Indirect Head of the Rectus Femoris Tendon as a Graft for Segmental Hip Labral Reconstruction: An Anatomic, Radiographical, and Biomechanical Study in Comparison With Iliotibial Labral Reconstruction.

BACKGROUND: The indirect head of the rectus femoris (IHRF) tendon has been used as an autograft for segmental labral reconstruction. However, the biomechanical properties and anatomic characteristics of the IHRF, as they relate to surgical applications, have yet to be investigated. PURPOSE: To (1) quantitatively and qualitatively describe the anatomy of IHRF and its relationship with surrounding arthroscopically relevant landmarks; (2) detail radiographic findings pertinent to IHRF; (3) biomechanically assess segmental labral reconstruction with IHRF, including restoration of the suction seal and contact pressures in comparison with iliotibial band (ITB) reconstruction; and (4) assess potential donor-site morbidity caused by graft harvesting. STUDY DESIGN: Descriptive laboratory study. METHODS: A cadaveric study was performed using 8 fresh-frozen human cadaveric full pelvises and 7 hemipelvises. Three-dimensional anatomic measurements were collected using a 3-dimensional coordinate digitizer. Radiographic analysis was accomplished by securing radiopaque markers of different sizes to the evaluated anatomic structures of the assigned hip.Suction seal and contact pressure testing were performed over 3 trials on 6 pelvises under 4 different testing conditions for each specimen: intact, labral tear, segmental labral reconstruction with ITB, and segmental labral reconstruction with IHRF. After IHRF tendon harvest, each full pelvis had both the intact and contralateral hip tested under tension along its anatomic direction to assess potential site morbidity, such as tendon failure or bony avulsion. RESULTS: The centroid and posterior apex of the indirect rectus femoris attachment are respectively located 10.3 ± 2.6 mm and 21.0 ± 6.5 mm posteriorly, 2.5 ± 7.8 mm and 0.7 ± 8.0 mm superiorly, and 5.0 ± 2.8 mm and 22.2 ± 4.4 mm laterally to the 12:30 labral position. Radiographically, the mean distance of the IHRF to the following landmarks was determined as follows: anterior inferior iliac spine (8.8 ± 2.5 mm), direct head of the rectus femoris (8.0 ± 3.9 mm), 12-o'clock labral position (14.1 ± 2.8 mm), and 3-o'clock labral position (36.5 ± 4.4 mm). During suction seal testing, both the ITB and the IHRF reconstruction groups had significantly lower peak loads and lower energy to peak loads compared with both intact and tear groups (P = .01 to .02 for all comparisons). There were no significant differences between the reconstruction groups for peak loads, energy, and displacement at peak load. In 60° of flexion, there were no differences in normalized contact pressure and contact area between ITB or IHRF reconstruction groups (P > .99). There were no significant differences between intact and harvested specimen groups in donor-site morbidity testing. CONCLUSION: The IHRF tendon is within close anatomic proximity to arthroscopic acetabular landmarks. In the cadaveric model, harvesting of the IHRF tendon as an autograft does not lead to significant donor-site morbidity in the remaining tendon. Segmental labral reconstruction performed with the IHRF tendon exhibits similar biomechanical outcomes compared with that performed with ITB. CLINICAL RELEVANCE: This study demonstrates the viability of segmental labral reconstruction with an IHRF tendon and provides a detailed anatomic description of the tendon in the context of an arthroscopic labral reconstruction. Clinicians can use this information during the selection of a graft and as a guide during an arthroscopic graft harvest.

Labral Augmentation With Either Iliotibial Band Allograft or Dermis Allograft Perform Similarly Regarding Peak Force, Displacement, and Work to Labral Repair in Suction Seal Restoration: A Biomechanical Study.

PURPOSE: To investigate whether allograft substitutes may be used to restore suctional seal properties with labral augmentation, the purpose of the current study was to evaluate the biomechanical properties of the labral suction seal under several scenarios, including: (1) intact labrum, (2) rim preparation, (3) labral repair, (4) labral augmentation with iliotibial band (ITB), and (5) labral augmentation with a dermis allograft. METHODS: Eleven hemi-pelvises were dissected to the level of the labrum and placed in a material testing system for biomechanical axial distraction. Each specimen was compressed to 250 newtons (N) and distracted at 10 mm/s while load, crosshead displacement, and time were continuously recorded. For each of the 5 labral states, 3 testing repetitions were performed. Peak force (N, newtons), displacement at peak force (mm, millimeter), and work (N-mm, newton, millimeter) were calculated and normalized to the intact state of each specimen. RESULTS: Eleven specimens were tested and 8 specimens (age: 58.6 ± 5.4 years, body mass index: 28.6 ± 6.8 kg/m2; 4 female patients; 5 right hips) were included in final analyses. Expressed as a percentage relative to the intact state, the average normalized peak force, displacement at peak force, and work for each labral state were as follows: intact (100.0% ± 0% for all), rim preparation (89.0% ± 9.2%, 93.3% ± 20.6%, 85.1% ± 9.0%), repair (61.3% ± 17.9%, 88.4% ± 36.9%, 58.1% ± 16.7%), ITB allograft (62.7% ± 24.9%, 83.9% ± 21.6%, 59.4% ± 22.4%), and dermis allograft (57.8% ± 27.2%, 88.2% ± 29.5%, 50.0% ± 20.1%). Regarding peak force, intact state was significantly greater compared with the labral repair, augmentation with ITB, and augmentation with the dermis allograft states (P < .001). No significant differences were demonstrated between displacement at peak force (P = .561). Regarding work, both intact state and rim preparation states were significantly greater than the repair, ITB augmentation, and dermis allograft augmentation states (P < .001). In all outcome measures, the dermis allograft augmentation performed with no statistical difference to the ITB augmentation state. CONCLUSIONS: Labral repair and labral augmentation with either ITB allograft or the dermis allograft resulted in significantly lower peak force and work to equilibrium compared with the intact and rim prep states. There was no statistical difference between repair and augmentation states as well as no statistical difference between ITB allograft and dermal allograft at time zero. CLINICAL RELEVANCE: This study compares biomechanical properties of the suction seal of the hip comparing labral states including intact, rim preparation, repair, and augmentation, which can be used for surgical decision-making.

