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PubMed2005

A prospective randomized comparison of bioabsorbable and titanium anterior cruciate ligament interference screws.

PURPOSE: To compare the Phantom bioabsorbable polymer interference screw (DePuy, Warsaw, IN) with a titanium metal interference screw when used in fixation of femoral and tibial bone blocks in central third bone-patellar tendon-bone autograft anterior cruciate ligament (ACL) reconstructions. TYPE OF STUDY: Multicentered prospective randomized study. METHODS: Two surgeons performed primary ACL reconstructions at different locations. Preoperatively, the patients were randomly assigned. One group received a titanium cannulated interference screw. The second group received the cannulated poly-L-lactic bioabsorbable Phantom screw. Data included subjective evaluation of activity level and International Knee Documentation Committee scores. Objective measures were made using the KT-1000 arthrometer (MedMetric, San Diego, CA), range of motion, presence of effusions, and complications intraoperatively or postoperatively. Measurements were made at 1 year and 2 years. Radiographic evaluation was carried out at least 2 years from the initial surgical date and interpreted by 2 independent orthopaedic surgeons. RESULTS: At the 1-year follow-up (N = 97), pain was reported more during moderate activity in the Phantom screw group (6) compared with the titanium screw group (0) (P = .03). No statistical difference between range of motion (P = .45), activity level (P = .83), swelling with activity (P = .95), partial (P = .13) or full (P = .31) giving way, knee effusions (P = .33), or KT-1000 side-to-side difference (P = .53) were found. At the 2-year follow-up (N = 65), more subjects (18) in the Phantom interference screw group reported activity levels in the strenuous category compared with those in the titanium interference screws (7) group (P = .02). No differences were reported with respect to pain (P = .97), effusion (P = .17), partial (P = .28) or full (P = .27) giving way, swelling with activity (P = .21), range of motion ( P = .64), or KT-1000 side-to-side difference (P = .96). Radiographic inspection showed no change in bone plug position, osteolysis, adverse effect, or complication caused by the bioabsorbable material. Some evidence of tunnel widening was seen in both groups. CONCLUSIONS: Use of a poly-L-lactic bioabsorbable interference screw can provide clinical results equal to that of a metal interference screw for fixation of a central third bone-patellar tendon-bone graft in ACL reconstruction. LEVEL OF EVIDENCE: Level II, therapeutic.

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PubMed2005

Primary stability of hamstring graft fixation with biodegradable suspension versus interference screws.

PURPOSE: During the early postoperative period, the stability of the fixation of a hamstring graft to the bone tunnel is the primary factor in limiting rehabilitation. The aim of this study was to evaluate if the initial fixation strength of a new suspension screw is comparable to that of the biodegradable interference screw fixation technique in the hamstring reconstruction of the anterior cruciate ligament (ACL). TYPE OF STUDY: Experimental laboratory study. METHODS: We evaluated the initial fixation strength of a biodegradable poly-L-lactide/tri-calcium phosphate (PLLA/TCP) screw that suspended the graft in the bone tunnel and compared it with the strength of an interference screw for fixation of hamstring grafts in ACL reconstruction using bovine knees. Single-cycle and cyclic loading tests were performed using a materials testing machine. RESULTS: The suspension screw provided a significantly higher yield load and ultimate failure load than the interference screw. There was no significant difference in the stiffness of both techniques. The typical failure mode for the suspension screw was fracture of the screw and for the interference screw it was slippage of the graft past the screw. In cyclic testing, both methods of fixation ran out to 1,000 cycles up to 250 N with a mean displacement of 2.6 mm (range, 1.8 to 3.3 mm) for the suspension screw and 4.1 mm (range, 2.3 to 6.0 mm) for the interference screw. Only the grafts fixed with the suspension screw survived a protocol with 1,000 cycles up to 400 N. CONCLUSIONS: Our biomechanical data suggest that hamstring graft fixation using a biodegradable PLLA/TCP suspension screw provides an alternative to interference screw fixation. CLINICAL RELEVANCE: Hamstring graft fixation using a suspension screw provides a reasonable alternative to interference screw fixation.

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PubMed2005

Loose intra-articular body following anterior cruciate ligament reconstruction.

