Suture Anchor Repair of Pectoralis Major Muscle Dehiscence After Modified Ravitch

During repair of pectus excavatum by the modified Ravitch procedure, the major pectoral muscles are detached from their sternal insertion to obtain adequate surgical exposure. Following repair, the muscles are approximated in midline and reinserted through scarring. Dehiscence of the major pectoral muscles after the modified Ravitch procedure is a rare phenomenon, not previously reported in literature. We report on 2 cases and describe an effective treatment method using sternal suture anchors with good long-term results.

Endoscopic Haglund’s Resection and Percutaneous Double-Row Insertional Achilles Repair

Insertional Achilles tendinopathy can be a debilitating condition that often fails to improve with nonsurgical management such as bracing and physical therapy. Traditional surgical techniques include an open debridement of the diseased tendon and resection of calcaneal spurs. This is followed by repair of the tendon. Suture anchors are often used to secure the tendon, but recent advances in tendon fixation, including the advent of double-row repairs, has allowed better biomechanical repairs and faster rehabilitation. Additionally, minimally invasive surgery and endoscopic techniques have advanced to allow successful treatment of all aspects of the condition while minimizing wound complications and infection. The authors present a technique to treat insertional Achilles tendinopathy and calcaneal bone spurs using minimally invasive surgery techniques while also incorporating a percutaneous double-row suture anchor repair. The technique utilizes 4 portals to access 2 endoscopic working planes. The burr is inserted deep to the tendon and the calcaneoplasty is performed. Subsequently, the endoscope is inserted alongside a shaver to remove bony debris and debulk the anterior aspect of the Achilles areas of tendinopathy. Following this, the portals are used to place a double-row suture anchor repair. Levels of Evidence: Level V

Double-crossed knotless suture anchor repair of quadriceps rupture

Quadriceps tendon rupture is an uncommon injury but may result in long term disability if not adequately repaired. Many techniques are described for repair of acute quadriceps tendon rupture, including tendon-to-tendon repair, trans-osseous tunnels, synthetic augmentation, tendon plasty and the use of suture anchors. There is no single accepted surgical treatment. This study's objective was to assess the efficacy of a double-crossed suture anchor repair in the management of quadriceps tendon rupture. Materials and methods: 85 patient attended our institute for surgical management of quadriceps tendon rupture over eight years (2012-2019). Seven patients were treated with the use of a double-crossed suture anchor fixation. These patients were allowed to weight bear in a hinged knee brace for six weeks following surgery. Six out of seven patients had one or more predisposing co-morbidities, including obesity, diabetes, renal failure, quinolone and steroid use. Results: Clinical and functional outcome were recorded during follow up visits prospectively for a mean of one year (10-14 months). The mean knee flexion was 124 degree (120 -130). All patients were able to return to activities of daily living (ADL) with a mean of 2 months (1.5-3 months) and return to work at a mean of 6 months (4-8 months). The mean Tegner, Cincinnati and Lysholm score at the latest follow up were 2.8 (0-5), 79.2 (60-88) and 90 (70-100), respectively. There were no early complications. There was no re-tear reported at the latest follow up. Conclusion : The double-crossed suture anchor fixation is a safe and effective treatment option in managing quadriceps tendon ruptures.

Surgical Repair of Distal Biceps Femoris Avulsion Injuries in Professional Athletes

Background: Understanding the optimal management of distal biceps femoris avulsion injuries is critical for restoring preinjury function, restoring hamstring muscle strength, increasing range of motion, and minimizing risk of complications and recurrence. Due to the rarity of these injuries, prognosis and outcomes within the literature are limited to case reports and small case series. Purpose: To assess the effect of surgical repair for acute distal avulsion injuries of the biceps femoris tendon on (1) return to preinjury level of sporting function and (2) time to return to preinjury level of sporting function, patient satisfaction, and complications. Study Design: Case series; Level of evidence, 4. Methods: This prospective single-surgeon study included 22 elite athletes (18 men [82%], 4 women [18%]; mean age, 26 years; age range, 17-35 years; mean body mass index, 25.3 ± 4.1 kg/m2) undergoing primary suture anchor repair of avulsion injuries of the distal biceps femoris confirmed on preoperative magnetic resonance imaging. Predefined outcomes relating to time for return to sporting activity, patient satisfaction, complications, and injury recurrence were recorded at regular intervals after surgery. Minimum follow-up time was 12 months (range, 12.0-26.0 months) from the date of surgery. Results: The mean time from injury to surgical intervention was 12 days (range, 2-28 days). All study patients returned to their preinjury level of sporting activity, predominately professional soccer or rugby. Mean time from surgical intervention to return to full sporting activity was 16.7 ± 8.7 weeks. At 1- and 2-year follow-up, all study patients were still participating at their preinjury level of sporting activity. There was no incidence of primary injury recurrence, and no patients required further operation to the biceps origin. Conclusion: Surgical repair of acute avulsion injuries of the distal biceps femoris facilitated early return to preinjury level of function with low risk of recurrence, low complication rate, and high patient satisfaction in elite athletes. Suture anchor repair of these injuries should be considered a reliable treatment option in athletes with high functional demands to permit an early return to sport with restoration of hamstring strength.