Isolated Posterior Lateral Meniscofemoral Ligament Tears Show Greater Meniscal Extrusion in Knee Extension, and Isolated Posterior Lateral Meniscal Root Tears Show Greater Meniscal Extrusion at 30° Using Ultrasound: A Cadaveric Study.

PURPOSE: To quantify the effects that posterior meniscofemoral ligament (pMFL) lesions have on lateral meniscal extrusion (ME) both with and without concomitant posterior lateral meniscal root (PLMR) tears and describe how lateral ME varied along the length of the lateral meniscus. METHODS: Ultrasonography was used to measure ME of human cadaveric knees (n = 10) under the following conditions: control, isolated pMFL sectioning, isolated PLMR sectioning, pMFL+PLMR sectioning, and PLMR repair. ME was measured anterior to the fibular collateral ligament (FCL), at the FCL, and posterior to the FCL in both unloaded and axially loaded states at 0° and 30° of flexion. RESULTS: Isolated and combined pMFL and PLMR sectioning consistently demonstrated significantly greater ME when measured posterior to the FCL compared with other image locations. Isolated pMFL tears demonstrated greater ME at 0° compared with 30° of flexion (P < .05), whereas isolated PLMR tears demonstrated greater ME at 30° compared with 0° of flexion (P < .001). All specimens with isolated PLMR deficiencies demonstrated greater than 2 mm of ME at 30° flexion, whereas only 20% of specimens did so at 0°. When the pMFL was sectioned following an isolated PLMR tear, there was a significant increase in ME at 0° (P < .001). PLMR repair after combined sectioning restored ME to levels similar to that of controls in all specimens when measured at and posterior to the FCL (P < .001). CONCLUSIONS: The pMFL protects against ME primarily in full extension, whereas the presence of ME in the setting of PLMR injuries may be better appreciated in knee flexion. With combined tears, isolated repair of the PLMR can restore near-native meniscus position. CLINICAL RELEVANCE: The stabilizing properties of intact pMFL may mask the presentation of PLMR tears and delay appropriate management. Additionally, the MFL is not routinely assessed during arthroscopy due to difficult visualization and access. Understanding the ME pattern of these pathologies in isolation and combination may improve detection rates so that the source of patients' symptoms can be addressed to satisfaction.

Medial Meniscal Extrusion of Greater Than 3 Millimeters on Ultrasound Suggests Combined Medial Meniscotibial Ligament and Posterior Medial Meniscal Root Tears: A Cadaveric Analysis.

PURPOSE: To evaluate how the meniscotibial ligament (MTL) affects meniscal extrusion (ME) with or without concomitant posterior medial meniscal root (PMMR) tears and to describe how ME varied along the length of meniscus. METHODS: ME was measured using ultrasonography in 10 human cadaveric knees in conditions: (1) control, either (2a) isolated MTL sectioning, or (2b) isolated PMMR tear, (3) combined PMMR+MTL sectioning, and (4) PMMR repair. Measurements were obtained 1 cm anterior to the MCL (anterior), over the MCL (middle), and 1 cm posterior to the MCL (posterior) with or without 1,000 N axial loads in 0° and 30° flexion. RESULTS: At 0°, MTL sectioning demonstrated greater middle than anterior (P < .001) and posterior (P < .001) ME, whereas PMMR (P = .0042) and PMMR+MTL (P < .001) sectioning demonstrated greater posterior than anterior ME. At 30°, PMMR (P < .001) and PMMR+MTL (P < .001) sectioning demonstrated greater posterior than anterior ME, and PMMR (P = .0012) and PMMR+MTL (P = .0058) sectioning demonstrated greater posterior than anterior ME. PMMR+MTL sectioning demonstrated greater posterior ME at 30° compared with 0° (P = .0320). MTL sectioning always resulted in greater middle ME (P < .001), in contrast with no middle ME changes following PMMR sectioning. At 0°, PMMR sectioning resulted in greater posterior ME (P < .001), but at 30°, both PMMR and MTL sectioning resulted in greater posterior ME (P < .001). Total ME surpassed 3 mm only when both the MTL and PMMR were sectioned. CONCLUSIONS: The MTL and PMMR contribute most to ME when measured posterior to the MCL at 30° of flexion. ME greater than 3 mm is suggestive of combined PMMR + MTL lesions. CLINICAL RELEVANCE: Overlooked MTL pathology may contribute to persistent ME following PMMR repair. We found isolated MTL tears able to cause 2 to 2.99 mm of ME, but the clinical significance of these magnitudes of extrusion is unclear. The use of ME measurement guidelines with ultrasound may allow for practical MTL and PMMR pathology screening and pre-operative planning.

