Suture augmentation of acromioclavicular and coracoclavicular ligament reconstruction for acute acromioclavicular dislocation

The objective of this report was to introduce a new suture augmentation of coracoclavicular (CC) and acromioclavicular ligament reconstruction for acute Rockwood grade III to V acromioclavicular dislocations.From January 2015 to January 2019, 43 patients with Rockwood III to VI acute acromioclavicular dislocations were retrospectively reviewed. For comparison, another series of 28 patients treated with double Endobutton technique from January 2011 to December 2014 were reviewed. A P < .05 was considered statistical significance.The mean follow-up period of the 2 series were 39.69 ± 7.42 months (range, 24-54 months) and 37.86 ± 8.23 months (range, 26-48 months) (P > .05), respectively. There were significant differences regarding CC space (11.62 ± 2.54 mm vs 16.78 ± 5.53 mm; P < .05), CC reduction loss (5.56 ± 4.73 mm vs 26.25 ± 4.42 mm; P < .05), and acromioclavicular space (6.89 ± 1.87 mm vs 7.95 ± 2.37 mm; P < .05). There were significant differences regarding the disabilities of the arm, shoulder, and hand questionnaire (3.3 ± 2.8 vs 5.32 ± 4.37; P < .05) and University of California-Los Angeles shoulder rating scale (31.19 ± 2.48 vs 29.24 ± 2.48; P < .05). The excellent to good percentages were 100% (n = 32) and 85% (n = 23), respectively.In conclusion, the suture augmentation of acromioclavicular and CC ligament reconstruction is a reliable technique for acute acromioclavicular dislocation with minimal complications.Type of study/level of evidence: Therapeutic IIa.

[Early effectiveness of minimally invasive open reduction and internal fixation versus arthroscopic double-tunnel suture fixation for tibial avulsion fracture of posterior cruciate ligament]

OBJECTIVE

To compare the early effectiveness of minimally invasive open reduction and internal fixation via posterior median approach versus arthroscopic double-tunnel suture fixation in treatment of tibial avulsion fracture of the posterior cruciate ligament (PCL).

METHODS

A clinical data of 31 patients with the tibial avulsion fracture of the PCL and met the criteria between January 2015 and January 2019 was retrospectively analyzed. Nineteen patients (group A) were treated with open reduction and internal fixation with cannulated screw via posterior median approach. The other 12 patients (group B) were treated with arthroscopic double-tunnel suture fixation technique. There was no significant difference between the two groups ( P>0.05) in the gender, age, side of effected limb, the injury cause, the time from injury to operation, the combined meniscus injury, Meyers & McKeever classification and preoperative Lysholm score, Tegner score, International Knee Documentation Committee (IKDC) score, and the difference of tibial posterior displacement between bilateral knees. The operation time, postoperative complications, fracture healing, and the difference of tibial posterior displacement between bilateral knees, Lysholm score, Tegner score, and IKDC score were recorded.

RESULTS

Group B spent significantly longer operation time than group A ( t=7.347, P=0.000). No postoperative complication occurred in group B, and 1 patient in group A had a screw breakage. All patients were followed up 6-36 months (mean, 22 months). X-ray films showed that all fractures healed at 3 months after operation. At last follow-up, there was no significant difference in the patients with normal knee range of motion between the two groups ( P=0.510). At last follow-up, the difference of tibial posterior displacement between bilateral knees, Lysholm score, Tegner score, and IKDC score in the two groups were superior to those before operation ( P<0.05); while there was no significant difference between the two groups ( P>0.05).

CONCLUSION

For the tibial avulsion fracture of PCL, the minimally invasive open reduction and internal fixation and arthroscopic double-tunnel suture fixation can obtain similar early effectiveness. However, arthroscopic surgery has the advantages of being able to simultaneously deal with intra-articular combined injuries, avoiding internal fixator complications, and eliminating the need for secondary operation.

Drainage tube hole suture improvement: Removal-free stitches

Surgical method improvements aim to optimize the patient experience. The problem of healing of the drainage tube hole has not received attention and is of concern because it can plague patient recovery. In this article we report on how we have improved the method of suturing the drainage tube hole and explore the safety and effectiveness of this method. Between December 2017 to August 2018, 102 patients underwent thoracoscopic lung resection (single port or single utility port) using different methods of suturing drainage tube holes. The intervention group received improved methods with subcuticular and intradermal suture and removal-free stitches, whilst the control group received a conventional mattress suture and fixed chest tube. A preset line was left to tie knots and close the hole after the removal of the chest tube. The stitches were removed 7-12 days after surgery. The baseline clinical features of the patients were subsequently analyzed. The objective and subjective conditions of scars were evaluated using the Vancouver Scar Scale (VSS) and the Patient and Observer Scar Assessment Scale (POSAS) at one month after surgery. The intervention group (n = 71) and control group (n = 31) had balanced baseline clinical characteristics. There were no significant differences between the two groups in terms of three-day postoperative pain and postoperative hospital stay. In the intervention group, three patients (4.23%) had wound splitting that required re-suturing, which was better than five patients (16.13%) in the control group (P < 0.05). The incidence of pleural fluid outflow, wound infection, post-removal pneumothorax, chest tube prolapse and incisional hernia were not different between the two groups. We conclude that the objective and subjective evaluation results of scars were significantly different between the two groups (P < 0.05), and the experimental group was superior to the control group. A balanced result between aesthetic appearance and safety as regards video-assisted thoracic surgery can be achieved through the chest tube hole improved suture method. This method also improves the patient's recovery experience.

Impact of electronic and blended learning programs for manual perineal support on incidence of obstetric anal sphincter injuries: a prospective interventional study

BACKGROUND

Obstetric anal sphincter injuries (OASIS) are associated with anal incontinence, dyspareunia and perineal pain. Bimanual perineal support technique (bPST) prevents OASIS. The aim of this study was to assess the effect of two different bPST training-methods on OASIS incidence.

METHODS

This is a prospective-interventional quality improvement study conducted in two Palestinian maternity units between June 1 2015 and December 31 2016. Women having spontaneous or operative vaginal-delivery at ≥24 gestational-weeks or a birthweight of ≥1000 g (n = 1694) were recruited and examined vaginally and rectally immediately after vaginal birth by a trained assessor. Data on baseline OASIS incidence were collected during Phase-1 of the study. Subsequently, birth attendants in both maternity units were trained in bPST using two training modalities. A self-directed electronic-learning (e-learning) using an animated video was launched in phase-2 followed by a blended learning method (the animated e-learning video+ structured face-to-face training) in phase-3. OASIS incidence was monitored during phases-2 and 3. Variations in OASIS incidence between the three phases were assessed using Pearson-χ²-test (or Fisher's-Exact-test). The impact of each training-method on OASIS incidence was assessed using logistic-regression analysis.

