10.1016/j.eats.2022.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 08/09/2022] [Indexed: 11/18/2022] Open
Abstract
Posterior meniscal root repair techniques continue to evolve, influenced by rapidly increasing clinical interest, surgical technology advances, and biomechanical insights. A posterior meniscal root repair technique is presented, utilizing a knotless, retensionable suspensory construct developed for anterior cruciate ligament repair but is also well suited for meniscal root repair. Benefits include built-in shuttling sutures, knotless technology, and poststressing retensioning capability to ensure maximal final repair security.
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Affiliation(s)
- Jim C. Hsu
- Address correspondence to Jim C. Hsu, M.D., The Polyclinic, 904 7th Avenue, 4th Floor, Seattle, WA, 98104, USA
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Hsu JC, Tran DH. Arthroscopic Fixation of Knee Osteochondritis Dissecans With Interlinked Knotless All-Suture Anchors. Arthrosc Tech 2022; 11:e1013-e1019. [PMID: 35782848 PMCID: PMC9245000 DOI: 10.1016/j.eats.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 02/05/2022] [Indexed: 02/03/2023] Open
Abstract
Unstable, displaced, and persistently symptomatic osteochondritis dissecans of the knee typically requires surgical treatment. An arthroscopic, knotless fixation method using interlinked all-suture anchors is presented, with potential advantages over other current techniques in fixation over a broad zone, treatment versatility for a wide range of fragment types, retensioning ability after stressing, decreased risk of implant-breakage complications, and avoidance of additional surgery for implant removal.
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Affiliation(s)
- Jim C. Hsu
- Address correspondence to Jim C. Hsu, M.D., The Polyclinic, 904 Seventh Ave., 4th Floor, Seattle, WA, 98104, U.S.A.
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Pearce SS, Ruzbarsky JJ, Ernat JJ, Rakowski DR, Hanson JA, Millett PJ. Arthroscopic Subcoracoid Decompression, Coracoplasty, and Subscapularis Repair for Subscapularis Tears in the Setting of Subcoracoid Impingement. Arthrosc Tech 2022; 11:e333-e338. [PMID: 35256972 PMCID: PMC8897572 DOI: 10.1016/j.eats.2021.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 10/28/2021] [Indexed: 02/03/2023] Open
Abstract
Subscapularis tears have been found to occur in the setting of subcoracoid impingement and are related to the narrowing of the coracohumeral interval. The advancement of arthroscopic techniques has allowed for improved identification and treatment of this historically overlooked pathology. Challenges of arthroscopic subscapularis treatment include nearby neurovascular structures, tendon retraction, and adhesions, which are further complicated by diminished arthroscopic visualization, resulting from the concomitant subcoracoid impingement. The purpose of this Technical Note is to describe our preferred technique for arthroscopic management of subscapularis tears in the setting of subcoracoid impingement that is simple and reproducible, as well as cost-effective and efficient with limited additional morbidity to that of a standard diagnostic shoulder arthroscopy.
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Affiliation(s)
- Stephanie S. Pearce
- The Steadman Clinic, Vail, Colorado, U.S.A
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Joseph J. Ruzbarsky
- The Steadman Clinic, Vail, Colorado, U.S.A
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Justin J. Ernat
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
- University of Utah Health, Salt Lake City, Utah, U.S.A
| | | | - Jared A. Hanson
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Peter J. Millett
- The Steadman Clinic, Vail, Colorado, U.S.A
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
- Address correspondence to Peter J. Millett, M.D., M.Sc., Steadman Philippon Research Institute, The Steadman Clinic, 181 W. Meadow Dr., Ste. 400, Vail, CO, 81657, U.S.A.
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Drabble E, Spanopoulou S, Sioka E, Politaki E, Paraskeva I, Palla E, Stockley L, Zacharoulis D. How to tie dangerous surgical knots: easily. Can we avoid this? BMJ SURGERY, INTERVENTIONS, & HEALTH TECHNOLOGIES 2022; 3:e000091. [PMID: 35047808 PMCID: PMC8749257 DOI: 10.1136/bmjsit-2021-000091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/23/2021] [Indexed: 11/04/2022] Open
Abstract
Objective Secure knots are essential in all areas of surgical, medical and veterinary practice. Our hypothesis was that technique of formation of each layer of a surgical knot was important to its security. Design Equal numbers of knots were tied, by each of three groups, using three techniques, for each of four suture materials; a standard flat reef knot (FRK), knots tied under tension (TK) and knots laid without appropriate hand crossing (NHCK). Each knot technique was performed reproducibly, and tested by distraction with increasing force, till each material broke or the knot separated completely. Setting Temporary knot tying laboratory. Materials The suture materials were, 2/0 polyglactin 910 (Vicryl), 3/0 polydioxanone, 4/0 poliglecaprone 25 (Monocryl) and 1 nylon (Ethilon). Participants Three groups comprised, a senior surgeon, a resident surgeon and three medical students. Outcome measures Proportion of each knot type that slipped, degree of slippage and length of suture held in loop secured by each knot type. Results 20% of FRK tied with all suture materials slipped; all knots tied with the other two techniques, with all materials, slipped, TK (100%) and NHCK (100%). The quantitative degree of slip was significantly less for FRK (mean 6.3%–, 95% CI 2.2% to 10.4%) than for TK (mean 312%, 95% CI 280.0% to 344.0%) and NHCK (mean 113.0%, –95% CI 94.3% to 131.0%). The mean length of suture in loops held within (FRK mean 25.1 mm 95% CI 24.2 to 26.0 mm) was significantly greater than mean lengths held by the other techniques (TK mean 17.0 mm, 95% CI 16.3 to 17.7 mm), (NHCK mean 16.3 mm, 95% CI 15.9 to 16.7 mm). The latter two types of knot may have tightened more than anticipated, in comparison to FRK, with potential undue tissue tension. Conclusion Meticulous technique of knot tying is essential for secure knots, appropriate tissue tension and the security of anastomoses and haemostasis effected.
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Affiliation(s)
- Eric Drabble
- Clinical lead BSS course RCS England, Consultant Surgeon (retired), University ofPlymouth Hospitals NHS Trust, Plymouth, UK.,Royal College of Surgeons of England, London, London, UK.,Surgical Directorate, University of Plymouth Hospitals NHS Trust, Derriford Hospital, PlymouthPL6, Greece
| | - Sofia Spanopoulou
- Department of Plastic Surgery, Hopital Universitaire Henri Mondor, Paris, France
| | - Eleni Sioka
- Department of Surgery, IASO Hospital Thessalias, Larissa, Greece
| | - Ellie Politaki
- Surgical clinic B, General Hospital Georgios Gennimatas, Athens, Greece
| | - Ismini Paraskeva
- Department of General Surgery, University Hospital of Larissa, Mezourlo, Greece
| | - Effrosyni Palla
- Department of Otorhinolaryngology, University Hospital of Larissa, Mezourlo, Greece
| | - Lauren Stockley
- Department of Statistical Analysis, University of Plymouth, Plymouth, Devon, UK
| | - Dimitris Zacharoulis
- Department of Surgery, IASO Hospital Thessalias, Larissa, Greece.,Department of General Surgery, University Hospital of Larissa, Mezourlo, Greece
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12
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Friedman LGM, Quigley R, Shewman E, Kirsch J, Freehill MT, Garrigues GE. Comparison of mechanical properties between Nice knot, Modified Nice knot, and surgeon's knot. Clin Biomech (Bristol, Avon) 2021; 90:105486. [PMID: 34560347 DOI: 10.1016/j.clinbiomech.2021.105486] [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: 01/19/2021] [Revised: 07/21/2021] [Accepted: 09/13/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The success of surgical repairs rely on the effectiveness and integrity of the surgical knots used to secure the repair. The purpose of this study is to examine and compare the performance of the Nice knot, the modified Nice knot, and a commonly used combination of surgeons' and square knots with respect to cyclic loading and load-to-failure usiflueng a high-strength suture composed of ultra-high molecular weight polyethylene in the hands of experienced surgeons. METHODS Two experienced surgeons threw 3 different knot types 9 times, consisting of the Nice knot, modified Nice knot, and a surgeon's knot utilizing Ultrabraid #2 sutures. Each knot was subject to cyclic loading and load to failure testing. FINDINGS Both surgeons had similar displacement data for the surgeon's knot, while the identity of the surgeon impacted displacement for the Nice knot (p = 0.03) and the modified Nice knot (p = 0.0002). The load to failure for the modified Nice knot (p < 0.001) and the Nice knot (p = 0.001) were significantly impacted by the surgeon tying the knot, while the surgeon's knot was not. Specimens failed where the sutures passed through the loop at the "base" of the knot. INTERPRETATIONS The strength and integrity of complex surgical knots are variable between surgeons. While the proposed Modified Nice Knot has a theoretical advantage because the half hitches reinforce the primary knot, in load to failure testing both the Modified Nice Knot and the Nice Knot failed where the suture passed through the loop in the primary knot.
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Affiliation(s)
| | - Ryan Quigley
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, United States of America.
| | - Elizabeth Shewman
- Rush University Medical Center, Chicago, IL, United States of America.
| | - Jacob Kirsch
- Boston Sports and Shoulder Center, Waltham, MA, United States of America
| | - Michael T Freehill
- Stanford University Medical Center, Stanford, CA, United States of America
| | - Grant E Garrigues
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, United States of America.