Lateral Patellofemoral Ligament Reconstruction: A Biomechanical Comparison of 2 Techniques.

BACKGROUND: The importance of maintaining lateral patellar stabilizing structures has been demonstrated by the presence of iatrogenic medial patellar instability after lateral retinacular release (LRR) procedures. In patients with medial patellar instability, lateral patellofemoral ligament (LPFL) reconstruction has been clinically shown to restore patellar stability while improving patient-reported outcomes. However, the biomechanics associated with different LPFL reconstruction techniques remain largely unknown. PURPOSE: To (1) investigate whether LPFL reconstruction restores medial patellar translation compared with the intact state after LRR and (2) evaluate for any biomechanical differences between soft tissue and osseous LPFL reconstruction techniques. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 7 knees were included in the final analysis. The knees were dissected, and the tibia and femur were potted. An eye screw was then placed at the midpoint of the patella perpendicular to the medial surface. A custom jig was constructed to allow for a 1-kg load to be applied to the quadriceps muscle. Medial patellar displacement was investigated at 0°, 10°, 20°, 30°, 45°, 60°, and 90° of knee flexion using a tensile testing machine with a 20-N medial force applied to the patella. Medial patellar displacement was assessed in 4 states: intact, LRR, soft tissue LPFL reconstruction (inserted through incisions in the iliotibial band, quadriceps tendon, and patellar tendon), and osseous LPFL reconstruction. RESULTS: The LRR group had significantly greater medial patellar translation compared with the intact group throughout flexion (P < .01 to P = .029). The soft tissue LPFL reconstruction group demonstrated significantly greater medial patellar translation at 30° (P = .020) and 45° (P = .025) compared with the intact group, with less translation compared with the LRR group at all degrees of knee flexion except for 45° (P = .065). The osseous LPFL reconstruction group demonstrated significantly greater medial patellar translation compared with the intact group at 30° of flexion (P = .036), with significantly less translation compared with the LRR group from 0° to 30° (P < .01 to P = .013). The soft tissue LPFL reconstruction group (15.94 ± 2.55 mm) demonstrated significantly greater medial patellar translation at 10° of flexion compared with the osseous LPFL reconstruction group (14.16 ± 2.34 mm) (P = .033). CONCLUSION: Soft tissue LPFL reconstruction led to significantly greater medial patellar translation at 30° and 45° compared with the intact state, while osseous LPFL reconstruction produced significantly greater translation only at 30°. Both the soft tissue and the osseous reconstruction techniques resulted in comparable medial patellar translation at all degrees of knee flexion except for 10°, in which osseous reconstruction was more similar to the intact state. CLINICAL RELEVANCE: Compared with LRR, soft tissue LPFL reconstruction was able to restore stability against medial patellar translation at most degrees of knee flexion, while osseous LPFL reconstruction did not provide adequate stabilization beyond 30° of flexion. While the LPFL does appear to have osseous insertions, soft tissue reconstruction functioned more similarly to the intact state after LRR.

Lateral Translation of the Patella in MPFC Reconstruction: A Biomechanical Study of Three Approaches.

The purpose of this study was to investigate whether differences exist in preventing lateral patellar translation between three distinct medial patellofemoral complex (MPFC) reconstruction procedures at varying knee flexion angles. Six cadaveric knee specimens were dissected, potted, and placed in a customized jig for testing. Lateral patellar displacement was measured at intervals between 0 and 90 degrees of knee flexion using a tensile testing machine with a 20 N lateral force applied to the patella. Each specimen was tested with the MPFC intact, sectioned, and after each of the three reconstruction techniques: MPFL, hybrid, and medial quadriceps-tendon femoral (MQTFL) reconstructions. There was significantly increased lateral patellar displacement following MPFC sectioning when compared with the intact state in early degrees of flexion (10-30 degrees) (p < 0.05). All three reconstruction groups restored patella stability and reduced lateral patellar displacement following sectioning from 0 to 30 degrees of flexion (p < 0.05). When compared with the intact group, all three reconstruction groups demonstrated reduced patella translation at full knee extension, while the MPFL and hybrid reconstruction groups additionally demonstrated significant reduction in patella translation at 10 degrees of flexion (p < 0.05). No significant differences were observed between the three reconstruction groups. This biomechanical study demonstrates the efficacy of three MPFC reconstruction techniques in patella stabilization following sectioning. Our results suggest that MPFL reconstruction may provide the most robust patella stabilization, whereas MQTFL reconstruction may be the most forgiving construct. This study suggests that MQTFL and hybrid reconstructions provide adequate resistance to lateral translation and may be used as an alternative to MPFL reconstruction.

Concomitant Meniscotibial Ligament Reconstruction Decreases Meniscal Extrusion Following Medial Meniscus Allograft Transplantation: A Cadaveric Analysis.

