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01241398-201306000-0001201241398_2013_33_409_schneppendahl_biodegradable_4miscellaneous-article< 112_0_12_6 >Journal of Pediatric Orthopaedics© 2013 by Lippincott Williams & WilkinsVolume 33(4)June 2013p 409–414The Use of Biodegradable Sutures for the Fixation of Tibial Eminence Fractures in Children: A Comparison Using PDS II, Vicryl and FiberWire[Trauma]Schneppendahl, Johannes MD*; Thelen, Simon MD*; Twehues, Sören MD*; Eichler, Christian MD†; Betsch, Marcel MD*; Windolf, Joachim MD, PhD*; Hakimi, Mohssen MD, PhD*; Wild, Michael MD, PhD‡*Department of Trauma and Hand Surgery, Heinrich Heine University Hospital Düsseldorf, Düsseldorf†Department of Anatomy II, University of Cologne, Cologne‡Department of Trauma and Orhopaedic Surgery, Klinikum Darmstadt, Darmstadt, GermanyNone of the authors received financial support for this study.The authors declare no conflict of interest.Reprints: Simon Thelen, MD, Department of Trauma and Hand Surgery, Heinrich Heine University Hospital Düsseldorf, Moorenstrasse 5, Düsseldorf 40225, Germany. E-mail: .AbstractBackground: Arthroscopic suture fixation of tibial eminence fractures using FiberWire is a favorable therapeutic option. The application of biodegradable material may be of advantage especially during childhood. The aim of this study was to evaluate the biomechanical properties using the biodegradable suture materials PDS II and Vicryl compared with FiberWire.Methods: Bone mineral density was evaluated by pqCT in 18 human knee specimens and 3 similar groups were formed. A standardized anterior tibial eminence fracture was created and suture fixation was performed using each suture material (PDS II, Vicryl, FiberWire) in 6 specimens. Cyclic testing and destructive loading to failure was conducted.Results: Both testing modalities showed PDS II to be inferior to the other evaluated suture materials. Although significantly higher failure loads were seen with FiberWire sutures, Vicryl yielded comparable stiffness in load-to-failure testing. No significant differences between Vicryl and FiberWire could be observed under nondestructive cyclic conditions.Conclusions: Even though FiberWire yields a superior ultimate failure load, Vicryl presented comparable results under cyclic conditions.Clinical Relevance: For tibial eminence fractures in children, Vicryl should be considered as an alternative biodegradable suture material. The use of PDS II cannot be advocated.A fracture of the tibial eminence is a serious injury to the knee and is a consequence of extreme anterior cruciate ligament (ACL) tension that results in tibial bone avulsion rather than ACL rupture.1 Immature epiphyseal bone offers less resistance to traction forces than the ACL substance.2 For this reason, the majority of these injuries are reported in skeletally immature patients and several studies reported on children and adolescents only.3–5Because of the loss of continuity of the ACL complex, displaced avulsion fractures of the tibial eminence may result in knee instability and the avulsed fragment may cause mechanical irritation and complete blocking of knee extension.4,6–9 Different options for open reduction and internal fixation were described7,10,11 and various arthroscopic options were presented over the last decades.4,12–18 Studies comparing biomechanical properties of different fixation options have shown superior results for suture fixation using FiberWire over other techniques.19,20In skeletally immature patients, all efforts must be made to spare the epiphysis and avoid growth disturbances and adverse effects caused by persisting foreign material.21 Although fixation of tibial eminence fractures using biodegradable sutures may be advantageous in this context, it has not yet been sufficiently investigated and discussed in literature with respect to its biomechanical properties.22The purpose of this study was to compare the biomechanical properties using 2 different biodegradable materials compared with FiberWire for the fixation of tibial eminence fractures. We performed transtibial fixation by guiding the suture through the ACL