Delayed Presentation of Unstable Triangular Fibrocartilage Complex Tears Treated with Volar Foveal Ligament Repair

Hypothesis An open volar surgical approach with suture anchor repair of the foveal ligament and temporary pinning of the distal radioulnar joint (DRUJ) is an effective way to treat DRUJ instability associated with chronic foveal tears of the triangular fibrocartilage complex (TFCC). Methods We retrospectively reviewed nine patients with foveal ligament tears of the TFCC and DRUJ instability who underwent open repair of the TFCC using a volar surgical approach, combined with temporary pinning of the DRUJ for 8 weeks. Pain, instability, arc of motion, and functional outcomes scores were evaluated. Results Mean patient age was 40.5 years (range 16.3–56.2). Average time from injury to surgery was 8.4 months (range 2.9–23.3 months). Average final follow-up was 18.9 months from injury (range 12.0–29.3 months), 10.5 months from surgery (range 3.9–18.6 months), and 8.7 months from pin removal (range 1.7–17.2 months). At final follow-up, all patients demonstrated clinically stable DRUJ. Pain scores diminished significantly from pre to final postoperative visits, with averages of 6.8 (range 4.0–9.0) improving to a mean of 0.70 (range 0.0–2.0), respectively. Average postoperative forearm rotation was 71.1 degrees in supination and 76.1 degrees in pronation (average total arc of motion 147.2 degrees, range 90–160 degrees). Average postoperative wrist motion was 68.8 degrees in flexion and 70.6 degrees in extension (average total arc of motion 139.4 degrees, range 110–160 degrees). No patients developed crepitus, recurrent DRUJ instability, or required revision surgery (subsequent to pin removal). Conclusion Volar suture anchor repair of the foveal ligament of the TFCC with DRUJ pinning led to reliable outcomes within this patient group including a stable DRUJ with improved functional outcomes regarding pain, stability, and range of motion in patients with foveal TFCC tears and associated DRUJ instability. These results compare favorably with dorsal repair of the foveal ligament. Level of Incidence This is a Level IV, therapeutic study.

Adjustable Cortical Fixation Device for Quadriceps Tendon Repair: A Cadaveric Biomechanical Study

Background: Adjustable cortical fixation devices have demonstrated utility in orthopaedic applications, such as ankle syndesmosis repair. Purpose: To assess the cyclic gap formation of a quadriceps tendon repair technique using an adjustable cortical fixation device compared with repair with knotless suture anchors and suture tape, a modification of conventional suture anchor repair. Study Design: Controlled laboratory study. Methods: Eight fresh-frozen matched pairs of cadaveric knees were used. Specimens in each pair were randomized to undergo either modified suture anchor repair (control) or adjustable cortical fixation repair. The control repair was performed as previously described. The experimental repair was performed using 2 No. 2 FiberWire sutures placed into the quadriceps tendon in a running locked Krackow configuration and 2 adjustable loop devices passed through transosseous tunnels. The lagging strands of the devices were tensioned to seat the cortical fixation buttons at the inferior patellar pole and then tied to the free Krackow strands at the superior pole to complete the repair. The mean plastic gap (permanent tendon displacement that did not recover with cyclic extension) and mean maximum gap (peak displacement that occurred with cyclic knee flexion and partially recovered with extension) were evaluated during cyclic loading for 500 cycles of full knee extension to 90° of flexion. Results: At all testing intervals, the mean plastic gap was significantly smaller for the cortical fixation group versus the suture anchor group ( P < .02). Similarly, the mean maximum gap was significantly smaller for the cortical fixation specimens at all testing intervals ( P < .01). After cyclic loading, the mean maximum gap was significantly smaller in the cortical fixation group (4.80 ± 1.56 mm) versus the suture anchor group (8.47 ± 1.47 mm; P = < .001). The mean plastic gap was also significantly smaller in the cortical fixation versus the suture anchor group (3.25 ± 1.10 mm vs 6.57 ± 1.62 mm, respectively; P = < .001). Conclusion: Quadriceps tendon repair using an adjustable cortical fixation device demonstrated superior biomechanical properties in cyclic displacement testing compared with repair using the suture anchor technique. Clinical Relevance: These results suggest that an adjustable cortical fixation device is a biomechanically viable alternative for quadriceps tendon repair.