We report a case of intra-articular fracture of a bioabsorbable fixation device from the femoral tunnel in an anterior cruciate ligament reconstruction using a bone-tendon-bone graft. Thirteen months after successful reconstruction surgery, the patient experienced episodes of locking and medial joint pain. There was no history of trauma and no symptoms of instability or swelling. On revision arthroscopy, a fractured tip of a bioabsorbable RIGIDfix cross pin (Mitek, Westwood, MA) was identified in the medial compartment of the knee. There was a broad area of chondral erosion affecting the medial femoral condyle and a small defect to the medial tibial plateau where the loose body had been lodged. The bone-tendon-bone graft was intact without disruption. After arthroscopy, the patient was symptom free for 3 weeks but then developed further symptoms of locking. Magnetic resonance imaging showed another loose body within the knee. A repeat arthroscopy was performed 6 weeks after the earlier procedure and another piece of the polylactic acid RIGIDfix cross pin was removed, this time from the lateral gutter. This case raises concern about the potential for breakage and resultant loose body formation that may occur after bioabsorbable cross-pin fixation and, particularly, the associated chondral damage that can occur if early intervention is not conducted.

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PubMed2005

In vitro analysis of rotator cuff repairs: a comparison of arthroscopically inserted tacks or anchors with open transosseous repairs.

PURPOSE: The purpose of this study was to employ a cyclic loading protocol to compare rotator cuff repair strengths of arthroscopically inserted cuff tacks and suture anchors with the traditional open transosseous suture repair. TYPE OF STUDY: In vitro cadaveric analysis. METHODS: Full-thickness 1 x 3-cm rotator cuff defects were created in 25 fresh-frozen cadaveric shoulders, and were randomized to 1 of 4 repair groups: (1) open repair with transosseous sutures, (2) arthroscopic repair with 2 singly loaded suture anchors, (3) arthroscopic repair with 2 doubly loaded suture anchors, and (4) arthroscopic repair with cuff tacks. All repairs were cyclically loaded from 10 to 180 N, and the numbers of cycles to 50% (5-mm gap) and 100% (10-mm gap) failure were recorded. RESULTS: The number of cycles to 100% failure was significantly higher for the arthroscopic doubly loaded suture anchor repairs when compared with the (1) open transosseous suture repair (P = .009), (2) arthroscopic cuff tack repair (P = .003), and (3) arthroscopic singly loaded suture anchor repair (P = .02). Additionally, the number of cycles to 50% failure was significantly higher for all anchors versus open or tack repair (P = .03 for both). CONCLUSIONS: Immediate postoperative fixation of rotator cuff repairs with doubly loaded suture anchors was more stable than that provided by the open transosseous suture repairs, arthroscopic singly loaded suture anchors, or cuff tacks. However, additional evaluation is needed to examine the effects on the sustained strength of the repair throughout the healing process. CLINICAL RELEVANCE: These in vitro results indicate that superior immediate postoperative fixation of rotator cuff repairs may be achieved with the doubly loaded suture anchors. However, additional evaluation is needed to examine the effects on the sustained strength of the repair throughout the healing process.

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PubMed2005

Arthroscopic meniscal repair using the BioStinger.

PURPOSE: Biodegradable devices are available for all-inside meniscal repairs. One device, the BioStinger (Linvatec, Largo, FL), is made of molded poly-L-lactic acid. The purpose of this study was to evaluate the effectiveness of and any adverse events associated with meniscus repair using this device. TYPE OF STUDY: Nonrandomized prospective cohort study. METHODS: A prospective, consecutive, 3-center meniscal repair series using BioStingers (group 1), vertical inside-out sutures (group 2), or hybrid repairs combining BioStingers and sutures (group 3) was studied. Lysholm, Tegner, Cincinnati, and IKDC activity scores were obtained and clinical outcomes and adverse events documented. RESULTS: There were 85 patients who underwent 89 meniscus repairs with an average 26.5 months of follow-up. There were 47 BioStinger repairs (group 1), 29 suture repairs (group 2), and 13 hybrid repairs (group 3). The tear length was statistically greater for the hybrid repair group (P < .5). There were 73 repairs associated with anterior cruciate ligament reconstructions and 12 repeat arthroscopies were performed. Meniscal healing failed in 6 knees (4 in group 1, 0 in group 2, and 2 in group 3). The meniscal healing failed in 7% of those associated with anterior cruciate ligament reconstructions. Mean Tegner scores improved from 2.8 to 6.3, the final IKDC activity score was 3.2 out of 4, the mean Lysholm score improved from 51 to 88, and the mean Cincinnati score improved from 44 to 84. Two BioStinger repair cases had joint-line tenderness from device migration confirmed by magnetic resonance imaging. No tenting of the skin or articular cartilage scuffing was observed. CONCLUSIONS: The success rate for the 29 suture repairs was 100% and for the 47 BioStinger repairs was 91%. These preliminary results are consistent with other repair techniques. LEVEL OF EVIDENCE: Level II, Therapeutic Prospective Cohort Study.