and tested FiberWire No. 5, Vicryl No. 5, and PDS II No. 2. It was hypothesized that biodegradable suture materials would yield similar stability of the ACL-tibia complex compared with FiberWire.METHODSAfter approval from the institutional review board was obtained to perform this study, 18 human cadaver knees preserved in formalin-based dilution for <6 months were used for biomechanical testing. The average donor age was 75.4 (SD±6.0; range 69 to 87) years. The mean trabecular bone mineral density (BMD) at the site of the osteotomy was determined using a peripheral quantitative computed tomography scanner (pqCT: XCT 3000; Stratec Medizintechnik GmbH, Pforzheim, Germany). Three study groups with a similar mean BMD were created (Table 1). Muscles and soft tissue, the patellar complex, collateral ligaments, and the posterior cruciate ligament were removed leaving only the ACL intact, allowing an isolated biomechanical investigation of the suture fixation of the ACL-tibia complex.TABLE 1 Trabecular Bone Mineral Density Evaluated by pqCTOsteotomies at the base of the tibial eminence were created as described previously.23Suture fixation was performed using a technique described by Berg,24 Medler and Jansson,25 and Matthews and Geissler.26 The fragment was reduced and held in its original location manually. Using a 1.4-mm stainless steel drill, 2 parallel running holes were placed through the medial proximal tibia to the medial and lateral side of the fragment. Suture material was placed through the ACL proximal to the insertion using a needle. Using a suture retriever, the suture material was passed through the tibial drill holes. After reduction of the tibial eminence, the suture material was tightly knotted over the bony bridge between the tibial drill holes at the medial side of the proximal tibia (Fig. 1).FIGURE 1. Osteotomy and suture fixation.FiberWire No. 5 (Arthrex Inc., Naples, FL) with a diameter of 0.7 mm was used as the reference material. It consists of an ultra high molecular weight polyethylene multifilament core with braided polyester jacket and has demonstrated superior characteristics compared with other suture materials and fixation techniques in previous biomechanical studies.19,20PDS II No. 2 and Vicryl No. 5 (Ethicon Inc., Somerville, NJ) represented the biodegradable suture materials. PDS II No. 2 has a diameter of 0.5 mm and is a monofilament polydioxanone suture. It provides 70% strength retention at 4 weeks and an absorption time of 183 to 238 days (manufacturer information). Vicryl No. 5 has a diameter of 0.7 mm and is a braided polyglactin 910 suture material providing 50% strength retention at 3 weeks and an absorption time of 56 to 70 days (manufacturer information).All specimens were mounted in a custom-made test setup described previously.23 Load was applied and displacement was measured using an electrodynamic material-testing machine (Instron Ltd., Model 5565, High Wycombe, UK). Testing was performed keeping the knee in a 30-degree flexed position and anterior shear force was applied to create anterior tibial displacement (Fig. 2).FIGURE 2. Testing setup.All experiments were started from a preload of 5 N. Cyclic loading was performed under constant recording of the elapsed time (s), the applied load (N), and the travel distance of the load frame (mm) using Merlin 2 software. Specimens underwent 200 cycles between 5 and 150 N with a displacement rate of 200 mm/min. A total of 200 cycles was chosen, as preliminary testing over 1000 cycles did not show any further changes after 100 cycles. A maximum load of 150 N was used, as forces up to 150 N appear at the ACL complex during activities of daily living.27 The achievement of a steady state, at which the traveled distance of the load frame between the maximum and minimum loads would no longer change, was the desired result. Inadequate suture elongation leading to a fragment dislocation of >2 mm, torn suture material, or a pull out of the suture was defined as failure (Fig. 3).FIGURE 3. Osteotomy and suture placement.After cyclic testing, a destructive load-to-failure test was performed. The resulting curve of load