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13
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Belk JW, Lindsay A, Houck DA, Dragoo JL, Genuario JW, Mayer SW, Frank RM, McCarty EC. Biomechanical Testing of Suture Anchor Versus Transosseous Tunnel Technique for Quadriceps Tendon Repair Yields Similar Outcomes: A Systematic Review. Arthrosc Sports Med Rehabil 2021; 3:e2059-e2066. [PMID: 34977665 PMCID: PMC8689238 DOI: 10.1016/j.asmr.2021.08.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 08/25/2021] [Indexed: 01/08/2023] Open
Abstract
PURPOSE To systematically review the literature to evaluate the biomechanical properties of the suture anchor (SA) versus transosseous tunnel (TO) techniques for quadriceps tendon (QT) repair. METHODS A systematic review was performed by searching PubMed, the Cochrane Library, and Embase using PRISMA guidelines to identify studies that evaluated the biomechanical properties of SA and TO techniques for repair of a ruptured QT. The search phrase used was "quadriceps tendon repair biomechanics". Evaluated properties included ultimate load to failure (N), displacement (mm), stiffness (N/mm), and mode of failure. RESULTS Five studies met inclusion criteria, including a total of 72 specimens undergoing QT repair via the SA technique and 42 via the TO technique. Three of 4 studies found QTs repaired with SA to have significantly less elongation upon initial cyclic loading when compared to QTs repaired with the TO technique (P < .05). Three of 5 studies found QTs repaired with SA to have significantly less elongation upon final cyclic loading when compared to QTs repaired with the TO technique (P < .05). The pooled analysis from 4 studies reporting on initial displacement showed a statistically significant difference in favor of the SA group compared to the TO group (P = .03). The pooled analysis from studies reporting on secondary displacement and ultimate load to failure showed no significant difference between the SA and TO groups (P > .05). The most common mode of failure in both groups was suture slippage. CONCLUSION On the basis of the included cadaveric studies, QTs repaired via the SA technique have less initial displacement upon cyclic testing when compared to QTs repaired via the TO technique. However, final displacement and ultimate load to failure outcomes did not reveal differences between the two fixation strategies. Knot slippage remains a common failure method for both strategies.
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Affiliation(s)
- John W. Belk
- University of Colorado School of Medicine, Department of Orthopaedics, University of Colorado, Aurora, Colorado, U.S.A
| | - Adam Lindsay
- University of Colorado School of Medicine, Department of Orthopaedics, University of Colorado, Aurora, Colorado, U.S.A
| | - Darby A. Houck
- University of Colorado School of Medicine, Department of Orthopaedics, University of Colorado, Aurora, Colorado, U.S.A
| | - Jason L. Dragoo
- University of Colorado School of Medicine, Department of Orthopaedics, University of Colorado, Aurora, Colorado, U.S.A
| | - James W. Genuario
- University of Colorado School of Medicine, Department of Orthopaedics, University of Colorado, Aurora, Colorado, U.S.A
| | - Stephanie W. Mayer
- University of Colorado School of Medicine, Department of Orthopaedics, University of Colorado, Aurora, Colorado, U.S.A
| | - Rachel M. Frank
- University of Colorado School of Medicine, Department of Orthopaedics, University of Colorado, Aurora, Colorado, U.S.A
| | - Eric C. McCarty
- University of Colorado School of Medicine, Department of Orthopaedics, University of Colorado, Aurora, Colorado, U.S.A
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14
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Ensminger WP, McIff T, Vopat B, Mullen S, Schroeppel JP. Mechanical Comparison of High-Strength Tape Suture Versus High-Strength Round Suture. Arthrosc Sports Med Rehabil 2021; 3:e1525-e1534. [PMID: 34712990 PMCID: PMC8527324 DOI: 10.1016/j.asmr.2021.07.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 07/16/2021] [Indexed: 12/04/2022] Open
Abstract
Purpose To compare knot and loop characteristics of commonly used high-strength tapes and high-strength round sutures. Methods Twenty tied 30-mm loops were prepared for using suture-knot combinations of 4 common arthroscopic knots or a hand-tied surgeon’s knot and 7 sutures. Two tapes (BroadBand, SutureTape) and three no. 2 sutures (MaxBraid, FiberWire, DynaCord) were compared. Two additional larger tape sutures (FiberTape, PermaTape) not commonly tied arthroscopically were included in the hand-tied group. Each suture-knot combination was evaluated for loop integrity (single load to a specified elongation), knot security (plastic loop deformation with cyclic testing), loop security, and knot volume. Data were compared using analysis of variance followed by Tukey-Kramer post hoc tests. Results BroadBand and SutureTape demonstrated superior loop integrity compared to most no. 2 suture-knot combinations. FiberTape (430.48 ± 89.00 N) and PermaTape (545.16 ± 95.09 N) required significantly greater force to undergo 3 mm of displacement than all other hand-tied sutures (P < .001). All suture-knot configurations demonstrated significant plastic deformation (cyclic elongation) over 1000 cycles (P < 0.001). DynaCord displayed the best loop security except when paired with the Duncan loop. Overall, BroadBand and SutureTape had lower knot volumes compared to all other sutures. Conclusion This study exhibits the ability of narrow tape sutures to provide reliable tissue apposition and fixation in multiple suture-knot configurations, while decreasing the potential adverse effects accompanying knot prominence. Generally, BroadBand and SutureTape demonstrated an ideal balance of mechanical characteristics to achieve the optimal suture-knot construct among those tested. Dynacord displayed superior loop security and performed best among round sutures. PermaTape and FiberTape showed greater loop integrity, albeit to the detriment of loop security and knot volume. Clinical Relevance When securing a rotator cuff repair construct with a knot, one should have a basic understanding of the mechanical properties of the suture and knot being used to provide the best possible repair. This study will provide information about the mechanical characteristics of commonly used high-strength tape suture knots and loops to help determine what knot type may provide the best overall construct.
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Affiliation(s)
- William P Ensminger
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas, United States
| | - Terence McIff
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas, United States
| | - Bryan Vopat
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas, United States
| | - Scott Mullen
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas, United States
| | - J Paul Schroeppel
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas, United States
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15
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Rapp CM, Koueiter DM, Bojnowski J, Kalma J, Wiater B, Kurdziel MD, Wiater JM. Are Suture Tape Knots as Secure as Standard Suture? A Biomechanical Study. Orthop J Sports Med 2021; 9:23259671211045411. [PMID: 34692881 PMCID: PMC8529320 DOI: 10.1177/23259671211045411] [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: 06/08/2021] [Accepted: 06/16/2021] [Indexed: 11/16/2022] Open
Abstract
Background Few studies have investigated the biomechanical performance of flat-braided suture tapes versus round-braided sutures after being knotted. Purpose To compare the loop security and knot strength of a standard round-braided suture with 3 commercially available flat-braided suture tapes using 2 types of arthroscopic knots. Study Design Controlled laboratory study. Methods One standard suture (SS) and 3 suture tapes (T1, T2, and T3) were tied with the surgeon's knot (SK) and the Tennessee slider (TS), 25 times each, by a single surgeon. Each combination of knots and sutures underwent a preload, cyclic loading, and load to failure. Outcomes were loop security (defined by loop stretch after a 5-N preload), load at clinical failure (3 mm of displacement), and load at ultimate failure (suture rupture or knot slippage). Two-way analysis of variance was used for analysis. Results Overall, the SK group had greater overall loop security than that of the TS group (0.4 ± 0.3 vs 0.5 ± 0.3 mm of stretch, respectively; P = .020). The clinical failure load varied by suture type (P < .001) but not knot type (P = .106). For both knot types, the SS had the lowest mean ± SD clinical failure load (SK, 171 ± 49 N; TS, 176 ± 37 N), which was significantly less than that of T2 (247 ± 85 N; P < .001) and T3 (251 ± 96 N; P < .001) for the SK type and T2 (231 ± 67 N; P = .023) for the TS type. T2 sutures had the greatest ultimate failure load for both knot types (SK, 418 ± 45 N; TS, 461 ± 57 N), which was significantly greater than SS, T1, and T3 (P < .001 for all). The TS knot had greater overall ultimate failure load than the SK (375 ± 64 vs 350 ± 66 N; P < .001). Conclusion Not all suture tape knots had the same biomechanical properties, although knot security and strength appeared to be adequate for all suture tapes as well as for SS. There was no evidence that suture tape knots are lower profile than SS knots. Clinical Relevance Surgeons should not use suture tape based only on the assumption that it has superior biomechanical properties to a standard round-braided suture.
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Affiliation(s)
- Catherine M Rapp
- Department of Orthopaedic Surgery, Beaumont Health, Royal Oak, Michigan, USA
| | - Denise M Koueiter
- Department of Orthopaedic Surgery, Beaumont Health, Royal Oak, Michigan, USA
| | - Jeremy Bojnowski
- Department of Orthopaedic Surgery, Beaumont Health, Royal Oak, Michigan, USA
| | - Jeremy Kalma
- Department of Orthopaedic Surgery, Beaumont Health, Royal Oak, Michigan, USA
| | - Brett Wiater
- Department of Orthopaedic Surgery, Beaumont Health, Royal Oak, Michigan, USA
| | - Michael D Kurdziel
- Department of Orthopaedic Surgery, Beaumont Health, Royal Oak, Michigan, USA
| | - J Michael Wiater
- Department of Orthopaedic Surgery, Beaumont Health, Royal Oak, Michigan, USA
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16
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Mei XY, Sheth U, Abouali J. Excellent Functional Outcomes and Low Complication Rates Following Knotless Arthroscopic Bankart Repair: A Systematic Review of Clinical and Biomechanical Studies. Arthrosc Sports Med Rehabil 2021; 3:e927-e938. [PMID: 34195663 PMCID: PMC8220618 DOI: 10.1016/j.asmr.2021.01.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 01/24/2021] [Indexed: 11/21/2022] Open
Abstract
PURPOSE To provide a comprehensive review of the current clinical and biomechanical evidence for the use of knotless suture anchors during arthroscopic Bankart repair. METHODS A comprehensive search of 5 electronic databases from inception to July 2020 was performed for clinical and biomechanical studies in English evaluating outcomes following arthroscopic Bankart repair using knotless suture anchors. Two independent reviewers assessed articles for inclusion. Risk of bias was assessed using the Methodological Index for Non-Randomized Studies (MINORs) criteria. Clinical outcomes of interest and key findings from biomechanical studies were summarized. RESULTS Ten clinical studies (430 knotless repairs), including 4 cohort studies directly comparing knotless (N = 117) to knot-tying repairs (N = 192), were deemed eligible. Four biomechanical studies were also identified. Heterogeneity and the lack of randomized studies precluded data pooling and quantitative meta-analysis. Rates of redislocation ranged from 2.2% to 14.7% and 1.5% to 23.8% for knot-tying and knotless repair, respectively. Both knot-tying and knotless repair demonstrated excellent postoperative functional outcome, as assessed by visual analog scale, Constant-Murley, Rowe, and QuickDASH scores, with 80% to 94% of patients returning to sports participation. Biomechanical studies showed similar stiffness and load to failure between knot-tying and knotless repairs, with the most common mode of failure being retear at the suture-soft tissue interface. CONCLUSIONS Current level II to IV clinical and biomechanical evidence supports knotless arthroscopic Bankart repair as an effective procedure with excellent functional outcomes and low rates of complication and reoperation. LEVEL OF EVIDENCE Level IV, systematic review of level II to IV studies.
