Extensor tendon rupture and preoperative mri confirmations of suture anchor prolapse: a case report and literature review

BACKGROUND

While suture anchors are widely used in medical procedures for their advantages, they can sometimes lead to complications, including anchor prolapse. This article presents a unique case of suture anchor prolapse at the base of the distal phalanx of the little finger after extensor tendon rupture reconstruction surgery.

CASE PRESENTATION

A 35-year-old male, underwent extensor tendon rupture reconstruction using a non-absorbable suture anchor. After seven years the patient visited our outpatients complaining of stiffness, pain, and protrusion at the surgical site. Initial X-ray imaging suggested suggesting either a fracture of the distal phalanx or tendon adhesion but lacked a definitive diagnosis. Subsequent magnetic resonance imaging (MRI) revealed bone connectivity between the middle and distal phalanges with irregular signal shadow and unclear boundaries while maintaining a regular finger shape. MRI proved superior in diagnosing prolapsed suture anchors, marking the first reported case of its kind. Surgical intervention confirmed MRI findings.

CONCLUSIONS

Suture anchor complications, such as prolapse, are a concern in medical practice. This case underscores the significance of MRI for accurate diagnosis and the importance of tailored surgical management in addressing this uncommon complication.

A case report about a ten times recurred inguinal hernia

INTRODUCTION

While the use of bone anchor fixation for abdominal wall reconstruction for supra-pubic incisional hernia is well described (Yee et al., 2008 [1]), we show in this case report, written in line with the SCARE criteria (Agha et al., 2020 [2]), a novel use of this tool as an adjunct in the repair of a ten time recurrent inguinal hernia.

CASE REPORT

A 65 years old multiparous, diabetic non-obese female, with previous abdominoplasty was submitted for left inguinal hernia for ten times, between multiples complications between infection, more than one mesh excision by anterior approach and laparoscopic approach. The wide range of procedures culminated in a destruction of the abdominal wall, making it impossible for a usual fixation of mesh in the region. Therefore, a multidisciplinary approach was planned for the patient with a bone anchor as a mesh fixation method. With a year follow up we did not observe a local hernia recurrence.

CLINICAL DISCUSSION

Hernia itself is a multifactorial disease. As a anatomical defect, surgery is the only effective treatment. Our report brings a novel approach to a challenging case with many previous unsuccessful applications of conventional surgeries. Hence, we stimulate the multidisciplinary discussion for enhancing post operatory outcomes and a better point of care for the patient.

Beyond the pedicle screw-a patent review

PURPOSE

This review provides an overview of the patent literature on posteriorly placed intrapedicular bone anchors. Conventional pedicle screws are the gold standard to create a fixation in the vertebra for spinal fusion surgery but may lack fixation strength, especially in osteoporotic bone. The ageing population demands new bone anchors that have an increased fixation strength, that can be placed safely, and, if necessary, can be removed without damaging the surrounding tissue.

METHODS

The patent search was conducted using a classification search in the Espacenet patent database. Only patents with a Cooperative Patent Classification of A61B17/70 or A61B17/7001 concerning spinal positioners and stabilizers were eligible for inclusion. The search query resulted in the identification of 731 patents. Based on preset inclusion criteria, a total of 56 unique patents on different anchoring methods were included, reviewed and categorized in this study.

RESULTS

Five unique fixation methods were identified; (1) anchors that use threading, (2) anchors that utilize a curved path through the vertebra, (3) anchors that (partly) expand, (4) anchors that use cement and (5) anchors that are designed to initiate bone ingrowth. Of the anchor designs included in this study, eight had a corresponding commercial product, six of which were evaluated in clinical trials.

CONCLUSION

This review provides insights into worldwide patented intrapedicular bone anchors that aim to increase the fixation strength compared to the conventional pedicle screw. The identified anchoring methods and their working principles can be used for clinical decision-making and as a source of inspiration when designing novel bone anchors.

A Comparison of Outcomes at Twelve Weeks of Traditional Button-Over-Nail versus Bone Anchor Repair of Zone I Flexor Digitorum Profundus Tendon Injury

Background: The repair of zone 1 flexor tendon injury often relies on re-inserting the flexor digitorum profundus (FDP) tendon to the distal phalanx. The aim of this retrospective study is to compare outcomes at 12 weeks following traditional button-over-nail (BON) versus bone anchor (BA) repair of zone I FDP injury. Methods: Patients undergoing zone 1 FDP repair between April 2007 and September 2018 using a BON or a BA were included in the study. Patient demographics, complications, arc of flexion of distal (distal interphalangeal joint [DIPJ]) and proximal interphalangeal joint (PIPJ) and patient-rated outcomes were analysed. Results: Forty-three patients were included in the study: 21 in the BA group and 22 in the BON group. Good function was achieved by 20 patients in BA versus nine in BON. Complications occurred in five BA patients versus 10 BON patients. Patients achieved a mean active DIPJ flexion of 49° and 31° and PIPJ flexion of 92° and 57° in the BA and BON groups, respectively. Conclusion: Our study demonstrates better arc of motion, patient-rated outcomes and lower complications at 12 weeks after surgery in patients undergoing zone 1 FDP repair using a BA. Level of Evidence: Level III (Therapeutic).