over elongation was recorded and ultimate failure load, elongation at failure, and stiffness were evaluated. Stiffness was determined as the maximum gradient in the linear (elastic) region of the load elongation curve.In the destructive tests, failure was defined as a sudden decrease of >20% in the stress-strain curve, torn suture material, or a pull out of the suture. The type of failure was determined by video analysis.Statistics were evaluated using the VassarStats statistical calculators. The distributions of differences in the population were assumed to approximate the normal (Gaussian) distribution that was confirmed using the Kolmogorov-Smirnov test. An unpaired t test for independent variables was performed. The possibility of a type 1 error was eliminated by an additional analysis of variance analysis. Statistical boundaries were a confidence interval of 95% and a significance level of P<0.05.RESULTSTrabecular BMDOverall mean BMD was 235.1 (±38.5; range 169.5 to 293.8) mg/cm3 and study groups were assorted with respect to the bone density to create comparable preconditions (Table 1).Failure ModeDuring cyclic testing, 4 of the 6 specimens of the PDS group failed because of suture rupture. None of the specimens in the other groups failed during cyclic testing. The 2 remaining fixations in the PDS group showed suture failure during load-to-failure testing. All 6 specimens of the FiberWire group and 5 of 6 of the Vicryl group failed because of fracture of the tibial eminence component with subsequent suture pull out. One of the Vicryl group samples showed a suture rupture.Cyclic TestingDuring dynamic testing, both the number of cycles needed to achieve steady state and the initial stiffness were evaluated. Although a steady state was reached in all specimens of the FiberWire and Vicryl groups, this state could only be achieved in 4 of 6 specimens in the PDS group. However, these 4 specimens in the PDS group were also classified as failure as the suture elongation led to a fragment dislocation of >2 mm. Although the number of cycles needed to reach a steady state did not differ significantly between the FiberWire and Vicryl groups (P=0.926), the PDS group was significantly inferior (P<0.05) (Table 2). All specimens in the FiberWire and Vicryl groups finished the cyclic testing intact and did not fulfill the mentioned failure criteria.TABLE 2 Results of Cyclic TestingLoad-to-Failure TestingAfter cyclic testing, the PDS samples had elongated so far (>2 mm) that they were excluded from the transient analysis.Reaching an average failure load of 306.3 N, the FiberWire group was significantly superior to the Vicryl group yielding 220.5 N (P=0.021). No significant differences in mean stiffness between the FiberWire group and the Vicryl group could be demonstrated (P=0.066) (Table 3).TABLE 3 Results of Load-to-Failure TestingDISCUSSIONIn displaced fractures of the tibial eminence, surgical treatment is warranted1,6,8,25,26 and several different procedures using various implants are described.4,7,10–18 Because of a high incidence in childhood and adolescence, sparing of the growth plate is essential in the treatment of these injuries and therapy should be minimally invasive.4,9,28 Arthroscopic fixation using suture material seems to be a favorable option considering the functional and biomechanical properties17,19,20,22,29 and FiberWire appears to be superior to other suture materials.19 However, FiberWire is nonabsorbable and can cause a mild histologic response with necrotic areas in surrounding tissue.21 Although not proven, because of its rigidity, it could theoretically even cause growth alterations when crossing the epiphysis. Modification of this technique using biodegradable suture material may have advantages for the application in childhood as no foreign material would remain.Depending on the activity, in situ forces on the native ACL are estimated to be between 30 and 450 N.27,30,31 Although forces up to 150 N occur at the ACL during activities of daily living, up to 450 N may appear during activities such as descending stairs or jogging.27,30,31 Hence, a tibial eminence avulsion fixation