In vitro and in vivo assessment of extended duration cathodic voltage-controlled electrical stimulation for treatment of orthopedic implant-associated infections

Effective treatment of orthopedic implant-associated infections (IAIs) remains a clinical challenge. The in vitro and in vivo studies presented herein evaluated the antimicrobial effects of applying cathodic voltage-controlled electrical stimulation (CVCES) to titanium implants inoculated with preformed bacterial biofilms of methicillin-resistant Staphylococcus aureus (MRSA). The in vitro studies showed that combining vancomycin therapy (500 µg/mL) with application of CVCES at -1.75 V (all voltages are with respect to Ag/AgCl unless otherwise stated) for 24 h resulted in 99.98% reduction in the coupon-associated MRSA colony-forming units (CFUs) (3.38 × 103 vs. 2.14 × 107 CFU/mL, p < 0.001) and a 99.97% reduction in the planktonic CFU (4.04 × 104 vs. 1.26 × 108 CFU/mL, p < 0.001) as compared with the no treatment control samples. The in vivo studies utilized a rodent model of MRSA IAIs and showed a combination of vancomycin therapy (150 mg/kg twice daily) with CVCES of -1.75 V for 24 h had significant reductions in the implant associated CFU (1.42 × 101 vs. 1.2 × 106 CFU/mL, p < 0.003) and bone CFU (5.29 × 101 vs. 4.48 × 106 CFU/mL, p < 0.003) as compared with the untreated control animals. Importantly, the combined 24 h CVCES and antibiotic treatments resulted in no implant-associated MRSA CFU enumerated in 83% of the animals (five out of six animals) and no bone-associated MRSA CFU enumerated in 50% of the animals (three out of six animals). Overall, the outcomes of this study have shown that extended duration CVCES therapy is an effective adjunctive therapy to eradicate IAIs.

Reverse total shoulder arthroplasty baseplate stability with locking vs. non-locking peripheral screws

BACKGROUND

There are many options for glenosphere baseplate fixation commercially available, yet there is little biomechanical evidence supporting one type of fixation over another. In this study, we compared the biomechanical fixation of a reverse total shoulder glenoid baseplate secured with locking or non-locking peripheral screws.

METHODS

Both a non-augmented mini baseplate with full backing support and an augmented baseplate were testing after implantation in solid rigid polyurethane foam. Each baseplate was implanted with a 30 mm central compression screw and four peripheral screws, either locking or non-locking (15 mm anterior/posterior and 30 mm superior/inferior). A 1 Hz cyclic force of 0-750 N was applied at a 60^o angle for 5000 cycles. Throughout the test, the displacement of the baseplate was measured using a 3D Digital Image Correlation System.

FINDINGS

The amount of migration measured in the both the non-augmented and augment cases shows no significant differences between locking and non-locking cases at the final cycle count (non-augment: 5.66 +/- 2.29 μm vs. 3.71 +/- 1.23 μm; p = 0.095, augment: 15.43 +/- 8.49 μm vs. 12.46 +/- 3.24 μm; p = 0.314). Additionally, the amount of micromotion measured for both sample types shows the same lack of significant difference (non-augment: 10.79 +/- 5.22 μm vs. 10.16 +/- 7.61 μm; p = 0.388, augment: 55.03 +/- 10.13 μm vs. 54.84 +/- 10.65 μm; p = 0.968).

INTERPRETATION

The presence of locking versus non-locking peripheral screws does not make a significant difference on the overall stability of a glenoid baseplate, in both a no defect case with a non-augmented baseplate and a bone defect case with an augmented baseplate.

Reverse Total Shoulder Arthroplasty Baseplate Stability in Superior Bone Loss With Augmented Implant

Background

Glenoid bone loss is commonly encountered in cases of rotator cuff tear arthropathy and can create challenges during reverse shoulder arthroplasty. In this study, we sought to investigate the biomechanical properties of a new treatment option for superior glenoid defect, an augmented reverse total shoulder baseplate.