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Affiliation(s)
- Xin Y. Mei
- Division of Orthopaedic Surgery, Michael Garron Hospital, Toronto, Ontario, Canada
| | - Ujash Sheth
- Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jihad Abouali
- Division of Orthopaedic Surgery, Michael Garron Hospital, Toronto, Ontario, Canada
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17
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Otlans PT, Buuck T, Rosencrans A, Brady JM. Orthopaedic Resident Arthroscopic Knot-Tying Skills Are Improved Using a Training Program and Knot-Tying Workstation. Arthrosc Sports Med Rehabil 2021; 3:e867-e871. [PMID: 34195656 PMCID: PMC8220621 DOI: 10.1016/j.asmr.2021.02.009] [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: 08/18/2020] [Accepted: 02/20/2021] [Indexed: 11/29/2022] Open
Abstract
Purpose To quantify an orthopaedic trainee’s ability to tie arthroscopic knots before and after a short cadaveric-based arthroscopy training period using a commercially available knot-tying workstation. Methods During a weeklong cadaveric arthroscopic training camp, 15 third- and fourth-year orthopaedic residents were evaluated using a commercially available benchtop knot-tying workstation. At the beginning of the week (baseline), each participant was asked to tie 3 knots of his or her choice backed up by 3 half-hitches using nonabsorbable suture. Successful knots fit the sizer and elongated less than 3 mm after application of a 15-lb load. Afterward, residents watched a video demonstrating a sample knot and were encouraged to practice over the ensuing days. At the end of the week (post-training), residents were asked to tie 3 knots. The time to completion and success of each knot were recorded. To compare baseline and post-training knot success, t tests and χ2 analysis were performed. Results During baseline testing, residents successfully tied 26.7% of their knots (12 of 45 knots) in 352 ± 116 seconds (mean ± standard deviation). During post-training testing, residents successfully tied 66.7% of knots (30 of 45 knots, P = .00014) in 294 ± 63 seconds (P = .023), showing significant improvement in the time and ability to tie arthroscopic knots. Conclusions With a short cadaveric-based training period, orthopaedic trainees showed a significant improvement in their ability to tie arthroscopic knots on a commercially available benchtop knot-tying workstation. Given the initial low percentage of successfully tied knots and the limited opportunities for trainees to improve, trainees should be encouraged to practice and improve their skills. Clinical Relevance With training, residents can improve arthroscopic knot-tying abilities, which may allow them to successfully perform this critical task in the operating room.
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Affiliation(s)
- Peters T Otlans
- School of Medicine, Oregon Health & Science University, Portland, Oregon, U.S.A
| | - Taylor Buuck
- School of Medicine, Oregon Health & Science University, Portland, Oregon, U.S.A
| | - Adam Rosencrans
- School of Medicine, Oregon Health & Science University, Portland, Oregon, U.S.A
| | - Jacqueline M Brady
- School of Medicine, Oregon Health & Science University, Portland, Oregon, U.S.A
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18
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Weick JW, Workman WB, Bush CJ, McCollum KA, Sugaya H, Freehill MT. Reported Technical Aspects of Type II SLAP Lesion Repairs in Athletes. Arthrosc Sports Med Rehabil 2021; 3:e289-e296. [PMID: 34027434 PMCID: PMC8128993 DOI: 10.1016/j.asmr.2020.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 09/01/2020] [Indexed: 12/14/2022] Open
Abstract
Purpose To systematically review the available literature to further describe and report the available data on SLAP repair techniques and the association with outcomes. Methods A systematic review of literature was performed on manuscripts describing type II SLAP repairs in athletes. Selection criteria included studies reporting exclusively type II SLAP tears without concomitant pathology, minimum 2-year postoperative follow-up, use of anchor fixation, and return to previous level of play data available. We extracted patient outcome as well as surgical construct details from each article. Average outcomes and return to play rates were calculated and substratified further by athlete type. Return to play rates were compared by repair constructs with the Student t test. Results Initial search resulted in 107 articles. After exclusion criteria were applied, 17 articles were included in the final analysis. Overall, 84% of patients had good-to-excellent results. Of all athletes, 66% returned to previous level of play. There was significant variation in reported technique in terms of anchor number, location, material, suture type, and knotless versus knotted constructs. No significant difference was reported in outcomes in comparison of suture type (P-value .96) or knotted versus knotless constructs (P-value .91). Given the significant variability in reporting, no statistical analysis was felt able to be performed on anchor location and number. Conclusions Repair of type II SLAP tears in athletes is a difficult problem to treat with overall low return to play despite a high rate of “good” outcomes when assessed by outcome measures. Significant variability exists in surgical technique, as well as reporting of surgical technique, potentially limiting the ability to define the best or most effective technique for SLAP repair. Level of Evidence IV, systematic review of level III and level IV studies.
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Affiliation(s)
- Jack W Weick
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, U.S.A
| | - Will B Workman
- Walnut Creek Orthopedics & Sports Medicine, Team Orthopedic Surgeon, Oakland Athletics, Walnut Creek, California
| | - Christopher J Bush
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, U.S.A
| | - Katherine A McCollum
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, U.S.A
| | | | - Michael T Freehill
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, U.S.A
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19
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Harato K, Yagi M, Kaneda K, Iwama Y, Masuda A, Kaneko Y, Oya A, Matsumura N, Suzuki T, Nakayama R, Kobayashi S. Differences of tensile strength in knot tying technique between orthopaedic surgical instructors and trainees. BMC Surg 2021; 21:75. [PMID: 33549063 PMCID: PMC7866735 DOI: 10.1186/s12893-021-01079-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 01/27/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Knot tying technique is an extremely important basic skill for all surgeons. Clinically, knot slippage or suture breakage will lead to wound complications. Although some previous studies described the knot-tying technique of medical students or trainees, little information had been reported on the knot-tying technique of instructors. The objective of the preset study was to assess surgeons' manual knot tying techniques and to investigate the differences of tensile strength in knot tying technique between surgical instructors and trainees. METHODS A total of 48 orthopaedic surgeons (postgraduate year: PGY 2-18) participated. Surgeons were requested to tie surgical knots manually using same suture material. They were divided into two groups based on each career; instructors and trainees. Although four open conventional knots with four throws were chosen and done with self-selected methods, knot tying practice to have the appropriate square knots was done as education only for trainees before the actual trial. The knots were placed over a 30 cm long custom made smooth polished surface with two cylindrical rods. All knots were tested for tensile strength using a tensiometer. The surgical loops were loaded until the knot slipped or the suture broke. The tensile strength of each individual knot was defined as the force (N) required to result in knot failure. Simultaneously, knot failure was evaluated based on knot slippage or suture rupture. In terms of tensile strength or knot failure, statistical comparison was performed between groups using two-tailed Mann-Whitney U test or Fisher exact probability test, respectively. RESULTS Twenty-four instructors (PGY6-PGY18) and 24 trainees (PGY2-PGY5) were enrolled. Tensile strength was significantly greater in trainees (83.0 ± 27.7 N) than in instructors (49.9 ± 34.4 N, P = 0.0246). The ratio of slippage was significantly larger in instructors than in trainees (P < 0.001). Knot slippage (31.8 ± 17.7 N) was significantly worse than suture rupture (89.9 ± 22.2 N, P < 0.001) in tensile strength. CONCLUSIONS Mean tensile strength of knots done by trainees after practice was judged to be greater than that done by instructors in the present study. Clinically, knot slippage can lead to wound dehiscence, compared to suture rupture.