PURPOSE: To compare meniscal extrusion (ME) following medial meniscus allograft transplantation (MMAT) with and without meniscotibial ligament reconstruction (MTLR). METHODS: Ten cadaveric knees were size-matched with meniscus allografts. MMAT was performed via bridge-in-slot technique. Specimens were mounted in a testing system and ME was assessed via ultrasound anterior, directly over, and posterior to the medial collateral ligament at the joint line under 4 testing conditions: (1) 0° flexion and 0 newtons (N) of axial load, (2) 0° and 1,000 N, (3) 30° and 0 N, and (4) 30° and 1,000 N. For each condition, "mean total extrusion" was calculated by averaging measurements at each position. Next, MTLR was performed using 2 inside-out sutures through the remnant allograft meniscotibial ligament and secured to the tibia using anchors. The testing protocol was repeated. Differences in ME between MMAT alone versus MMAT + MTLR were examined. Within-group differences between the measurement positions, loading states, and flexion angles also were assessed. RESULTS: "Mean total extrusion" was greater following MMAT alone (2.56 ± 1.23 mm) versus MMAT + MTLR (2.14 ± 1.07 mm; P = .005) in the loaded state at 0° flexion. ME directly over the MCL was greater following MMAT alone (3.51 ± 1.00 mm) compared with MMAT + MTLR (2.93 ± 0.79 mm; P = .054). Posteriorly, in the loaded state at 0°, ME was greater following MMAT alone (2.43 ± 1.10 mm) compared with MMAT + MTLR (1.96 ± 0.99 mm; P = .010). In all conditions, ME was greater in the loaded state versus the unloaded state. CONCLUSIONS: Following MMAT, the addition of MTLR significantly reduced overall ME when compared with isolated MMAT during loading at 0° of flexion in a cadaveric model; given the small absolute values of change in extrusion, clinical significance cannot be gleaned from these findings. CLINICAL RELEVANCE: During medial meniscus allograft transplantation, augmentation with meniscotibial ligament reconstruction may limit meniscal extrusion and improve the biomechanical milieu of the knee joint following transplant.

Medial Patellofemoral Complex Reconstruction Techniques Are Not Equivalent at Lower Flexion in the Setting of Patella Alta: A Biomechanical Comparison.

PURPOSE: To (1) determine the effect of severe patella alta on lateral patellar displacement after medial patellofemoral ligament (MPFL) reconstruction and medial quadriceps tendon-femoral ligament (MQTFL) reconstruction and (2) determine whether lateral displacement significantly differs between MPFL and MQTFL reconstructions in the setting of severe patella alta (Caton-Deschamps Index [CDI] of 1.6). METHODS: Eight cadaveric specimens were included. High-tensile strength suture was used to create a model of adjustable patellar height. Patellar height was set using fluoroscopy to CDI ratios of 1.0 (normal) and 1.6 (alta). Specimens underwent testing (1) with MPFL reconstruction, (2) with MQTFL reconstruction, and (3) in a medial patellofemoral complex (MPFC)-deficient control state, in randomized order, at both CDI settings: 1.0 and 1.6. Lateral patellar translation was measured at 0°, 10°, 20°, 30°, 45°, 60°, and 90° of knee flexion with 10 N of laterally directed load. RESULTS: At a CDI of 1.6, MPFL reconstruction showed significantly lower lateral displacement than MQTFL reconstruction at 0° and 20°. When compared with MPFC-deficient controls at a CDI of 1.6, MPFL reconstruction showed significantly lower displacement at 0° and 20° whereas MQTFL reconstruction was not significantly different at any degree of flexion. CONCLUSIONS: In the setting of severe patella alta (CDI of 1.6), MPFL reconstruction results in less lateral patellar displacement than MQTFL reconstruction at 0° and 20° of knee flexion. At higher flexion angles (≥30°), there is no difference between the 2 reconstruction techniques and the CDI no longer has an effect. At a CDI of 1.0, MPFL reconstruction shows lower displacement than MQTFL reconstruction in full extension only. Surgeons performing MPFC reconstruction should evaluate patients for patella alta and consider patellar height when deciding on the reconstruction technique. CLINICAL RELEVANCE: This study suggests that MQTFL reconstruction may be less stable than MPFL reconstruction in the setting of patella alta, without other known pathoanatomic factors, at early knee flexion angles. Patellar height should be considered when choosing the appropriate reconstruction technique in the absence of a distalization procedure.

The Effect of Rim Preparation, Labral Augmentation, and Labral Reconstruction on the Suction Seal of the Hip.

PURPOSE: To evaluate the biomechanical properties of the labral suction seal in the native labrum and after rim preparation, labral augmentation, and labral reconstruction. METHODS: Eight hemi-pelvises were dissected to the level of labrum and mounted for biomechanical testing. Each specimen was tested in axial distraction starting with the native labrum and then sequentially following rim preparation from 12 to 3 o'clock, labral augmentation, and segmental labral reconstruction using the iliotibial band allograft. In each condition, the specimens were compressed to 250 N and then distracted at 10 mm/s with force and displacement continuously recorded. Each test was repeated 3 times, and the mean peak force, displacement at peak force, and work were calculated. Data were reported as a percentage of the intact values to account for sex and size differences. Statistical testing was performed via a repeated-measures analysis of variance with a post hoc Tukey analysis. RESULTS: Peak loads occurred within 2.21 to 3.11 mm of displacement. The mean peak force, displacement at peak force, and work relative to the intact condition were the following: rim preparation (91.1% ± 8.5%, 94.4% ± 14.3%, 93.4% ± 23.5%, respectively), augmentation (66.1% ± 27.6%, 78.2% ± 16.3%, 55.7% ± 30.7%, respectively), and reconstruction (55.6% ± 25.7%, 64.7% ± 31.4%, 38.7% ± 27.2%, respectively). There was no significant difference in peak force following the rim preparation (P = .807), but peak force was significantly decreased after augmentation and reconstruction (P = .010 and P < .001, respectively). There was no significant difference in displacement at peak force following rim preparation or augmentation (P = .936 and P = .125, respectively), but displacement at peak force was significantly decreased after reconstruction (P = .005). The work from the suction seal was significantly less in both augmentation and reconstruction states compared to the intact labrum (P = .004 and P < .001, respectively) and rim preparation (P = .017 and P < .001, respectively). CONCLUSIONS: The results show that the suction seal is not significantly changed following rim preparation. Relative to the rim preparation, labral augmentation may re-create the labral suction seal better than labral reconstruction. CLINICAL RELEVANCE: This study provides a biomechanical basis for surgical decision making and clinical management of patients with labral tears of the hip.