RESULTS

A total of 1694 women were included; 376 in phase-1, 626 in phase-2 and 692 in phase-3. Compared to Phase-1, OASIS incidence was reduced by 45% (12.2 to 6.7%, aOR: 0.56, CI; 0.35-0.91, p = 0.018) and 74% (12.2 to 3.2%, aOR, 0.29, CI; 0.17-0.50, p < 0.001) in phases-2 and 3, respectively. There was also a significant reduction in OASIS incidence by 52% from phase-2 to phase-3 (6.7% (42/626) to 3.2% (22/692), p = 0.003). These reductions reached statistical significance among parous-women only (aOR: 0.18, CI; 0.07-0.49, p = 0.001) after the first training method tested in phase-2. However, the reduction was significant among both primiparous (aOR: 0.39, CI; 0.21-0.74, p = 0.004) and parous-women (aOR: 0.11, CI; 0.04-0.32, p < 0.001) after implementing the blended learning method in phase-3.

CONCLUSION

The animated e-learning video had a positive impact on reducing OASIS incidence. However, this reduction was enhanced by the use of a blended learning program combining both e- learning and face-to-face training modalities.

STUDY REGISTRATION NUMBER

ClinicalTrialo.gov identifier: NCT02427854 , date: 28 April 2015.

Comparative Evaluation of N-Butyl Cyanoacrylate and Silk Sutures on Healing of Periodontal Flaps: A Clinico Histological Evaluation

Background The periodontal flap is one of the most frequently employed procedures. Closure of reflected flap is important step in flap surgery. Black silk sutures are most often used material in routine surgical procedures. These suture materials demand more time and effort and expertise from the surgeon. Tissue adhesives have been developed as alternatives to overcome these problems such as cyanoacrylates. Objective The present study is an attempt to compare effectiveness of the black silk suture with cyanoacrylate adhesives in closing reflected periodontal flap. Method Thirty systemically healthy patients who underwent bilateral flap surgery were given 3-0 black silk sutures on one side and N-butyl cyanoacrylate adhesive on the other side to close a surgical incision. All the participants in the study were recalled on the seventh, 21st, 42nd day. Participants were evaluated for healing and plaque accumulation by assessing the gingival index, plaque index, wound healing index. Biopsy specimens were obtained on seventh and 42nd postoperative day. Result The amount of inflammation was less during the first week of healing when cyanoacrylate was compared with silk. However, over a period of 21 days to 42 days, the sites treated with both the materials showed similar healing patterns without any significant difference in the evaluated parameter. Conclusion The result of the study showed that the use of cyanoacrylate for the closure of periodontal flaps results in better initial post-operative healing as compared to closure with silk suture and that this method of closure can be advocated in a routine surgical periodontal practice.

Expert Consensus on Achieving Optimal Outcomes With Absorbable Suspension Suture Technology for Tissue Repositioning and Facial Recontouring

A complete approach to facial rejuvenation includes restoration of the skin's surface, relaxation of muscles that contribute to hyperkinetic movement, revolumization, and repositioning/recontouring of descended tissues and fat pads. After receiving 510(k) clearance from the US Food and Drug Administration (FDA) in 2015, the Silhouette InstaLift™ absorbable suspension suture became the only available non-surgical technique for repositioning of facial tissue. In January 2017, a consensus paper presented a review of the literature on the efficacy and safety of absorbable suspension sutures and provided information on treatment procedures. Since that time, the clinical experience of the authors has further shaped their treatment practices, highlighting the need for additional guidelines to support an optimal treatment approach. This update will expand upon the 2017 consensus paper on the safety and efficacy of absorbable suspension sutures and provide guidance for obtaining consistently high patient satisfaction with the procedure. Recommendations are based on the extensive clinical experience of expert physicians with absorbable suspension sutures over the past 2.5 years. Here, the authors provide guidance on full face assessment and treatment to support maximum benefit and provide patient selection and procedural recommendations. In addition, the authors stress the benefits of the dual mechanisms of action within the absorbable suspension suture: the immediate lift and volumizing over time that together lead to the outcome of recontouring. J Drugs Dermatol. 2018;17(6):647-655.

Mesh versus suture repair of umbilical hernia in adults: a randomised, double-blind, controlled, multicentre trial

BACKGROUND

Both mesh and suture repair are used for the treatment of umbilical hernias, but for smaller umbilical hernias (diameter 1-4 cm) there is little evidence whether mesh repair would be beneficial. In this study we aimed to investigate whether use of a mesh was better in reducing recurrence compared with suture repair for smaller umbilical hernias.

METHODS

We did a randomised, double-blind, controlled multicentre trial in 12 hospitals (nine in the Netherlands, two in Germany, and one in Italy). Eligible participants were adults aged at least 18 years with a primary umbilical hernia of diameter 1-4 cm, and were randomly assigned (1:1) intraoperatively to either suture repair or mesh repair. In the first 3 years of the inclusion period, blocked randomisation (of non-specified size) was achieved by an envelope randomisation system; after this time computer-generated randomisation was introduced. Patients, investigators, and analysts were masked to the allocated treatment, and participants were stratified by hernia size (1-2 cm and >2-4 cm). At study initiation, all surgeons were invited to training sessions to ensure they used the same standardised techniques for suture repair or mesh repair. Patients underwent physical examinations at 2 weeks, and 3, 12, and 24-30 months after the operation. The primary outcome was the rate of recurrences of the umbilical hernia after 24 months assessed in the modified intention-to-treat population by physical examination and, in case of any doubt, abdominal ultrasound. This trial is registered with ClinicalTrials.gov, number NCT00789230.

FINDINGS

Between June 21, 2006, and April 16, 2014, we randomly assigned 300 patients, 150 to mesh repair and 150 to suture repair. The median follow-up was 25·1 months (IQR 15·5-33·4). After a maximum follow-up of 30 months, there were fewer recurrences in the mesh group than in the suture group (six [4%] in 146 patients vs 17 [12%] in 138 patients; 2-year actuarial estimates of recurrence 3·6% [95% CI 1·4-9·4] vs 11·4% (6·8-18·9); p=0·01, hazard ratio 0·31, 95% CI 0·12-0·80, corresponding to a number needed to treat of 12·8). The most common postoperative complications were seroma (one [<1%] in the suture group vs five [3%] in the mesh group), haematoma (two [1%] vs three [2%]), and wound infection (one [<1%] vs three [2%]). There were no anaesthetic complications or postoperative deaths.