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PubMed2005

Cyclic loading of rotator cuff repairs: an in vitro biomechanical comparison of bioabsorbable tacks with transosseous sutures.

PURPOSE: This study compares rotator cuff repair strength after cyclic loading of bioabsorbable tacks and traditional transosseous sutures, and correlates the results with bone density, age, and gender. The hypotheses were that tack repair strength would be inferior to transosseous sutures and that repair strength would be directly related to bone quality. TYPE OF STUDY: In vitro randomized biomechanical study. METHODS: Eight paired cadaveric shoulders with a standardized supraspinatus defect were randomized to tack or suture repair and subjected to step-wise cyclic loading. Repair migration was measured by quantifying the motion of markers affixed to tendon and bone using a digital camera. Failure mode, cycles, and load were measured for 50% and 100% loss of repair. Results were correlated with bone density, age, and gender. RESULTS: Tack repairs failed at the tack-tendon interface, whereas suture rupture was the mode of failure for the suture repairs. Mean values for 50% loss of repair were 206 +/- 88 cycles and 44 +/- 15 N for the sutures, and 1,193 +/- 252 cycles and 156 +/- 20 N for the tacks (P < .05). The corresponding values for 100% loss of repair were 2,458 +/- 379 cycles and 294 +/- 27 N for the sutures, and 2,292 +/- 333 cycles and 263 +/- 28 N for the tacks (P > .05). These results did not correlate with bone density, age, or gender. CONCLUSIONS: This study has shown that bioabsorbable tacks provide improved repair strength in comparison with traditional suture techniques. Repair strength did not correlate with bone quality, and this may be attributed to failure primarily through the repair construct or at the tack-tendon interface and not through bone. This report describes a new high-resolution optical method of measuring tendon repair strength that should be a useful model for future studies. CLINICAL RELEVANCE: This study demonstrates the biomechanical advantages of a sutureless tack device for rotator cuff repair compared with a traditional augmented suture repair technique.

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PubMed2005

Arthroscopic anterior cruciate ligament reconstruction using quadriceps tendon autograft and bioabsorbable cross-pin fixation.

We describe a technique for arthroscopic anterior cruciate ligament (ACL) reconstruction using the middle third of the quadriceps tendon without a patellar bone block and absorbable tibial and femoral cross-pin fixation. The central part of the quadriceps tendon is harvested through a 5-cm long anterior skin incision without a patellar bone block. Tibial and femoral tunnels are prepared, the graft is passed up the tunnels, and is fixed both in the femur and the tibia using absorbable cross pins (Rigid Fix; Mitek, Johnson & Johnson, Norwood, MA). In this way, the graft is stabilized near the joint line, providing outlet fixation. In our practice, very good results have been obtained with the use of this technique.

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PubMed2005

Influence of thread design on bioabsorbable interference screw insertion torque during retrograde fixation of a soft-tissue graft in synthetic bone.

