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.

Arthroscopic Bankart repair with all-suture anchors does not cause important glenoid bone osteolysis: a volumetric CT study of 143 anchors.

PURPOSE: To evaluate with computed tomography (CT) the incidence of anchor-related osteolysis after implantation of two types of all-suture anchors for the management of labral lesions in shoulder instability. METHODS: Single-cohort, observational study with 12-month follow-up. Thirty-three participants (27 males/6 females; age 38.3 years [SD 11.3]) with anterior labral lesions in which 143 all-suture anchors (71 Iconix 1.4 mm and 72 Suturefix 1.7 mm) were implanted were evaluated with a CT performed a mean of 15.4 [3.85] months after surgery. The volume of the bone defects was measured in the CT. Every anchor was classified into one of four groups: (1) no bone defect. (2) Partial bone defect (defects smaller than the drill used for anchor placement). (3) Tunnel enlargement (defects larger than the drill volume but smaller than twice that volume). (4) Cystic lesion (defects larger than twice the drill volume). RESULTS: No bone defect was identified in 16 anchors (11.2%, [95% CI 6.5-17.5%]). A partial bone defect was found in 84 anchors (58.7% [50.2-66.9%]). Tunnel enlargement was found in 43 anchors (30.11% [22.6-37.6%]). No anchor caused cystic lesions (0% [0-2.5%]). The defect volume was a mean of 27.8 mm3 (SD 18.4 mm3, minimum 0 mm3, maximum 94 mm3). Neither the position in the glenoid nor the type of implant used had a significant effect in the type or size of the defects. CONCLUSION: When using all-suture anchors in the glenoid during instability surgery, relevant bone osteolytic defects are rare at 1-year follow-up. Most anchor insertion tunnels will fill completely (11%) or partially (59%) with bone. Tunnel enlargement will develop in 30% of anchors. No cystic defects larger than 0.125 cm3 were observed. There is a low risk that all-suture anchors cause significant osteolytic bone defects in the glenoid. These implants can be used safely. Level of evidence IV.

Arthroscopic remplissage with all-suture anchors causes cystic lesions in the humerus: a volumetric CT study of 55 anchors.

PURPOSE: To evaluate with computed tomography (CT) the incidence of implant-related osteolysis after implantation of two types of all-suture anchors during remplissage for the management of Hill-Sachs lesions in shoulder instability. METHODS: Single-cohort, observational study with a minimum of 12 months follow-up. Twenty-five participants (19 males and 6 females; mean age 37.4 years [SD: 11.6]) with Hill-Sachs lesions requiring remplissage were evaluated with a CT performed a mean of 14.1 [3.74] months after surgery. Fifty-five all-suture anchors (19 2.3 mm Iconix and 36 1.7 mm Suturefix) were used. The volume of the bone defects was measured in the CT. Every anchor was classified into one of four groups: (1) no bone defect. (2) Partial bone defect (bone defects smaller than the drill used for anchor placement). (3) Tunnel enlargement (bone defect larger than the drill volume but smaller than twice that volume). (4) Cystic lesion (bone defect larger twice the drill volume). RESULTS: No bone defect was identified in only two anchors (3.6%, 95% CI 0.4-12.5%). A partial bone defect was found in eight anchors (14.5%, 95% CI 6.5-26.7%). In 35 anchors (63.6%, 95% CI 49.6-76.2%), there was enlargement of the bone defect that was smaller than 200% the size of the drill used. Ten anchors caused bone defects larger than twice the size of the drill used (18.2%, 95% CI 9.1-30.9%). The defect size was a mean of 89 mm3 (SD: 49 mm3, minimum 0 mm3, maximum 230 mm3). CONCLUSION: When using all-suture anchors in arthroscopic remplissage during instability surgery, relevant bone osteolytic defects are common at 1-year-follow-up. Cystic defects larger than twice the volume of the resected bone during implantation develop in one in six anchors and significant tunnel widening will develop in another three out of five anchors. This bone loss effectively increases the size and depth of the Hill-Sachs lesions but does not seem to affect short-term clinical outcomes. LEVEL OF EVIDENCE: Level IV.