INTERPRETATION

This is the first study showing high level evidence for mesh repair in patients with small hernias of diameter 1-4 cm. Hence we suggest mesh repair should be used for operations on all patients with an umbilical hernia of this size.

FUNDING

Department of Surgery, Erasmus University Medical Center, Rotterdam, Netherlands.

Suture Technique Influences the Biomechanical Integrity of Pectoralis Major Repairs

Pectoralis major ruptures occur in large, muscular individuals, and repair constructs may experience significant tension. Four different suture techniques were evaluated biomechanically to determine the effect of suture technique on optimizing fixation strength. Forty fresh-frozen cadaveric shoulders were repaired using endosteal buttons. The control group was repaired with #2 polyblend suture in a modified Mason-Allen stitch configuration. The triple group was repaired using the same suture and configuration, but with the addition of triple-loaded buttons. The configuration group was repaired using the same suture in a Krackow/Bunnell configuration. The tape group was repaired using 2-mm polyethylene tape and #5 polyblend suture in the Krackow/Bunnell configuration. Under cyclic loading, there was no significant difference between groups. Under load-to-failure testing, the tape group withstood a significantly greater maximum load (726.0±90.0 N) than the control and triple groups (330.2±20.2 and 400.2±35.2 N, respectively; P<.005), and similar load to the configuration group (509.9±68.6 N; P=.16). The configuration group failed via suture breakage (9/10); the other groups failed via suture pullout, in which suture pulled through tendon (26/30). Pectoralis major repair in a running, locked configuration appears to improve biomechanical performance by preventing suture pullout. Use of a polyethylene tape construct demonstrates the potential for improved failure loads, but its role remains undefined.

Nylon sutures for wound closure in cataract operation

In this series of patients the use of nylon sutures in wound closure produced wounds which were watertight, secure but astigmatic. The complications which occurred from premature suture absorption were averted and suture removal was not necessary. Less postoperative astigmatism was produced with postplaced running sutures than with interrupted ones and suture knot erosion was avoided by turning suture knots into suture tracks.

In vitro and in situ characterization of arthroscopic loop security and knot security of braided polyblend sutures: a biomechanical study

We conducted a study to evaluate biomechanical performance during destructive testing of several different suture materials in various arthroscopic knot configurations under both in vitro and in situ conditions. Surgeons of different levels of experience tied the knots. Three different arthroscopic knots (static surgeon's, Weston, Tennessee slider) with 3 reverse half-hitches on alternating posts were tested using Fiberwire, ForceFiber, Orthocord, and Ultrabraid suture materials under both in vitro and in situ (blood plasma at 37°C) conditions. Three surgeons of different experience levels tied the knots on a post 30 mm in circumference. A single load-to-failure test was performed. There were no significant in vitro-in situ differences for Ultrabraid in the different knot configurations or with the different experience levels. Surgeon B (intermediate experience) showed no significant differences between test conditions for any knot configuration or suture material. With Tennessee slider knots, surgeon C (least experience) showed significantly lower clinical failure load under both test conditions and had a higher percentage of complete knot slippage. Surgeon B had no knot slippage with use of Fiberwire. Both the aqueous environment and the surgeon's familiarity with certain knots have an effect on knot security.

Perineal care

INTRODUCTION

More than 85% of women having a vaginal birth suffer some perineal trauma. Spontaneous tears requiring suturing are estimated to occur in at least one third of women in the UK and US. Perineal trauma can lead to long-term physical and psychological problems.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of different methods and materials for primary repair of first- and second-degree tears and episiotomies? What are the effects of different methods and materials for primary repair of obstetric anal sphincter injuries (third- and fourth-degree tears)? We searched: Medline, Embase, The Cochrane Library, and other important databases up to November 2013 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 33 studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review, we present information relating to the effectiveness and safety of the following interventions: conventional suturing; different methods and materials for primary repair of obstetric anal sphincter injuries; non-suturing of muscle and skin (or perineal skin alone); and sutures (absorbable synthetic sutures, catgut sutures, continuous sutures, interrupted sutures).

Ex vivo evaluation of 7 polydioxanone for closure of equine ventral midline celiotomies

The objective of this study was to compare the bursting strength (BS) and mode of failure (MF) of ventral midline (VM) celiotomies closed with USP 7 polydioxanone (7PD) in 1 or 2 simple continuous sections. A bursting strength model, consisting of inserting and inflating a 200-L polyurethane bladder through a 25-cm VM celiotomy, was used on 15 fresh equine cadavers. Celiotomies were closed using 7PD in 2 separate sections (4 knots), 2 continuous sections (3 knots), or a single section (2 knots) using a simple continuous pattern. The horses' signalment, body weight, number of total knots, MF, and BS were recorded and analyzed statistically for interactions. No difference was found between the BS of VM celiotomies closure types (P = 0.4). All celiotomy/ suture constructs failed at the abdominal wall. The celiotomy closure types evaluated in this study provided a secure method of closure in VM celiotomies in vivo.

Force sensing in surgical sutures

The tension in a suture is an important factor in the process of wound healing. If there is too much tension in the suture, the blood flow is restricted and necrosis can occur. If the tension is too low, the incision opens up and cannot heal properly. The purpose of this paper is to describe the design and evaluation of the Stitch Force (SF) sensor and the Hook-In Force (HIF) sensor. These sensors were developed to measure the force on a tensioned suture inside a closed incision and to measure the pulling force used to close the incision. The accuracy of both sensors is high enough to determine the relation between the force in the thread of a stitch and the pulling force applied on the suture by the physician. In a pilot study, a continuous suture of 7 stitches was applied on the fascia of the abdominal wall of multiple pigs to study this relationship. The results show that the max force in the thread of the second stitch drops from 3 (SD 1.2) to 1 (SD 0.3) newton after the 4(th) stitch was placed. During placement of the 5(th), 6(th) and 7(th) stitch, the force in the 2(nd) stitch was not influenced anymore. This study indicates that in a continuous suture the force in the thread remains constant up to more than 3 stiches away from the pulled loose end of the suture. When a force feedback tool is developed specially for suturing in surgery on patients, the proposed sensors can be used to determine safety threshold for different types of tissue and sutures.