[Avulsion injuries of the adductors and iliopsoas]

Avulsion injuries of the tendon-bone junction of the adductor longus are rare. Avulsions of the iliopsoas tendon insertion on the lesser trochanter are even rarer. Avulsion injuries of the adductor insertion occur predominantly in active athletes. Iliopsoas tendon avulsions are described mainly in nonathletes, in old age and frequently with no triggering event. In these cases possible underlying pathologies (e.g. tumor or metastases in the lesser trochanter) must be ruled out. In the literature no generally accepted recommendations for treatment of these injuries can be found because only a few retrospective anecdotal case reports and case studies have been published. For this reason, it is mostly unclear if and when a conservative or operative approach is indicated.A PubMed/Medline literature search resulted in 86 articles for iliopsoas avulsions and 155 hits for adductor tendon avulsions. Accordingly, both injuries can basically be treated conservatively. A surgical treatment is recommended only occasionally when conservative treatment fails and when the adductor insertion or the apophysis of the lesser trochanter is dislocated more than 2 cm after avulsion. Reinsertion for adductor longus tendon avulsion injuries is usually performed by open repair using various anchor systems, while extensive avulsion injuries or non-unions of the apophysis of the lesser trochanter are treated by refixation by cannulated screw systems or resection and anchor refixation of the tendon. The postoperative outcome in most cases is described as good or very good (excellent). No major complications were reported in both groups.

Postoperative results of distal tibialis anterior tendinosis

INTRODUCTION

Although distal tibialis anterior tendinopathy is a common condition, it has rarely been described in literature. It is often a condition in overweight women around 50-70 years old with pain that worsens at night. The purpose of this retrospective study is to describe the specific clinical signs and postoperative results of distal tibialis anterior tendinopathy.

MATERIAL AND METHODS

Between 2013 and 2017 we operated 9 patients (10ft) who failed a conservative treatment of distal tibialis anterior tendinopathy. Surgery consisted of debridement of the diseased tendon and reinsertion with a bone anchor. There was a minimum follow-up of 12 months. All patients were clinically evaluated postoperative (range 14-57 months after surgery) with the use of the American Orthopaedic Foot and Ankle Society (AOFAS) score and Visual Analog Scale (VAS) RESULTS: The mean AOFAS score postoperative was 99 (range 94-100). The mean VAS score postoperative was 1 (range 0-3). In all 10 cases the patient was completely satisfied with the result following surgery. There was no recurrence or rupture of tendon after debridement.

CONCLUSION

Distal tibialis anterior tendinopathy is mainly a clinical diagnosis where conservative treatment should always be the first choice. However, our results show that when conservative treatment fails, surgical treatment can lead to very good long term results with a high level of patient satisfaction.

The Accommodation of Bone Anchors Within the Distal Phalanx for Repair of Flexor Digitorum Profundus Avulsions

PURPOSE

Avulsion injury of the flexor digitorum profundus (FDP) tendon has been traditionally repaired with a pull-out suture over the nail plate. Complication rates with this method and improvements in anchor design have led to the increased use of bone anchors to give a rigid all-inside repair. However, the dimensions of the distal phalanx may limit their use. The primary hypothesis was that 2 micro bone anchors could fit in either perpendicular or 45° proximally angled positions within each distal phalanx. A further hypothesis was that 1 mini bone anchor could fit in similar positions in the distal phalanx.

METHODS

Thirty-two fresh frozen fingers were dissected, and the FDP tendon was removed from the distal phalanx footprint. Two bone anchor types were used, mini and micro sizes, and inserted at 2 angles, perpendicular and 45° proximally angled. Observations of dorsal cortex and joint space penetration were recorded. Distal phalanx dimensions were measured for each finger.

RESULTS

The micro anchors penetrated the dorsal cortex in perpendicular tests in little fingers only. The micro anchor did not penetrate the joint in any angled tests. The mini bone anchor penetrated the dorsal cortex in 100% of perpendicular tests and the joint in 63% of angled tests, although none of these included the middle finger.

CONCLUSIONS

Two micro bone anchors fit within the distal phalanx in all fingers tested, except the little finger, when placed in the perpendicular position. At a 45° angle, the distal phalanx of the little finger can also accommodate micro bone anchors without any evidence of complication when placed 4 mm from the joint. The mini anchors were too large to fit in a perpendicular position within the distal phalanx. In the 45° angled position, the joint was not penetrated by the mini anchor in only middle fingers.