Mid-term to long-term results of primary arthroscopic Bankart repair for traumatic anterior shoulder instability: a retrospective study.

BACKGROUND: The arthroscopic method offers a less invasive technique of Bankart repair for traumatic anterior shoulder instability. The aim of the study is to determine the mid-/long-term functional outcome, failure rates and predictors of failure after primary arthroscopic Bankart repair for traumatic anterior shoulder instability. METHODS: A total of 100 patients were primarily operated using arthroscopic Bankart repair after traumatic anterior shoulder instability. Medical records were retrospectively reviewed, and patients were assessed using postal questionnaire after a mean follow-up of 8.3 years [3-14]. Clinical assessment was performed using Constant score, Rowe score, and American Shoulder and Elbow Surgeons score. RESULTS: The overall recurrence rate was 22%. The Kaplan-Meier failure-free survival estimates. were 80% at 5 years and 70% at 10 years. Nearly half (54.5%) of recurrences occurred at 2 years postoperative. Compared with normal shoulder, there were statistical differences in all 3 scores. Failure rate was significantly affected by age at the time of surgery with 86% of recurrence cases observed in patients aged 30 years or younger. Nevertheless, Younger age at the time of surgery (P = 0.007) as well age at the time of initial instability (P = 0.03) was found to correlate negatively with early recurrence within 2 years of surgery. Among those with recurrent instability, recurrence rate was found to be higher if there had been more than 5 instability episodes preoperatively (P = 0.01). Return to the preinjury sport and occupational level was possible in 41 and 78%, respectively. CONCLUSION: Failure-free survival rates dropped dramatically over time. Alternative reconstruction techniques should be considered in those aged ≤30 years due to the high recurrence rate.

Does anchor insertion angle or placement of the suture anchor affect glenoid rim fracture occurrence after arthroscopic Bankart repair?

BACKGROUND: The purposes were to compare the characteristics of 2 groups of patients who underwent revision Bankart repair with and without glenoid rim fractures and to examine risk factors for glenoid rim fractures. METHODS: We retrospectively analyzed 39 patients who needed revision surgery after arthroscopic Bankart repair and identified 19 patients with and 20 patients without glenoid rim fractures. The insertion angle of the suture anchor, anchor position on the glenoid, and demographic data were compared between the groups. RESULTS: The mean anchor insertion angles in the glenoid fracture group (group F) at the 2-, 3-, 4-, and 5-o'clock positions were 64°, 58°, 55°, and 55°, respectively; those in the no-fracture group (group R) were 60°, 63°, 60°, and 55°, respectively (P = .630, P = .207, P = .166, and P = .976, respectively). At the 5-o'clock position, anchors were fixed to the glenoid face in 13 cases in group F and in 3 cases in group R (P = .040). Although age (P = .529) and sex (P = 1.0) did not differ between the groups, elite and professional athletes had a significantly higher incidence of glenoid rim fractures (P = .009). CONCLUSION: The anchor insertion angle did not affect glenoid rim fracture occurrence after arthroscopic Bankart repair. However, the placement of the suture anchor at the 5-o'clock position on the glenoid face could increase the risk of glenoid rim fracture after trauma. Athletes were more likely to have glenoid rim fractures owing to major trauma after arthroscopic Bankart repair.

Checkrein Deformity of the Hallux Caused by Misplaced Suture-Button Syndesmosis Fixation: A Case Report.

Ankle fractures are common injuries. If an ankle fracture is combined with tibiofibular syndesmosis separation, then tibiofibular transfixation should be used to stabilize the syndesmosis; in such cases, flexible (suture-button) fixation is an option. We surgically treated a male patient's unstable ankle fracture with internal fixation devices, including a suture-button fixator, and observed the development of a flexor hallucis longus checkrein deformity in the postoperative period. The aim of this report is to describe this rare postoperative complication associated with the use of suture-button transfixation of the tibiofibular syndesmosis.