Methods

Three conditions were examined: non-augmented baseplate without defect, non-augmented baseplate with defect, and augmented baseplate with defect. The augmented baseplates included a 30-degree half wedge which also matched the created superior defect. The samples were cyclically loaded at a 60^° simulated abduction angle to mimic baseplate loosening. The migration and micromotion of the baseplate were measured on the superior edge using a 3D Digital Image Correlation System.

Results

The migration measured in the augmented baseplate showed no significant difference when compared to the no defect or defect cases. In terms of micromotion, the augmented baseplate showed values that were between the micromotions reported for the no defect and defect conditions, but not by a statistically significant amount.

Conclusion

This study provides biomechanical evidence that augmented baseplates can reduce the amount of micromotion experienced by the RSA construct in the presence of significant superior glenoid bone deficiency, but do not fully restore stability to that of a full contact non-augmented baseplate.

Effect of radio frequency glow-discharge treatment of titanium on human gingival fibroblasts as a function of distance

The mechanical stability and long-term success of an implant depends on the early healing phase and osseointegration of the bone around it. In addition, a healthy gingival tissue around the implant acts as a barrier that prevents bacteria and pathological byproducts from reaching the implant site. This study investigated the in-vitro attachment and spreading of human gingival fibroblasts (HGF) on bacterial grade polystyrene (PS) at different distances from radio-frequency glow-discharge (RFGD)-treated commercially pure titanium (cpTi) specimens. Controls included sterile cpTi specimens without RFGD treatment. A second set of experiments utilized media transferred to new bacterial grade polystyrene dishes (no cpTi) after the medium was conditioned by exposure to cpTi, either with or without RFGD treatment, for 24 hr. Surface characterization of the dishes was conducted through contact angle measurements and infrared spectroscopy. Cell numbers and surface areas were determined from Image J analysis of multiple microscopic images of fixed, stained cells. The results showed significantly greater numbers and surface areas on bacterial grade PS dishes at distances up to 15 mm from the RFGD-treated cpTi groups than for the controls. Moreover, a significant effect of the conditioned medium from RFGD-treated cpTi versus control cultures was shown on the numbers of fibroblasts attached to bacterial grade polystyrene dishes after 24 hr (p < 0.005) and 48 hr (p = 0.002) incubation. Surface areas of cells exposed to conditioned medium were not significantly different (p ≥ 0.05). Surface characterization of the PS dishes showed a higher value of the critical surface tensions of the treated group when compared to the control group.

Electrochemical methods to enhance osseointegrated prostheses

Osseointegrated (OI) prosthetic limbs have been shown to provide an advantageous treatment option for amputees. In order for the OI prosthesis to be successful, the titanium implant must rapidly achieve and maintain proper integration with the bone tissue and remain free of infection. Electrochemical methods can be utilized to control and/or monitor the interfacial microenvironment where the titanium implant interacts with the biological system (host bone tissue or bacteria). This review will summarize the current understanding of how electrochemical modalities can influence bone tissue and bacteria with specific emphasis on applications where the metallic prosthesis itself can be utilized directly as a stimulating electrode for enhanced osseointegration and infection control. In addition, a summary of electrochemical impedance sensing techniques that could be used to potentially assess osseointegration and infection status of the metallic prosthesis is presented.

Reverse total shoulder glenoid baseplate stability with superior glenoid bone loss

BACKGROUND

Superior wear of the glenoid bone is common in patients with rotator cuff arthropathy. This can become a treatment challenge for patients who require shoulder arthroplasty. In reverse shoulder arthroplasty (RSA), glenoid bone loss may affect the stability of baseplate fixation. The primary purpose of this biomechanical laboratory study was to assess the initial fixation stability of RSA glenosphere baseplates in the presence of variable amounts of superior glenoid bone loss.