Strength comparison of mitral annuloplasty ring and suturing combinations: an in-vitro study

BACKGROUND AND AIM OF THE STUDY

While mattress sutures are commonly used to secure annuloplasty rings during mitral valve repair, the use of a flexible ring secured with a running polypropylene suture has recently been advocated. The study aim was to assess the separation tensions of semi-rigid and flexible rings using mattress and running suture techniques in an in-vitro static load model.

METHODS

Semi-rigid and flexible annuloplasty rings were sutured with either mattress or running sutures (RM, RR, FM, FR) in four groups, of eight hearts each. Twelve additional sutures were passed through the surfaces of each ring to fix the preparation to a testing machine. In a fifth (control) group the mattress sutures securing a flexible ring (FMS) were connected directly to the machine. Each preparation was subjected to progressive axially directed (base-apex) tension until ring-tissue separation occurred.

RESULTS

The first major decrease in tension (defined as > or = 10 N in < or = 1.5 s) typically occurred with the separation of at least three adjacent sutures. These starting tensions (N) were: FMS 117 +/- 32.6, RR 131.7 +/- 30.5, RM 137.4 +/- 35.3, FM 152.1 +/- 32.3, and FR 213.2 +/- 30.5. The magnitudes of tension decrease with separation (and percentage of starting tensions) were: FMS 25.4 (21.2%), RR 26.8 (17.6%), RM 28.9 (21.6%), FM 24.6 (17.6%), and FR 22.5 (10.8%). The FR group required more tension to separate than the other groups (p < 0.001), but had a lower magnitude of force drop at dehiscence.

CONCLUSION

Flexible rings secured with a running suture required more force to separate than other ring-suture combinations. The lower magnitude of force drop in this group indicated a better tension distribution than in the other groups. Semi-rigid rings separated with a lower force, and had larger drops in tension, regardless of the suture technique used.

A randomized, prospective trial evaluating surgeon preference in selection of absorbable suture material

This study is the first double-blinded, randomized comparison of two absorbable sutures. To better understand product characteristics and surgeon preference, we conducted a study of two similar-appearing FDA-approved sutures, glyconate and poliglecaprone 25. Four dermatologic surgeons were enlisted. A total of 48 patients with 53 surgical sites were examined. One half of each surgical wound was closed with one type of suture and the other half with the other type. Each half was evaluated for product characteristics. There was no statistically significant difference in surgeon preference for glyconate versus poliglecaprone 25 (P=0.64). Of the cohort preferring poliglecaprone 25, there was a correlation with speed of closure (P=0.06). Of the surgeons that preferred glyconate, we found significantly better visibility (P=0.03), reduced suture breakage during knot tying (P=0.05), and correlation with better handling properties (P=0.06) associated with that preference. The data from this study will enable products to be designed towards these needs and allow surgeons to select sutures that more precisely fit their particular requirements.

Minimum number of throws needed for knot security

OBJECTIVE

The purpose of the study was to determine the optimal number of throws to ensure knot security.

STUDY DESIGN

Knots were tied with 3, 4, 5, or 6 square throws with 0-gauge coated polyester, polydioxanone, polypropylene, and polyglactin 910. The suture was soaked in 0.9% sodium chloride and subsequently transferred to a tensiometer and broken.

RESULTS

A total of 225 knots were tied. Regardless of the suture type, tension at failure for knots with 4 throws, 5 throws, and 6 throws was higher than tension at failure of knots with only 3 throws (p < 0.05 for each). We found no difference in the tensile strength between knots with 4, 5, or 6 throws (p > 0.05 for each). Knots with 4 throws were significantly more likely to come untied than knots with 5 or 6 throws (p < 0.01).

CONCLUSIONS

Under laboratory conditions, the ideal knot has 5 throws to maximize tensile strength and rate of untying. This finding does not seem to vary by type of suture material.

Knot integrity as a function of suture expiration

OBJECTIVE

To test the integrity of knots tied with expired suture and non-expired suture, using 5 different suture materials.

STUDY DESIGN

Knots were tied using expired and non-expired chromic catgut, polyglactin 910, polydioxanone, silk, or coated polyester. Expired sutures were a mean of 10.5 years past the date of expiration stamped on the packaging. Suture packaging was inspected for any flaws or humidity. There were 116 knots with expired suture and 109 non-expired knots. All knots were tied by hand. Suture was soaked in 0.9% sodium chloride for 60 seconds and subsequently transferred to a tensiometer where the tails of the knots were cut to 3 mm length. We compared the tensile strength of knots using a tensiometer to pull the knots until the suture broke or untied. A minimum of 30 knots were needed in order to detect a statistically significant main effect for expired and non-expired sutures with 80% power and a 5% chance of type I error.

RESULTS

A total of 225 knots were tied. Overall, we found no difference in mean tension between expired suture (77.5 ± 31.7 N) and non-expired suture at failure (81.9 ± 30.2 N). All the sutures broke at the knot and none untied. Expired chromic and polydioxanone were significantly weaker than the non-expired suture of the same material (p = 0.002 and p = 0.001, respectively). There was no statistically significant difference in tensile strength between expired absorbable or permanent suture materials. Based on a univariate analysis of variance ([SCAP]ANOVA)[R] there was no difference in the tension at failure between expired and non-expired sutures with suture packet as a covariate. No suture untied when knotted with expired suture.

CONCLUSIONS

Under laboratory conditions, expired chromic and polydioxanone sutures broke at lower tensile strength than non-expired sutures of the same material.

[The influence of draining on the quality of the intestinal suture]

The Billroth II gastric resection with mechanical suture of the gastro-jejunoanastomosis was performed in 8 dogs. The amount of E.coli and neutrophiles in tissue edges were registered morphometrically within 30 days. The important defencive role of the mucosa was proved. The inverted and everted mechanical intestinal suture were accessed from the positions of draining possibility.