Differential Contributions of the Quadriceps and Patellar Attachments of the Proximal Medial Patellar Restraints to Resisting Lateral Patellar Translation.

PURPOSE: To define the contributions of the of the medial patellofemoral ligament (MPFL) and medial quadriceps tendon femoral ligament (MQTFL) to lateral patellar translation as the knee moves through a 90° arc of motion. METHODS: Six pairs of bilateral cadaveric knee specimens (12 knees) were dissected and potted in perfect lateral position using fluoroscopy. An eye screw was placed in the midpoint on the lateral aspect of the patella. Each knee underwent testing in 4 conditions after sequential sectioning: intact, lateral retinacular release, randomized MQTFL or MPFL sectioning, and complete proximal medial patellar restraint (PMPR) sectioning. With a custom machined jig, all knees were tested at 0, 10, 20, 30, 45, 60, and 90° of flexion on an MTS machine with 20N of lateral patellar force applied and displacement recorded. RESULTS: PMPR extensor mechanism insertion on all specimens was identified 50% on the quadriceps tendon and 50% on the proximal aspect of the medial patella. Isolated MPFL sectioning resulted in significantly increased lateral displacement compared to the lateral release state at all flexion angles tested except 0°. There was significantly increased lateral patellar displacement with complete sectioning compared with isolated proximal sectioning at all degrees of knee flexion except 0°. However, complete sectioning following isolated MPFL sectioning did not demonstrate significance at any angle. CONCLUSIONS: Compared with the MQTFL, the MPFL is primarily responsible for resistance to lateral patellar translation throughout a 0° to 90° arc of motion. The MPFL provides a similar resistance to lateral patellar displacement as the fully intact PMPR; however, the MQTFL may contribute to resistance in full extension. CLINICAL SIGNIFICANCE: Proximal medial patellar restraint reconstruction techniques involving both the patellar and quadriceps insertion have been described; however, the unique contributions of the native anatomy to lateral patellar restraint have not been investigated.

Biomechanical comparison of subscapularis peel and lesser tuberosity osteotomy for double-row subscapularis repair technique in a cadaveric arthroplasty model.

INTRODUCTION: Management of the subscapularis during shoulder arthroplasty is controversial. The purpose of this study was to compare the biomechanical performance of subscapularis peel (SP) and lesser tuberosity osteotomy (LTO) in a cadaveric model. METHODS: The subscapularis and proximal humerus were dissected from all soft tissues in 21 fresh-frozen human cadaveric shoulders and randomized to undergo SP, LTO, or standard subscapularis tenotomy (ST, control). For SP and LTO, six #5 sutures were passed through eyelets in the implant (on lateral border and through drill holes in bicipital groove [2] and under trunion [4]). Double-row repair was performed using two lateral row transosseous sutures and four medial row sutures through the tendon (SP) or osseotendinous junction (LTO). Biomechanical properties and mode of failure were tested. RESULTS: There were no significant differences in elongation amplitude, cyclic elongation, or maximum load to failure between the three groups (P > 0.05). Mean stiffness was significantly higher in LTO (P = 0.009 vs. SP and ST). In the ST group, 7/7 specimens failed at the tendon-suture interface. For SP, 4/7 failed at the tendon-suture interface, one at the suture-bone interface, one fractured around the implant stem, and one at the knots. For LTO, 3/7 failed at the tendon-suture interface, two at the suture-bone interface and two fractured around the implant stem. CONCLUSIONS: In this cadaveric model, subscapularis repair via ST, SP, and LTO techniques was biomechanically equivalent. Additional studies are needed to confirm these findings and determine the influence of biologic healing on healing rates and clinical outcomes. LEVEL OF EVIDENCE: N/a, biomechanical laboratory study.

Biomechanical Analysis of All-Suture Suture Anchor Fixation Compared With Conventional Suture Anchors and Interference Screws for Biceps Tenodesis.