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Affiliation(s)
- Kengo Harato
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjukuku, Tokyo, 160-8582, Japan.,Keio Orthopedic Advancing Squad for the Interactive Study (OASIS), Keio University School of Medicine, Tokyo, Japan
| | - Mitsuru Yagi
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjukuku, Tokyo, 160-8582, Japan. .,Keio Orthopedic Advancing Squad for the Interactive Study (OASIS), Keio University School of Medicine, Tokyo, Japan.
| | - Kazuya Kaneda
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjukuku, Tokyo, 160-8582, Japan.,Keio Orthopedic Advancing Squad for the Interactive Study (OASIS), Keio University School of Medicine, Tokyo, Japan
| | - Yu Iwama
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjukuku, Tokyo, 160-8582, Japan.,Keio Orthopedic Advancing Squad for the Interactive Study (OASIS), Keio University School of Medicine, Tokyo, Japan
| | - Akihiko Masuda
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjukuku, Tokyo, 160-8582, Japan.,Keio Orthopedic Advancing Squad for the Interactive Study (OASIS), Keio University School of Medicine, Tokyo, Japan
| | - Yosuke Kaneko
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjukuku, Tokyo, 160-8582, Japan.,Keio Orthopedic Advancing Squad for the Interactive Study (OASIS), Keio University School of Medicine, Tokyo, Japan
| | - Akihito Oya
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjukuku, Tokyo, 160-8582, Japan.,Keio Orthopedic Advancing Squad for the Interactive Study (OASIS), Keio University School of Medicine, Tokyo, Japan
| | - Noboru Matsumura
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjukuku, Tokyo, 160-8582, Japan.,Keio Orthopedic Advancing Squad for the Interactive Study (OASIS), Keio University School of Medicine, Tokyo, Japan
| | - Taku Suzuki
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjukuku, Tokyo, 160-8582, Japan.,Keio Orthopedic Advancing Squad for the Interactive Study (OASIS), Keio University School of Medicine, Tokyo, Japan
| | - Robert Nakayama
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjukuku, Tokyo, 160-8582, Japan.,Keio Orthopedic Advancing Squad for the Interactive Study (OASIS), Keio University School of Medicine, Tokyo, Japan
| | - Shu Kobayashi
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjukuku, Tokyo, 160-8582, Japan.,Keio Orthopedic Advancing Squad for the Interactive Study (OASIS), Keio University School of Medicine, Tokyo, Japan
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20
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Schubert MF, Duralde XA. Posterior Shoulder Instability in the Throwing Athlete. OPER TECHN SPORT MED 2021. [DOI: 10.1016/j.otsm.2021.150802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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Golz A, Yun J, Garbis N, Salazar D. The effect of pulsed lavage irrigation on suture knot security. J Orthop Surg (Hong Kong) 2020; 28:2309499019888129. [PMID: 31916493 DOI: 10.1177/2309499019888129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE The purpose of this study was to determine the effect of low-pressure and pulsed lavage irrigation on suture knot security. METHODS Ninety-tied suture loops were measured for baseline circumference and then subjected to no irrigation, bulb syringe irrigation, or pulsed lavage irrigation. The sutures were placed under a load and then measured for final circumference. A larger circumference difference indicated poorer knot security. RESULTS There was a statistically significant difference in the knot security between all three groups (p < 0.001). Pulsed lavage resulted in the greatest circumference increase (0.52 ± 0.19 mm), followed by bulb syringe (0.24 ± 0.18 mm), and lastly no irrigation (0.08 ± 0.00 mm). None of the groups had any catastrophic failures. No knots met the predetermined criteria for knot failure. CONCLUSION Pulsed lavage irrigation resulted in a statistically significant decrease in suture knot security as compared to bulb syringe irrigation and no irrigation. None of the groups met the currently accepted criteria for clinical suture failure, which has a relatively arbitrary value. While the available literature does not discuss increases in loop circumference for specific orthopedic applications, this small difference suggests that pulse lavage is unlikely to have a clinically significant impact on the suture integrity for most orthopedic procedures.
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Affiliation(s)
- Andrew Golz
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Loyola University Chicago, Maywood, IL, USA
| | - Jonathan Yun
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Loyola University Chicago, Maywood, IL, USA
| | - Nickolas Garbis
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Loyola University Chicago, Maywood, IL, USA
| | - Dane Salazar
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Loyola University Chicago, Maywood, IL, USA
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22
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Hirahara AM, Andersen WJ, Dooney T. Arthroscopic Knotless Rotator Cuff Repair With Decellularized Dermal Allograft Augmentation: The "Canopy" Technique. Arthrosc Tech 2020; 9:e1797-e1803. [PMID: 33294343 PMCID: PMC7695626 DOI: 10.1016/j.eats.2020.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 08/05/2020] [Indexed: 02/03/2023] Open
Abstract
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.
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Affiliation(s)
- Alan M. Hirahara
- Private Practice Sacramento, California, U.S.A.,Address correspondence to Alan M. Hirahara, M.D., FR.C.S.C., 2801 K St., #330, Sacramento, CA 95816.
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23
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Sheean AJ, Arner JW, Bradley JP. Posterior Glenohumeral Instability: Diagnosis and Management. Arthroscopy 2020; 36:2580-2582. [PMID: 32442706 DOI: 10.1016/j.arthro.2020.05.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 05/08/2020] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Andrew J Sheean
- San Antonio Military Medical Center, San Antonio, Texas, U.S.A..
| | - Justin W Arner
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| | - James P Bradley
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
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24
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Posterior Labral Injury and Glenohumeral Instability in Overhead Athletes: Current Concepts for Diagnosis and Management. J Am Acad Orthop Surg 2020; 28:628-637. [PMID: 32732654 DOI: 10.5435/jaaos-d-19-00535] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
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.
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25
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Nolte PC, Midtgaard KS, Ciccotti M, Miles JW, Tanghe KK, Lacheta L, Millett PJ. Biomechanical Comparison of Knotless All-Suture Anchors and Knotted All-Suture Anchors in Type II SLAP Lesions: A Cadaveric Study. Arthroscopy 2020; 36:2094-2102. [PMID: 32591261 DOI: 10.1016/j.arthro.2020.04.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 03/25/2020] [Accepted: 04/16/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the biomechanical performance of knotless versus knotted all-suture anchors for the repair of type II SLAP lesions with a simulated peel-back mechanism. METHODS Twenty paired cadaveric shoulders were used. A standardized type II SLAP repair was performed using knotless (group A) or knotted (group B) all-suture anchors. The long head of the biceps (LHB) tendon was loaded in a posterior direction to simulate the peel-back mechanism. Cyclic loading was performed followed by load-to-failure testing. Stiffness, load at 1 and 2 mm of displacement, load to repair failure, load to ultimate failure, and failure modes were assessed. RESULTS The mean load to repair failure was similar in groups A (179.99 ± 58.42 N) and B (167.83 ± 44.27 N, P = .530). The mean load to ultimate failure was 230 ± 95.93 N in group A and 229.48 ± 78.45 N in group B and did not differ significantly (P = .958). Stiffness (P = .980), as well as load at 1 mm (P = .721) and 2 mm (P = .849) of displacement, did not differ significantly between groups. In 16 of the 20 specimens (7 in group A and 9 in group B), ultimate failure occurred at the proximal LHB tendon. Failed occurred through slippage of the labrum in 1 specimen in each group and through anchor pullout in 2 specimens in group A. CONCLUSIONS Knotless and knotted all-suture anchors displayed high initial fixation strength with no significant differences between groups in type II SLAP lesions. Ultimate failure occurred predominantly as tears of the proximal LHB tendon. CLINICAL RELEVANCE All-suture anchors have a smaller diameter than solid anchors, can be inserted through curved guides, preserve bone stock, and facilitate postoperative imaging. There is a paucity of literature investigating the biomechanical capacities of knotless versus knotted all-suture anchors in type II SLAP repair.
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Affiliation(s)
- Philip-C Nolte
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.; Department of Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
| | - Kaare S Midtgaard
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.; Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway; Norwegian Armed Forces Joint Medical Services, Oslo, Norway
| | - Michael Ciccotti
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.; The Steadman Clinic, Vail, Colorado, U.S.A
| | - Jon W Miles
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Kira K Tanghe
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Lucca Lacheta
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.; Center for Musculoskeletal Surgery, Charité Universitaetsmedizin Berlin, Berlin, Germany
| | - Peter J Millett
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.; The Steadman Clinic, Vail, Colorado, U.S.A..
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Maldonado DR, Chen SL, Chen JW, Shapira J, Rosinksy PJ, Annin S, Lall AC, Domb BG. Prospective Analysis of Arthroscopic Hip Anatomic Labral Repair Utilizing Knotless Suture Anchor Technology: The Controlled-Tension Anatomic Technique at Minimum 2-Year Follow-up. Orthop J Sports Med 2020; 8:2325967120935079. [PMID: 33403217 PMCID: PMC7745569 DOI: 10.1177/2325967120935079] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 03/09/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Labral tears are the most common abnormalities in patients undergoing hip arthroscopic surgery. Appropriate management is crucial, as it has been shown that better overall outcomes can be achieved with labral restoration. PURPOSE To report the patient-reported outcomes (PROs) at minimum 2-year follow-up of patients who underwent hip arthroscopic surgery for labral tear repair using the knotless controlled-tension anatomic technique in the setting of femoroacetabular impingement syndrome (FAIS). STUDY DESIGN Case series; Level of evidence, 4. METHODS Data were prospectively collected for patients who underwent hip arthroscopic surgery for FAIS for labral tear repair using the knotless controlled-tension anatomic technique. Patients were excluded if they had prior hip conditions, prior ipsilateral surgery, Tönnis grade >1, a lateral center-edge angle (LCEA) <25°, or workers' compensation claims. Preoperative and postoperative scores at minimum 2-year follow-up were recorded for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score-Sport-Specific Subscale (HOS-SSS), International Hip Outcome Tool (iHOT-12), and visual analog scale (VAS) for pain. The proportion of patients who achieved the minimal clinically important difference (MCID) or patient acceptable symptomatic state (PASS) for the mHHS, HOS-SSS, and iHOT-12 were also reported. RESULTS A total of 309 hips were included. The mean patient age was 36.2 years (range, 12.8-75.9 years). The mean preoperative LCEA and alpha angle were 31.9° and 57.1°, respectively. A significant improvement on the mHHS (62.6 ± 15.7 preoperatively vs 86.9 ± 16.2 at 2-year follow-up), NAHS (63.1 ± 16.7 vs 86.1 ± 16.7), and HOS-SSS (39.8 ± 22.0 vs 74.2 ± 27.3) was found (P < .001 for all). A significant decrease was shown for VAS scores (P < .001). Also, 78.6% and 82.2% of patients achieved the MCID and PASS for the mHHS, respectively; 60.8% and 69.9% of patients met the MCID and PASS for the HOS-SSS, respectively; and the MCID for the iHOT-12 was met by 77.3% of patients. CONCLUSION In the setting of FAIS and labral tears, patients who underwent hip arthroscopic surgery for labral tear repair using the knotless controlled-tension anatomic technique demonstrated significant improvement in several validated PRO measures, the VAS pain score, and patient satisfaction at a minimum 2 years of follow-up. Based on this evidence, labral tear repair using the knotless controlled-tension anatomic technique seems to be a safe option.
