Shoulder Proprioception: A Review.

The purpose of this review is to provide a comprehensive resource for shoulder proprioception assessment and its integration into clinical decision making as well as targeted rehabilitation protocols. Data for this review were acquired from peer-reviewed articles from computerized online databases, namely PubMed and Medline, published between 1906 and 2021. The development of digital/smart phone goniometers can improve shoulder joint range of motion (ROM) measurements and demonstrate comparable measurement accuracy to the universal standard goniometer. The inclinometer offers a portable and cost-effective method for measuring shoulder joint angles and arcs of motion in the vertical plane. Two types of dynamometers, the computerized isokinetic machine and the handheld hydraulic dynamometer, are reliable tools for objective shoulder rotator cuff strength assessment. Motion analysis systems are highly advanced modalities that create three-dimensional models of motion arcs using a series of cameras and reflective beads, offering unparalleled precision in shoulder proprioception measurement; however, they require time-consuming calibration and skilled operators. Advancements in wearable devices and compact mobile technology such as iPhone applications may make three-dimensional motion analysis more affordable and practical for outpatient settings in the future. The complex interplay between proprioception and shoulder dysfunction is not fully understood; however, shoulder proprioception can likely both contribute to and be caused by shoulder pathology. In patients with rotator cuff tears, glenohumeral osteoarthritis, and shoulder instability, clinicians can track proprioception to understand a patient's disease progression or response to treatment. Finally, rehabilitation programs targeting shoulder proprioception have shown promising initial results in restoring function and returning athletes to play.

Mass Participation and Tournament Event Management for the Team Physician: A Consensus Statement (2022 Update).

ABSTRACT: Mass participation events include endurance events (e.g., marathon, triathlon) and/or competitive tournaments (e.g., baseball, tennis, football (soccer) tournaments). Event management requires medical administrative and participant care planning. Medical management provides safety advice and care at the event that accounts for large numbers of participants, anticipated injury and illness, variable environment, repeated games or matches, and mixed age groups of varying athletic ability. This document does not pertain to the care of the spectator.

Mass Participation and Tournament Event Management for the Team Physician: A Consensus Statement (2022 Update).

ABSTRACT: Mass participation events include endurance events (e.g., marathon, triathlon) and/or competitive tournaments (e.g., baseball, tennis, football (soccer) tournaments). Event management requires medical administrative and participant care planning. Medical management provides safety advice and care at the event that accounts for large numbers of participants, anticipated injury and illness, variable environment, repeated games or matches, and mixed age groups of varying athletic ability. This document does not pertain to the care of the spectator.

Surgical Treatment of Focal Chondral Lesions of the Knee in the Military Population: Current and Future Therapies.

INTRODUCTION: Chondral and osteochondral defects of the knee are common injuries in the military population that have a significant impact on readiness. Definitive treatment of these injuries is challenging since cartilage has a limited capacity for self-repair and regeneration. Management is particularly challenging in military patients who maintain a higher level of activity similar to athletes. Existing surgical techniques have variable results and often long recovery times, sparking the development of several new innovative technologies to return service members back to duty more quickly and effectively after cartilage injury. The purpose of this article is to review the current and future surgical treatments for chondral and osteochondral knee lesions and their relevance in managing these injuries in the military. METHODS: In this review article, we describe the current treatments for chondral and osteochondral defects of the knee, reporting on outcomes in military populations. We explore emerging treatment modalities for cartilage defects, reporting innovations, stage of research, and current data. Published results of each treatment option in military populations are reviewed throughout the article. RESULTS: This review includes 12 treatments for chondral lesions. Of these therapies, four are considered synthetic and the remaining are considered regenerative solutions. Regenerative therapies tend to perform better in younger, healthier populations with robust healing capacity. Success of treatment depends on lesions and patient characteristics. Nearly all modalities currently available in the USA were successful in improving patients from presurgical function in the short (<6 months) term, but the long-term efficacy is still challenged. Upcoming technologies show promising results in clinical and animal studies that may provide alternative options desirable for the military population. CONCLUSIONS: The current treatment options for cartilage lesions are not entirely satisfactory, usually with long recovery times and mixed results. An ideal therapy would be a single procedure that possesses the ability to enable a quick return to activity and duty, alleviate pain, provide long-term durability, and disrupt the progression of osteoarthritis. Evolving technologies for cartilage lesions are expanding beyond currently available techniques that may revolutionize the future of cartilage repair.