PURPOSE: To compare the biomechanical properties of all-suture suture anchors (ASSAs) with conventional interference screws (CISs) and conventional suture anchors (CSAs) for long head of the biceps tendon fixation during proximal biceps tenodesis (BT). METHODS: We randomized 21 fresh-frozen human cadaveric shoulders into 3 subpectoral BT treatment groups: ASSA, CSA, and CIS. Each construct was cyclically loaded from 5 to 70 N for 500 cycles (1 Hz). All specimens that survived cyclic loading were then pulled to failure (1 mm/s). Elongation, maximum load, energy, and failure mode were recorded. The humerus was stripped of tissue and then subjected to torsional displacement at a rate of 1°/s until fracture occurred. Maximum load, displacement, stiffness, and energy were recorded. RESULTS: During tendon testing, 3 specimens (43%) in the CIS group failed early during cyclic testing by the tendon tearing at the screw-tendon interface. All other specimens in the CIS group, as well as all specimens in the ASSA and CSA groups, survived cyclic testing and failed during pull-to-failure testing. Failure occurred at the tendon-anchor or -screw interface in all specimens (100%), with no anchor or screw pullout. The CIS group had significantly decreased elongation (8.9 ± 2.23 mm) at maximum load compared with the ASSA (19.2 ± 5.2 mm) and CSA (18.9 ± 2.23 mm) groups (P = .001). During torsional testing, the ASSA group was able to withstand significantly greater torsional displacement (9.22° ± 0.86°) before failure and had greater energy to failure (497.3 ± 45 Nmm-degrees) than the CIS group (6.13° ± 1.24° and 256.6 ± 70.3 Nmm-degrees, respectively; P = .005). CONCLUSIONS: This study shows that the biomechanical properties of ASSA, CSA, and CIS constructs are similar. The interference screw group had lower tendon elongation at maximum load but had several early failures compared with the suture anchor groups. The use of suture anchors results in maximum tendon and torsional bone loads similar to interference screws for the long head of the biceps tendon. Torsional testing of the CIS resulted in spiral fractures traversing the screw tunnel in 100% of the specimens, which was not found in the suture anchor groups. CLINICAL RELEVANCE: The ASSA is a viable fixation method for BT in comparison with the CSA and CIS.

A biomechanical comparison of two arthroscopic suture techniques in biceps tenodesis: whip-stitch vs. simple suture techniques.

BACKGROUND: The aim of this study was to compare the biomechanical performance of whip-stitch (WS) and simple suture techniques (SST) of the long head of the biceps tendon in suprapectoral intraosseous tenodesis with interference screw fixation. METHODS: A total of 10 paired cadavers (61.1 ± 4.6 years) were randomized to receive WS or SST biceps tenodesis beginning at the musculotendinous junction. Both groups implemented a No. 2 FiberLoop wire and underwent suprapectoral fixation with a polyetheretherketone interference screw at the bicipital grove. A Materials Testing System performed cyclic testing (500 cycles), followed by load to failure at 1 mm/s. Load, displacement, and time were recorded during cyclic and failure testing. A 2-tailed Student's t-test and χ2 analysis were performed for failure load and mode of failure, respectively. RESULTS: Two SST specimens and 1 WS specimen failed during cyclic loading via tendon rupture at the screw-tendon interface. There was no significant statistical difference in the cyclic displacement after 500 cycles between the WS (12.9 mm ± 4.4 mm) and SST groups (14.0 mm ± 3.8 mm, P = .2); cyclic strain, defined as the peak displacement at the 500th cycle divided by the initial gauge length, between the WS (0.4 ± 0.2) and SST groups (0.7 ± 0.7, P = .3); maximal load (162.7 N ± 56.8 N vs. 153.1 N ± 39.3 N, respectively, P = .6); and stiffness (50.5 N/mm ± 17.7 N/mm vs. 43.3 N/mm ± 10.9 N/mm, respectively, P = .3). All specimens ruptured at the screw-tendon interface. CONCLUSION: The WS technique can provide equivalent biomechanical performance to the SST in suprapectoral intraosseous biceps tenodesis with interference screw fixation.

Biomechanical Analysis of Medial-Row All-Suture Suture Anchor Fixation for Rotator Cuff Repair in a Pair-Matched Cadaveric Model.

PURPOSE: To compare the biomechanical properties of all-suture suture anchors (ASSAs) with conventional suture anchors (CSAs) for double-row rotator cuff repair (RCR). METHODS: Fourteen fresh-frozen human cadaveric shoulders were randomized into 2 RCR treatment groups: ASSA and CSA. All constructs received a double-row repair, with the lateral-row implants consisting of two 5.5-mm PEEK (polyether ether ketone) Footprint anchors. Each construct was loaded to a 10-N preload for 2 minutes, followed by cyclic loading from 10 to 160 N at a rate of 100 N/s for 100 cycles. Load-to-failure testing was performed immediately after cyclic loading testing at 1 mm/s from the zero position until failure. Cyclic creep, elongation amplitude, maximum load, stiffness, energy, and failure mode were recorded. RESULTS: No significant difference in cyclic creep (P = .117) or elongation amplitude (P = .428) was found between the ASSA and CSA groups during cyclic testing. Three specimens in each group (43% in each) failed by the suture tearing through the tendon. The remaining specimens in each group failed by the anchor pulling out of the humeral head. The mean maximum load was 617.73 ± 177.77 N and 545.13 ± 212.98 N for the ASSA and CSA groups, respectively (P = .339). Maximum elongation before failure was not different between groups (P = .122). Mean energy and stiffness were not statistically different between the ASSA and CSA groups (P = .629 and P = .973, respectively). CONCLUSIONS: In this cadaveric analysis with a simplified unidirectional experimental setup, failure mechanics and maximum load between the ASSA and CSA constructs were similar, with no difference in energy and stiffness. Although the ASSA group showed slightly larger elongation than the CSA group, these differences may not be clinically relevant. CLINICAL RELEVANCE: This study provides a biomechanical head-to-head comparison of ASSAs and CSAs, indicating that ASSAs may be clinically equivalent to CSAs for use in an RCR.