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Affiliation(s)
| | - Sarah L. Chen
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jeffery W. Chen
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Jacob Shapira
- American Hip Institute Research Foundation, Des Plaines, Illinois, USA
| | | | - Shawn Annin
- American Hip Institute Research Foundation, Des Plaines, Illinois, USA
| | - Ajay C. Lall
- American Hip Institute Research Foundation, Des Plaines, Illinois, USA
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Benjamin G. Domb
- American Hip Institute Research Foundation, Des Plaines, Illinois, USA
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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Morrissey CD, Houck DA, Jang E, McCarty EC, Bravman JT, Seidl AJ, Wolcott ML, Vidal AF, Frank RM. Sliding or Nonsliding Arthroscopic Knots for Shoulder Surgery: A Systematic Review. Orthop J Sports Med 2020; 8:2325967120911646. [PMID: 32426398 PMCID: PMC7218991 DOI: 10.1177/2325967120911646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Caellagh D Morrissey
- Division of Sports Medicine and Shoulder Surgery, Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Darby A Houck
- Division of Sports Medicine and Shoulder Surgery, Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Esther Jang
- Division of Sports Medicine and Shoulder Surgery, Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Eric C McCarty
- Division of Sports Medicine and Shoulder Surgery, Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jonathan T Bravman
- Division of Sports Medicine and Shoulder Surgery, Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Adam J Seidl
- Division of Sports Medicine and Shoulder Surgery, Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Michelle L Wolcott
- Division of Sports Medicine and Shoulder Surgery, Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | | | - Rachel M Frank
- Division of Sports Medicine and Shoulder Surgery, Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
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Westberg SE, Acklin YP, Hoxha S, Ayranci C, Adeeb S, Bouliane M. Is suture comparable to wire for cerclage fixation? A biomechanical analysis. Shoulder Elbow 2019; 11:225-232. [PMID: 31210795 PMCID: PMC6555108 DOI: 10.1177/1758573217735323] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 08/21/2017] [Accepted: 08/24/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cerclage wire is the current standard for circumferential bone fixation. Advances in technology have improved modern sutures, allowing for expanded utility and broader application. The present study compared the strength and durability of cerclage fixation between modern suture materials and monofilament wire. METHODS The Surgeon's Knot, the Nice Knot and the Modified Nice Knot, were each tied using three separate suture materials: no. 2 FiberWire (Arthrex, Naples, FL, USA), no. 2 Ultrabraid (Smith & Nephew, Andover, MA, USA) and no. 5 Ethibond (Johnson & Johnson, Somerville, NJ, USA). These sutures were compared with monofilament wire. Sutures were secured around a fixed diameter using three additional half hitches, whereas a 1.2-mm (18 gauge) stainless steel monofilament wire was used for comparison. One fellow and one orthopaedic surgery resident each tied five trials with every knot/material combination. Samples were subjected to cyclic loading and quasi-static load testing. Respectively, cyclic displacement over time and load to failure were analyzed. Clinical failure (3 mm of cyclic displacement) and absolute failure (opening of the knot or material failure) were the outcomes of interest. RESULTS During cyclic loading, Ethibond displaced significantly less over time compared to monofilament wire (p < 0.003), whereas FiberWire showed no significant difference. Ultrabraid also behaved similar to wire, except displacing significantly more than wire only with the Surgeon's Knot (p = 0.02). During load to failure, Ethibond and FiberWire failed at significantly greater loads than monofilament wire (p < 0.001), whereas Ultrabraid performed similar to wire. Knot types did not appear to impact the results. CONCLUSIONS High-performance sutures achieve superior results in biomechanical testing under cyclic and quasi-static load compared to monofilament wire, suggesting that they provide an alternative to wire for cerclage fixation with select clinical application. Biomechanical security of suture cerclage is dependent on suture material, although it is not altered significantly by choice of knot. An ex-vivo study with clinical application would further reinforce whether suture cerclage offers a valid alternative to wire cerclage.
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Affiliation(s)
- Scott E. Westberg
- Division of Orthopaedic Surgery, University of Alberta, Edmonton, AB, Canada
| | - Yves P. Acklin
- Division of Orthopaedic Surgery, University of Alberta, Edmonton, AB, Canada
| | - Siva Hoxha
- Faculty of Engineering, Department of Mechanical Engineering, University of Alberta, Edmonton, AB, Canada
| | - Cagri Ayranci
- Faculty of Engineering, Department of Mechanical Engineering, University of Alberta, Edmonton, AB, Canada
| | - Samer Adeeb
- Faculty of Engineering, Department of Mechanical Engineering, University of Alberta, Edmonton, AB, Canada
| | - Martin Bouliane
- Division of Orthopaedic Surgery, University of Alberta, Edmonton, AB, Canada,Martin Bouliane, Division of Orthopaedic Surgery, University of Alberta, 6-110B Clinical Sciences Building, 8440-112 Street NW, Edmonton, AB T6G 2B7, Canada.
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Simmer Filho J, Voss A, Pauzenberger L, Dwyer CR, Obopilwe E, Cote MP, Mazzocca AD, Dyrna F. Footprint coverage comparison between knotted and knotless techniques in a single-row rotator cuff repair: biomechanical analysis. BMC Musculoskelet Disord 2019; 20:123. [PMID: 30909902 PMCID: PMC6434825 DOI: 10.1186/s12891-019-2479-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 02/25/2019] [Indexed: 01/08/2023] Open
Abstract
Abstract Background The objective of this biomechanical study is to compare two variations of single-row knotless techniques (Knotless repair and Rip-stop Knotless repair) against a single-row double-loaded anchor (DL) repair, focused on evaluating contact pressure and contact area amongst three different single-row techniques for rotator cuff repairs. Methods A total of 24 fresh frozen human shoulders were tested. Specimens were randomly assigned into one of the three single-row (SR) repair groups: A Knotted single-row double-loaded anchor (DL) repair, a Knotless (K) repair, or a Knotless Rip-Stop (KRS) repair. The footprint was measured after complete detachment of the supraspinatus tendon from the greater tuberosity, introducing pressure sensors between bony footprint and detached rotator cuff, and finally reconstructing it. All specimens were mounted onto a servohydraulic test system to analyze contact variables at 0° and 30° of abduction with 0 N, 30 N and 50 N of tension. Results Groups did not differ significantly in their footprint sizes: DL group 359.75 ± 58.37 mm2, K group 386.5 ± 102.13 mm2, KRS group 415.87 ± 93.80 mm2 (p = 0.84); nor in bone mineral density: DL group 0.25 ± 0.14 g/cm2, K group 0.32 ± 0.19 g/cm2, KRS group 0.32 ± 0.13 g/cm2, (p = 0.75) or average age. The highest mean pressurized contact area measured for the K repair was 248.1 ± 50.9 mm2, which equals a reconstruction of 67.1 ± 19.3% at 0° abduction and a 50 N supraspinatus load. This reconstructed area was significantly greater compared with the DL repair 152.8 ± 73.1 mm2, reconstructing 42.0 ± 18.5% on average when under the same conditions (p = 0.04). The mean contact pressure did not significantly differ amongst groups (p = 1.0): DL group 30.8 ± 17.4 psi, K group 30.9 ± 17.4 psi and KRS group 30.0 ± 10.9 psi. Neither the 30° abduction angle nor the supraspinatus load had a significant influence on the contact pressure in our study. Conclusion Both single-row knotless techniques resulted in significantly higher footprint reconstruction, providing larger contact area and a more uniform pressure distribution when compared with the single-row Knotted techniques. The mean contact pressure did not differ among groups significantly. These knotless techniques may be an alternative if the surgeon decides to perform a single-row rotator cuff repair. Level of evidence Basic Science Study, Biomechanics.
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Affiliation(s)
- Jair Simmer Filho
- Department of Orthopaedic Surgery, Hospital Estadual de Urgência e Emergência (HEUE), Vitória, Espírito Santo, Brasil.
| | - Andreas Voss
- Department of Trauma Surgery, University Hospital Regensburg, Regensburg, Germany
| | | | - Corey R Dwyer
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, CT, USA
| | - Elifho Obopilwe
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, CT, USA
| | - Mark P Cote
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, CT, USA
| | - Augustus D Mazzocca
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, CT, USA
| | - Felix Dyrna
- Department of Orthopaedic Sports Medicine, Technical University of Munich, Munich, Germany
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Hirahara AM, Andersen WJ, Yamashiro K. Arthroscopic Knotless Remplissage for the Treatment of Hill-Sachs Lesions Using the PASTA Bridge Configuration. Arthrosc Tech 2019; 8:e275-e281. [PMID: 31019885 PMCID: PMC6471291 DOI: 10.1016/j.eats.2018.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 11/02/2018] [Indexed: 02/03/2023] Open
Abstract
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.