Posterior Interosseous Nerve Proximity to Cortical Button Implant for Distal Biceps Repair With Single and 2-Incision Approaches.

PURPOSE: Fixation with a cortical button is the biomechanically strongest surgical approach for distal biceps repair, and utilization of the 2-incision approach may provide a more anatomical repair and improved terminal supination strength. The risk of injury to the posterior interosseous nerve (PIN) associated with this approach requires further investigation. METHODS: A distal biceps repair with a cortical button was performed on 10 cadavers, 5 utilizing the single-incision approach and 5 utilizing the 2-incision approach. Contrast was injected into the radial nerve and computed tomography scans were obtained. The distance between the drilled cortical perforation and the PIN was measured. RESULTS: The mean distance from the cortical perforation to the PIN was not significantly different between approaches (9.4 mm and 8.8 mm). A PIN entrapment was seen in 0 out of 5 for the single-incision approach and 1 out of 5 for the 2-incision approach. CONCLUSIONS: Distal biceps repair with cortical button fixation places the PIN at risk of injury regardless of the approach used. Methods of fixation that require bicortical drilling should be especially avoided when using the 2-incision approach. CLINICAL RELEVANCE: Distal biceps repair utilizing bicortical drilling for fixation through a 2-incision approach poses high risk of injury to the PIN and should be avoided.

Biomechanical analysis of conventional anchor revision after all-suture anchor pullout: a human cadaveric shoulder model.

HYPOTHESIS AND BACKGROUND: The possibility of implanting a conventional anchor at the pullout site following all-suture anchor failure was evaluated in a biomechanical cadaveric model. The hypothesis of the study was that anchor revision would yield equal biomechanical properties. METHODS: Ten human humeri were obtained, and bone density was determined via computed tomography. After all-suture anchor (n = 5) and conventional 4.5-mm anchor (n = 5) insertion, biomechanical testing was conducted. Following all-suture anchor pullout, a conventional 5.5-mm anchor was inserted at the exact site of pullout (n = 5) and biomechanical testing was reinitiated. Testing was conducted using an initial preload of 20 N, followed by an unlimited cyclic protocol, with a stepwise increasing force of 0.05 N for each cycle at a rate of 1 Hz until system failure. The number of cycles, maximum load to failure, stiffness, displacement, and failure mode, as well as macroscopic observation at the failure site including diameter, shape, and cortical destruction, were registered. RESULTS: The defect following all-suture pullout showed a mean diameter of 4 mm, and conventional revision was possible in each sample. There was no significant difference between the initial all-suture anchor implantation and the conventional anchor implantation or the conventional revision following all-suture failure regarding mean pullout strength, stiffness, displacement, or total number of cycles until failure. CONCLUSION: Conventional anchor revision at the exact same site where all-suture anchor pullout occurred is possible and exhibits similar biomechanical properties.

No influence of patellar fixation technique on clinical outcomes of double-bundle medial patellofemoral ligament reconstruction: a systematic review.

PURPOSE: To compare clinical outcomes of double-bundle medial patellofemoral ligament (MPFL) reconstruction with different patellar fixation techniques including Kujala score, functional failure and complications. METHODS: Pubmed, Embase, and Cochrane Library databases were searched for studies with clinical results of double-bundle MPFL reconstruction. The hamstring tendon autografts were used, and femoral fixation was performed with bone tunnel and an interference screw, and knee fixation angle was less than or equal to 45°. Patellar fixation methods were broadly categorized into 3 treatment groups: suture anchor (SA), bone tunnel (BT) and suture techniques (SU). Pooled means for Kujala score and pooled estimates for functional failure rate and complication rate were compared. RESULTS: 21 studies (23 groups) consisting of 691 knees met the inclusion criteria. 12 groups with 344 knees were in SA group, 5 groups of 161 knees were in BT group and 6 groups with 186 knees were in SU group. Statistically significant differences in Kujala score were found among three groups, 90.2 (95% CI 88.7-91.7) in SA group, 88.7 (95% CI 85.3-92.2) in BT group and 89.4 (95% CI 84.2-94.6) in SU group (all P < 0.001), but these differences were not clinically significant. No statistically significant differences were found in the positive apprehension sign rate, recurrent subluxation or dislocation rate, and major or minor complication rate among three groups. CONCLUSION: Patellar fixation with bone tunnel, suture anchor or suture techniques were all effective in the double-bundle MPFL reconstruction. The present systematic review failed to show that one technique was better than the others. More high-quality trials and randomized controlled trials are needed.