MATERIALS AND METHODS

High-density solid rigid polyurethane foam (30 pounds/cubic foot) was machined to model the glenoid with variable superior defects that provided different levels of support (100%, 90%, 75%, and 50%) for the glenosphere baseplate. The samples were cyclically loaded (0-750 N at 1 Hz for 5000 cycles) at a 60° glenohumeral angle. The micromotion and migration of the baseplate were calculated from displacement data captured during the loading tests with an array of 3 linear variable differential transformers mounted around the baseplate.

RESULTS

Micromotion was significantly greater in samples with 50% defects compared with those with smaller defects. Migration was significantly greater after testing for all defect sizes.

CONCLUSIONS

Initial fixation of RSA glenosphere baseplates was significantly reduced in models with 50% bone loss on the superior edge compared with models with less bone loss in this high-density bone foam model.

Bio-Corrosion of Magnesium Alloys for Orthopaedic Applications

Three Mg alloys, Mg–1.34% Ca–3% Zn (MCZ), Mg–1.34% Ca–3% Zn–0.2% Sr (MCZS), and Mg–2% Sr (MS), were examined to understand their bio-corrosion behavior. Electrochemical impedance spectroscopy and polarization scans were performed after 6 days of immersion in cell culture medium, and ion release and changes in media pH were tracked over a 28 day time period. Scanning electron microscopy (SEM) of alloy microstructure was performed to help interpret the results of the electrochemical testing. Results indicate that corrosion resistance of the alloys is as follows: MCZ > MCZS > MS.

Magnesium alloy AZ91 exhibits antimicrobial properties in vitro but not in vivo

Magnesium alloys hold great promise for developing orthopedic implants that are biocompatible, biodegradable, and mechanically similar to bone tissue. This study evaluated the in vitro and in vivo antimicrobial properties of magnesium-9%aluminum-1%zinc (AZ91) and commercially pure titanium (cpTi) against Acinetobacter baumannii (Ab307). The in vitro results showed that as compared to cpTi, incubation with AZ91 significantly reduced both the planktonic (cpTi = 3.45e8, AZ91 = 8.97e7, p < 0.001) colony forming units (CFU) and biofilm-associated (cpTi = 3.89e8, AZ91 = 1.78e7, p = 0.01) CFU of Ab307. However, in vivo results showed no significant differences in the CFU enumerated from the cpTi and AZ91 implants following a 1-week implantation in an established rodent model of Ab307 implant associated infection (cpTi = 5.23e3, AZ91 = 2.46e3, p = 0.29). It is proposed that the in vitro results were associated with an increased pH in the bacterial culture as a result of the AZ91 corrosion process. The robust in vivo buffering capacity likely diminished this corrosion associated pH antimicrobial effect. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 221-227, 2018.

The effect of fretting associated periodic cathodic potential shifts on the electrochemistry and in vitro biocompatibility of commercially pure titanium

This study explored how periodic cathodic polarization of commercially pure titanium (cpTi) alters its electrochemical properties and biocompatibility. MC3T3-E1 preosteoblast cells were cultured directly on cpTi samples and maintained at open circuit potential (OCP) for 24 h followed by an additional 24-h sequence of periodic cathodic polarization to -1000 or -750 mV (vs. Ag/AgCl) for 1 s followed by a 5-s recovery at OCP. Control experiments were performed where the samples were maintained at OCP throughout the entire test. Subsequent electrochemical impedance spectroscopy revealed both of the periodic cathodic polarization conditions significantly reduced the polarization resistance (R_p ), while only the -1000 mV condition significantly increased the capacitance (C) as compared to the controls. Scanning electron micrographs showed that the cells were fragmented and balled up on the samples periodically shifted to -1000 mV as compared to the cells that were well spread on the controls and samples periodically shifted to -750 mV. Additionally, live/dead fluorescence microscopy revealed that periodic polarizations to -1000 mV reduced cell viability to around 12% as compared to the greater than 95% cell viability observed on the controls and samples periodically polarized to -750 mV. This work showed that periodic cathodic potential shifts can notably alter the electrochemical behavior of cpTi and the viability and morphology of cells seeded directly onto its surface. © 2015 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 104B: 1591-1601, 2016.

