Avulsion fractures of the tip of the olecranon are a common traumatic injury. Kirshner-wire fixation (1.6mm) with a figure of eight tension band wire (1.25mm) remains the most popular technique. Hardware removal mat be required in up to 80% of cases. Modern suture materials have very high tensile strength coupled with excellent usability. In this study we compare a repair using 1.6mm k-wires with a 1.25mm surgical steel, against a repair that uses two strands of 2 fibrewire.

Twelve Pairs of cadaveric arms were harvested. A standard olecranon osteotomy was performed to mimic an avulsion fracture. In each pair one was fixed using standard technique, 2 × 1.6mm transcortical ?-wire plus figure of 8 loop of 1.25mm wire. The other fixed with the same ?-wires with a tension band suture of 2.0 fibrewire (two loops, one figure of 8 and one simple loop). The triceps tendon was cyclically loaded (10-120 Newtons) to simulate full active motion 2200 cycles. Fracture gap was measured with the ‘Smart Capture’ motion analysis system. The arm was fixed at 90 degrees and triceps tendon was loaded until fixation failure, ultimate load to failure and mode of failure was noted.

The average gap formation at the fracture site for the suture group was 0.91mm, in the wire group 0.96mm, no specimen in either group produced a significant gap after cyclical loading. Mean load to failure for the suture group was 1069 Newtons (SD=120N) and in the wire group 820 Newtons (SD=235N).

Both types of fixation allow full early mobilisation without gap formation. The Suture group has a significantly higher load to failure (p=0.002, t-test). Tension Band suture allows a lower profile fixation, potentially reducing the frequency of wound complications and hardware removal.

We present a biomechanical cadaveric study investigating the effect of type II Superior Labrum Anterior Posterior (SLAP) lesions on the load-deformation properties of the Long Head of Biceps (LHB) and labral complex. We also report our assessment of whether repair of the type II SLAP lesion restored normal biomechanical properties to the superior labral complex.

Using a servo-controlled hydraulic material testing system (Bionix MTS 858, Minneapolis, MA), we compared the load-deformation properties of the LHB tendon with:

the LHB anchor intact;

Seven fresh-frozen, cadaveric, human scapulae were tested. We found that the introduction of a type II SLAP lesion significantly increased the toe region of the load deformation curve compared to the labral complex with an intact LHB anchor. The repair techniques restored the stiffness of the intact LHB but failed to reproduce the normal load versus displacement profile of the labral complex with an intact LHB anchor.

Of the two suture techniques, the mattress suture best restored the normal biomechanics of the labral complex.

We conclude that a type II SLAP lesion significantly alters the biomechanical properties of the LHB tendon. Repair of the SLAP lesion only partially restores the biomechanical properties. We hypothesise that repairs of type II SLAP lesions may fail at loads as low as 150N, hence the LHB should be protected following surgery.

Fibular head avulsion fractures represent a significant injury to the posterolateral corner of the knee. There is a high rate of concomitant injuries including rupture of the cruciate ligaments. Surgical fixation is indicated to restore stability, protect repaired or reconstructed cruciate ligaments and possibly decrease the likelihood of degenerative change. The current presentation describes a novel technique which provides secure fixation to the fibular head, restoring integrity of the posterolateral ligament complex and facilitating early motion. We also present a case series of our experience by a single surgeon at our tertiary referral center. Twenty patients underwent open reduction and internal fixation between 2006 and 2016 using a large fragment cannulated screw and soft tissue washer inserted obliquely from the proximal fibula to tibia. Fixation was augmented with suture repair of the lateral collateral ligament and biceps tendon. The orientation of the fracture was assessed based on preoperative imaging. Repair / reconstruction of concomitant injuries was performed during the same procedure. Early range of motion was initiated at 2 weeks postoperatively under physical therapy guidance. All patients returned for clinical and radiographic assessment (average 3.5 years). All fractures went on to bony union. There were no reoperations for recurrent instability. All patients regained functional range of motion with mean extension of 0.94 degrees and mean flexion of 121.4 degrees. Two patients underwent hardware removal. One patient developed a late local infection, which occurred greater than 5 years after surgery. Eleven patients underwent postoperative varus stress radiographs which demonstrated less than 1 mm difference between the operated and contralateral side. Fracture morphology typically demonstrated an oblique pattern in the coronal plane and a transverse pattern in the sagittal plane. This study represents a novel surgical technique for the repair of fibular head avulsion fractures with a large fragment cannulated screw placed obliquely from the fibula to tibia. Fixation is augmented with a soft tissue washer and suture repair. Our results suggest that this technique allows for early range of motion with maintenance of reduction, high rates of union, and excellent postoperative stability