Biomechanical Analysis of Latarjet Screw Fixation: Comparison of Screw Types and Fixation Methods.

PURPOSE: To compare the initial fixation stability, failure strength, and mode of failure of 5 different screw types and fixation methods commonly used for the classic Latarjet procedure. METHODS: Thirty-five fresh-frozen cadaveric shoulder specimens were allocated into 5 groups. A 25% anteroinferior glenoid defect was created, and a classic Latarjet coracoid transfer procedure was performed. All grafts were fixed with 2 screws, differing by screw type and/or fixation method. The groups included partially threaded solid 4.0-mm cancellous screws with bicortical fixation, partially threaded solid 4.0-mm cancellous screws with unicortical fixation, fully threaded solid 3.5-mm cortical screws with bicortical fixation, partially threaded cannulated 4.0-mm cancellous screws with bicortical fixation, and partially threaded cannulated 4.0-mm captured screws with bicortical fixation. All screws were stainless steel. Outcomes included cyclic creep and secant stiffness during cyclic loading, as well as load and work to failure during the failure test. Intergroup comparisons were made by a 1-way analysis of variance. RESULTS: There were no significant differences among different screw types or fixation methods in cyclic creep or secant stiffness after cyclic loading or in load to failure or work to failure during the failure test. Post-failure radiographs showed evidence of screw bending in only 1 specimen that underwent the Latarjet procedure with partially threaded solid cancellous screws with bicortical fixation. The mode of failure for all specimens analyzed was screw cutout. CONCLUSIONS: In this biomechanical study, screw type and fixation method did not significantly influence biomechanical performance in a classic Latarjet procedure. When performing this procedure, surgeons may continue to select the screw type and method of fixation (unicortical or bicortical) based on preference; however, further studies are required to determine the optimal method of treatment. CLINICAL RELEVANCE: Surgeons may choose the screw type and fixation method based on preference when performing the Latarjet procedure.

Biomechanical Performance of Medial Row Suture Placement Relative to the Musculotendinous Junction in Transosseous Equivalent Suture Bridge Double-Row Rotator Cuff Repair.

PURPOSE: To compare the biomechanical performance of medial row suture placement relative to the musculotendinous junction (MTJ) in a cadaveric transosseous equivalent suture bridge (TOE-SB) double-row (DR) rotator cuff repair (RCR) model. METHODS: A TOE-SB DR technique was used to reattach experimentally created supraspinatus tendon tears in 9 pairs of human cadaveric shoulders. The medial row sutures were passed either near the MTJ (MTJ group) or 10 mm lateral to the MTJ (rotator cuff tendon [RCT] group). After the supraspinatus repair, the specimens underwent cyclic loading and load to failure tests. The localized displacement of the markers affixed to the tendon surface was measured with an optical tracking system. RESULTS: The MTJ group showed a significantly higher (P = .03) medial row failure (5/9; 3 during cyclic testing and 2 during load to failure testing) compared with the RCT group (0/9). The mean number of cycles completed during cyclic testing was lower in the MTJ group (77) compared with the RCT group (100; P = .07) because 3 specimens failed in the MTJ group during cyclic loading. There were no significant differences between the 2 study groups with respect to biomechanical properties during the load to failure testing. CONCLUSIONS: In a cadaveric TOE-SB DR RCR model, medial row sutures through the MTJ results in a significantly higher rate of medial row failure. CLINICAL RELEVANCE: In rotator cuff tears with tendon tissue loss, passage of medial row sutures through the MTJ should be avoided in a TOE-SB RCR technique because of the risk of medial row failure.

Biomechanical Evaluation of Posterior Cruciate Ligament Reconstruction With Quadriceps Versus Achilles Tendon Bone Block Allograft.

BACKGROUND: Long-term studies of posterior cruciate ligament (PCL) reconstruction suggest that normal stability is not restored in the majority of patients. The Achilles tendon allograft is frequently utilized, although recently, the quadriceps tendon has been introduced as an alternative option due to its size and high patellar bone density. PURPOSE/HYPOTHESIS: The purpose of this study was to compare the biomechanical strength of PCL reconstructions using a quadriceps versus an Achilles allograft. The hypothesis was that quadriceps bone block allograft has comparable mechanical properties to those of Achilles bone block allograft. STUDY DESIGN: Controlled laboratory study. METHODS: Twenty-nine fresh-frozen cadaveric knees were assigned to 1 of 3 groups: (1) intact PCL, (2) PCL reconstruction with Achilles tendon allograft, or (3) PCL reconstruction with quadriceps tendon allograft. After reconstruction, all supporting capsular and ligamentous tissues were removed. Posterior tibial translation was measured at neutral and 20° external rotation. Each specimen underwent a preload, 2 cyclic loading protocols of 500 cycles, then load to failure. RESULTS: Construct creep deformation was significantly lower in the intact group compared with both Achilles and quadriceps allograft (P = .008). The intact specimens reached the greatest ultimate load compared with both reconstructions (1974 ± 752 N, P = .0001). The difference in ultimate load for quadriceps versus Achilles allograft was significant (P = .048), with the quadriceps group having greater maximum force during failure testing. No significant differences were noted between quadriceps versus Achilles allograft for differences in crosshead excursion during cyclic testing (peak-valley [P-V] extension stretch), creep deformation, or stiffness. Construct stiffness measured during the failure test was greatest in the intact group (117 ± 9 N/mm, P = .0001) compared with the Achilles (43 ± 11 N/mm) and quadriceps (43 ± 7 N/mm) groups. CONCLUSION: While the quadriceps trended to be a stronger construct with a greater maximum load and stiffness required during load to failure, only maximum force in comparison with the Achilles reached statistical significance. Quadriceps and Achilles tendon allografts had similar other biomechanical characteristics when used for a PCL reconstruction, but both were inferior to the native PCL. CLINICAL RELEVANCE: The quadriceps tendon is a viable graft option in PCL reconstruction as it exhibits a greater maximum force and is otherwise comparable to the Achilles allograft. These findings expand allograft availability in PCL reconstruction.