Cathodic Voltage-controlled Electrical Stimulation Plus Prolonged Vancomycin Reduce Bacterial Burden of a Titanium Implant-associated Infection in a Rodent Model

BACKGROUND

Cathodic voltage-controlled electrical stimulation (CVCES) of titanium implants, either alone or combined with a short course of vancomycin, has previously been shown to reduce the bone and implant bacterial burden in a rodent model of methicillin-resistant Staphylococcus aureus (MRSA) implant-associated infection (IAI). Clinically, the goal is to achieve complete eradication of the IAI; therefore, the rationale for the present study was to evaluate the antimicrobial effects of combining CVCES with prolonged antibiotic therapy with the goal of decreasing the colony-forming units (CFUs) to undetectable levels.

QUESTIONS/PURPOSES

(1) In an animal MRSA IAI model, does combining CVCES with prolonged vancomycin therapy decrease bacteria burden on the implant and surrounding bone to undetectable levels? (2) When used with prolonged vancomycin therapy, are two CVCES treatments more effective than one? (3) What are the longer term histologic effects (inflammation and granulation tissue) of CVCES on the surrounding tissue?

METHODS

Twenty adult male Long-Evans rats with surgically placed shoulder titanium implants were infected with a clinical strain of MRSA (NRS70). One week after infection, the rats were randomly divided into four groups of five: (1) VANCO: only vancomycin treatment (150 mg/kg, subcutaneous, twice daily for 5 weeks); (2) VANCO + 1STIM: vancomycin treatment (same as the VANCO group) coupled with one CVCES treatment (-1.8 V for 1 hour on postoperative day [POD] 7); (3) VANCO + 2STIM: vancomycin treatment (same as the VANCO group) coupled with two CVCES treatments (-1.8 V for 1 hour on POD 7 and POD 21); or (4) CONT: no treatment. On POD 42, the implant, bone, and peripheral blood were collected for CFU enumeration and histological analysis, where we compared CFU/mL on the implants and bone among the groups. A pathologist, blinded to the experimental conditions, performed a semiquantitative analysis of inflammation and granulation tissue present in serial sections of the humeral head for animals in each experimental group.

RESULTS

The VANCO + 1STIM decreased the implant bacterial burden (median = 0, range = 0-10 CFU/mL) when compared with CONT (median = 5.7 × 10(4), range = 4.0 × 10(3)-8.0 × 10(5) CFU/mL; difference of medians = -5.6 × 10(4); p < 0.001) and VANCO (median = 4.9 × 10(3), range = 9.0 × 10(2)-2.1 × 10(4) CFU/mL; difference of medians = -4.9 × 10(3); p < 0.001). The VANCO + 1STIM decreased the bone bacterial burden (median = 0, range = 0-0 CFU/mL) when compared with CONT (median = 1.3 × 10(2), range = 0-9.4 × 10(2) CFU/mL; difference of medians = -1.3 × 10(2); p < 0.001) but was not different from VANCO (median = 0, range = 0-1.3 × 10(2) CFU/mL; difference of medians = 0; p = 0.210). The VANCO + 2STIM group had implant CFU (median = 0, range = 0-8.0 × 10(1) CFU/mL) and bone CFU (median = 0, range = 0-2.0 × 10(1) CFU/mL) that were not different from the VANCO + 1STIM treatment group implant CFU (median = 0, range = 0-10 CFU/mL; difference of medians = 0; p = 0.334) and bone CFU (median = 0, range = 0-0 CFU/mL; difference of medians = 0; p = 0.473). The histological analysis showed no deleterious effects on the surrounding tissue as a result of the treatments.

CONCLUSIONS

Using CVCES in combination with prolonged vancomycin resulted in decreased MRSA bacterial burden, and it may be beneficial in treating biofilm-related implant infections.