needs to withstand approximately 150 N repeatedly to allow adequate controlled postsurgical treatment. According to the demonstrated data, suture fixation using FiberWire or Vicryl initially meets this mechanical load requirement.Investigating the initial strength of different fixation techniques for tibial eminence fractures in a porcine knee model, Eggers et al19 demonstrated superior results for suture fixation using FiberWire under load-to-failure and cyclic conditions. Using a bovine knee model, Mahar et al32 did not show significant differences in initial strength between fixation using Ethibond sutures, bioabsorbable nails, resorbable screws, and metal screws. Although in these biomechanical studies porcine or bovine specimens were used, we believe that the distinct anatomy of the human ACL complex can hardly be simulated using knees of a quadruped.19,32The authors were aware of only 2 biomechanical studies that investigated fixation of tibial eminence fractures in a human cadaveric model. Using 7 matched pairs of fresh-frozen knees, Bong et al20 found suture fixation using FiberWire No. 2, significantly superior to screw fixation yielding ultimate strength of 319 N (±125 N). However, Bong and colleagues did not describe the factors relevant for matching of the specimens and performed load-to-failure testing only. Although in 6 specimens sutures failed by cutting through bone, 1 failed by ACL tear. As cyclic testing was not performed, no statement concerning the performance under repetitive physiological loads could be made.20 Comparing suture fixation to antegrade and retrograde screw fixation in a human cadaveric model, Tsukada et al33 showed slight advantages of antegrade screw fixation over suture fixation. However, they did not test the biomechanical properties of an isolated ACL. Therefore, the results of this study must be interpreted cautiously as the data could have been influenced by other stabilizing structures. In addition, matching was done by donor age only and did not include BMD, no destructive loading to failure was performed and the cyclic testing was performed up to a load of 100 N only.33 As peak forces up to 150 N occur during activities of daily living such as walking, this setup did not cover early rehabilitation with early mobilization.27One limitation of this study is the use of embalmed specimens. As a reactive electrophilic chemical, formalin reacts by cross-linking functional groups in tissue proteins, polysaccharides, and nucleic acid creating irreversible methylene crosslinks.34 There is evidence that formalin, thereby, alters mechanical properties of bone.35–37 However, Stefan et al37 presented biomechanical data showing similar elastic energy absorption for formalin-fixed and fresh-frozen bone, whereas the plastic energy absorption is significantly decreased for embalmed specimens. van Haaren et al38 did not find significant differences in the mechanical properties of frozen and embalmed bone and they suggested either of the use in biomechanical studies.The relatively high donor age of 75.4 years (SD±6.0) is a limitation of this study as tibial eminence fractures are predominantly diagnosed in children and adolescents. To minimize individual differences and to allow a high comparability, pqCT examinations were performed on all specimens. Then groups with similar composition of bone mineral density (BMD) were created. Upon formalin fixation of bone, the histologic structure and density seems not to be affected.39,40 Furthermore, pqCT provides good prediction of the bone failure load in embalmed specimens and BMD has been shown not to be altered by formalin fixation.37,38,41 Despite the limitations mentioned, the trabecular BMD measured in this study is comparable to the reported values in tibiae of prepubescent children.42 By minimizing individual differences and creating homogenous study groups, a high comparability could be achieved. This is the first study on tibial eminence fractures using pqCT-matched groups. Nonetheless, as failure in the Vicryl and FiberWire group was predominantly due to fracture of the bony fragment, the presented data should