In-line Pullout Strength of 2 Acetabular Fixation Methods for Ligamentum Teres Reconstruction of the Hip: A Cadaveric Study

Background: Ligamentum teres (LT) reconstruction is an appropriate alternative in select cases of LT full-thickness tears, resulting in hip micro- or macroinstability. Graft fixation at the acetabular fossa is critical to achieving the best functional results. Purpose: The purpose of this study is to compare the pullout strength of 2 graft fixation methods used for LT reconstruction of the hip. Study Design: Controlled laboratory study. Methods: In 7 cadaveric specimens, the acetabular socket was prepared after the native LT was transected and the femoral head was removed. Seven separate tibialis anterior grafts were then prepared by suturing a running-locking No. 2 suture on each tail of the graft. Three specimens had fixation of the graft to the acetabulum using an adjustable cortical suspension suture button; the remaining 4 were fixed to the acetabulum using a knotless suture anchor. Specimens were then mounted onto a custom jig within a mechanical test frame to allow for the in-line pull of the graft fixation construct. After a preload of 5 N, each specimen was loaded to failure at 0.5 mm/s. Stiffness and load to failure were measured for each specimen construct. Results: Suture button fixation had a higher mean load to failure when compared with the knotless anchor fixation method (mean ± SD, 438.1 ± 114.3 vs 195.9 ± 50.0 N; P = .01). There was no significant difference in mean stiffness between the methods of fixation (24.5 ± 1.4 vs 26.5 ± 5.8 N/mm; P = .6). Conclusion: In this cadaveric study, the suture button fixation demonstrated greater load to failure than the knotless anchor fixation. Clinical Relevance: Results of this study can guide surgical decision making when selecting an acetabular fixation method for LT reconstruction.

A prospective randomized study of arthroscopic ACL reconstruction with adjustable- versus fixed-loop device for femoral side fixation

Purpose Suspensory devices are extensively used in the management of anterior cruciate ligament (ACL) tear. They include fixed- and adjustable-loop devices. There are only a few studies comparing the efficacy of these two devices in the available literature. Therefore, the aim of this study is to compare clinical outcomes between the adjustable-loop device (group I) and fixed-loop device (group II). Materials and methods This was a prospective randomized study. Both groups were equivalent in demographic, preoperative, and intraoperative variables. Twenty-three patients underwent femoral side graft fixation with adjustable-loop and 20 with fixed-loop devices. Four patients were lost to follow-up. Assessment of clinical outcome was done with International Knee Documentation Committee (IKDC) score, Lysholm score, and knee stability tests (Lachman test and pivot shift test). Patient evaluation was performed preoperatively and finally postoperatively 2 years after surgery. Results Postoperative IKDC scores of group I and II were 91.9 ± 3.6 and 91.5 ± 3.6, respectively, and Lysholm scores were 91.0 ± 3.6 and 91.4 ± 3.5, respectively, after 2 years; however, the difference in the outcomes was statistically insignificant (p > 0.05). Twenty patients (87%) in group I and 17 patients (85%) in group II had a negative Lachman test (p = 0.8). Twenty-two patients (95.7%) in group I and 19 patients (95%) in group II had a negative pivot shift test (p = 0.9). Conclusion ACL reconstruction with fixed- and adjustable-loop suspensory devices for graft fixation gives equivalent and satisfactory clinical results. Level of evidence 1.

Ultimate Load Measuring System for Fixation of Soft Tissue to Bone

Background: The initial ultimate load for graft fixation is one of the essential factors in the reconstruction of lateral ankle ligaments. Several anchoring devices have been developed to fix the substitute ligament into the bone. A fair comparison of these fixation methods warrant a reproducible examination system. The purpose of this study was to make an experimental animal model and to compare the initial ultimate loads of 3 graft fixation methods, including the use of EndoButton (EB), interference screw (IFS), and a novel socket anchoring (SA) technique. Methods: Porcine calcaneus bones and 5-mm-wide split bovine Achilles tendons were used as fixation bases and graft materials, respectively. Both ends were firmly sutured side-by-side, using the circumferential ligation technique as a double-strand substitute that was 45 mm in length. Porcine calcanei with similar characteristics to adult human calcanei were mounted on a tensile testing machine, and substitutes were fixed into bones using the 3 fixation methods. A polyester tape was passed through the tendon loop and connected to a crosshead jig of the testing machine. The initial ultimate loads were measured in 15 specimens for each fixation method to simulate a lateral ankle ligament (LAL) injury. Results: The ultimate loads (ULs) were 223.6 ± 52.7 N for EB, 229.7 ± 39.7 N for SA, and 208.8 ± 65.3 N for IFS. No statistically significant difference was observed among the 3 groups ( P = .571). All failures occurred at the bone–ligament substitute interface. Conclusion: The initial ULs in all 3 fixation methods were sufficient for clinical usage. These values were larger than the UL of the anterior talofibular ligament; however, these were smaller than the UL of the calcaneofibular ligament. Clinical Relevance: In an experimental animal model, ULs for SA, EB, and IFS techniques showed no significant difference. All failures were observed in the fixation site of the calcaneus and were overwhelmingly related to suture fixation failure.