PURPOSE: Bioabsorbable interference screw design may influence biomechanical characteristics. This study compared the insertion torque and load at failure characteristics of 2 types of screws during retrograde fixation of a soft-tissue graft. TYPE OF STUDY: Biomechanical study. METHODS: Eight matched pairs of doubled 100-mm long tibialis anterior allografts were prepared and fixed in appropriately sized tunnels created in 10 lb/ft 3 (0.16 g/cm3) dense synthetic bone blocks using screws of similar length and root and thread diameter designed with either a large buttress thread with a smaller taper or small buttress thread with a larger taper. Insertion torque was measured at one-third, two-thirds, and full screw insertion. After the graft fixation constructs were mounted in a servohydraulic-testing device with the loading axis aligned directly with the tunnel and preloaded to 25 N, they were cycled 3 times from 0 to 50 N, and then subjected to a 20 mm/minute traction force to failure. RESULTS: All constructs failed by graft slippage past the screw. Mean maximum load at failure (360.5 +/- 68 N v 341.6 +/- 58 N, P = .2) and stiffness (63.6 +/- 16 N/mm 2 v 66.4 +/- 14 N/mm 2 , P = .89) was similar between constructs fixed with a large buttress thread small-taper screw and small buttress thread large-taper screw, respectively. The small buttress thread screw with a large taper displayed greater mean insertion torque at one-third insertion (4.1 +/- 0.57 in-lb v 3.2 +/- 0.49 in-lb, P = .03), whereas the large buttress thread screw with a small taper displayed greater mean insertion torque at full insertion (11.1 +/- 0.74 in-lb v 9.4 +/- 1.3 in-lb, P = .012). Mean differences were not observed at two-thirds screw insertion (P = .12). CONCLUSIONS: Large buttress thread small-taper screws displayed biomechanical fixation characteristics comparable to small buttress thread large-taper screws. CLINICAL RELEVANCE: Given reports of superior screw-graft-bone tunnel contact area, these biomechanical results suggest that use of a large buttress screw with a small taper may be preferable for retrograde soft-tissue graft fixation.

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PubMed2006

Pretibial cyst formation after anterior cruciate ligament reconstruction with a hamstring tendon autograft.

We report a case of pretibial cyst formation, which is a rare complication, after anterior cruciate ligament (ACL) reconstruction. The patient had undergone ACL reconstruction at age 18 and complained of pain and swelling localized on the anteromedial aspect of the ipsilateral proximal tibia 2 years postoperatively. Magnetic resonance imaging showed a multilocular fluid-filled cyst arising from the outlet of the tibial bone tunnel. Open resection of the cyst was performed and communication between the tibial tunnel and the joint space was confirmed arthroscopically. The cavity of the tibial tunnel was packed with cancellous bone to seal off a water channel. The laboratory examination revealed slightly concentrated chondroitin sulfate in the cyst fluid compared with the articular fluid, despite histologic observation of no glycosaminoglycan synthesis in the cells of the cyst wall. These findings indicated that leakage of the articular fluid via the tibial tunnel might have caused the pretibial cyst after ACL reconstruction.

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PubMed2005

Posterior cruciate ligament reconstruction: double-loop hamstring tendon autograft versus Achilles tendon allograft--clinical results of a minimum 2-year follow-up.

PURPOSE: The purpose of this study was to compare clinical results of arthroscopic posterior cruciate ligament (PCL) reconstructions using double-loop hamstring tendon autograft and Achilles tendon allograft while preserving the original PCL remnant. TYPE OF STUDY: Case-control study of results of treatment. METHODS: From September 1997 to December 2000, 36 patients who received only PCL reconstruction were reviewed retrospectively. Of these, 18 patients received autogenous double-loop hamstring tendon reconstruction (group I) and 18 received Achilles tendon allograft reconstruction (group II). The same PCL reconstruction procedure was performed in both groups. At final follow-up at a minimum of 2 years, patients were evaluated by 4 measures: the International Knee Documentation Committee (IKDC) evaluation, Lysholm knee scores, the posterior draw test, and Telos stress radiography. RESULTS: Between the 2 groups, preoperative demographic factors (age, gender, activity level, and mean duration to surgery) showed no statistically significant difference (P > .05). According to IKDC evaluation of group I, 16 of the 18 knees rated normal or nearly normal, whereas 2 fell into the abnormal category. By the same criteria, 14 of the 18 knees in group II were normal to nearly normal, 3 were abnormal, and 1 was severely abnormal. IKDC scores showed no statistical difference between the 2 groups (P = .98). Postoperative mean Lysholm knee scores were 90 points (range, 78-100) for group I and 85 (range, 70-95) for group II; improvements of 22 and 17 points, respectively. According to the Lysholm knee scores, group I showed slightly better results than did group II, with a statistical significance of P < .01. Telos stress radiography showed the mean difference in posterior translation between the injured and uninjured knees to be 2.2 mm (range, 0 to 7.0 mm) for group I and 2.9 mm (range, 1.0 to 7.0 mm) for group II. The Telos stress test showed no statistical difference between the 2 groups (P = .14). CONCLUSIONS: The clinical outcome was the same for both groups. Despite its comparatively short length and small diameter, the double-loop hamstring tendon autograft was as good as Achilles tendon allograft in PCL reconstruction. LEVEL OF EVIDENCE: Level III, case-control study.