It is unusual to require the use of a total knee implant with more constraint than a posterior-stabilised post in primary knee arthroplasty. The most common indication is a knee with a severe deformity, usually fixed valgus with an incompetent medial collateral ligament, and an inability to correctly balance the knee in both flexion and extension. The pre-operative deformity is usually greater than 15–20 degrees fixed valgus and may be associated with a severe flexion contracture. This is usually seen in an elderly female patient with advanced osteoarthritis. Those pre-operative diagnoses more likely to require a constrained design include advanced rheumatoid arthritis, true neuropathic joint, and the “Charcot-like” joint due to bone loss or crystalline arthritis. Rarely, patients with periarticular knee Paget's disease of bone may require more constraint following correction of a severe deformity through the knee joint. Beware those patients with a staple or screw at the medial epicondyle or those with severe heterotopic ossification at the medial joint line, as this may signify a serious prior injury to the medial collateral ligament. Finally, there is a possibility of inadvertent division of the medial collateral ligament intra-operatively. Although this situation may be treated with suture repair and bracing, my choice is to switch to more constraint and early unbraced motion. There are over 20 designs of varus-valgus constrained components, with a variety of tibial post designs with specific rotary and angular biomechanics, and many have the option of adding modular stems. Our experience with constrained, non-linked designs has been favorable with both the use of nonmodular and modular stem extensions. Longer-term survival analysis has shown a 96% survival at 10 years with these constrained components. However, the older designs frequently required a lateral retinacular release for proper patella tracking, and there were patella complications (fracture and osteonecrosis) in 16%. With a more modern design, over the past 12 years, the need for a lateral retinacular release and patella complications have been notably decreased. Varus-valgus constrained components have a small but important role in primary total knee arthroplasty for patients with severe deformity or an incompetent medial collateral ligament

The absence of menisci in the knee leads to early degenerative changes. Complete radial tears of the meniscus are equivalent to total meniscectomy and repair should be performed if possible. The purpose of this study was to biomechanically compare the cross suture, hashtag and crosstag meniscal repairs using all-inside implants for radial tears. Radial tears were created at the mid-body of 36 fresh-frozen lateral human menisci and then repaired, in randomiSed order, with Fast-Fix™ 360s (Smith & Nephew, Andover, MA) using the cross suture, hashtag and crosstag techniques. The repaired menisci were tested using an Instron Electropuls E10000 (Instron, Norwood, MA). The tests consisted of cyclic loading from 5 to 30N at 1Hz for 500 cycles, then a load to failure test. Displacement following cyclic loading, load at 3mm of displacement, load to failure, and stiffness were recorded. Any differences between repairs were assessed using Kruskal-Wallis and Mann Whitney tests (p<0.05). Cross suture repairs displaced more following cyclic loading and resisted less load to failure than both the hashtag and crosstag repairs. However, these differences were not statistically significant. The average displacement following cyclic loading of cross suture, hashtag, and crosstag repairs was 4.34 mm (±2.02 mm), 3.46 mm (±2.12 mm), and 3.24 mm (±1.52 mm) respectively (p=0.33). Maximal load to failure was 64.83 N (±17.41 N), 74.52 N (±9.03 N), and 74.98N (±10.50N), respectively (p=0.419). All-inside cross suture, hashtag and crosstag repairs all displaced >3mm with cyclic loading, which is the threshold for meniscal insufficiency. This contrasts previous studies using inside-out sutures, where crosstag and hashtag repairs resisted cyclic loading (< 3mm). Inside-out suturing for radial tears of the lateral meniscus currently remains the gold standard