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Kim KH, Long MK, McCormack R, Ruotolo C. Use of a Safety Clamp When Performing Arthroscopic Knot Tying Preserves the Suture When It Is Placed Under Excessive Tension. Orthopedics 2019; 42:e25-e28. [PMID: 30371924 DOI: 10.3928/01477447-20181023-06] [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: 12/26/2017] [Accepted: 07/12/2018] [Indexed: 02/03/2023]
Abstract
The purpose of this study was to compare the location of the suture breakage between tying by hand vs with a safety clamp, needle driver. FiberWire No. 2 and 2-0 (Arthrex, Naples, Florida) were fastened onto the hook attachment of the digital force gauge. Sutures were placed under excessive strain using a hand tying technique vs a safety clamp, or instrument tying. Peak forces at which the sutures failed under tension along with locations of the suture breakage, measured from the site of the knot, were recorded. For FiberWire No. 2, the mean load to failure was 142.60±2.33 N for hand tying and 78.79±1.97 N for the safety clamp (P<.0001). For FiberWire 2-0, the mean load to failure was 62.98±4.90 N for hand tying and 34.43±2.46 N for the safety clamp (P<.0001). For FiberWire No. 2, the mean location of suture breakage was 0 cm, at the site of the knot, for hand tying and at the clamping point (10.45±0.34 cm from the knot) for the safety clamp (P<.0001). For FiberWire 2-0, the mean location of suture breakage was 0 cm, at the site of the knot, for hand tying and at the clamping point (10.47±0.22 cm from the knot) for the safety clamp (P<.0001). Use of a safety clamp while mastering arthroscopic suture technique preserves the suture knot when placed under excessive tension. [Orthopedics. 2019; 42(1):e25-e28.].
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Reattachment of the flexor and extensor tendons at the epicondyle in elbow instability: a biomechanical comparison of techniques. BMC Musculoskelet Disord 2018; 19:432. [PMID: 30509244 PMCID: PMC6278143 DOI: 10.1186/s12891-018-2341-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 11/14/2018] [Indexed: 11/10/2022] Open
Abstract
Background Elbow dislocation represents a common injury, especially in the younger population. If treated surgically, the reattached tendons require a high amount of primary stability to allow for an early rehabilitation to avoid postoperative stiffness. The purpose of this study was to assess the biomechanical properties of a single and a double row technique for reattachment of the common extensor and common flexor muscles origin. We hypothesized that the double row technique would provide greater stability in terms of pullout forces than the single row technique. Methods Twelve cadaveric specimens were randomized into two groups of fixation methods for the common extensor tendon or the common flexor tendon at the elbow (1): a single row technique using two knotted 3.0 mm suture anchors, and (2) a double row technique using an additional knotless 3.5 mm anchor. The repairs were cyclically loaded over 500 cycles at 1 Hz from 10 N to a maximum of 100 N (extensors) or 150 N (flexors), and then pulled to failure. Stiffness and maximum load at failure and mode of failure were recorded and calculated. Results No significant differences in stiffness were observed between the two techniques for both the extensor and flexor reattachment (P = 0.701 and P = 0.306, respectively). The mean maximum load at failure indicated that the double row construct was significantly stronger than the single row construct. This was found to be true for both the extensor and flexor reattachment (213.6; SD 78.7 N versus 384.1; SD 105.6 N, P = 0.010 and 203.7; SD 65.8 N versus 318.0; SD 64.6 N, P = 0.013, respectively). Conclusions The double row technique provides significant greater stability to the reattached common flexor or extensor origin to the medial or lateral epicondyle. Thus, it should be considered in the development of improved repair techniques for stabilizers of the elbow. Study design Controlled laboratory study.
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Funakoshi T, Hartzler R, Stewien E, Burkhart S. Remplissage Using Interconnected Knotless Anchors: Superior Biomechanical Properties to a Knotted Technique? Arthroscopy 2018; 34:2954-2959. [PMID: 30292597 DOI: 10.1016/j.arthro.2018.06.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 06/07/2018] [Accepted: 06/10/2018] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Tadanao Funakoshi
- University of Department of Orthopaedic Surgery, Hokkaido University School of Medicine, Sapporo, Japan
| | - Robert Hartzler
- The San Antonio Orthopaedic Group and Burkhart Research Institute for Orthopaedics, San Antonio, Texas, U.S.A..
| | | | - Stephen Burkhart
- The San Antonio Orthopaedic Group and Burkhart Research Institute for Orthopaedics, San Antonio, Texas, U.S.A
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Pedowitz RA. Editorial Commentary: What's Knot to Like? In the Biomechanics Laboratory, Knotless Shoulder Anchors Hold Their Own. Arthroscopy 2018; 34:2960-2961. [PMID: 30392680 DOI: 10.1016/j.arthro.2018.08.024] [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: 08/26/2018] [Accepted: 08/28/2018] [Indexed: 02/02/2023]
Abstract
Arthroscopic knot tying remains challenging, and the knots are a weak link for many repair constructs. Knotless strategies continue to evolve, and in some cases, these methods enhance biomechanical repair characteristics. The associated impact on clinical outcomes remains unknown.
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Schneider AM, Pedowitz RA, Evans DA. Validation of the FAST Workstation as an Objective Evaluator of Hand-Tied Surgical Knots. Simul Healthc 2018; 14:29-34. [PMID: 30216274 DOI: 10.1097/sih.0000000000000333] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Hand-tying surgical knots is an important skill that is applicable across all surgical disciplines. Knot quality is traditionally assessed in the operating room by visual inspection, which is inherently subjective. With the increasing prevalence of simulation training, surgical trainees having access to objective feedback of their knot-tying skills are paramount for skill evaluation. Our study aimed to validate a mechanical suture loop security tester as an objective evaluation method of hand-tied surgical knot quality. METHODS Seventy-three subjects were recruited and categorized based on surgical expertise into one of the following three groups: medical students, surgical residents, and attending surgeons. They hand-tied five surgical knots consecutively using 0 Vicryl sutures. The knots were tested using the suture loop security workstation with 10 lbs of linear force for 10 seconds. Success of the suture loop was set at less than 3 mm of loop expansion. This protocol was based on previous research showing that 3 mm of loop expansion would represent clinical failure of the knot in vivo. RESULTS The students, residents, and attending surgeons tied a median of two, three, and four successful knots, respectively. Post hoc pairwise comparisons revealed that residents tied more successful knots than students (p < 0.001), and attending physicians tied more successful knots than students (p < 0.001). However, there was no statistically significant difference in the number of successes between residents and attending physicians (p = 0.24). CONCLUSIONS Using the mechanical loop security workstation demonstrates construct validity as a reliable objective evaluation tool of hand-tied surgical knots.
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Affiliation(s)
- Andrew M Schneider
- From the Loyola University Medical Center (A.S., D.E.), Maywood, IL; and University of California Los Angeles (R.P.), Encinitas, CA
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Cronin KJ, Cox JL, Hoggard TM, Marberry ST, Santoni BG, Nofsinger CC. The effect of residency training on arthroscopic knot tying and knot stability: which knot is best tied by Orthopaedic surgery residents? J Exp Orthop 2018; 5:19. [PMID: 29904825 PMCID: PMC6002326 DOI: 10.1186/s40634-018-0138-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 06/06/2018] [Indexed: 11/10/2022] Open
Abstract
Background The aim of this study is to evaluate which of three arthroscopic knots are most reliably taught to and executed by residents at varying levels of training. Methods Three arthroscopic knots, the Samsung Medical Center (SMC), the Weston, and the surgeon’s knot, were taught to 16 orthopaedic surgery residents. Each knot was tied in triplicate at two sessions 1 week apart. The knots were then biomechanically tested for strength. Corresponding knots tied by a sports medicine fellow served as the respective controls. Results Comparing all knots regardless of year of training, the SMC knot failed at significantly higher loads (237.2 ± 66.6 N) than the surgeon’s knot (203.7 ± 45.3 N, p = 0.049) and the Weston knot (193.5 ± 56.1 N, p = 0.013). No significant differences in knot strength were found when comparing knots tied by residents at different levels of training and when comparing residents to the sports medicine fellow. There was no difference in conditioning elongation between surgeon’s (p = 0.343), Weston (p = 0.486), or SMC knots (p = 0.200) tied by post-graduate year one and five residents. Conclusions We report the first study that evaluates the loop strength of an arthroscopically tied knot performed by orthopaedic surgery residents in various levels of training. In our cohort, the SMC knot required a higher load to failure, when compared to the Surgeon’s and Weston knot, after a simple arthroscopic knot tying curriculum. Based on these findings, he SMC knot should be considered as a part of future orthopaedic surgery resident arthroscopic training programs.
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Affiliation(s)
- Kevin J Cronin
- Department of Orthopaedics and Sports Medicine, University of Kentucky, 740 S. Limestone, k403, Lexington, KY, 40536, USA.