Evaluation of Risk to the Suprascapular Nerve During Arthroscopic SLAP Repair: Is a Posterior Portal Safer?

PURPOSE: The purpose of this study was to compare the risk of glenoid perforation during SLAP repair for suture anchors placed through an anterolateral portal versus a posterolateral portal of Wilmington. METHODS: Ten bilateral cadaveric shoulders were randomized to suture anchor placement through an anterolateral portal on one shoulder and a posterolateral portal on the contralateral shoulder. Anchors were placed into anterior, posterior, and far posterior positions on the glenoid rim (1 o'clock, 11 o'clock, and 10 o'clock positions for right shoulders). The shoulder was then dissected, and the distance from the suture anchor tip to the nerve was measured if perforation occurred. The maximum load and failure mechanism of each anchor was assessed with a materials testing system machine. RESULTS: Only 2 of 20 anchors placed in the posterosuperior glenoid through the posterolateral portal perforated compared with 16 of 20 of the anchors placed through the anterolateral portal (P < .05). The mean distance from the perforated anchor tip to the suprascapular nerve was 2.5 ± 1.4 mm for the anterolateral portal and 4.4 ± 0.6 mm for the posterolateral portal (P = .18). We did not observe a significant difference in biomechanical strength (P > .05). CONCLUSIONS: There is a high rate of glenoid perforation in close proximity to the suprascapular nerve when placing anchors in the posterosuperior glenoid through an anterolateral portal. Use of the posterolateral portal results in a much lower incidence of glenoid perforation for anchors placed in the posterosuperior glenoid, but there is a higher risk of glenoid perforation for an anchor placed in the anterosuperior glenoid from the posterolateral portal. CLINICAL RELEVANCE: There is a higher risk of injury to the suprascapular nerve when suture anchors are placed in the posterosuperior glenoid through an anterolateral portal compared with a posterolateral portal for SLAP repair.

Acetabular All-Suture Anchor for Labral Repair: Incidence of Intraoperative Failure due to Pullout.

PURPOSE: To report on the incidence and features of intraoperative anchor pullout in a consecutive series of patients undergoing arthroscopic labral repair of the hip. METHODS: Over an 18-month period, 434 consecutive cases underwent labral repair by a single surgeon with a particular anchor system. The following data were recorded: (1) age and gender of all cases; (2) number of anchors used; (3) number of cases in which intraoperative anchor failure occurred; (4) number of anchors that failed; and (5) age and gender of those cases in which anchor failure occurred. Failures were reported for 3-month intervals. One patient underwent repair with an alternative anchor system during this time period and was excluded. RESULTS: Mean age was 34.2 (14-71) years with 180 males and 254 females. A total of 2,007 anchors were used, averaging 4.6 per case (1-8). Thirty-three anchors pulled out among 30 patients, representing a 1.6% incidence among all anchors. Mean age among pullouts was 37.8 (17-54) years with 11 males and 19 females. There was no difference compared with patient population in which no anchor pulled: mean 33.9 (14-71) years (P = .085) with 169 males and 235 females (P = .578). Pullouts were evenly distributed over the 3-month intervals (4, 4, 6, 6, 5, 8). Pullout was mostly due to failure to securely imbed the anchor in bone. Only 2 were known to pull out in the presence of being securely seated in bone. CONCLUSIONS: These data support that the security of this particular all-suture anchor at implantation is exceptionally reliable for a single experienced surgeon, and there is no demonstrable learning curve. LEVEL OF EVIDENCE: Level IV, retrospective review of a case series.