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PubMed2005

Soft-tissue interference fixation: bioabsorbable screw versus metal screw.

PURPOSE: To compare the biomechanical properties of eccentrically positioned bioabsorbable and titanium interference screws for quadrupled hamstring tendon graft (QHTG) fixation. TYPE OF STUDY: In vitro, biomechanical study. METHODS: In 10 paired cadaveric tibiae and femurs (mean age, 66.5 years; range, 53 to 81 years), QHTG fixation was performed in tunnels sized to within 0.5 mm of QHTG diameter using either a titanium (RCI; Smith & Nephew Donjoy, Carlsbad, CA) or a bioabsorbable (BioScrew; Linvatec, Largo, FL) screw of equal size. Constructs then underwent biomechanical load-to-failure testing on a servo-hydraulic device at 20 mm/min. RESULTS: Load at failure was greater for femoral-side QHTG fixation using the bioabsorbable screw than the titanium screw (486 +/- 223.7 N v 246 +/- 99.1 N, P = .006); however, displacement did not differ (P = .81). There were no statistically significant differences between groups for tibial side load at failure (P = .54), stiffness (P = .44), or displacement (P = .50). Screw thread-induced graft laceration was more frequently observed in the titanium screw group (9 of 10 grafts during femoral-side testing, 0 of 10 grafts during tibial-side testing) than in the bioabsorbable screw group (0 of 10 grafts during femoral-side testing, 1 of 10 grafts during tibial-side testing). CONCLUSIONS: BioScrew interference screw fixation was comparable or superior to RCI titanium interference screw fixation. BioScrew interference screw fixation also produced less screw thread-induced laceration of the QHTG during load-to-failure testing. CLINICAL RELEVANCE: Use of a biodegradable interference screw positioned directly against a soft-tissue graft provides fixation properties similar to those of a metal interference screw.

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PubMed2005

Unstable isolated SLAP lesion: clinical presentation and outcome of arthroscopic fixation.

PURPOSE: The purpose of this study was to describe the clinical presentation and sensitivity of testing of unstable isolated SLAP (superior labrum anterior posterior) lesions and to evaluate the efficacy of arthroscopic treatment. TYPE OF STUDY: Case series. METHODS: A retrospective review was made of 44 unstable SLAP lesions in 41 patients (40 male, 1 female) who did not have other pathologic shoulder findings. The mean follow-up period was 33 months (range, 25 to 67 months) and the mean age at the time of surgery was 24 years (range, 17 to 43 years). Twenty-six patients had an injury on the dominant shoulder and 3 had bilateral shoulder involvement. Arthroscopic fixation was performed with the use of a biodegradable tack (Suretac; Acufex, Mansfield, MA) in 14 cases, and with a screw-type metallic suture anchor (mini-Revo; Linvatec, Largo, FL) in 30 cases. RESULTS: Pain (100%) and clicking (57%) were the most common symptoms. The compression-rotation test was positive in 84% of the patients before surgery. The average UCLA score at the last follow-up was 32.3 points; 22 cases were graded excellent, 16 good, and 6 poor. Based on the postoperative performance data collected from 33 athletes, 25 of them (76%) were able to return to their athletic activities. Among them, throwing athletes showed statistically better performance than did nonthrowing athletes (P = .011). CONCLUSIONS: Pain, followed by clicking, was the most common symptom, and the most common sign was a positive compression rotation test. Arthroscopic treatment of unstable isolated SLAP lesions resulted in good or excellent UCLA scores in 86% of the patients. Throwing athletes showed more satisfactory results than nonthrowing athletes. LEVEL OF EVIDENCE: Type IV, case series with no, or historical, control group.