be interpreted cautiously.PDS was previously used for fixation of tibial eminence fractures with good clinical and functional results.22 At present, no biomechanical data on suture fixation of tibial eminence fractures using PDS II exists. The use of PDS II, smaller in diameter than Vicryl and FiberWire, is because of the lack of larger sizes of available PDS II. This may shorten the comparability to the other materials tested and the presented data must be interpreted cautiously. However, our data suggest that because of its elastic properties resulting in a remarkable suture elongation with fragment dislocation, a steady state cannot be achieved reliably during cyclic testing. In addition, PDS II No. 2 does not provide enough strength to sustain the loads during early mobilization and can therefore not be recommended for use in fixation of tibial eminence fractures.The authors are not aware of any study using Vicryl for suture fixation of tibial eminence fractures. For decades, Vicryl sutures have been used widely and good biocompatibility was reported.43,44 However, the relatively fast biodegradation of Vicryl narrows its potential application to tissues with fast regeneration capabilities. Therefore, Vicryl may be a suitable biodegradable suture material for fixation of these fractures at young ages, considering the fast consolidation of fractures during childhood. By reliably achieving steady state after a similar number of cycles, Vicryl provides comparable results to FiberWire. During load-to-failure testing, Vicryl yields inferior failure loads than FiberWire. Nonetheless, by providing a mean failure load of 220 N without significant differences in stiffness compared with FiberWire, Vicryl could be considered as a biodegradable suture alternative for the fixation of tibial eminence fractures.CONCLUSIONSThe design of this study was based on the hypothesis that biodegradable suture materials provide similar stability to FiberWire. Even though FiberWire yields superior ultimate failure loads by sustaining the expected loads during postoperative rehabilitation, Vicryl proved to be a possible biodegradable alternative. Because of its poor biomechanical properties, the use of PDS II No. 2 cannot be advocated.ACKNOWLEDGMENTThe authors thank Prof Dr Jürgen Koebke for his support during this study.REFERENCES1. Ahmad CS, Stein BE, Jeshuran W, et al. Anterior cruciate ligament function after tibial eminence fracture in skeletally mature patients. Am J Sports Med. 2001;29:339–345 [Medline Link] [Context Link]2. Woo SL, Hollis JM, Adams DJ, et al. 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Link]|01241398-201306000-00012#xpointer(id(R13-12))|11065213||ovftdb|SL0000186820011745011065213P72[CrossRef]|01241398-201306000-00012#xpointer(id(R13-12))|11065405||ovftdb|SL0000186820011745011065405P72[Medline Link]|01241398-201306000-00012#xpointer(id(R14-12))|11065213||ovftdb|SL0004366020071585711065213P73[CrossRef]|01241398-201306000-00012#xpointer(id(R14-12))|11065405||ovftdb|SL0004366020071585711065405P73[Medline Link]|01241398-201306000-00012#xpointer(id(R15-12))|11065213||ovftdb|SL000436602001934611065213P74[CrossRef]|01241398-201306000-00012#xpointer(id(R15-12))|11065405||ovftdb|SL000436602001934611065405P74[Medline Link]|01241398-201306000-00012#xpointer(id(R16-12))|11065405||ovftdb|SL00007547200410752511065405P75[Medline Link]|01241398-201306000-00012#xpointer(id(R17-12))|11065213||ovftdb|SL00002228200512527211065213P76[CrossRef]|01241398-201306000-00012#xpointer(id(R17-12))|11065404||ovftdb|SL00002228200512527211065404P76[Full Text]|01241398-201306000-00012#xpointer(id(R17-12))|11065405||ovftdb|SL00002228200512527211065405P76[Medline Link]|01241398-201306000-00012#xpointer(id(R18-12))|11065213||ovftdb|SL00001868200824123911065213P77[CrossRef]|01241398-201306000-00012#xpointer(id(R18-12))|11065405||ovftdb|SL00001868200824123911065405P77[Medline Link]|01241398-201306000-00012#xpointer(id(R19-12))|11065213||ovftdb|00000475-200703000-00007SL0000047520073540411065213P78[CrossRef]|01241398-201306000-00012#xpointer(id(R19-12))|11065404||ovftdb|00000475-200703000-00007SL0000047520073540411065404P78[Full