CLINICAL RELEVANCE

The study provides anatomical evidence of the accommodation of micro bone anchors within the distal phalanx in perpendicular or 45° angled positions for the repair of FDP tendon avulsion injury.

[Endo-exo prostheses : Osseointegrated percutaneously channeled implants for rehabilitation after limb amputation]

BACKGROUND

In 1999 the first endo-exo femoral prosthesis (EEFP) was implanted in Germany in a patient who had suffered a traumatic above-knee amputation. This procedure involves a skeletally anchored exoprosthetic device that is inserted into the residual femur. The distal part of the implant protrudes transcutaneously and allows attachment to a prosthetic limb which provides direct force transmission to the external prosthetic components. The technique originated from dental implantology and helps to avoid possible problems resulting from treatment of amputated limbs using socket prostheses. In the meantime, durability times of over 10 years have now helped to invalidate the initially well-founded reservations held against the procedure.

OBJECTIVE

What advantages can be achieved by osseointegrated and percutaneously channeled prostheses and which problems had to be overcome for treatment.

MATERIAL AND METHODS

Critical evaluation of data from patients operated on in Lübeck, Germany from January 2003 to December 2014.

RESULTS

With osseointegrated and percutaneously channeled prostheses permanent durability times can be achieved. Infection-associated soft tissue problems at the site of skin protrusion (stoma) can be successfully prevented. The creation of this so-called stoma means acceptance of a possible bacterial portal of entry into the body. Patient satisfaction has so far been high, postoperative rehabilitation is simplified and the technique could possibly lower the costs of medical treatment.

CONCLUSION

Endo-exo prostheses have proved to be successful for more than 15 years. A critical appraisal of the indications as well as a close cooperation between the surgeon, orthopedic technician and the associated rehabilitation facilities with the patient are the basis for the long-term success of this relatively new treatment approach.

[Arthroscopic refixation of TFCC by bone screw anchor]

OBJECTIVE

The goal of this operation technique is a stable refixation of the triangular fibrocartilage complex (TFCC) to the fovea ulnaris. The stability of the distal radio-ulnar joint (DRUJ) should be re-established. The patients pain and the feeling of instability should be reduced.

INDICATIONS

Lesions of the foveal component of the TFCC resulting in DRUJ instability. Combined lesions of both components of the TFCC. Complete detachment of the TFCC from the ulna either without fracture of the styloid process of the ulna or with fracture (floating styloid).

CONTRAINDICATIONS

Severe lacerations of the TFCC and clinically relevant arthrosis of the DRUJ. Severely osteoporotic bone.

SURGICAL TECHNIQUE

Following diagnostic arthroscopy and performance of stability control of the TFCC with a palpation hook, reduction of the DRUJ with supination position of the wrist. Bone anchor fixation through the direct foveal portal (DF). Under arthroscopic control through the 3/4 portal, the suture from the DF portal is placed through the TFCC. Pull out and tie the strands through the 6 U portal.

POSTOPERATIVE MANAGEMENT

Restriction of rotation of the forearm in a Munster cast or special cast brace for 6 weeks. Self-controlled exercise of the wrist after 6 weeks. Physiotherapy and strength building 8 weeks postoperatively.

RESULTS

Clinical studies of this technique showed a significant amelioration of pain perception, improved range of motion and DASH score in all patients after anchor fixation. The results are comparable to other techniques. All patients returned to work after the operation. Accordingly, using this technique a very good stabilization of the DRUJ with low complications can be achieved.

Mechanical characterization of bone anchors used with a bone-attached, parallel robot for skull surgery

Bone-attached robots and microstereotactic frames, intended for deep brain stimulation and minimally invasive cochlear implantation, typically attach to a patient's skull via bone anchors. A rigid and reliable link between such devices and the skull is mandatory in order to fulfill the high accuracy demands of minimally invasive procedures while maintaining patient safety. In this paper, a method is presented to experimentally characterize the mechanical properties of the anchor-bone linkage. A custom-built universal testing machine is used to measure the pullout strength as well as the spring constants of bone anchors seated in four different bone substitutes as well as in human cranial bone. Furthermore, the angles at which forces act on the bone anchors are varied to simulate realistic conditions. Based on the experimental results, a substitute material that has mechanical properties similar to those of cranial bone is identified. The results further reveal that the pullout strength of the investigated anchor design is sufficient with respect to the proposed application. However, both the measured load capacity as well as the spring constants vary depending on the load angles. Based on these findings, an alternative bone anchor design is presented and experimentally validated. Furthermore, the results serve as a basis for stiffness simulation and optimization of bone-attached microstereotactic frames.