CLINICAL RELEVANCE

CVCES combined with clinically relevant lengths of vancomycin therapy may be a treatment option for IAI and allow for component retention in certain clinical scenarios. However, more animal research and human trials confirming the efficacy of this approach are needed before such a clinical recommendation could be made.

Influence of MC3T3-E1 preosteoblast culture on the corrosion of a T6-treated AZ91 alloy

This study investigated the corrosion of artificially aged T6 heat-treated Mg-9%Al-1%Zn (AZ91) for biomedical applications. Corrosion tests and surface analysis were completed both with and without a monolayer of mouse preosteoblast MC3T3-E1 cells cultured on the sample. Electrochemical impedance spectroscopy (EIS) and inductively coupled plasma mass spectroscopy (ICPMS) were used to explore the corrosion processes after either 3 or 21 days of AZ91 incubation in cell culture medium (CCM). The EIS showed both the inner layer resistance (Rin ) and outer layer resistance (Rout ) were lower for samples without cells cultured on the surface at 3 days (Rin  = 2.64 e4 Ω/cm(2) , Rout  = 140 Ω/cm(2) ) compared to 21 days (Rin  = 3.60 e4 Ω/cm(2) , Rout  = 287 Ω/cm(2) ) due to precipitation of magnesium and calcium phosphates over time. Samples with preosteoblasts cultured on the surface had a slower initial corrosion (3 day, Rin  = 1.88 e5 Ω/cm(2) , Rout  = 1060 Ω/cm(2) ) which was observed to increase over time (21 day, Rin  = 2.99 e4 Ω/cm(2) , Rout  = 287 Ω/cm(2) ). Changes in the corrosion processes were thought to be related to changes in the coverage provided by the cell layer. Our results reveal that the presence of cells and biological processes are able to significantly influence the corrosion rate of AZ91.

Cathodic voltage-controlled electrical stimulation of titanium implants as treatment for methicillin-resistant Staphylococcus aureus periprosthetic infections

Effective treatment options are often limited for implant-associated orthopedic infections. In this study we evaluated the antimicrobial effects of applying cathodic voltage-controlled electrical stimulation (CVCES) of -1.8 V (vs. Ag/AgCl) to commercially pure titanium (cpTi) substrates with preformed biofilm-like structures of methicillin-resistant Staphylococcus aureus (MRSA). The in vitro studies showed that as compared to the open circuit potential (OCP) conditions, CVCES of -1.8 V for 1 h significantly reduced the colony-forming units (CFU) of MRSA enumerated from the cpTi by 97% (1.89 × 106 vs 6.45 × 104 CFU/ml) and from the surrounding solution by 92% (6.63 × 105 vs. 5.15 × 104 CFU/ml). The in vivo studies, utilizing a rodent periprosthetic infection model, showed that as compared to the OCP conditions, CVCES at -1.8 V for 1 h significantly reduced MRSA CFUs in the bone tissue by 87% (1.15 × 105 vs. 1.48 × 104 CFU/ml) and reduced CFU on the cpTi implant by 98% (5.48 × 104 vs 1.16 × 103 CFU/ml). The stimulation was not associated with histological changes in the host tissue surrounding the implant. As compared to the OCP conditions, the -1.8 V stimulation significantly increased the interfacial capacitance (18.93 vs. 98.25 μF/cm(2)) and decreased polarization resistance (868,250 vs. 108 Ω-cm(2)) of the cpTi. The antimicrobial effects are thought to be associated with these voltage-dependent electrochemical surface properties of the cpTi.