529 Safeguarding Skin Grafts: A 21st Century Algorithm for Fixation Techniques

Aim Effective skin graft fixation is fundamental in preventing sheering forces, seroma and haematoma from compromising graft take. However, determining the ideal method of graft fixation remains a contentious subject. Currently, there is significant variation in fixation techniques used, based not only on clinical requirement, but also surgeon preference. Evidence-based recommendations are necessary to guide the decision-making process. Method We undertook a PRISMA-based assessment of the literature to define all fixation techniques and analyse their outcomes. Inclusion and exclusion criteria were composed. A search of Medline and Embase was performed, yielding 399 articles. After abstract screening, 96 were included for qualitative data analysis. Results Nine fixation techniques were identified: ‘tie over bolster’, ‘staple fixation’, ‘simple dressings’, ‘quilting sutures’, ‘re-look methods’, ‘foam sponge bolster’, ‘adhesive glues’, ‘negative pressure wound therapy’ and ‘less common techniques. We analyse the available evidence for each technique, identifying 13 studies with level I/II evidence. We summarise the research that underpins these nine categories, proposing an algorithm to facilitate technique selection based on anatomical and patient-specific factors. Conclusions An array of skin graft fixation techniques are used in plastic surgery, without clear guidelines. To our knowledge, this is the first time all fixation techniques have been defined. Our suggested algorithm is intended to aid surgeons in selecting an appropriate fixation technique and should be challenged by future research, particularly randomised control trials.

Comparison of Bioabsorbable and Metallic Interference Screws for Graft Fixation During ACL Reconstruction: A Meta-analysis of Randomized Controlled Trials

Background: Bioabsorbable interference screws and metallic interference screws are both widely used for graft fixation, but it remains unclear which screw type is superior. Purpose: To compare clinical outcomes and complications between bioabsorbable and metallic interference screws for anterior cruciate ligament reconstruction (ACLR). Study Design: Systematic review; Level of evidence, 1. Methods: The literature was searched for relevant randomized controlled trials published between 1966 and 2020. Two investigators independently assessed risk of bias in the included studies, and data were pooled to calculate mean differences (MDs) for continuous outcomes and risk ratios (RRs) for dichotomous outcomes, together with 95% CIs. Meta-analysis was performed using a random- or fixed-effects model, depending on the heterogeneity in the data. Results: Included were 14 randomized controlled trials involving 1032 patients who underwent ACLR: 528 patients with bioabsorbable screws and 504 patients with metallic screws. The 2 groups did not differ significantly in International Knee Documentation Committee score (RR, 1.04; 95% CI, 0.97 to 1.11), Lysholm score (MD, 0.59; 95% CI, –0.46 to 1.63), range of motion deficit (RR, 0.95; 95% CI, 0.67 to 1.34), positive pivot-shift test (RR, 0.87; 95% CI, 0.61 to 1.24), positive Lachman test (RR, 0.82; 95% CI, 0.48 to 1.39), or KT-1000 arthrometer value (MD, 0.01; 95% CI, –0.16 to 0.18). However, bioabsorbable screws were associated with a significantly higher risk of complications (RR, 1.70; 95% CI, 1.16 to 2.50), such as graft rupture, joint effusion, and infection. Conclusion: The results of this review showed that there was no difference between metallic and bioabsorbable screws for ACLR in terms of subjective knee function or knee laxity, but metallic interference screws had fewer complications.