Material properties of common suture materials in orthopaedic surgery

Suture materials in orthopaedic surgery are used for closure of wounds, repair of fascia, muscles, tendons, ligaments, joint capsules, and cerclage or tension band of certain fractures. The purpose of this study was to compare the biomechanical properties of eleven commonly used sutures in orthopaedic surgery. Three types of braided non-absorbable and one type of braided absorbable suture material with different calibers (n=77) underwent biomechanical testing for maximum load to failure, strain, and stiffness. All samples were tied by one surgeon with a single SMC (Seoul Medical Center) knot and three square knots. The maximum load to failure and strain were highest for #5 FiberWire and lowest for #0 Ethibond Excel (p<0.001). The stiffness was highest for #5 FiberWire and lowest for #2-0 Vicryl (p<0.001). In all samples, the failure of the suture material occurred at the knot There was no slippage of the knot in any of the samples tested. This data will assist the orthopaedic surgeon in selection and application of appropriate suture materials and calibers to specific tasks.

Dural bridge sutures to prevent sinking of dural substitutes: technical note

INTRODUCTION

Following Simpson Grade 1 excision of large convexity meningioma there is often a need for synthetic dural substitutes.

DISCUSSION

One problem with some of these grafts is that they lack tensile strength when wet and therefore sink into the cavity left following removal of the meningioma.

CONCLUSION

A simple method to prevent 'sinking' or sagging of such synthetic dural grafts is described and illustrated.

Intraoperative handling and wound healing of arthroscopic portal wounds: a clinical study comparing nylon suture with wound closure strips

This prospective, single-centre study compared wound closure methods in patients undergoing arthroscopy. Closure of arthroscopic portal wounds with sterile adhesive strips is effective and convenient for wound management. The method was associated with a reduced potential for infection, faster renewal of tensile strength, greater cost effectiveness, and better cosmetic effects comparing with suture closure. This method of wound closure may also reduce the incidence of needle stick injury in the theatre environment. Thereby the incidence of percutaneous exposure following a surgical procedure may not facilitate transmission of blood borne pathogens such as human immunodeficiency virus (HIV), hepatitis C virus and hepatitis B virus. As a result it may reduce litigation in today's changing healthcare climate.

Pre-closure of femoral venous access sites used for large-sized sheath insertion with the Perclose device in adults undergoing cardiac intervention

BACKGROUND

Interventional procedures in adults with congenital cardiac conditions often require insertion of large-sized sheaths into the femoral veins. Data on the use of suture-mediated devices for femoral venous access site closure are scant and no data are available regarding venous patency after device use.

OBJECTIVE

To assess the efficacy of the 6Fr Perclose (Abbott Vascular Devices, CA, USA) suture-mediated device in achieving haemostasis and venous patency after closure.

DESIGN AND SETTING

146 consecutive patients (80 women, mean (SD) age 45 (14) years) undergoing closure of 205 femoral venous access sites in a tertiary cardiac centre were studied. All received heparin and were taking concomitant aspirin or clopidogrel, or both. The majority (98%) had a >or=10Fr sheath inserted.

RESULTS

Immediate haemostasis was achieved in 202 (99%) sites. Two patients (1.4%) had a major complication. On follow-up (111 patients, mean (SD) 71 (33) days) there was no evidence of haematoma or fistula formation. Doppler studies from a subgroup of 43 (29%) patients (mean (SD) age 45 (15) years, mean (SD) follow-up 47 (18) days) showed a common femoral venous diameter of 11.6 (2.7) mm on the device closed right and 12.2 (2.5) mm on the left vein (p>0.05). All accessed veins were patent with no pseudoaneurysm or arteriovenous fistula formation.

CONCLUSION

Pre-closure of large-size sheath femoral venous access sites using the suture-mediated Perclose device is efficacious in achieving rapid haemostasis in the presence of anticoagulation. Doppler follow-up shows no loss of venous patency or luminal venous diameter as compared with the contralateral side.

Tensiometry as a measure of improvement in knot quality in undergraduate medical students

INTRODUCTION

This study examined the validity of tensiometry as an objective method of assessing the improvements in the quality of knots and technical performance due to practice on suturing and knot-tying skills.

METHODS

We evaluated the quality of 1,830 knots produced by undergraduate medical students before training (pre-test), after (post-test), and after a week retention (retention-test) using tensiometry. These results were compared to expert-based assessments of products and performance.

RESULTS

Tensiometry, as well as expert-based assessments can detect changes in the quality of knots and technical performance from pre to post and retention-test ( p<0.05). However, these three methods may assess different dimensions of the same products and actions.

CONCLUSIONS

The development of trainee evaluation criteria for the acquisition of surgical skills is a crucial element in surgical education. Based on our patterns of results it is hypothesized that tensiometry can serve as an economic first approximation of the quality of knots and suturing performance.

Does suture material and technique really matter? Lessons learned from 800 consecutive blepharoplasties

OBJECTIVES

The purpose of this study was to evaluate established suture materials and techniques for blepharoplasty closure and evaluate for any differences in rates of complications between these groups.

STUDY DESIGN AND METHODS

This was a prospective study of a large sequential series of patients undergoing upper blepharoplasty who were treated by the same senior author over a 5-year period. Patients were assigned one of four techniques for closure of the incision based on the senior author's experience. After 6 weeks, rates of complications and revisions were noted and addressed. Satisfaction rates were noted at 3 months.

RESULTS

In the group whose incisions were closed with running subcuticular polypropylene (Prolene), 5 (2.5%) presented with milia, and 11 (5.5%) had a standing cone deformity (SCD). Use of running cutaneous locked Prolene resulted in 8 patients (17%) with milia and 2 patients (4.4%) requiring revision of a SCD. Use of a running 6-0 plain gut suture resulted in 12 patients (6.7%) with milia and 5 patients (2.8%) with unsightly scarring. In the group whose incisions were closed with running 6-0 fast-absorbing gut, 10 patients (2%) presented with milia, and there were no scar revisions. There were statistically significant differences between the groups with respect to formation of milia, scarring, and persistent erythema (P < .008).

CONCLUSIONS

Blepharoplasty is a safe and effective procedure that can be performed successfully with several established techniques. In our experience, closure with two interrupted 6-0 Prolene sutures and a running 6-0 fast-absorbing gut resulted in the lowest rates of complications and revisions.

Prognostic factors for neuroreflexotherapy in the treatment of subacute and chronic neck and back pain: a study of predictors of clinical outcome in routine practice of the Spanish National Health Service

STUDY DESIGN

Prospective cohort follow-up study.

OBJECTIVES

To refine the indication criteria for neuroreflexotherapy (NRT) in the treatment of subacute and chronic neck (NP), thoracic (TP) and low back pain (LBP) in the Spanish National Health Service (SNHS), by identifying prognostic factors for clinical outcome.