Text]|01241398-201306000-00012#xpointer(id(R19-12))|11065405||ovftdb|00000475-200703000-00007SL0000047520073540411065405P78[Medline Link]|01241398-201306000-00012#xpointer(id(R20-12))|11065213||ovftdb|SL00001868200521117211065213P79[CrossRef]|01241398-201306000-00012#xpointer(id(R20-12))|11065405||ovftdb|SL00001868200521117211065405P79[Medline Link]|01241398-201306000-00012#xpointer(id(R21-12))|11065404||ovftdb|SL0000634320093282811065404P80[Full Text]|01241398-201306000-00012#xpointer(id(R21-12))|11065405||ovftdb|SL0000634320093282811065405P80[Medline Link]|01241398-201306000-00012#xpointer(id(R22-12))|11065213||ovftdb|SL0004366020031125511065213P81[CrossRef]|01241398-201306000-00012#xpointer(id(R22-12))|11065405||ovftdb|SL0004366020031125511065405P81[Medline Link]|01241398-201306000-00012#xpointer(id(R23-12))|11065213||ovftdb|SL00043660201120209211065213P82[CrossRef]|01241398-201306000-00012#xpointer(id(R24-12))|11065213||ovftdb|SL000018681993944611065213P83[CrossRef]|01241398-201306000-00012#xpointer(id(R24-12))|11065405||ovftdb|SL000018681993944611065405P83[Medline Link]|01241398-201306000-00012#xpointer(id(R25-12))|11065213||ovftdb|SL0000186819941029211065213P84[CrossRef]|01241398-201306000-00012#xpointer(id(R25-12))|11065405||ovftdb|SL0000186819941029211065405P84[Medline Link]|01241398-201306000-00012#xpointer(id(R26-12))|11065213||ovftdb|SL0000186819941041811065213P85[CrossRef]|01241398-201306000-00012#xpointer(id(R26-12))|11065405||ovftdb|SL0000186819941041811065405P85[Medline Link]|01241398-201306000-00012#xpointer(id(R27-12))|11065213||ovftdb|SL00004617197035111065213P86[CrossRef]|01241398-201306000-00012#xpointer(id(R27-12))|11065405||ovftdb|SL00004617197035111065405P86[Medline Link]|01241398-201306000-00012#xpointer(id(R30-12))|11065405||ovftdb|SL000017021969457311065405P89[Medline Link]|01241398-201306000-00012#xpointer(id(R31-12))|11065405||ovftdb|SL00004623197456140611065405P90[Medline Link]|01241398-201306000-00012#xpointer(id(R32-12))|11065213||ovftdb|01241398-200803000-00006SL0000469420082815911065213P91[CrossRef]|01241398-201306000-00012#xpointer(id(R32-12))|11065404||ovftdb|01241398-200803000-00006SL0000469420082815911065404P91[Full Text]|01241398-201306000-00012#xpointer(id(R32-12))|11065405||ovftdb|01241398-200803000-00006SL0000469420082815911065405P91[Medline Link]|01241398-201306000-00012#xpointer(id(R33-12))|11065213||ovftdb|SL00001868200521119711065213P92[CrossRef]|01241398-201306000-00012#xpointer(id(R33-12))|11065405||ovftdb|SL00001868200521119711065405P92[Medline Link]|01241398-201306000-00012#xpointer(id(R34-12))|11065213||ovftdb|SL0000486119853384511065213P93[CrossRef]|01241398-201306000-00012#xpointer(id(R34-12))|11065405||ovftdb|SL0000486119853384511065405P93[Medline Link]|01241398-201306000-00012#xpointer(id(R36-12))|11065213||ovftdb|SL00001694199516126711065213P95[CrossRef]|01241398-201306000-00012#xpointer(id(R36-12))|11065405||ovftdb|SL00001694199516126711065405P95[Medline Link]|01241398-201306000-00012#xpointer(id(R40-12))|11065405||ovftdb|SL0000015019663714111065405P99[Medline Link]|01241398-201306000-00012#xpointer(id(R41-12))|11065213||ovftdb|SL0000222520023084211065213P100[CrossRef]|01241398-201306000-00012#xpointer(id(R41-12))|11065405||ovftdb|SL0000222520023084211065405P100[Medline Link]|01241398-201306000-00012#xpointer(id(R42-12))|11065213||ovftdb|SL00002225200536101211065213P101[CrossRef]|01241398-201306000-00012#xpointer(id(R42-12))|11065405||ovftdb|SL00002225200536101211065405P101[Medline Link]|01241398-201306000-00012#xpointer(id(R43-12))|11065213||ovftdb|SL0000653420011073811065213P102[CrossRef]|01241398-201306000-00012#xpointer(id(R43-12))|11065404||ovftdb|SL0000653420011073811065404P102[Full Text]|01241398-201306000-00012#xpointer(id(R43-12))|11065405||ovftdb|SL0000653420011073811065405P102[Medline Link]11176599The Use of Biodegradable Sutures for the Fixation of Tibial Eminence Fractures in Children: A Comparison Using PDS II, Vicryl and FiberWireSchneppendahl, Johannes MD; Thelen, Simon MD; Twehues, Sören MD; Eichler, Christian MD; Betsch, Marcel MD; Windolf, Joachim MD, PhD; Hakimi, Mohssen MD, PhD; Wild, Michael MD, PhDTrauma433