Glenohumeral kinematics after soft tissue interposition graft and glenoid reaming: A cadaveric study.

BACKGROUND: The management of young patients with glenohumeral arthritis is controversial. Resurfacing of the glenoid with biologic interposition and reaming of the glenoid have been suggested as potential treatment options. The goal of this study was to determine the change in glenohumeral contact pressures in interposition arthroplasty, as well as glenoid reaming in an arthritis model. We hypothesized that interposition with meniscal allograft will lead to the best normalization of contact pressure throughout the glenohumeral range of motion. MATERIALS AND METHODS: Eight fresh-frozen cadaveric shoulders were tested in static positions of humeral abduction with a compressive load. Glenohumeral contact area, contact pressure, and peak force were determined sequentially for (1) intact glenoid (2) glenoid with cartilage removed (arthritis model) (3) placement of lateral meniscus allograft (4) placement of Achilles allograft (5) arthritis model with reamed glenoid. RESULTS: The arthritis model demonstrated statistically higher peak pressures than intact glenoid and glenoid with interpositional allograft. Meniscal and Achilles allograft lowered mean contact pressure and increased contact area to a level equal to or more favorable than the control state. In contrast, the reamed glenoid did not show any statistical difference from the arthritis model for any of the recorded measures. CONCLUSION: Glenohumeral contact pressure is significantly improved with interposition of allograft at time zero compared to an arthritic state. Our findings suggest that concentric reaming did not differ from the arthritic model when compared to normal. These findings favor the use of allograft for interposition as a potential treatment option in patients with glenoid wear.

Suture Technique Influences the Biomechanical Integrity of Pectoralis Major Repairs.

Pectoralis major ruptures occur in large, muscular individuals, and repair constructs may experience significant tension. Four different suture techniques were evaluated biomechanically to determine the effect of suture technique on optimizing fixation strength. Forty fresh-frozen cadaveric shoulders were repaired using endosteal buttons. The control group was repaired with #2 polyblend suture in a modified Mason-Allen stitch configuration. The triple group was repaired using the same suture and configuration, but with the addition of triple-loaded buttons. The configuration group was repaired using the same suture in a Krackow/Bunnell configuration. The tape group was repaired using 2-mm polyethylene tape and #5 polyblend suture in the Krackow/Bunnell configuration. Under cyclic loading, there was no significant difference between groups. Under load-to-failure testing, the tape group withstood a significantly greater maximum load (726.0±90.0 N) than the control and triple groups (330.2±20.2 and 400.2±35.2 N, respectively; P<.005), and similar load to the configuration group (509.9±68.6 N; P=.16). The configuration group failed via suture breakage (9/10); the other groups failed via suture pullout, in which suture pulled through tendon (26/30). Pectoralis major repair in a running, locked configuration appears to improve biomechanical performance by preventing suture pullout. Use of a polyethylene tape construct demonstrates the potential for improved failure loads, but its role remains undefined.

Effect of highly purified capsaicin on articular cartilage and rotator cuff tendon healing: An in vivo rabbit study.

Highly purified capsaicin has emerged as a promising injectable compound capable of providing sustained pain relief following a single localized treatment during orthopedic surgical procedures. To further assess its reliability for clinical use, the potential effect of highly purified capsaicin on articular cartilage metabolism as well as tendon structure and function warrants clarification. In the current study, rabbits received unilateral supraspinatus transection and repair with a single 1 ml injection of capsaicin (R+C), PEG-only placebo (R+P), or saline (R+S) into the glenohumeral joint (GHJ). An additional group received 1 ml capsaicin onto an intact rotator cuff (I+C). At 18 weeks post-op, cartilage proteoglycan (PG) synthesis and content as well as cell viability were similar (p>0.05) across treatment groups. Biomechanical testing revealed no differences (p>0.05) among tendon repair treatment groups. Similarly, histologic features of both cartilage and repaired tendons showed minimal differences across groups. Hence, in this rabbit model, a single injection of highly purified capsaicin into the GHJ does not induce a deleterious response with regard to cartilage matrix metabolism and cell viability, or rotator cuff healing. These data provide further evidence supporting the use of injectable, highly purified capsaicin as a safe alternative for management of postoperative pain following GHJ surgery.