**11. Conclusions**

patients treated with the myorrhaphy. However, these articles have a poor methodology and take into account only a small number of patients; obviously future larger and better conducted studies are required in order to determine more specifically which type of treatment is most suitable in humans. It remains clear, however, that surgical treatment is rarely necessary, only for certain types of injuries, and only with a specific indication. We perform surgery only when

Once you choose a surgical approach it is important to decide the surgical technique and how

The suture of a muscle belly is easier in its proximal third and distal third, whereas only in some muscles in the middle third; this is because the tendon fibers flatten and extend into the

Literature describes many types of knots and sutures, such as the conventional Kessler, the modified Kessler and the figure-eight horiziontal mattress and more complex ones, such as

The integrity and viability of the remaining muscle tissue is important and indicative for a good prognosis; furthermore the preservation of the epimiysium and the possibility of suturing it to the muscle makes the suture more resistant. From an in vitro study on pig muscles [55], it has been shown that suturing the epimysium gives the suture greater resistance to tensile stress compared to sutures made only on he muscle tissue and perimysium. This is because the epimysium consists of more connective tissue and is composed of two layers, hence

The Kessler stitch would seem to be more resistant to pull-out suturing than simple stitch or

Kragh [16] compared the Kessler stitch and a stitch combinations (Mason-Allen stitch and stitch around perimeter) in pig muscle. These two types of sutures were considered the strongest in a pilot study carried out before the main study where 9 different types of suturing were compared: simple stitch, running simple (epimysium based, non-core) stitch, the figure of eight stitch, the modifed Kessler stitch, a vertical mattress stitch, a horizontal mattres stitch (core), a horizontal mattress stitch (inverted, epimysium based, non-core), a double right angle stitch, a combination (Modified Mason-Allen and perimeter) stitch. At the tensile tests carried out, the Kessler stitch achieved a maximum load of 35 N, whereas the combined suture achieved 74 N. Not only did the combined suture achieve a greater tensile load, but also the Kessler stitch failed because the sutures were pulled away from the muscle tissue, whereas in the combined suturing, the better distribution of the forces induced a gradual lengthening of the muscle fibers and the stitches were not torn away from the tissue at the 35 mm lengthening. Similar results were obtained on fresh frozen cadaveric human tissue [58]. Comparing Kessler, figure eight, mattress, Mason-Allen, perimeter and perimeter-Mason-Allen on different

the Mason-Allen, the Modified Mason-Allen and suturing the perimeter of the lesion.

strictly necessary.

232 Muscle Injuries in Sport Medicine

**10. Types of sutures**

muscle belly giving the stitches a greater support [54].

much more resistant to tension compared to the perimysium [56].

simple suturing with a tendon graft [57].

to suture the muscle.

The indication for surgical treatment applies to a small number of muscle lacerations. The tearing of the muscle belly is a common occurrence in athletes and nowadays are difficult to predict or prevent. There is no clear indication for surgical suture for these lesions and there is no real guide line to follow. The majority of the authors in literature consider performing surgery when the lesion affects more than 50% of the total of muscle fibers. Such an extensive injury would provoke a massive scar reaction making it difficult to achieve efficient and functional tissue leading to an excess of collagen and fibrotic tissue which would change the muscle mechanics and facilitate the onset of new lesions. It has also been evaluated and demonstrated that large lesions also present decreased strength, especially in those cases where the affected muscle is not assisted by other agonist muscles. The best results were obtained in patients treated with surgery compared to those treated conservatively with splinting.

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In addition, such an extensive lesion would also be very disfiguring in appearance for those who make fitness and muscle shape their job such as body builders. These lacerations leave the muscle anatomy altered, and conservative treatment fails to restore the geometric lines and shapes of the muscle.

The muscles most affected by these injuries in sports are the pectoralis major (in lifters), the biceps brachii (in the paratroopers and water sportsmen who are pulled by ropes) and the rectus femoris.

Surgery brings the margins of the lesion together thus decreasing the hematoma and reducing the reactive fibrous reaction which in turn leads to smaller scars. The approach also enhances a faster return to mobilization of the affected segment and an earlier recovery of muscle tone.

The muscle belly tissue is not a robust structure for anchoring the stitches to, therefore the choice of method, anchor points and suture type must be made carefully.

It is evident how few publications there are in literature that deal with the management of massive muscle injuries; only a few studies comparing the therapeutic options have been conducted and the majority of articles available concern in vitro studies or animal studies. It is necessary that further studies are conducted in order to obtain enough scientific evidence to guide the treatment and management of these patients.