Beach-Chair Versus Lateral Decubitus Positioning for Primary Arthroscopic Anterior Shoulder Stabilization: A Consecutive Series of 641 Shoulders.

BACKGROUND: There are limited data comparing the beach-chair (BC) versus lateral decubitus (LD) position for arthroscopic anterior shoulder stabilization. PURPOSE: To identify predictors of instability recurrence and revision after anterior shoulder stabilization and evaluate surgical position and glenoid bone loss as independent predictors of recurrence and revision at short- and midterm follow-ups. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A consecutive series of 641 arthroscopic anterior stabilization procedures were performed from 2005 to 2019. All shoulders were evaluated for glenohumeral bone loss on magnetic resonance imaging. The primary outcomes of interest were recurrence and revision. Multivariable logistic regression models were used to assess the relationships of outcomes with age, position, glenoid bone loss group, and track. RESULTS: A total of 641 shoulders with a mean age of 22.3 years (SD, 4.45 years) underwent stabilization and were followed for a mean of 6 years. The overall 1-year recurrent instability rate was 3.3% (21/641) and the revision rate was 2.8% (18/641). At 1 year, recurrence was observed in 2.3% (11/487) and 6.5% (10/154) of BC and LD shoulders, respectively. The 5-year recurrence and revision rates were 15.7% (60/383) and 12.8% (49/383), respectively. At 5 years, recurrence was observed in 16.4% (48/293) and 13.3% (12/90) of BC and LD shoulders, respectively. Multivariable modeling demonstrated that surgical position was not associated with a risk of recurrence after 1 year (odds ratio [OR] for LD vs BC, 1.39; P = .56) and 5 years (OR for LD vs BC, 1.32; P = .43), although younger age at index surgery was associated with a higher risk of instability recurrence (OR, 1.73 per SD [4.1 years] decrease in age; P < .03). After 1 and 5 years, surgical position results were similar in a separate multivariable logistic regression model of revision surgery as the dependent variable, when adjusted for age, surgical position, bone loss group, and track. At 5 years, younger age was an independent risk factor for revision: OR 1.68 per SD (4.1 years) decrease in age (P < .05). CONCLUSION: Among fellowship-trained orthopaedic surgeons, there was no difference in rates of recurrence and revision surgery after performing arthroscopic anterior stabilization in either the BC or the LD position at 1- and 5-year follow-ups. In multivariable analysis, younger age, but not surgical position, was an independent risk factor for recurrence.

Outcomes of Activity-Related Lower Extremity Muscle Tears After Application of the British Athletics Muscle Injury Classification: A Systematic Review.