Functional outcome in patients who underwent distal biceps tendon repair.

INTRODUCTION: To asses physical function and quality of life after distal biceps tendon repair and compare suture anchor and cortical button fixation. Secondarily, we assessed the impact of other factors: acute repair, graft use, concomitant arm conditions, contralateral rupture, and complications. METHODS: We approached all 50 patients that underwent distal biceps tendon rupture repair (2009-2016) to participate in our study and complete a questionnaire including: patient demographics, QuickDASH, Quality of life EQ-5D-5L, pain score, and Mayo Elbow Performance score (MEPS). RESULTS: In total, 37 (76%) of 49 alive patients participated in our study. All were men, with a median age of 47 years. Median follow-up was 34 months (range 8-100 months). On average, we found perfect upper extremity (QuickDASH, median: 0, IQR 0-7.9; 53% had no [QuickDASH = 0] upper extremity disability) and elbow function (MEPS, median: 100, IQR 100-100; 83% had perfect [MEPS > 90] clinical elbow function), perfect quality of life (EQ-5D-5L, median: 1, IQR 0.85-1; 59% had perfect [EQ-5D-5L = 1] quality of life), and no pain (median 0, IQR 0-0; 68% had no pain). We found no difference in upper extremity (QuickDASH: anchor, median 1.1, IQR 0-6.8; endobutton, median 0, IQR 0-9.1, p = 0.972) and elbow (MEPS: anchor, median 100, IQR 100-100; endobutton, median 100, IQR 100-100, p = 0.895) function, quality of life (EQ-5D-5L: anchor, median 1, IQR 0.85-1; endobutton, median 1, IQR 0.84-1, p = 0.507), and pain score (anchor, median 0, IQR 0-0.5; endobutton, median 0, IQR 0-0, p = 0.742) when comparing the anchor to endobutton fixation technique. CONCLUSIONS: Overall, patients have excellent outcome after distal biceps tendon rupture repair. There was no difference in patient-reported outcome measures between suture anchor and endobutton fixation. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Outcome of arthroscopic SLAP repair using knot-tying-suture anchors compared with knotless-suture anchors in athletes.

INTRODUCTION: Arthroscopic repair is one option for the surgical treatment of type II superior labrum tears from anterior to posterior (SLAP) lesions in athletes' shoulders. MATERIALS AND METHODS: Sixty-one of 78 (78.2%) athletes were retrospectively examined after isolated arthroscopic SLAP repair (group 1/G1: 28x knot-tying anchors; group 2/G2: 33 knotless anchors; follow-up 24 months) and compared to two specific, separate matched volunteer athlete control groups (group 3/G3: 28 athletes matched to G1; group 4/G4: 33 athletes matched to G2). The assessment of G1-4 included numerical analogue scales (NASs: 1-15 scales) and the Athletic Shoulder Outcome Scoring System (ASOSS) score, and the Shoulder Sport Activity Score (SSAS). The preinjury status (FU-1), the status before surgery (FU0), and at follow-up (FU1) were assessed. RESULTS: High external rotation at abduction (hER) was significantly worse in G1 than G2 (FU1: G1, 86.6° ± 7.7° versus = vs G2, 91.1° ± 10.7°; p = 0.03). The ASOSS and SSAS revealed significant impairment in G1-2 compared to G3-4 (ASOSS FU1: 83.9 ± 19.9 G1 vs 94.6 ± 7.7 G3; p = 0.002 and 80.3 ± 17.7 G2 vs 91.8 ± 9.1 G4; p = 0.002; SSAS 5.9 ± 2.7 G1 vs 6.9 ± 1.8 G3; p = 0.02 and 6.3 ± 2.5 G2 vs 7.4 ± 1.4 G4; p = 0.06), with 17-20% loss on ASOSS and 23-25% deficits on SSAS. The NAS analysis detected for pain (4 ± 3.5 vs 3.2 ± 2.6), satisfaction (2 ± 0.8 vs 1.8 ± 0.9), reduction of function (4.6 ± 3.9 vs 3.9 ± 3.8) and proficiency (9.6 ± 4.7 vs 10.9 ± 3.9) similar impairments in G1-2 (p > 0.05) and better results in G3 and G4 (all p < 0.001). CONCLUSIONS: After SLAP repair, athletes showed underestimated impairment of shoulder sport resumption and proficiency with high rates of shoulder sports cessation. The present data favor the knotless fixation technique, because this fixation technique allowed bilaterally equivalent ranges of motions. The uninjured shoulder athletes also showed functional deficits with significant shoulder sport impairments, which must be considered in outcome analysis and for the rehabilitation program. LEVEL OF EVIDENCE: III, retrospective cohort study.