Treatment of acute Achilles tendon rupture is based on obtaining and maintaining apposition of the ruptured tendon ends. Surgical treatment utilises direct suture repair to produce this objective, while conservative or non-surgical management achieves the same effect of closing the tendon gap by immobilisation of the ankle joint in a plantar flexed position within a plaster cast or POP. There is still variability in the conservative treatment practices and protocols of acute Achilles tendon ruptures. The purpose of this study is to examine the current practice trends in the treatment of Achilles tendon ruptures amongst orthopaedic surgeons in the UK. A postal questionnaire was sent to 221 orthopaedic consultants in 25 NHS hospitals in the Greater London area in June 2010. Type and duration of immobilisation were considered along with the specifics of the regime used. Ninety questionnaires were returned giving a 41% response rate. Conservative treatment methods were used by 72% of respondents. A below knee plaster was the top choice of immobilisation (83%) within this group. The mean period of immobilisation was 9.2 weeks (Range 4-36). Weight bearing was allowed at a mean of 5.3 weeks (range 0-12). The specific regime used by consultants was quite heterogeneous across the group, however the most used immobilisation regimen was a below knee plaster in equinus with 3 weekly serial plaster changes to a neutral position, for a total of nine weeks. A heel raise after plaster removal was favoured by 73% of respondents used for a mean period of 6.4 weeks (Range 2-36). In response to ultrasound use as a diagnostic tool, 42.4% of respondents would never use it, 7.6% would use it routinely, while 50% would use it only according to the clinical situation. Comparison of foot and ankle specialists with non-specialists did not reveal a significant difference in practice in duration of immobilisation or time to bearing weight. Conservative management remains a widely practice option in the treatment of Achilles tendon ruptures. Although there are available a number of modern walking aids, the concept of functional brace immobilisation is not as widely used as below knee plaster cast immobilisation, which remains a popular choice amongst orthopaedic surgeons today. There is still no consensus on the ideal immobilisation regimen although a below knee plaster in equinus with serial changes for a total of nine weeks is the most frequently used choice. Further randomised controlled trials are required to establish the optimal treatment strategy for conservative management of Achilles tendon rupture

The transosseous equivalent/Suture Bridge or TOE/SB repair has received much attention in recent years as more shoulder surgeons transition to all arthroscopic rotator cuff repairs. The purpose of this study was to compare the biomechanical behaviour of several variants of the Suture Bridge repair performed by the authors. Four different Suture Bridge constructs were performed six times on 24 sheep infraspinatus tendon humerus constructs. The first group was a standard Suture Bridge with two medial mattress stitches with knots (KSSB4). The second group had four medial mattress stitches with knots and was called KDSB8. The third group had two medial mattress stitches without knots and was called USBFT4. These first three repairs used two medial 5.5 mm Bio-Corkscrew FT Anchors and two lateral 3.5 mm PushLock Anchors (Arthrex). The fourth repair had two medial mattress stitches without knots and used all Pushlocks and was called USBP4. The repairs were then analysed for failure force, cyclic creep and stiffnessafter. Cycling was performed from 10 to 100 N at 1 Hz for 500 cycles. Following cyclic testing a single cycle pull to failure at 33 mm/sec was performed. The constructs were also observed for failure mechanism and gap formation using digital video recording. The KDSB8 repair with a mean failure force of 456.9N was significantly stronger than the USBP4 repair at 299.7N (P=0.023), the KSSB4 repair at 295.4N (P=0.019) and lastly the USBFT4 repair at 284.0N (P=0.011). There was no statistical difference between the measured failure force for the two mattress stitch KSSB4 repair with knots and the knotless two mattress stitch repairs USBFT4 and USBP4. There was not a statistical difference between any of the repairs for measured stiffness and cyclic creep. However, the KDSB8 repair showed no discernable gap formation or movement at the footprint during cyclic testing. The KSSB4, USBFT4 and USBP4 repairs demonstrated bursal sided gap formation in the range of 1 to 3 mm. Based on the results of this study the transosseous equivalent/Suture Bridge repair with four stitches tied in the medial row and maximal lateral suture strand utilization (KDSB8 TOE/SB) is the strongest. The KDSB8 also appeared to show less bursal sided gap formation and greater footprint stability than the other Suture Bridge constructs tested