CONTEXT: Muscle injury classification and grading systems have been reported for >100 years; yet it offer limited evidence relating the clinical or radiological qualities of a muscle injury to the pathology or clinical outcome. The British Athletics Muscle Injury Classification (BAMIC) incorporates recent predictive features of muscle injuries and provides a precise radiographic framework for clinical prediction and management. OBJECTIVE: To investigate clinical outcomes, particularly time to return to play (RTP), reinjury rate (RIR), and prognostic value of specific magnetic resonance imaging (MRI) findings, of activity-related muscle injuries (tears) in athletes after application of the BAMIC. DATA SOURCES: A search of PubMed (NLM), EMBASE (Ovid), Web of Science (Clarivate), Cochrane Library (Wiley), and ClinicalTrials.gov from the inception date of each database through August 31, 2022, was conducted. Keywords included the BAMIC. STUDY SELECTION: All English language studies evaluating clinical outcomes of RTP and RIR after activity-related muscle injuries and where BAMIC was applied were included. A total of 136 articles were identified, and 11 studies met inclusion criteria. STUDY DESIGN: Systematic review (PROSPERO: CRD42022353801). LEVEL OF EVIDENCE: Level 2. DATA EXTRACTION: Two reviewers independently screened studies for eligibility and extracted data. Methodological quality of included study was assessed independently by 2 reviewers with the Newcastle-Ottawa Quality Scale (NOS); 11 good quality studies (4 prospective cohort studies, 7 retrospective cohort studies) with 468 athletes (57 female) and 574 muscle injuries were included. RESULTS: All studies reported a statistically significant relationship between BAMIC grade, BAMIC injury site, and/or combined BAMIC grade and injury site with RTP. A statistically significant increased RIR was reported by BAMIC grade and BAMIC injury site in 2 of 4 and 3 of 4 studies, respectively. The prognostic value of individual MRI criteria was limited. CONCLUSION: Consistent evidence suggests that BAMIC offers prognostic and therapeutic guidance for clinical outcomes, particularly RTP and RIR, after activity-related muscle injuries in athletes that may be superior to previous muscle injury classification and grading systems.

Outcomes of Revision Arthroscopic Posterior Labral Repair and Capsulorrhaphy: A Systematic Review.

Background: Failure rates up to 14% have been reported after arthroscopic posterior capsulolabral repair. It is unknown if revision arthroscopic posterior capsulolabral stabilization has inferior restoration of stability and return to sport when compared with primary repair. Optimal management of failed posterior capsulolabral stabilization is unknown. Purpose: To report outcomes of revision posterior capsulolabral repair and factors that contribute to failure and to determine optimal management of failed posterior stabilization procedures. Study Design: Systematic review; Level of evidence, 4. Methods: A computerized search of the PubMed, EMBASE, and Web of Science databases and manual screening of selected article reference lists were performed in January 2022. Randomized controlled trial, cohort, case-control, and case series studies reporting clinical outcomes of revision arthroscopic posterior capsulolabral repair were eligible. Patient characteristics, indications for revision, intraoperative findings, surgical techniques, and patient-reported outcomes were recorded. Owing to heterogeneity of reported outcomes, data were summarized and presented without pooled statistics. Results: Only 3 of the 990 identified studies met inclusion criteria. The included studies encompassed 26 revision arthroscopic posterior capsulolabral repairs, with follow-up ranging from 2.3 to 5.3 years. The failed index procedure was arthroscopic capsulolabral repair with suture anchors (n = 22) or posterior thermal capsulorrhaphy (n = 4). The primary indications for revision were recurrent instability and pain. Six patients experienced recurrent instability after revision. Patient satisfaction ranged from 15% to 25%. Conclusion: This systematic review of 3 studies demonstrated that the incidence of persistent pain and recurrent instability after revision arthroscopic posterior shoulder stabilization is common, and despite slight improvement in patient-reported outcomes, many patients are dissatisfied with their clinical outcomes. Revision arthroscopic posterior shoulder stabilization appears to have a significant failure rate, and there is need for additional prospective studies to help determine the best intervention for these patients.

How to Be a Mentee: Getting the Most of Your Mentorship.

Mentorship is a key part of the development of knowledge and skills in orthopedics. Mentorship at each of these different phases is important to preparing and enabling a competent, knowledgeable, and well-rounded surgeon. Although the mentor is generally the one in a senior position, experienced in their field, the mentee is the protégé or the trainee engaged in a relationship with the person with expertise. There should be mutual responsibility on both sides to develop a collaborative relationship in order to optimize value in the relationship for both parties.

Posterior Glenoid Bone Loss and Instability: An Evidence-based Approach to Diagnosis and Management.