SUMMARY OF BACKGROUND DATA

NRT consists of the temporary subcutaneous implantation of surgical devices in trigger points. Previous randomized controlled trials have shown its efficacy, effectiveness, and cost-effectiveness for treating subacute and chronic LBP. Clinical audits in routine practice have shown similar results in NP, TP, and LBP patients.

PATIENTS AND METHODS

All 1514 patients from the SNHS in the Balearic Islands in which a NRT intervention was performed and who were discharged between January 1, 2004, and December 31, 2005, were included in this study. Treatment failure was defined as a baseline score equivalent to or lower than the corresponding one at discharge for local pain, referred pain, or LBP-related disability. Multivariate logistic regression models were developed for each of those variables. Maximal models included reason for referral (NP, TP, or LBP), age, sex, baseline values for each variable, number of days in which the surgical devices used in NRT were left implanted, duration of the current episode, time elapsed since the first episode, and previous failed surgery for the current episode. Calibration of the models was assessed through the Hosmer-Lemeshow test, while discrimination was assessed through the area under the ROC curve and the Nagelkerke R test.

RESULTS

When referred to NRT, patients' median (IQR) duration of the episode was 210 (90, 730) days. Failure rates ranged between 9.9% for local pain and 14.5% for disability. Variables associated with a worst prognosis for local pain, referred pain, and disability were surgical devices remaining implanted for a shorter duration and, especially, a longer pain duration. Patients referred for NP were more likely to improve than those referred for TP or LBP. Regarding the evolution of local and referred pain, lesser improvement was observed in the least severe complaint at baseline. Models showed a good calibration. The area under the ROC curve ranged between 0.719 and 0.804, and R ranged between 0.101 and 0.255.

CONCLUSION

A longer duration of the current episode is the worst detected prognostic factor for response to NRT, but prognostic models are inaccurate for predicting the clinical outcome of a given patient. In order to improve the success rate of this technology, these results only support earlier referral for patients complying with current indication criteria.

Anterior sacral meningocele. A case report

A case of anterior sacral meningocele in a 6-year-old girl is reported. The laminotomies of L5, S1, and S2 vertebrae were performed through a median posterior approach. The communication between the subarachnoid space and the meningocele was closed using dural fibrin patch, which has not yet been described in the literature. The relevant literature is reviewed.

Suture of transected nerve suppresses expression of BH3-only protein Noxa in nerve-transected motor neurons of C57BL/6J mouse

Disrupted peripheral nerves are typically sutured as spontaneous recovery does not always occur. However, the molecular mechanisms involved in nerve regeneration following end-to-end nerve suture are obscure. Here, we investigated effects of end-to-end nerve suture after peripheral nerve transection on motor neurons, using the C57BL/6J mouse hypoglossal nerve injury model. In this animal model, 60-80% of injured motor neurons gradually progress to neuronal death, while the remaining injured neurons survive and regenerate. Mice were divided into the Cut and Suture groups. In the Cut group, the right hypoglossal nerve was transected. In the Suture group, the right hypoglossal nerve was transected and then was repaired using end-to-end nerve suture. We assessed differences between the Cut and Suture groups by analyzing the neuronal survival rate by thionine staining and the nerve terminal regeneration rate by vesicular acetylcholine transporter (VAChT) immunohistochemistry, which is a marker for cholinergic presynaptic terminal. We found that 82.9% of motor neurons survived in the Suture group, whereas only 39.2% of motor neurons did in the Cut group 56 days after surgery. At that time point, 86% of presynaptic terminals compared to controls were regenerated in the Suture group, and 21% were regenerated in the Cut group. These results demonstrate that peripheral nerve suture prevented death of nerve-transected motor neurons and promoted nerve regeneration. We also examined expression profiles of major survival and death signal-associated genes in hypoglossal nuclei using in situ hybridization and real-time polymerase chain reaction (PCR). Although most of the survival- and death-associated genes were regulated in a similar manner in both groups, expression of BH3-only protein Noxa mRNA was significantly lower in the Suture than in the Cut group. A significant suppression of Noxa expression by the Suture may be a major reason why nerve suture induces survival and regeneration of nerve-injured motor neurons.

Teaching suturing and knot-tying skills to medical students: A randomized controlled study comparing computer-based video instruction and (concurrent and summary) expert feedback

BACKGROUND

We carried out a prospective, randomized, 4-arm study including control arm, blinding of examiners to determine effectiveness of computer-based video instruction (CBVI) and different types of expert feedback (concurrent and summary) on learning of a basic technical skill.

METHODS

Using bench models, participants were pre-tested on a suturing and instrument knot-tying skill after viewing an instructional video. The students were subsequently assigned randomly to 4 practice conditions: no additional intervention (control), self study with CBVI, expert feedback during practice trials (concurrent feedback), and expert feedback after practice trials (summary feedback). All participants underwent 19 trials of practice, over 1 hour, in their assigned training condition. The effectiveness of training was assessed both at an immediate post-test and 1 month later at a retention test. Performance was evaluated using both expert-based (Global Rating Scores) and computer-based assessment (Hand Motion Analysis). Data were analyzed using repeated-measures ANOVA.

RESULTS

There were no differences in GRS between groups at pre-test. The CBVI, concurrent feedback and summary feedback methods were equally effective initially for the instruction of this basic technical skill to naive medical students and displayed better performance than control (control, 12.71 [10.79 to 14.62]; CBVI, 16.39 [14.38 to 18.40]; concurrent, 16.97 [15.79 to 18.15]; summary, 16.09 [13.57 to 18.62]; P < .001 each). At retention. however, only CBVI and summary feedback groups retained superior suturing and knot-tying performance versus control (control, 8.13 [6.94 to 9.85]; CBVI, 11.92 [10.19 to 14.99] P = .037; concurrent, 9.80 [8.55 to 13.45] P = .635; summary, 111.19 [10.27 to 14.29] P = .037). Hand motion data displayed a similar pattern of results. There were no group differences in the rate of learning (P > .05).

CONCLUSION

Our study showed that CBVI can be as effective as summary expert feedback in the instruction of basic technical skills to medical students. Thoughtfully incorporated into technical curricula, CBVI can make efficient use of faculty time and serve as a useful pedagogic adjunct for basic skills training. Additionally, our study provides evidence supporting an increased role of summary feedback to effectively train novices in technical skills.