Comparison of dural grafts and methods of graft fixation in Chiari malformation type I decompression surgery

Suboccipital decompression with duraplasty is a widely accepted method for treating patients with Chiari malformation type I. However, important details of the duraplasty technique are still controversial. This retrospective study analyzes clinical and radiological outcomes after surgery depending upon the type of graft and methods of graft fixation. Seventy consecutive decompressions with duraplasty were analyzed. Two types of grafts, nonautologous (Non-AutoG; 60.0%) and autologous (AutoG; 40.0%), and two methods of graft fixation, suturing (S; 67.1%) and gluing (G; 32.9%), were used in four different combinations: (Non-AutoG+S: 31.4%; Non-AutoG+G: 28.6%; AutoG+S: 35.7%; AutoG+G: 4.3%) according to surgeon preference. The mean follow-up was 63.4 months. According to gestalt and Chicago Chiari Outcome Scales, satisfactory results were obtained in 72.9% and 78.6% of cases, respectively, in the long term. The outcomes were not related to the kind of graft (p = 0.44), fixation method (p = 0.89) or duraplasty pattern (p = 0.32). Decreased syringomyelia was observed in 88.9% of cases, and no associations with the kind of graft (p = 0.84), fixation method (p = 1) or duraplasty pattern were found (p = 0.96). Pseudomeningocele occurred 5 times more often in the Non-AutoG group than in the AutoG group (52.4% vs. 10.7%; p < 0.05), whereas their formations were not related to the fixation method (p = 0.34). Three cases (12.0%) required reoperation with reduraplasty. Autologous and nonautologous dural grafts can be sutured or glued with similar clinical results; however, the use of nonautologous grafts is linked with a much higher risk of pseudomeningocele formation.

Computed Tomography Imaging Results of Single Band Anterior Cruciate Ligament Reconstruction: A Retrospective Study Comparing Fixed- and Adjustable-Length Loop Cortical Fixation on the First Day After Surgery

Background: Cortical suspensory femoral fixation is commonly performed for graft fixation of the femur in anterior cruciate ligament (ACL) reconstruction using hamstring tendons. This study aimed to compare the morphology of femoral tunnel and graft insertion between fixed-length loop devices (FLD) and adjustable-length loop devices (ALD) using computed tomography (CT) images on the first day after hamstring ACL reconstruction. Methods: Overall, 94 patients who underwent ACL reconstruction from January 2016 to January 2021 were included. For femoral graft fixation, FLD (Smith & Nephew, ENDOBUTTON) and ALD (DePuy Synthes, Mitek sports medicine, RIGIDLOOP Adjustable cortical system) were used in 56 and 38 patients, respectively (FLD and ALD groups). For evaluation of the morphology of the humeral tunnel and graft depth, CT scans were performed immediately on the first postoperative day. The gap distance between the top of the graft and the socket tunnel end, the length of lateral bone preservation, and the depth of graft insertion were measured on the CT images. Results: The gap distance and bone preservation significantly differed between the two groups (1.90±1.81 mm and 14.35±4.67 mm in ALD groups; 7.08±2.63 mm and 7.35±3.62 mm in FLD groups, respectively; both P values < 0.01). The graft insertion depth did not significantly differ between the groups. Conclusion: The ALD group had a smaller gap distance, better bone preservation, and a similar graft insertion length in the femoral tunnel when compared to the FLD group. Based on these findings, ALD might be better for bone preservation and tunnel utilization in patients with short femoral tunnels. Trial registration: retrospectively registered

A comprehensive scoping review of tibial cysts after anterior cruciate ligament reconstruction

Purpose The purpose of this study was to perform a scoping review of published literature reporting on surgical management of tibial cysts which developed after ACLR. Methods A scoping review was conducted following the Arksey and O’Malley framework for scoping studies and Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) extension for scoping reviews (PRISMA-ScR) guidelines. A search strategy using the terms [“Tibial Cyst” AND “ACL”], [“Pretibial Cyst” AND “ACL”] was applied to the PUBMED database. Results Thirty-seven studies published between 1990 and 2019 were a part of this scoping review. Non-absorbable implants for tibial graft fixation were used in 10 studies (comprising a total 21 patients), while bio-absorbable implants were used in 27 studies (comprising a total 115 patients). Incidence of tibial cyst was reported in 3 studies (434 primary ACLRs) from whom 3.9% (n = 17) developed tibial cyst. Tibial cyst development in relation to use of bio-absorbable screws for tibial ACL graft fixation was reported in 16 studies (42.1%). Use of bio-absorbable screws with another factor was found to be related to tibial cyst development in another 1 study (2.6%). Most common symptoms were presence of mass or swelling, pain, tenderness, drainage, instability and effusion. Conclusion This scoping review demonstrated that tibial cysts is more frequently related to bioabsorbable screws, however it can also occur due to other causes. Current literature on tibial cyst after ACLR is of low-quality evidence. Future research is required to better understand aetiology, risk factors for cyst formation and the best possible mode of management. Level of evidence IV