Posterior glenohumeral instability is an underappreciated cause of disability that may necessitate surgical intervention to allow functional glenoid restoration. However, posterior glenoid bone abnormalities, when sufficiently severe, may contribute to persistent instability despite a well-performed capsulolabral repair. Recognition and understanding of these lesions is critical to both surgical decision making and execution of the surgical plan. Numerous procedures have been described to address posterior instability including recent developments in arthroscopic grafting techniques. The purpose of this article was to provide an evidence-based strategy for diagnosis and management of posterior shoulder instability and glenoid bone loss.

Revision Arthroscopic Bankart Repair Results in High Failure Rates and a Low Return to Duty Rate Without Recurrent Instability.

PURPOSE: The purpose of this study was to determine, in a military population without critical bone loss, the rate of recurrent instability after revision arthroscopic stabilization for failed primary arthroscopic Bankart repair. METHODS: Forty-one revision arthroscopic stabilizations were performed at a single military institution between 2005 to 2016 for recurrent anterior shoulder instability after primary arthroscopic Bankart repair. Minimum follow-up was 2 years, and shoulders with glenoid bone loss >20% were excluded. The primary outcome of interest was the incidence of failure, defined by recurrent instability. RESULTS: Age at revision surgery averaged 22.9 ± 4.3 years, and 88% were either service academy cadets or active duty combat arms soldiers. Mean follow-up was 7.8 years. Twenty-three patients (56%) returned to duty without recurrent instability after revision arthroscopic stabilization. Eighteen patients (44%) experienced recurrent instability after return to duty. Glenoid bone loss averaged 6.2% (95% confidence interval [CI], 3.2%-9.2%) in the successful group and 5.7% (95% CI, 3.1%-8.3%) in the failure group (P = .808). CONCLUSIONS: Revision arthroscopic stabilization of failed primary arthroscopic Bankart repair has a failure rate of 44% in a young military population. The similar amounts of bone loss between groups indicates that bone loss is not the primary determinant of failure in revision arthroscopic stabilization. LEVEL OF EVIDENCE: IV, Case Series.

A Review of Evidence for Infection Reduction With Vancomycin-treated Anterior Cruciate Ligament Grafts.

Septic arthritis after anterior cruciate ligament (ACL) reconstruction is a rare but devastating complication. Several risk factors and known sources of infection have been identified in the literature. There is growing interest and supportive evidence for a targeted invention aimed at graft decontamination, which has led some surgeons to adopt the use of antibiotic solution soaks and/or wraps applied to ACL grafts before graft implantation in an attempt to reduce the risk of postoperative infection. Despite this, adoption of this technique remains relatively low among surgeons because of a variety of factors: (1) lack of awareness, (2) confusion over optimal protocols, (3) concern for graft viability and clinical outcomes, and (4) efforts to minimize the cost of surgery. However, recently published literature demonstrates notable risk reduction for infection, acceptable safety, no detrimental effect on clinical outcomes, and overall cost-effectiveness with the use of vancomycin graft soaks and wraps. Currently, there is a lack of consensus for clinical protocols, and the protocol that is most efficacious remains unclear. The purpose of this review article was to present the current evidence for ACL graft treatment with vancomycin for the prevention of postoperative infection.

Prospective Evaluation of Posterior Glenoid Bone Loss After First-time and Recurrent Posterior Glenohumeral Instability Events.