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PubMed2005

Cyclic loading comparison between biodegradable interference screw fixation and biodegradable double cross-pin fixation of human bone-patellar tendon-bone grafts.

PURPOSE: The aim of this study was to compare ultimate load, yield load, stiffness, and displacement after cyclic loading of a cross-pin technique and an interference screw technique for the fixation of bone-patellar tendon-bone (BPTB) grafts in anterior cruciate ligament (ACL) reconstruction. TYPE OF STUDY: Biomechanical in vitro study. METHODS: The devices tested were 2 2.7-mm biodegradable pins (RigidFix; Ethicon, Mitek Division, Norderstedt, Germany) and biodegradable interference screws (Absolute; Innovasive Devices, Marlborough, MA). Each device was used for the fixation of 10 8-mm, 9-mm, or 10-mm sized human BPTB grafts in tunnels drilled in bovine knees. Ultimate load, yield load, stiffness, and displacement after cyclic loading (1,000 cycles between 50 and 250 N) were then evaluated. RESULTS: All 8-mm grafts that were fixed with cross-pins failed after a mean of 124 cycles of load. The 9-mm and 10-mm grafts survived the cyclic loading protocol. Yield load and maximum load of the 10-mm groups (cross-pin and interference screw) were significantly higher than that of the 9-mm groups. There was no significant difference in maximum load, yield load, and stiffness between the cross-pin and interference screw fixation technique for 1 graft size. CONCLUSIONS: The biomechanical data suggest that femoral fixation of 9-mm and 10-mm BPTB grafts using 2.7-mm biodegradable cross-pins leads to primary stability that is comparable to that of biodegradable interference screws. Fixation of 8-mm BPTB grafts using 2.7-mm biodegradable cross-pins had poor results. CLINICAL RELEVANCE: The diameter of the bone block is the limiting factor for the final fixation strength and the cyclical survival when using cross-pins. We strongly recommend not using this technique for bone blocks smaller than 9 mm in diameter.

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PubMed2005

Anatomic posterolateral corner knee reconstruction.

Injuries to the lateral collateral ligament and posterolateral corner of the knee, particularly when combined with anterior cruciate or posterior cruciate ligament injuries, can result in profound symptomatic knee instability. Although many surgical improvements have been made in reconstruction of anterior and posterior cruciate ligament injuries, reconstruction of the posterolateral corner has had less predictable results, with residual pathologic laxity especially in the chronic situation. This has stimulated many surgeons to recommend acute repair of posterolateral knee injuries. This article describes a more anatomic reconstruction of the posterolateral corner for chronic instability, recreating the lateral collateral ligament and popliteofibular ligament using either autogenous or allograft soft tissue and an interference screw technique. In a small clinical series, this has proven to restore varus rotation and external rotation patholaxities with a high degree of predictability.

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PubMed2005

Arthroscopic labral repair in the hip: surgical technique and review of the literature.

Hip pain can be caused by multiple pathologies. Injuries to the acetabular labrum are the most common pathologic findings identified at the time of hip arthroscopy. Five causes of labral tears have been identified; these include trauma, femoroacetabular impingement, capsular laxity, dysplasia, and degeneration. Studies have shown the function and the importance of the labrum. To restore function of the labrum, new surgical techniques, such as suture anchor repair, have been described. The goal of arthroscopic treatment of a torn labrum is to relieve pain by eliminating the unstable flap tear that causes hip discomfort. The goals of these treatments are to maintain the function of the hip joint and decrease the development of premature arthrosis.

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PubMed2005

Arthroscopic biceps tenodesis using interference screw: end-tunnel technique.

The conflict between tenotomy versus tenodesis for biceps lesions of the shoulder has not been resolved. We, however, believe that tenodesis is the treatment of choice until proven otherwise. Hence our department has been performing arthroscopic tenodesis for biceps subluxation or partial tears that involved over 50% of its diameters. We introduce our technique of arthroscopic biceps tenodesis in which the biceps tendon is fixed in the sequentially enlarged bony end-tunnel using bioabsorbable interference screws without transosseous drilling.

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