| | - Jacob L Cox
- Department of Orthopaedics and Sports Medicine, University of South Florida, 13220 USF Laurel Drive, MDC 106, Tampa, FL, 33612, USA
| | - Timothy M Hoggard
- Department of Orthopaedic Surgery, University of Virginia, 400 Ray C. Hunt Drive, Suite 330, Charlottesville, VA, 22903, USA
| | - Scott T Marberry
- Foundation for Orthopaedic Research and Education, Phillip Spiegel Orthopaedic Research Laboratory, 13020 Telecom Pkwy. N, Tampa, FL, 33637, USA
| | - Brandon G Santoni
- Foundation for Orthopaedic Research and Education, Phillip Spiegel Orthopaedic Research Laboratory, 13020 Telecom Pkwy. N, Tampa, FL, 33637, USA
| | - Charles C Nofsinger
- Department of Orthopaedics and Sports Medicine, University of South Florida, 13220 USF Laurel Drive, MDC 106, Tampa, FL, 33612, USA
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Denard PJ, Adams CR, Fischer NC, Piepenbrink M, Wijdicks CA. Knotless Fixation Is Stronger and Less Variable Than Knotted Constructs in Securing a Suture Loop. Orthop J Sports Med 2018; 6:2325967118774000. [PMID: 29845084 PMCID: PMC5964856 DOI: 10.1177/2325967118774000] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: Historically, tendon-to-bone fixation has relied on knot tying. However, considerable variability exists in knot-tying strength among surgeons. Purpose/Hypothesis: The purpose of this study was to compare the biomechanical properties of knotted and knotless fixation and to evaluate variability among surgeons. The hypothesis was that knotless constructs would be stronger and have less variability as compared with knotted constructs. Study Design: Controlled laboratory study. Methods: A total of 34 orthopaedic surgeons participated in a laboratory study to compare knotted and knotless constructs, where 104 knotted constructs were performed with No. 2 suture, 21 knotless constructs with No. 2 suture (K2 group), and 79 knotless constructs with suture tape (KT group). Mechanical testing was performed to compare load at 3 mm of displacement, load to failure, and stiffness of each construct. Results: The mean load at 3 mm of displacement was greatest in the KT group, with significant differences among all 3 groups (P < .001). Load to failure was significantly greater in the KT group as compared with the K2 group and the knotted group (P < .001), but there was no difference between the K2 and knotted groups (P ≥ .999). Stiffness and displacement were also greatest in the KT group. Based on the F test, the variance in load to failure was significantly different between the knotted and knotless constructs, with the knotted group demonstrating greater variability (SD, 94 N) than the KT (SD, 38 N) and K2 (SD, 17 N) groups (P < .001). Conclusion: Knotless fixation with suture tape had improved biomechanical performance as compared with knots or knotless fixation with No. 2 suture. In addition, knotless fixation had less variability in biomechanical properties among multiple surgeons. Clinical Relevance: This study may be relevant for surgeons choosing between knotted and knotless constructs as well as for considerations in the design of rotator cuff repair constructs.
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Affiliation(s)
| | - Christopher R Adams
- Naples Community Hospital Healthcare System, Naples, Florida, USA.,Department of Medical Education, Arthrex Inc, Naples, Florida, USA
| | - Nicole C Fischer
- Department of Research and Development, Arthrex GmbH, Munich, Germany
| | | | - Coen A Wijdicks
- Department of Research and Development, Arthrex GmbH, Munich, Germany
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Noyes MP, Lederman E, Adams CR, Denard PJ. Triple-Loaded Suture Anchors Versus a Knotless Rip Stop Construct in a Single-Row Rotator Cuff Repair Model. Arthroscopy 2018; 34:1414-1420. [PMID: 29456064 DOI: 10.1016/j.arthro.2017.12.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 11/07/2017] [Accepted: 12/04/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the biomechanical properties of single-row repair with triple-loaded (TL) anchor repair versus a knotless rip stop (KRS) repair in a rotator cuff repair model. METHODS Rotator cuff tears were created in 8 cadaveric matched-pair specimens and repaired with a TL anchor or KRS construct. In the TL construct, anchors were placed in the greater tuberosity and then all suture limbs were passed through the rotator cuff as simple sutures and tied. In the KRS construct, a 2-mm suture tape was passed through the tendon in an inverted mattress fashion, and a free suture was passed medial to the suture tape to create a rip-stop. Then, the suture tape and free suture were secured with knotless anchors. Displacement was observed with video tracking after cyclic loading, and specimens were loaded to failure. RESULTS The mean load to failure was 438 ± 59 N in TL anchor repairs compared with 457 ± 110 N in KRS repairs (P = .582). The mean displacement with cyclic loading was 3.8 ± 1.6 mm in TL anchor repairs versus 4.3 ± 1.8 mm in the KRS group (P = .297). Mode of failure was consistent in both groups, with 6 of 8 failures in the TL anchor group and 7 of 8 failures in KRS group occurring from anchor pullout. CONCLUSIONS There is no statistical difference in load to failure and cyclic loading between TL anchor and KRS single-row repair techniques. CLINICAL RELEVANCE KRS repair technique may be an alternative method of repairing full-thickness supraspinatus tendon tears with a single-row construct.
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Affiliation(s)
- Matthew P Noyes
- Department of Orthopaedic Surgery, Western Reserve Hospital, Cuyahoga Falls, Ohio, U.S.A
| | - Evan Lederman
- The Orthopedic Clinic Association, Phoenix, Arizona, U.S.A.; Department of Orthopedic Surgery, Banner University Medical Center, Phoenix, Arizona, U.S.A
| | | | - Patrick J Denard
- Southern Oregon Orthopedics, Medford, Oregon, U.S.A.; Department of Orthopedics and Rehabilitation, Oregon Health and Science University, Portland, Oregon, U.S.A..
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Pogorzelski J, Muckenhirn KJ, Mitchell JJ, Katthagen JC, Schon JM, Dahl KD, Hirahara AM, Dines JS, Adams CR, Dooney T, Denard PJ, Turnbull TL, Millett PJ. Biomechanical Comparison of 3 Glenoid-Side Fixation Techniques for Superior Capsular Reconstruction. Am J Sports Med 2018; 46:801-808. [PMID: 29281797 DOI: 10.1177/0363546517745626] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Superior capsular reconstruction (SCR) was recently introduced as a treatment for irreparable superior rotator cuff tears in younger patients. Purpose/Hypothesis: The purpose was to assess the biomechanical strength of 3 methods for fixation of the graft to the glenoid for SCR. It was hypothesized that a 4-anchor technique would provide greater load to failure than 3-anchor techniques. STUDY DESIGN Controlled laboratory study. METHODS Thirty-six cadaveric specimens were randomized into 3 groups of previously established glenoid-side graft fixation techniques: (1) three 3.5-mm knotless screw-in anchors, (2) three 3.0-mm knotless push-in anchors, and (3) a 4-anchor hybrid construct with two 3.0-mm knotted push-in anchors and two 2.9-mm knotless push-in anchors. The repairs were cyclically loaded at 0.5 Hz from 10 to 200 N, then pulled to failure. Elongation, stiffness, maximum load at failure, and mode of failure were recorded and calculated. RESULTS There were no significant differences in graft elongation or stiffness among the 3 techniques ( P > .37 and P > .26, respectively). Maximum load to failure was significantly greater in technique 1 (mean ± SD, 427.85 ± 119.70 N) than technique 3 (319.5 ± 57.60 N) ( P = 0.024). There were no significant differences in load to failure between techniques 1 and 2 or between techniques 2 and 3. CONCLUSION Glenoid-side graft fixation with 3 threaded 3.5-mm suture anchors showed a significant superior pull-out strength when compared with a 4-anchor hybrid technique and thus might be recommended in SCR for patients with irreparable superior rotator cuff tears to achieve maximum stability. CLINICAL RELEVANCE SCR presents a novel alternative for treatment of irreparable superior rotator cuff tears in younger patients. Glenoid fixation is essential to provide adequate fixation of the graft to prevent the humeral head from rising and to restore normal biomechanics.
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Affiliation(s)
| | | | - Justin J Mitchell
- Steadman Philippon Research Institute, Vail, Colorado, USA.,The Steadman Clinic, Vail, Colorado, USA
| | - J Christoph Katthagen
- Steadman Philippon Research Institute, Vail, Colorado, USA.,Department of Trauma, Hand, and Reconstructive Surgery, University Hospital Muenster, Muenster, Germany
| | - Jason M Schon
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Kimi D Dahl
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | | | | | | | | | | | | | - Peter J Millett
- Steadman Philippon Research Institute, Vail, Colorado, USA.,The Steadman Clinic, Vail, Colorado, USA
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Mook WR, Greenspoon JA, Millett PJ. Arthroscopic Double-Row Transosseous Equivalent Rotator Cuff Repair with a Knotless Self-Reinforcing Technique. Open Orthop J 2016; 10:286-295. [PMID: 27733881 PMCID: PMC5043448 DOI: 10.2174/1874325001610010286] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Revised: 04/28/2015] [Accepted: 02/01/2016] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Rotator cuff tears are a significant cause of shoulder morbidity. Surgical techniques for repair have evolved to optimize the biologic and mechanical variables critical to tendon healing. Double-row repairs have demonstrated superior biomechanical advantages to a single-row. METHODS The preferred technique for rotator cuff repair of the senior author was reviewed and described in a step by step fashion. The final construct is a knotless double row transosseous equivalent construct. RESULTS The described technique includes the advantages of a double-row construct while also offering self reinforcement, decreased risk of suture cut through, decreased risk of medial row overtensioning and tissue strangulation, improved vascularity, the efficiency of a knotless system, and no increased risk for subacromial impingement from the burden of suture knots. CONCLUSION Arthroscopic knotless double row rotator cuff repair is a safe and effective method to repair rotator cuff tears.