Equine pericardium for dural grafts: clinical results in 200 patients

AIM

Serous sheets are currently used in Neurosurgery as dural substitute. The aim of this study is to demonstrate that the horse pericardium, which has the essential charasteristics of reabsorbable membranes and moreover is BSE-free, is an excellent dural substitute.

METHODS

200 patients, 53 suffering from cranial traumatic conditions and 97 from cranial and craniospinal neoplastic pathologies, underwent a surgical procedure with the application of horse pericardium as a dural prosthesis.

RESULTS

The follow-up controls of the patients included a neurosurgical visit and advanced diagnostic imaging (CT or MR). In the first 3 cases, an accumulation of CSF occurred under the surgical edge. Lumbar 7-days drainage was required in just one case. The use of Zero 5 suture seems to have obviated this problem, as it was never observed again in subsequent cases. The diagnostic imaging showed no alterated images and no clinical-neurological sequelae regarding the prosthesis in question were recorded.

CONCLUSIONS

The Audiomesh Neuro prosthesis has all the characteristics of reabsorbable membranes: they are free from antigenic effects and do not produce any toxic catabolites. The membrane proved to be resistant to surgical suture, impermeable to CSF and is transparent. Yet the suture must be carried out carefully through a small non-traumatic needle. Audiomesh Neuro does not adhere to the underlying cerebral cortex and does not cause any clinical evidence or radiological artifacts.

[A randomized clinical trail of 2 fast-resorbing suture materials]

VICRYL rapide is a fast-resorbing synthetic suture material which is widely used in (oral) surgery. The suture wire is broken down by hydrolysis, making its removal unnecessary. The aim of this study was to compare the clinical suitability of the renewed generation VICRYL rapide with that of the original generation. 'Suitability' was defined as absence of discomfort, minimal pain for the patient, good knot security and tensile strength, predictable resorption, minimal tissue response and good wound healing. The trial comprised 120 patients who underwent an apicoectomy at the department of Oral and Maxillofacial Surgery. The patients were assigned at random to a group treated with the renewed generation VICRYL rapide (n = 60) and a control group treated with the original generation (n = 60). The trial was performed double-blind. Regarding the clinical suitability it can be concluded that the renewed generation VICRYL rapide does not yield any significant improvement over the original generation.

Cerebral Protection During Retrograde Carotid Artery Stenting for Proximal Carotid Artery Stenosis-Technical Note-

Carotid artery stenting for carotid bifurcation stenosis usually uses the transfemoral approach. However, in patients with proximal common carotid artery (CCA) stenosis, the guiding catheter is difficult to introduce into the narrow origin of the CCA without risking cerebral embolization before activation of the protection device. A technique of cerebral protection by internal carotid artery (ICA) clamping with or without simultaneous external carotid artery (ECA) clamping was used to treat patients with proximal CCA stenosis by the retrograde direct carotid approach. The carotid bifurcation was surgically exposed and retrograde catheterization was performed to approach the stenosis. The ICA was clamped during angioplasty and stenting to avoid cerebral embolization. The ECA was clamped simultaneously if any extracranial-intracranial anastomosis was present. None of five patients treated with this technique experienced ischemic complications attributable to this technique.

In Vitro Bursting Pressures of Jejunal Enterotomy Closures in Llamas

OBJECTIVE

To evaluate closure strength (in vitro bursting pressure) of jejunal enterotomies in llamas.

STUDY DESIGN

In vitro experimental study.

SAMPLE POPULATION

Jejunal specimens (n=72) from 6 llamas.

METHODS

Differences in bursting pressures and luminal diameters were compared between 2 layer enterotomy closures with an initial full thickness simple continuous pattern oversewn with either a continuous Lembert or Cushing suture pattern using 3 sizes (2-0, 3-0, 4-0) of polyglactin 910 and polydioxanone.

RESULTS

Bursting pressures were significantly higher for enterotomies closed with polydioxanone than polyglactin 910, independent of suture size, but there was no difference between Lembert and Cushing oversew patterns. Use of a Lembert pattern reduced intestinal diameter more than a Cushing pattern regardless of suture material or size.

CONCLUSIONS

Although polydioxanone resisted higher bursting pressures than polyglactin 910, both suture materials should be considered satisfactory for jejunal enterotomy closure in llamas based on typical intraluminal pressures expected in clinical patients. The optimal oversew pattern may be continuous Cushing to maximize the luminal diameter in small intestinal enterotomy closures.

CLINICAL RELEVANCE

In vitro bursting pressures may help to predict which enterotomy sites would leak post-operatively, although further studies are necessary to determine the outcome in clinical patients.

A compression force comparison study among three staple fixation systems

Traditional staples have recently been redesigned with both new materials and engineering techniques to facilitate interfragmentary compression in theory, resulting in greater friction between bone fragments to counteract shearing forces. In the current study, the biomechanical properties of 3 different staples were investigated. The interfacial force at 2 different sites within a calcaneal bone model was measured after insertion and activation of the OSStaple, the UNI-CLIP, and the Smith and Nephew Standard Large Staple after precompression with the SYNTHES Small Distractor. Additionally, the ability of each staple to maintain compression over a short period of time was investigated. In the current bench study, the OSStaple consistently generated the greatest and most uniform compression across the bone model osteotomy and was also capable of sustaining the compression over the duration of all of the trials.

The subcutaneous loop: a single suture technique for skin closure after superficial and subcutaneous surgery

BACKGROUND

Removal of subcutaneous skin masses and certain deep skin injuries results in defects, which demand immediate closure. Although primary closure of these defects in 2 layers is an acceptable solution, this technique has a number of drawbacks, such as extended time consumption upon performance, demand for additional suture material and occasional tissue response or foreign body reaction to retained absorbable stitches leading to infection and its sequelae.

OBJECTIVE

We describe an approach intended to furnish a satisfactory solution to the needs of tissue closure in such cases. The significant innovation of this technique is the closure of both deep and superficial layers of skin in one single suture.

MATERIALS AND METHODS

Our suture combines the advantages of the classic mattress suture together with those of the buried subcutaneous suture. We performed the vertical mattress suture with 3/0 polypropylene or monofilament suture and added a subcutaneous loop to achieve sufficient approximation of deep tissue surfaces. This suture technique was applied in our first 50 cases. The defects were closed without adverse sequelae. No tissue infections were observed. Wound dehiscence occurred in one case after premature suture removal. The stitches were slightly more difficult to remove than regular sutures. Review of the resulting scars exhibited acceptable results similar to those of parallel closure techniques.