Effects of medial meniscal posterior horn avulsion and repair on meniscal displacement

Medial meniscal posterior root avulsion (MMRA) leads to deleterious alteration of medial joint compartment loading profiles and increased risk of medial degenerative changes. Surgical repair restores more normal biomechanics to the knee. Our hypothesis is that MMRA will cause medial meniscal (MM) extrusion and gap formation between the root attachment site and MM. Meniscal root repair will restore the ability of the meniscus to resist extrusion, and reduce gap formation at the defect. Seven fresh frozen human cadaveric knees were dissected and mechanically loaded using a servo-hydraulic load frame (MTS ®) with 0 and 1800 N. The knees were tested under three conditions: native, avulsed, and repaired. Four measurements were obtained: meniscal displacement anteriorly, medially, posteriorly, and gap distance between the root attachment site and MM after transection and repair. The medial displacement of the avulsed MM (3.28 mm) was significantly greater (p < 0.001) than the native knee (1.60mm) and repaired knee (1.46 mm). Gap formation is significantly larger in the avulsed compared to repaired state at 0 (p < 0.02) and 1800N (p < 0.02) and also larger with loading in both avulsed (p < 0.05) and repaired (p < 0.02) conditions. Therefore, MMRA results in MM extrusion from the joint and gap formation between the MM root and the MM. Subsequent surgical repair reduces meniscal displacement and gap formation at the defect.

Titanium is not "the most biocompatible metal" under cathodic potential: The relationship between voltage and MC3T3 preosteoblast behavior on electrically polarized cpTi surfaces

An electrochemically controlled system has been developed which allows for cell culture directly on electrically polarized metal surfaces with simultaneous control and assessment of the electrochemical current, potential, and impedance of the interface. This system was utilized in this study to assess the interactions between electrochemically polarized commercially pure titanium (cpTi) and MC3T3 preosteoblast cells. Cells were cultured on CpTi for 24 h at static potentials between -1000 mV and +1000 mV vs. Ag/AgCl and cell morphology (SEM and cell area) and viability (MTT and Live-Dead assay) were assessed along with the electrochemical current densities and surface oxide impedance properties. The results indicate that cathodic polarization in the range of -600 mV to -1000 mV markedly reduces the spreading and viability of cells cultured directly on cpTi within 24 h, while anodic polarization (-300 mV to +1000 mV) out to 72 h shows no difference in cell behavior as compared to the OCP condition. Analysis of the relationship between the cell outcomes and the electrochemical current densities and impedance indicated the presence of voltage-dependent electrochemical thresholds (cathodic current density, i(c) > 1.0 microA/cm(2), R(p) < 10(5) Omega cm(2)) which may control the biocompatibility of cpTi. In addition, these outcomes have direct clinical significance for modular orthopedic implants whose potential can shift, via fretting corrosion, down into the range of potentials exhibiting poor cell behavior.

The effect of scanning electrochemical potential on the short-term impedance of commercially pure titanium in simulated biological conditions

The electrochemical history (voltage-time variations) of titanium oxide-solution interfaces can vary widely in vivo, particularly where oxide abrasion is present, and it is important to assess the effects of voltage on the impedance behavior of the interface. Potential step impedance analysis (PSIA) utilizes a time and frequency domain methodology to assess the electrochemical impedance of electrified interfaces over a range of voltages. The PSIA method was used to study the combined effects of scanning electrical potential and the presence of solution-born organic species (protein, amino acids, etc.) on the electrochemical properties of cpTi. The specific solutions used in these scanning PSIA experiments were phosphate buffered saline and cell culture medium supplemented with 10% fetal bovine serum. The results show that electrochemical impedance properties of cpTi are voltage-time history dependent and strongly influenced by electrical potential within the -1000 mV to +1000 mV range studied. Moreover, the presence of biologically relevant molecules in the electrolyte solution alters the impedance properties only at cathodic potentials. Specifically, at cathodic potentials, these organic species have been shown to suppress the cathodic current density, shift the zero current potential in the cathodic direction, and increase the interfacial capacitance, polarization resistance, and the distribution of surface relaxation times. At anodic potentials, the presence of the organic species does not alter any of the electrochemical properties examined. Overall, these results show the importance of understanding of the variation in electrochemical potentials achievable in vivo and the effects voltage history has on interfacial electrochemical behavior.