BACKGROUND: Although posterior glenohumeral instability is becoming an increasingly recognized cause of shoulder pain, the role of posterior glenoid bone loss on outcomes remains incompletely understood. PURPOSES: To prospectively determine the amount of bone loss associated with posterior instability events and to determine predisposing factors based on preinstability imaging. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A total of 1428 shoulders were evaluated prospectively for ≥4 years. At baseline, a subjective history of shoulder instability was ascertained for each patient, and bilateral noncontrast magnetic resonance imaging (MRI) scans of the shoulders were obtained regardless of any reported history of shoulder instability. The cohort was prospectively followed during the study period, and those who were diagnosed with posterior glenohumeral instability were identified. Postinjury MRI scans were obtained and compared with the screening MRI scans. Glenoid version, perfect-circle-based bone loss was measured for each patient's pre- and postinjury MRI scans using previously described methods. RESULTS: Of the 1428 shoulders that were prospectively followed, 10 shoulders sustained a first-time posterior instability event and 3 shoulders sustained a recurrent posterior instability event. At baseline, 11 of 13 shoulders had some amount of glenoid dysplasia and/or bone loss. The change in glenoid bone loss was 5.4% along the axis of greatest loss (95% CI, 3.8%-7.0%; P = .009), 4.4% at the glenoid equator (95% CI, 2.7%-6.2%; P = .016), and 4.2% of total glenoid area (95% CI, 2.9%-5.3%; P = .002). Recurrent glenoid instability was associated with a greater amount of absolute bone loss along the axis of greatest loss compared with first-time instability (recurrent: 16.8% ± 1.1%; 95% CI, 14.6%-18.9%; first-time: 10.0% ± 1.5%; 95% CI, 7.0%-13.0%; P = .005). Baseline glenoid retroversion ≥10° was associated with a significantly greater percentage of bone loss along the axis of greatest loss (≥10° of retroversion: 13.5% ± 2.0%; 95% CI, 9.6%-17.4%; <10° of retroversion: 8.5% ± 0.8%; 95% CI, 7.0%-10.0%; P = .045). CONCLUSIONS: Posterior glenohumeral instability events were associated with glenoid bone loss of 5%. The amount of glenoid bone loss after a recurrent posterior glenohumeral instability event was greater than that after first-time instability. Glenoid retroversion ≥10° was associated with a greater amount of posterior glenoid bone loss after a posterior instability event.

The Military Orthopedics Tracking Injuries and Outcomes Network: A Solution for Improving Musculoskeletal Care in the Military Health System.

INTRODUCTION: Musculoskeletal injuries are an endemic amongst U.S. Military Service Members and significantly strain the Department of Defense's Military Health System. The Military Health System aims to provide Service Members, military retirees, and their families the right care at the right time. The Military Orthopedics Tracking Injuries and Outcomes Network (MOTION) captures the data that can optimize musculoskeletal care within the Military Health System. This report provides MOTION structural framework and highlights how it can be used to optimize musculoskeletal care. MATERIALS AND METHODS: MOTION established an internet-based data capture system, the MOTION Musculoskeletal Data Portal. All adult Military Health System patients who undergo orthopedic surgery are eligible for entry into the database. All data are collected as routine standard of care, with patients and orthopedic surgeons inputting validated global and condition-specific patient reported outcomes and operative case data, respectively. Patients have the option to consent to allow their standard of care data to be utilized within an institutional review board approved observational research study. MOTION data can be merged with other existing data systems (e.g., electronic medical record) to develop a comprehensive dataset of relevant information. In pursuit of enhancing musculoskeletal injury patient outcomes MOTION aims to: (1) identify factors which predict favorable outcomes; (2) develop models which inform the surgeon and military commanders if patients are behind, on, or ahead of schedule for their targeted return-to-duty/activity; and (3) develop predictive models to better inform patients and surgeons of the likelihood of a positive outcome for various treatment options to enhance patient counseling and expectation management. RESULTS: This is a protocol article describing the intent and methodology for MOTION; thus, to date, there are no results to report. CONCLUSIONS: MOTION was established to capture the data that are necessary to improve military medical readiness and optimize medical resource utilization through the systematic evaluation of short- and long-term musculoskeletal injury patient outcomes. The systematic enhancement of musculoskeletal injury care through data analyses aligns with the National Defense Authorization Act (2017) and Defense Health Agency's Quadruple Aim, which emphasizes optimizing healthcare delivery and Service Member medical readiness. This transformative approach to musculoskeletal care can be applied across disciplines within the Military Health System.