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Affiliation(s)
- William R Mook
- The Steadman Philippon Research Institute (W.R.M, J.A.G., P.J.M.) and The Steadman Clinic (W.R.M., P.J.M.), Vail, Colorado, U.S.A
| | - Joshua A Greenspoon
- The Steadman Philippon Research Institute (W.R.M, J.A.G., P.J.M.) and The Steadman Clinic (W.R.M., P.J.M.), Vail, Colorado, U.S.A
| | - Peter J Millett
- The Steadman Philippon Research Institute (W.R.M, J.A.G., P.J.M.) and The Steadman Clinic (W.R.M., P.J.M.), Vail, Colorado, U.S.A
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Chong ACM, Pate RC, Prohaska DJ, Bron TR, Wooley PH. Validation of Improvement of Basic Competency in Arthroscopic Knot Tying Using a Bench Top Simulator in Orthopaedic Residency Education. Arthroscopy 2016; 32:1389-99. [PMID: 27117823 DOI: 10.1016/j.arthro.2016.01.059] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 01/04/2016] [Accepted: 01/18/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE To validate basic competency in arthroscopic knot tying using a unique simulator device to compare the level of training needed for learning and tying the arthroscopic knot by evaluating the tensile properties of the arthroscopic knots. METHODS Three groups of surgeons of various experience levels (postgraduate year [PGY] 1, PGY 3, and experienced surgeons) tied 2 different arthroscopic knots (Tennessee Slider, considered easier, and Weston, considered more difficult) over a 10-week period. Each group went through 3 separate stages of knot tying: stage 1, tying 8 knots without cannula or knot pusher; stage 2, tying 12 knots with knot pusher; and stage 3, tying 20 knots with knot pusher through a cannula that simulates knot tying during surgery. A single load-to-failure test was performed and ultimate clinical failure loads were recorded. Time needed to tie each knot was also recorded. RESULTS At stages 1 and 2, the PGY 1 group had a significantly weak knot tensile strength (Tennessee Slider stage 1: 60 v 129 N, P = .001; Tennessee Slider stage 2: 69 v 132 N, P = .0029; Weston stage 1: 73 v 184 N, P = .0000; Weston stage 2: 125 v 173 N, P = .0045) and were slower (Weston: 56 v 30 seconds, P = .0010) than the experienced surgeon group for both knots. At stage 3, only the initial 2 weeks of Tennessee Slider showed a significant difference between groups 1 and 3 (week 6: 87 v 118 N, P = .0492; week 7: 89 v 126, P = .01485). Even though the Tennessee Slider knot is one of the easier arthroscopic knots to learn to tie, the results showed a slow trend of improvement in this knot-tying skill for group 1 after each stage. CONCLUSIONS The data validated an important learning effect in all trainees in arthroscopic knot tying over a 10-week period and showed that inexperienced trainees will be able to improve their knot-tying skill with training in 3 stages with a simulator environment. CLINICAL RELEVANCE The findings of this study indicated the importance of hands-on experience in performing arthroscopic knot tying, as determined by both knot performance and ultimate suture loop strength. In addition, each orthopaedic resident learned and developed his or her arthroscopic knot-tying skills and provided a foundation for his or her future practice in orthopaedic medicine.
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Affiliation(s)
- Alexander C M Chong
- Department of Orthopaedics Surgery, The University of Kansas School of Medicine-Wichita, Wichita, Kansas, U.S.A.; Via Christi Health-Orthopedic Research Institute, Wichita, Kansas, U.S.A..
| | - Ryan C Pate
- Department of Orthopaedics Surgery, The University of Kansas School of Medicine-Wichita, Wichita, Kansas, U.S.A.; Robert J Dole VA Medical Center, Wichita, Kansas, U.S.A
| | - Daniel J Prohaska
- Department of Orthopaedics Surgery, The University of Kansas School of Medicine-Wichita, Wichita, Kansas, U.S.A.; Advanced Orthopaedics Associates, Wichita, Kansas, U.S.A
| | - Tyler R Bron
- Department of Orthopaedics Surgery, The University of Kansas School of Medicine-Wichita, Wichita, Kansas, U.S.A
| | - Paul H Wooley
- Department of Orthopaedics Surgery, The University of Kansas School of Medicine-Wichita, Wichita, Kansas, U.S.A.; Via Christi Health-Orthopedic Research Institute, Wichita, Kansas, U.S.A
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Reverse Flipping Technique: An Alternate Approach to Tie Reversing Half-Hitches on Alternating Posts. Arthrosc Tech 2016; 5:e403-5. [PMID: 27462541 PMCID: PMC4948563 DOI: 10.1016/j.eats.2016.01.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 01/12/2016] [Indexed: 02/03/2023] Open
Abstract
Arthroscopic knot tying requires practice and attention to detail, especially tying the 3 reversing half-hitches on alternating posts (RHAPs) in a knot. Mistakes can occur that result in an unintentional tension (>10 N) applied to the wrapping suture limb, and by placing tension in the wrong limb, the previously "flipped" half-hitch is converted from a series of RHAPs into a series of identical half-hitches on the same post, thereby producing insecure knots or suture loops. This was hypothesized to be a source of knot failure by knot slippage. This error can be avoided by using a technique we describe as "reverse flipping," which purposely "flips" the half-hitch down at the main knot while tying the 3 RHAPs in a knot, and then the half-hitch is retightened using either a past-pointing or over-pointing technique. This way the surgeon can be absolutely sure that the half-hitch is tightened in the direction that it was intended to be placed, and can also prevent the unintentional tension applied to the wrapping suture limb that causes the half-hitch to "flip." However, caution should be used when tensioning the half-hitches; overtensioning (>40 N) during past-pointing or over-pointing could also potentially "flip" the previous half-hitch that has already been tightened and cause potential knot failure.
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Rodes SA, Favorito PJ, Piccirillo JM, Spivey JT. Performance Comparison of a Pretied Suture Knot With Three Conventional Arthroscopic Knots. Arthroscopy 2015; 31:2183-90. [PMID: 26188782 DOI: 10.1016/j.arthro.2015.05.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 05/18/2015] [Accepted: 05/29/2015] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Stephen A Rodes
- Wellington Orthopaedic and Sports Medicine, Cincinnati, Ohio, U.S.A
| | - Paul J Favorito
- Wellington Orthopaedic and Sports Medicine, Cincinnati, Ohio, U.S.A..
| | | | - James T Spivey
- DePuy Mitek Sports Medicine, Raynham, Massachusetts, U.S.A
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Objective Assessment of Knot-Tying Proficiency With the Fundamentals of Arthroscopic Surgery Training Program Workstation and Knot Tester. Arthroscopy 2015; 31:1872-9. [PMID: 26298642 DOI: 10.1016/j.arthro.2015.06.021] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 05/27/2015] [Accepted: 06/17/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess a new method for biomechanical assessment of arthroscopic knots and to establish proficiency benchmarks using the Fundamentals of Arthroscopic Surgery Training (FAST) Program workstation and knot tester. METHODS The first study group included 20 faculty at an Arthroscopy Association of North America resident arthroscopy course (19.9 ± 8.25 years in practice). The second group comprised 30 experienced surgeons attending an Arthroscopy Association of North America fall course (17.1 ± 19.3 years in practice). The training group included 44 postgraduate year 4 or 5 orthopaedic residents in a randomized, prospective study of proficiency-based training, with 3 subgroups: group A, standard training (n = 14); group B, workstation practice (n = 14); and group C, proficiency-based progression using the knot tester (n = 16). Each subject tied 5 arthroscopic knots backed up by 3 reversed hitches on alternating posts. Knots were tied under video control around a metal mandrel through a cannula within an opaque dome (FAST workstation). Each suture loop was stressed statically at 15 lb for 15 seconds. A calibrated sizer measured loop expansion. Knot failure was defined as 3 mm of loop expansion or greater. RESULTS In the faculty group, 24% of knots "failed" under load. Performance was inconsistent: 12 faculty had all knots pass, whereas 2 had all knots fail. In the second group of practicing surgeons, 21% of the knots failed under load. Overall, 56 of 250 knots (22%) tied by experienced surgeons failed. For the postgraduate year 4 or 5 residents, the aggregate knot failure rate was 26% for the 220 knots tied. Group C residents had an 11% knot failure rate (half the overall faculty rate, P = .013). CONCLUSIONS The FAST workstation and knot tester offer a simple and reproducible educational approach for enhancement of arthroscopic knot-tying skills. Our data suggest that there is significant room for improvement in the quality and consistency of these important arthroscopic skills, even for experienced arthroscopic surgeons. LEVEL OF EVIDENCE Level II, prospective comparative study.
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Gilmer BB, Guerrero DM, Coleman NW, Chamberlain AM, Warme WJ. Orthopaedic Residents Improve Confidence and Knot-Tying Speed With a Skills Course. Arthroscopy 2015; 31:1343-8.e2. [PMID: 25863727 DOI: 10.1016/j.arthro.2015.02.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 01/27/2015] [Accepted: 02/06/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine the effect of a knot-tying module, within an arthroscopic training course, on resident speed, resident confidence, and biomechanical quality of arthroscopically tied knots. METHODS Sixty-four participants (8 postgraduate year [PGY]-3 and 8 PGY-4 orthopaedic residents annually for 4 years) were enrolled in a 5-day training course, which included a daily knot-tying module. Self-assessed confidence was obtained by pre-course (day 1) and post-course (day 5) questionnaire. Each participant tied 5 sequential knots using an arthroscopic knot-tying station. Time per knot was recorded in seconds. Knots were later preloaded, cycled, and tested for peak load to failure and displacement change. Mean peak load to failure, displacement change, speed, and confidence were compared before and after training. RESULTS The mean time to complete 5 knots was significantly faster after training (12.8 minutes before the course [day 1] v 9.39 minutes after the course [day 5]) (P < .0001). Confidence improved from pre-course (mean, 3.3) to post-course (mean, 7.8) questionnaires (P < .0001). No statistically significant difference was found between peak force for pre-course (mean, 136 N) and post-course (mean, 138 N) knots (P = .076). No statistically significant difference was detected in mean displacement change (mean, 3.51 mm before the course v 3.57 mm after the course) (P = .61). Comparison of PGY-3 and PGY-4 residents was significant only for a higher pre-course confidence in PGY-4 residents (P = .02). CONCLUSIONS Participation in an arthroscopic knot-tying module improves resident speed and confidence in tying arthroscopic knots. Our data did not show a significant change in peak load to failure or loop security with training. These findings suggest that participation in a knot-tying module improves efficiency regarding arthroscopic knot tying by residents. CLINICAL RELEVANCE Residents who practice arthroscopic knot tying 5 days per year as part of an arthroscopic training course may be more efficient in the operating room.
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Affiliation(s)
- Brian B Gilmer
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington, U.S.A..
| | - Dolores M Guerrero
- Department of Biomedical Research, Mammoth Orthopedic Institute, Mammoth Lakes, California, U.S.A
| | - Nathan W Coleman
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington, U.S.A
| | - Aaron M Chamberlain
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington, U.S.A
| | - Winston J Warme
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington, U.S.A
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