Complete or nearly complete disruption of the attachment of the gluteus is seen in 10–20% of cases at the time of THA. Special attention is needed to identify the lesion at the time of surgery because the avulsion often is visible only after a thickened hypertrophic trochanteric bursa is removed. From 1/1/09 to 12/31/13, 525 primary hip replacements were performed by a single surgeon. After all total hip components were implanted, the greater trochanteric bursa was removed, and the gluteus medius and minimus attachments to the greater trochanter were visualised and palpated. Ninety-five hips (95 patients) were found to have damage to the muscle attachments to bone. Fifty-four hips had mild damage consisting of splits in the tendon, but no frank avulsion of abductor tendon from their bone attachments. None of these cases had severe atrophy of the abductor muscles, but all had partial fatty infiltration. All hips with this mild lesion had repair of the tendons with #5 Ticron sutures to repair the tendon bundles together, and drill holes through bone to anchor the repair to the greater trochanter. Forty-one hips had severe damage with complete or nearly complete avulsion of the gluteus medius and minimus muscles from their attachments to the greater trochanter. Thirty-five of these hips had partial fatty infiltration of the abductor muscles, but all responded to electrical stimulation. The surface of the greater trochanter was denuded of soft tissue with a rongeur, the muscles were repaired with five-seven #5 Ticron mattress sutures passed through drill holes in the greater trochanter, and a gluteus maximus flap was transferred to the posterior third of the greater trochanter and sutured under the vastus lateralis. Six hips had complete detachment of the gluteus medius and minimus muscles, severe atrophy of the muscles, and poor response of the muscles to electrical stimulation. The gluteus medius and minimus muscles were sutured to the greater trochanter, and gluteus maximus flap was transferred as in the group with functioning gluteus medius and minimus muscles. Postoperatively, patients were instructed to protect the hip for 8 weeks, then abductor exercises were started. The normal hips all had negative Trendelenburg tests at 2 and 5 years postoperative with mild lateral hip pain reported by 11 patients at 2 years, and 12 patients at 5 years. In the group of 54 with mild abductor tendon damage that were treated with simple repair, positive Trendelenburg test was found in 5 hips at 2 years and in 8 hips at 5 years. Lateral hip pain was reported in 7 hips at 2 years, and in 22 at 5 years. In the group of 35 hips with severe avulsion but good muscle tissue, who underwent repair with gluteus maximus flap transfer, all had good abduction against gravity and negative Trendelenburg tests at 2 and 5 years postoperative, and none had lateral hip pain. Of the 6 hips with complete avulsion and poor muscle who underwent abductor muscle repair and gluteus maximus flap transfer, all had weak abduction against gravity, mildly positive Trendelenburg sign, and mild lateral hip pain at 2 and 5 years postoperative. Abductor avulsion is uncommon but not rare, and is detected during THA only by direct examination of the tendon and removal of the trochanteric bursa. Simple repair of mild abductor tendon damage did not prevent progressive abductor weakness in some hips; and the increase in number of patients with lateral hip pain from 2 to 5 years suggests progressive deterioration. Augmentation of the repair with a gluteus maximus flap appears to provide a stable reconstruction of the abductor muscles, and seemed to restore abductor function in the hips with functioning muscles

Tendinopathy is a debilitating musculoskeletal condition which can cause significant pain and lead to complete rupture of the tendon, which often requires surgical repair. Due in part to the large spectrum of tendon pathologies, these disorders continue to be a clinical challenge. Animal models are often used in this field of research as they offer an attractive framework to examine the cascade of processes that occur throughout both tendon pathology and repair. This review discusses the structural, mechanical, and biological changes that occur throughout tendon pathology in animal models, as well as strategies for the improvement of tendon healing.

Cite this article: Bone Joint Res 2014;3:193–202.