The effect of static applied potential on the 24-hour impedance behavior of commercially pure titanium in simulated biological conditions

Potential step impedance analysis was utilized to evaluate the electrochemical impedance of commercially pure titanium (cpTi) samples that were polarized to static potentials (range from -1000 mV to +1000 mV vs. Ag/AgCl) and immersed in physiologically relevant electrolytes [phosphate buffered saline (PBS) and cell culture medium with 10% fetal bovine serum (AMEM + FBS)] for 24 hrs. The cpTi impedance outcomes were a complex function of voltage, solution constituents, and immersion time. In the 0 mV to +1000 mV range, oxide growth was observed over 24 hr immersion in both solutions based on decreasing current density (approximately 10(-6) A/cm(2) to approximately 10(-8) A/cm(2)) and increasing R(p) (200 kOmega cm(2) to approximately 10 MOmega cm(2)). Below 0 mV, the 24 hr R(p) decreased with negative potential to approximately 15 kOmega cm(2). After 24 hr immersion, oxide dissolution and/or adsorption of organic species caused the capacitance to increase at -1000 mV (AMEM + FBS & PBS) and at -600 mV (AMEM + FBS only). Twenty-four hours of immersion in AMEM + FBS at -1000 mV and -600 mV produced a surface coloration that is likely due to alteration of oxide valance state and/or doping level. This work shows that Ti surface oxide and its electrochemical behavior can be altered dramatically under sustained cathodic potentials.

Influence of suture material on the biomechanical behavior of suture-tendon specimens: a controlled study in bovine rotator cuff

BACKGROUND

Despite technical advances in rotator cuff surgery, recurrent or persistent defects in the repaired tendon continue to occur. Improved strength of sutures and suture anchors has resulted in the most common site of failure being the suture-tendon interface.

HYPOTHESIS

The type of suture material used has a significant effect on the biomechanics of the suture-tendon interface.

STUDY DESIGN

Controlled laboratory study.

METHODS

Thirty-two bovine infraspinatus specimens were randomly assigned to simple suture fixation using No. 2 Fiberwire, Ultrabraid, Orthocord, or Ethibond. Each specimen was subjected to cyclic testing from 5 to 30 N for 30 cycles, followed by load-to-failure testing.

RESULTS

Cyclic testing revealed significantly greater elongation with Ultrabraid, whereas peak-to-peak displacements were lowest for Fiberwire and greatest for Orthocord. Load-to-failure testing revealed no significant differences between any suture material for ultimate tensile load. Fiberwire and Orthocord repairs had the highest stiffness. The most common failure mode during load-to-failure testing was suture breakage in Ethibond specimens and suture cutting through the tendon in the polyblend suture specimens.

CONCLUSION

The type of suture material has a significant effect on the biomechanical behavior of the suture-tendon interface.

CLINICAL RELEVANCE

The type of suture may influence early gap formation and ultimate healing of rotator cuff repairs.

Is it safe to perform aggressive rehabilitation after distal biceps tendon repair using the modified 2-incision approach? A biomechanical study

BACKGROUND

Despite improved methods of fixation, there is still a delay in early active motion after distal biceps repair.

HYPOTHESIS

Distal biceps repairs using the modified 2-incision technique can be treated with early motion, and there is no difference in the cyclic performance of Ethibond and Fiberwire when used for the repair.

STUDY DESIGN

Controlled laboratory study.

METHODS

Nine matched pairs of cadaveric elbows had release of the distal biceps followed by repair with either No. 5 Ethibond or Fiberwire through a bone tunnel. The repairs were cyclically loaded for 3000 cycles (1000 cycles from 10-50 N, 1000 cycles from 10-75 N, 1000 cycles from 10-100 N) followed by single-load displacement to failure in surviving specimens.

RESULTS

There was no difference in the displacement or stiffness between surviving repairs at any point measured. Ethibond repairs survived significantly more cycles than did Fiberwire repairs, particularly at higher loads.

CONCLUSION

Distal biceps repair using the 2-incision technique with Ethibond should allow early active motion, but early active motion may not be possible with Fiberwire.