Clinical and sonographic evaluation of subpectoral biceps tenodesis with a dual suture anchor technique demonstrates improved outcomes and a low failure rate at a minimum 2-year follow-up.

INTRODUCTION: The purpose of this study was to evaluate the clinical outcomes and integrity of an open subpectoral biceps tenodesis using a dual suture anchor construct. MATERIALS AND METHODS: Patients with at least 2 years of follow-up were retrospectively evaluated for simple shoulder test (SST), American Shoulder and Elbow Surgeons (ASES) score, and visual analog scales (VAS) for pain, function and satisfaction. A physical exam assessed shoulder range of motion and elbow strength. Ultrasonography visualized construct integrity. RESULTS: Of 43 eligible patients, 36 completed questionnaire evaluation and 22 completed an additional physical examination. Indications included superior labral anterior-posterior (SLAP) lesions (4), partial thickness tears (6), instability (6), and tenosynovitis of the biceps tendon (20). Eighteen patients (50%) had an associated rotator cuff tear. Patient-reported outcomes improved pre- vs postoperatively: ASES score (45.4 vs 78.6, P < 0.001), SST (5.1 vs 9.6, P < 0.001), pain-VAS (4.8 vs 2.0, P < 0.001), and function-VAS (4.9 vs 2.3, P < 0.001). Satisfaction-VAS was 8.3 postoperatively. Patient-reported outcomes did not differ for patients with an associated rotator cuff tear compared to those without (P ≥ 0.427). None of the physical exam measures were lower on the operative side compared to the healthy side (P ≥ 0.516). Sonographic evaluation revealed preserved integrity of the tenodesis construct in all cases. No complications were noted. CONCLUSIONS: Subpectoral biceps tenodesis utilizing a dual suture anchor technique is a treatment option for SLAP lesions, partial thickness tears, subluxation, and tenosynovitis of the long head of the biceps with high rates of postoperative patient satisfaction, a low failure rate, and improved outcome scores. The presence of a concomitant rotator cuff tear did not influence clinical outcomes.

Recurrent Instability After Arthroscopic Bankart Reconstruction: A Systematic Review of Surgical Technical Factors.

PURPOSE: Recurrent instability remains of concern after arthroscopic Bankart reconstruction. We evaluated various technical factors including anchor design, anchor material, number of anchors used, and interval closure on risk of recurrent instability after arthroscopic Bankart reconstruction. METHODS: A systematic review of MEDLINE and Cochrane databases was conducted, following PRISMA guidelines. Extracted data were recorded on a standardized form. Methodological index for non-randomized studies (MINORS) and Newcastle-Ottawa Scale (NOS) were used to assess study quality and risk bias. Because of study heterogeneity and low levels of evidence, meta-analysis was not possible. Pooled weighted means were calculated and individual study evaluation and comparisons (qualitative analysis) were performed for systematic review. RESULTS: Of 2097 studies identified, 26 met criteria for systematic review. Pooled weighted means revealed 11.4% versus 15% recurrent instability with 3 or more suture anchors versus fewer than 3 anchors, 10.1% versus 7.8% with absorbable versus nonabsorbable suture anchors, respectively, and 8.0% versus 9.4% with knotless versus standard anchors, respectively. Interval closure did not qualitatively decrease recurrent instability or decrease range of motion. CONCLUSIONS: Our systematic review reveals that despite individual study, and previous systematic reviews pointing to the contrary, the composite contemporary published literature would support no difference in the risk of recurrent instability after arthroscopic Bankart reconstruction with rotator interval closure, differing numbers of anchors used for the repair, use of knotless versus standard anchors, or use of bioabsorbable versus nonabsorbable anchors. We recommend surgeons focus on factors that have been shown to modify the risk factors after arthroscopic Bankart reconstruction, such as patient selection. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and IV studies.

