A 3-Dimensional Suture Technique for Flexor Tendon Repair: A Biomechanical Study.

PURPOSE: Flexor tendon injury continues to pose a number of challenges for hand surgeons. Improving mechanical properties of repairs should allow for earlier and unprotected rehabilitation. A 3-dimensional (3D) 4-strand suture technique has been proposed to combine high tensile strength and low gliding resistance without causing suture pullout due to tendon delamination. Our hypothesis is that the 3D technique can result in better mechanical properties than the Adelaide technique. METHODS: Four groups of 10 porcine flexor tendons were sutured using the 3D or Adelaide technique with a 3-0 polypropylene or ultrahigh molecular weight polyethylene (UHMWPE) suture. The axial traction test to failure was performed on each tendon to measure 2-mm gap force and ultimate tensile strength. RESULTS: The mean 2-mm gap force was 49 N for group A (3D + polypropylene), 145 N for group B (3D + UHMWPE), 47 N for group C (Adelaide + polypropylene), and 80 N for group D (Adelaide + UHMWPE). Failure mode was caused by suture breakage for group A (10/10) and mainly by suture pullout for the other groups (8/10 up to 10/10). With the UHMWPE suture, the mean ultimate tensile strength was 145 N for the 3D technique and 80 N for the Adelaide technique. CONCLUSIONS: Porcine flexor tendons repaired using the 3D technique and UHMWPE suture exceeded a 2-mm gap force and tensile strength of 140 N. The ultimate tensile strength was superior to that of the Adelaide technique, regardless of the suture material. CLINICAL RELEVANCE: This in vitro study on porcine flexor tendon suture highlights that the mechanical properties of 3D repair are better than those of 3D repair using the Adelaide technique when a UHMWPE suture is used.

Femoral Positioning of the Anterolateral Ligament Graft With and Without Ultrasound Location of the Lateral Epicondyle.

BACKGROUND: In anterior cruciate ligament (ACL) reconstruction with anterolateral ligament (ALL) reconstruction, precise positioning of the ALL graft on the femur and tibia is key to achieve rotational control. The lateral femoral epicondyle is often used as a reference point for positioning of the ALL graft and can be located by palpation or with ultrasound guidance. PURPOSE: To compare the ALL graft positioning on the femoral side between an ultrasound-guided technique and a palpation technique for the location of the lateral epicondyle. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A total of 120 patients receiving a primary combined ACL and ALL reconstruction between June and December 2019 were included. The location of the lateral epicondyle was determined by palpation in the palpation group (n = 60) and with preoperative ultrasound guidance in the ultrasound group (n = 60). Groups were comparable in age, sex, body mass index (BMI), and operated side. The planned positioning of the femoral ALL graft was proximal and posterior to the lateral epicondyle. The effective positioning of the femoral ALL graft was evaluated on postoperative lateral radiographs. The primary outcome was location of the graft in a 10-mm quadrant posterior and proximal to the lateral epicondyle. Results were analyzed in 2 subgroups according to BMI. RESULTS: All 60 anterolateral grafts (100%) in the ultrasound group were positioned in a 10-mm quadrant posterior and proximal to the lateral epicondyle, as opposed to 52 (87%) in the palpation group (P = .006). Errors in graft positioning with palpation occurred in overweight patients (BMI >25) as well as nonoverweight patients (P = .3). CONCLUSION: Femoral positioning of the ALL graft posterior and proximal to the lateral epicondyle is more reproducible with ultrasound guidance when compared with palpation alone, regardless of BMI.

A Randomized Controlled Trial of Bone-Patellar Tendon-Bone Anterior Cruciate Ligament Reconstruction With and Without Lateral Extra-articular Tenodesis: 19-Year Clinical and Radiological Follow-up.

BACKGROUND: Arthroscopic anterior cruciate ligament (ACL) reconstruction (ACLR) with a bone-patellar tendon-bone graft (BTB) is a reliable surgical option for the control of anterior knee laxity after ACL injury. The addition of a lateral extra-articular tenodesis (LET) may improve control of rotation knee laxity and improve short-term graft survival in high-risk patients. PURPOSE: The aims of this study were to compare long-term patient-reported outcomes, graft survival, and risk of osteoarthritis between ACLR with and without LET. STUDY DESIGN: Randomized controlled trial; Level of evidence, 2. METHODS: This study included 121 consecutive knees (120 patients) presenting to a single center with an ACL rupture between 1998 and 1999. In total, 61 knees were randomized to an isolated BTB ACLR, and 60 knees were randomized to a BTB ACLR with an extra-articular lateral tenodesis with gracilis tendon (modified Lemaire). RESULTS: Eighty knees in 79 patients (66%) were available for follow-up at a postoperative mean of 19.4 years (range, 19-20.2). Of those patients, 43 had a clinical examination and completed patient-reported outcome questionnaires, and the other 37 patients were evaluated through the questionnaires alone. Standard radiographs were available for 45 patients and laximetry (TELOS) for 42 patients. Mean subjective International Knee Documentation Committee score at last follow-up was 81.8, and no differences were noted between the BTB and BTB-LET groups (P = .7). Two-thirds of patients were still participating in pivoting sports. A total of 17 knees (21%) experienced a graft failure, 5 of which (6%) underwent revision ACLR. There was no significant difference in graft failure risk between the BTB group (29%) and the BTB-LET group (13%; P = .1). Lateral tibiofemoral osteoarthritis was significantly more frequent in the BTB-LET group (59%) as compared with the BTB group (22%; P = .02). Lateral compartment osteoarthritis was correlated with partial lateral meniscectomy. CONCLUSION: There were no significant differences in long-term patient-reported outcomes after ACLR with or without an LET. LET may increase the risk of lateral compartment osteoarthritis at long-term follow-up. There was a trend toward decreased graft failure risk with the addition of LET but this study was underpowered to assess this outcome.

Minimally Invasive Ultrasound-Guided Anterolateral Ligament Reconstruction With Autologous 2-Strand Gracilis Graft.

We describe an ultrasound-guided anterolateral ligament (ALL) reconstruction technique that uses the gracilis tendon and can be added to any anterior cruciate ligament reconstruction technique. Preoperative ultrasound imaging is used to view the ruptured ALL and confirm the location of bony landmarks. Two minimally invasive incisions are made: one posterior to the lateral epicondyle and one posterior to the Gerdy tubercle. After anterior cruciate ligament graft fixation, the 2-strand gracilis tendon is introduced from the tibial incision, under the fascia lata, toward the femoral incision. The ALL graft is secured to the femur with a 5.5-mm anchor, positioned posteriorly and proximally to the lateral epicondyle. The distal end of the graft is tightened in full extension and fixed to the tibia with a ligament staple posterior to the Gerdy tubercle. This ALL technique requires no graft preparation.