A High-Sensitivity International Knee Documentation Committee Survey Index From the PROMIS System: The Next-Generation Patient-Reported Outcome for a Knee Injury Population.

BACKGROUND: Patient-reported outcomes (PROs) measure progression and quality of care. While legacy PROs such as the International Knee Documentation Committee (IKDC) survey are well-validated, a lengthy PRO creates a time burden on patients, decreasing adherence. In recent years, PROs such as the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function and Pain Interference surveys were developed as computer adaptive tests, reducing time to completion. Previous studies have examined correlation between legacy PROs and PROMIS; however, no studies have developed effective prediction models utilizing PROMIS to create an IKDC index. While the IKDC is the standard knee PRO, computer adaptive PROs offer numerous practical advantages. PURPOSE: To develop a nonlinear predictive model utilizing PROMIS Physical Function and Pain Interference to estimate IKDC survey scores and examine algorithm sensitivity and validity. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: The MOTION (Military Orthopaedics Tracking Injuries and Outcomes Network) database is a prospectively collected repository of PROs and intraoperative variables. Patients undergoing knee surgery completed the IKDC and PROMIS surveys at varying time points. Nonlinear multivariable predictive models using Gaussian and beta distributions were created to establish an IKDC index score, which was then validated using leave-one-out techniques and minimal clinically important difference analysis. RESULTS: A total of 1011 patients completed the IKDC and PROMIS Physical Function and Pain Interference, providing 1618 complete observations. The algorithms for the Gaussian and beta distribution were validated to predict the IKDC (Pearson = 0.84-0.86; R2 = 0.71-0.74; root mean square error = 9.3-10.0). CONCLUSION: The publicly available predictive models can approximate the IKDC score. The results can be used to compare PROMIS Physical Function and Pain Interference against historical IKDC scores by creating an IKDC index score. Serial use of the IKDC index allows for a lower minimal clinically important difference than the conventional IKDC. PROMIS can be substituted to reduce patient burden, increase completion rates, and produce orthopaedic-specific survey analogs.

Stacked Biocomposite Screws in a Single-Stage Revision Anterior Cruciate Ligament Reconstruction Has Acceptable Fixation Strength in a Porcine Cadaveric Model.

BACKGROUND: Stacked screws is a commonly used technique in single-stage revision anterior cruciate ligament (ACL) reconstruction in the setting of bone loss, but there are limited data to support its use. HYPOTHESIS: Two configurations of a biocomposite stacked screws construct have similar fixation strength and linear stiffness as a primary ACL reconstruction construct in a biomechanical model. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 30 porcine legs were divided into 3 groups. Group 1 underwent primary ACL reconstruction with a patellar tendon graft fixed into the femur, with an 8-mm biocomposite interference screw of beta-tricalcium phosphate and poly lactide-co-glycolide. For a revision ACL reconstruction model, groups 2 and 3 had bone tunnels created and subsequently filled with 12-mm biocomposite screws. New bone tunnels were drilled through the filler screw and the surrounding bone, and the patellar bone plug was inserted. Group 2 was fixed with 8-mm biocomposite screws on the side of the graft opposite the filler screw, while group 3 had the interference screw interposed between the graft and the filler screw. The construct was loaded at 1.5 mm/s in line with the tunnel until failure. Load to failure, linear stiffness, and mode of failure were recorded. RESULTS: The mean pullout strength for groups 1, 2, and 3 was 626 ± 145 N, 653 ± 152 N, and 720 ± 125 N, respectively (P = .328). The mean linear stiffness of the construct in groups 1, 2, and 3 was 71.4 ± 9.9 N/mm, 84.1 ± 11.1 N/mm, and 82.0 ± 10.8 N/mm, respectively. Group 2 was significantly stiffer than group 1 (P = .037). CONCLUSION: Two configurations of a biocomposite stacked screws construct for a single-stage revision ACL reconstruction in the setting of bone loss show a similar fixation strength and linear stiffness to a primary ACL reconstruction at time zero in a porcine model. CLINICAL RELEVANCE: In the setting of bone loss from tunnel malpositioning, a single-stage revision ACL reconstruction using a stacked screws construct may provide adequate fixation strength and linear stiffness.