Are pelvic anatomical structures in danger during arthroscopic acetabular labral repair? Definition of safe bone depth.

PURPOSE: The purpose of this study was to evaluate safe depth for suture anchor insertion during acetabular labral repair and to determine the neighbouring structures at risk during drilling and anchor insertion. METHODS: Ten human cadaveric hips (six males and four females) were obtained. Acetabular labral surface was prepared and marked for right hips as 12, 1 and 3 o'clock positions, for left hips 12, 11 and 9 o'clock positions. Those were defined as anterior, anterior-superior and superior zones, respectively. These labral positions were drilled at defined zones. After measurements, depth of the bone at 10° and 20° drill angles on zones was compared statistically. RESULTS: Acetabular bone widths at investigated labral insertion points did not statistically differ. A total of 14 injuries in 60 penetrations occurred (23.3 %) with free drill penetrations, and no injuries occurred with stopped drill penetrations. The bone depth was gradually decreasing from 10° to 20° drill angles and from anterior to superior inserting zones without significant importance. The risk of perforation to the pelvic cavity started with 20 mm drill depth, and the mean depth for all insertions was calculated as 31.7 mm (SD 2.6). CONCLUSIONS: It is anatomically possible that some pelvic structures sustain iatrogenic injury during acetabular drilling for anchor placement. Being aware of mean pelvic vault is important in which drilling after excessive pincer rim trimming could easily decrease the depth of acetabular bone without a standard. Careful drilling by using stopped drill bit is crucial to prevent iatrogenic injury.

Growing Rods Are an Effective Fusionless Method of Controlling Early-Onset Scoliosis Associated With Neurofibromatosis Type 1 (NF1): A Multicenter Retrospective Case Series.

BACKGROUND: Spinal deformities associated with neurofibromatosis type 1 (NF1) often have an early onset. These curves frequently develop dysplastic features. Rapid progression is common, and is often difficult to control with casting or bracing. Spinal fusion at a young age can potentially interfere with chest and trunk growth. Growing rods (GRs) have been used in early-onset scoliosis (EOS) effectively. The purpose of this study was to evaluate GR use in NF1. METHODS: Retrospective data collection was performed from a multicenter EOS database with additional patients from our own institute. Each patient had a genetic diagnosis of NF1 and was treated with GR. Results were compared with reported results of GR in EOS in the literature. RESULTS: Fourteen patients from 5 centers underwent a total of 71 procedures with an average follow-up of 54 months. Mean age at surgery was 6.8 years. Means of initial and final curves were 74 and 36 degrees, respectively (51% correction). Spine grew at an average of 39 mm (11.2 mm per year). Implant-related complications were the most common (8/14, 57%), including failure of proximal construct (5/14), rod breakage (2/14), and prominent implants (1/14). There was no significant difference between screws and hooks as proximal anchors (Fischer test). Two patients had deep infection that needed debridement. CONCLUSIONS: This retrospective pooled data study is the first report on the treatment of early-onset NF1 scoliosis with GRs. The use of GRs in these patients effectively controls the spinal deformity and facilitates growth of the spine. The complications were no greater than those seen in other conditions causing EOS. Failure of proximal anchors was found to be the most common complication. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Results of lateral ankle ligament repair surgery in one hundred and nineteen patients: do surgical method and arthroscopy timing matter?

PURPOSE: Ankle sprains are the most common athletic injury. One of five chronic lateral ankle instability patients will require surgery, making operative outcomes crucial. The purpose of this study is to determine if operative method influences failure and complication rates in chronic lateral ankle ligament repair surgery. METHODS: We retrospectively reviewed 119 cases (118 patients) of lateral ankle ligament surgery between 2006 and 2016. Patient charts and operative reports were examined for demographics, use and timing of ankle arthroscopy, ligament fixation method, type of surgical incision, presence of calcaneofibular ligament repair, and operative technique. Impact of operative methods on failure (one-year minimum follow-up) and complication outcomes was explored using Chi-square test of independence (or Fisher's exact test). Statistical significance was set at p less than .05. RESULTS: Mean age at surgery was 40 (range, 18-73) years. Mean follow-up was 51 (range, 12-260) weeks. Failure rate was 8.4% (10/89 cases) while complication rate was 17.6% (21/119). Failure rate did not differ significantly between any data subgroups (p > .05). Single stage arthroscopy was associated with a significantly lower complication rate (11%, 4/37) than double-stage arthroscopy (47%, 9/19) (p < .01) as was suture anchor ligament fixation (9%, 6/67) compared to direct suture ligament fixation (29%, 15/52) (p < .01). CONCLUSION: Failure rate was not impacted by any of the studied variables. Use of suture anchors and concurrent ankle arthroscopy may be favourable options to achieve fewer complications in chronic lateral ankle instability repair surgery.

Suture slippage in knotless suture anchors resulting in subacromial-subdeltoid bursitis.

Rotator cuff repair using a suture bridge and knotless suture anchors is a relatively new, but increasingly used technique. The suture bridge technique creates an anatomically similar and more secure rotator cuff repair compared with conventional arthroscopic techniques and the use of knotless anchors eliminates the challenges associated with knot tying during arthroscopic surgery. However, previous in vitro biomechanical tests have shown that the hold of the suture in a knotless suture anchor is far lower than the pullout strength of the anchor from bone. Up until now slippage has been a theoretical concern. We present a prospectively diagnosed case of in vivo suture loosening after rotator cuff repair using a knotless bridge technique resulting in subacromial-subdeltoid bursitis.

Serial MRI evaluation following arthroscopic rotator cuff repair in double-row technique.

INTRODUCTION: So far, recurrent rotator cuff defects are described to occur in the early postoperative period after arthroscopic repair. The aim of this study was to evaluate the musculotendinous structure of the supraspinatus, as well as bone marrow edema or osteolysis after arthroscopic double-row repair. Therefore, magnetic resonance (MR) images were performed at defined intervals up to 2 years postoperatively. STUDY DESIGN: Case series; Level of evidence, 3. MATERIALS AND METHODS: MR imaging was performed within 7 days, 3, 6, 12, 26, 52 and 108 weeks after surgery. All patients were operated using an arthroscopic modified suture bridge technique. Tendon integrity, tendon retraction ["foot-print-coverage" (FPC)], muscular atrophy and fatty infiltration (signal intensity analysis) were measured at all time points. Furthermore, postoperative bone marrow edema and signs of osteolysis were assessed. RESULTS: MR images of 13 non-consecutive patients (6f/7m, ∅ age 61.05 ± 7.7 years) could be evaluated at all time points until ∅ 108 weeks postoperatively. 5/6 patients with recurrent defect at final follow-up displayed a time of failure between 12 and 24 months after surgery. Predominant mode of failure was medial cuff failures in 4/6 cases. The initial FPC increased significantly up to 2 years follow-up (p = 0.004). Evaluations of muscular atrophy or fatty infiltration were not significant different comparing the results of all time points (p > 0.05). Postoperative bone marrow edema disappeared completely at 6 months after surgery, whereas signs of osteolysis appeared at 3 months follow-up and increased to final follow-up. CONCLUSIONS: Recurrent defects after arthroscopic reconstruction of supraspinatus tears in modified suture bridge technique seem to occur between 12 and 24 months after surgery. Serial MRI evaluation shows good muscle structure at all time points. Postoperative bone marrow edema disappears completely several months after surgery. Signs of osteolysis seem to appear caused by bio-absorbable anchor implantations.