Latarjet After Failed Arthroscopic Bankart Repair Results in Twice the Rate of Recurrent Instability Compared With Primary Latarjet.

PURPOSE: To assess recurrent instability of the shoulder following open Latarjet performed as the primary stabilization procedure or as a salvage procedure. METHODS: A retrospective, comparative cohort study was performed for a consecutive series of patients in the Military Health System who underwent open Latarjet from January 1, 2010, to December 31, 2018. All patients were diagnosed with recurrent anterior shoulder instability and had a minimum of 2 years of postoperative follow-up. Patients were categorized as either having a primary Latarjet (PL; no prior shoulder stabilization procedure) or salvage Latarjet (SL; ≥1 previous arthroscopic surgical stabilization procedures). RESULTS: A total of 234 Latarjet procedures were performed in 234 patients. The overall recurrent instability rate was 15.8% (37/234), the overall reoperation rate was 16.7% (36/234), and the overall complication rate was 14.2% (33/234) over a mean 5.0 years of follow-up. There were 99 PL procedures and 135 SL procedures. The SL group had significantly more recurrent instability than the PL group (SL 28/135, 20.7%; PL 9/99, 9.1%; P = .0158). There was no difference in overall reoperation rates (SL 26/135, 19.3%; PL 13/99, 13.1%; P = .2140) or complication rates (SL 20/135, 14.8%; PL 13/99, 13.3%; P = .9101). CONCLUSION: The rate of recurrent instability following the Latarjet procedure in an active, high-risk population is 15.8%. Primary Latarjet was found to have lower rates of recurrence compared with salvage Latarjet procedures (9.1% versus 20.7%). LEVEL OF EVIDENCE: III.

A Biomechanical Comparison of High-Tensile Strength Tape Versus High-Tensile Strength Suture for Tendon Fixation Under Cyclic Loading.

PURPOSE: To compare the biomechanical properties of high-tensile strength tape and high-tensile strength suture across 2 selected stitch techniques, the Krackow and whip stitch, in securing tendinous tissue during 5,000 cycles of nondestructive loading followed by a load to failure. METHODS: Fourteen matched pairs each of cadaveric Achilles, quadriceps, and patellar tendons (n = 84) were randomly assigned to either Krackow or whip stitch and sutured with either 2-mm high-tensile strength tape or No. 2 high-tensile strength suture. Specimens were preloaded to 20 N, cyclically loaded from 20 to 200 N for 5,000 cycles at 2 Hz, and then loaded to failure at 200 mm/min. Linear mixed models evaluated the effects of suture material and stitch technique on cyclic normalized tendon-suture elongation, total normalized tendon-suture elongation at 5,000 cycles, and maximum load at failure. RESULTS: Across all suture constructs, normalized elongation was greater during the initial 10 cycles, compared with all subsequent cycling intervals (all P < .001). There was less total normalized elongation (ß = -0.239; P = .007) and greater maximum load at failure in tape (ß = 163.71; P = .014) when used in the Krackow stitch compared with the whip stitch. CONCLUSIONS: Our findings indicate that tape used in the Krackow stitch maintains the most favorable fixation strength after enduring cyclic loading, with greater maximum load at failure. In addition, overall normalized elongation during long-term cyclic loading was predominately affected by the stitch technique used, regardless of the suture material; however, tape allowed less normalized elongation during the initial loading cycles, especially when placed in the whip stitch. CLINICAL RELEVANCE: Understanding the potential short- and long-term outcomes of suture material and stitch technique on securing tendinous tissue under repetitive stresses can help inform clinicians on optimal tendon fixation techniques for early postoperative activities.