CONCLUSIONS

This easily performed technique yields the benefits of reducing suture cost, annulling foreign body reaction, and resulting in both a functional and aesthetically pleasing outcome. The subcutaneous loop technique has become our standard closure of choice for wounds demanding simultaneous cutaneous and subcutaneous repair.

Mechanical and handling properties of braided polyblend polyethylene sutures in comparison to braided polyester and monofilament polydioxanone sutures

PURPOSE

This study was designed to comprehensively compare the mechanical properties of 4 types of braided polyblend sutures with widely used braided polyester and monofilament polydioxanone sutures.

METHODS

Polyblend polyethylene sutures (FiberWire [Arthrex, Naples, FL], Herculine [Linvatec, Largo, FL], Orthocord [DePuy Mitek, Raynham, MA], and Ultrabraid [Smith & Nephew Endoscopy, Andover, MA]), a braided polyester suture (Ethibond; Ethicon, Somerville, NJ), and an absorbable monofilament polydioxanone suture (PDS II; Ethicon), all USP No. 2, were mechanically tested. Fraying resistance was tested on eyelets of metallic and absorbable suture anchors. Cartilage abrasion caused by an intra-articularly placed suture knot was simulated by fraying on distal porcine femora.

RESULTS

All polyblend sutures were stronger than Ethibond or PDS II sutures by at least a factor of 2, with or without a knot. When knotted, Herculine (261 +/- 44 N) was strongest, followed by Ultrabraid (244 +/- 3 N). FiberWire was most resistant against fraying on metallic anchors. Orthocord was by far least abrasive with absorbable anchors. Resistance to fraying was 100- to 500-fold (absorbable anchors) and 6- to 30-fold (metallic anchor) better for all polyblend sutures than for Ethibond. All braided sutures caused a similar amount of abrasion of joint cartilage, but they caused significantly more abrasion (>20-fold) than the monofilament degradable suture.

CONCLUSIONS

The ultimate strength of polyblend suture material was 2- to 2.5-fold greater than that of polyester or polydioxanone sutures, but the resistance to fraying was up to 500-fold greater than that of polyester or polydioxanone sutures. With regard to strength, this makes polyblend sutures particularly advantageous for use with metallic edges of anchors or prostheses or with absorbable anchor eyelets.

CLINICAL RELEVANCE

With a high resistance to fraying against metallic edges or a decrease in cutting of absorbable suture eyelets being up to 500-fold greater than with polyester or polydioxanone sutures, the new polyblend sutures appear to fill a void in the armamentarium of the surgeon, provided that at least 2 throws more than with conventional sutures are used for knot tying.

Ideal suture diameter is critical for consistent middle cerebral artery occlusion in mice

OBJECTIVE

The use of transgenic and knockout mice has led to a need for a consistent model of mouse transient focal cerebral ischemia. In a great majority of the published mouse middle cerebral artery (MCA) occlusion studies, the methods indicated the type of intraluminal suture used without indicating the actual suture diameter after modification. We attempted to determine the ideal suture diameter to produce consistent occlusion in the MCA of adult male C57BL/6 mice.

METHODS

Suture tips were coated to a depth 4 mm with glue, and 6-0 sutures of eight different, precisely measured diameters were produced. The coated 6-0 sutures in different diameters were introduced 10 mm into the internal carotid artery via the external carotid artery of the mice to produce MCA occlusion (n = 40; five animals for each diameter), and the mice (22-24 g) were transaortically perfused with saline. The base of the brain was exposed, and photographs of the vessels were obtained before and after transaortic injection of Evans blue dye to determine the consistency of MCA occlusion for each suture diameter. Cerebral blood flow was measured 10 minutes before occlusion and 20 minutes after reperfusion, and 2,3,5-triphenyltetrazolium chloride staining was performed to demonstrate the ischemic damage in additional animals with 110-microm (n = 5) and 180-microm (n = 8) diameter sutures.

RESULTS

Sutures measuring 170 microm and 180 microm in diameter consistently occluded the MCA of C57BL/6 mice. In addition, 2,3,5-triphenyltetrazolium chloride staining demonstrated consistent infarction with 180-microm diameter sutures. The infarct volume was 36.3 +/- 4.2 mm3.

CONCLUSION

Small changes in the diameter of the occlusion suture tip affect consistency in the mouse MCA occlusion model.

Cost savings and quality improvement--single-use suture instruments?

AIM

To determine if the instruments found in single-use suture kits are of satisfactory quality when compared with re-useable instruments and to determine the cost implications of changing to these kits.

METHODS

Audit of established practice, followed by trial of new suture kits and their introduction to the department. The new practice was then audited. A cost analysis was conducted.

RESULTS

The audit showed numerous problems with the traditional suture kits (instruments were breaking or no longer suitable for suturing wounds). A trial of single-use instruments demonstrated them to be high quality and provided new instruments each time. A repeat audit at one year post-introduction demonstrated no identifiable problem with the new suture kits. The subjective impression of staff was of an improvement compared to the old kits. Costs of sterilising suture instruments were determined and it was found that single use suture kits were cost effective. Assuming an average usage of 150 kits per month, at pound 4.45 each cost for sterilisation, and a total cost of pound 3.05 each for a single-use suture kit plus dressing pack per patient, this yielded a projected cost saving of pound 2520.00 per annum. The actual cost saving was pound 1981.00 that year. The shortfall was due to overestimation of average usage.

CONCLUSION

Single use instruments would appear to be safe and cost effective in the emergency department setting.

Cyclic loading of Achilles tendon repairs: a comparison of polyester and polyblend suture

BACKGROUND

Early functional rehabilitation is widely used after open suture repair of the Achilles tendon. To our knowledge, no previous studies have assessed gap formation from cyclic loading and subsequent failure loads of simulated Achilles tendon repairs. A synthetic (polyblend) suture has been introduced for tendon repairs with reportedly greater strength than polyester suture. This stronger, stiffer suture material may provide stronger repairs with less elongation of the tendon repair.

METHODS

Simulated Achilles tendon ruptures in bovine Achilles tendon were repaired with a four-strand Krackow suture technique using No. 2 polyester suture. Specimens were loaded for 3,000 cycles at maximal loads of 50, 75, 100, or 125 N, and gap formation at the repair site was continuously measured. After cyclic loading, each specimen was loaded to failure. Identical repairs were performed with number 2 polyblend suture and cyclically loaded to 75 N for 3,000 cycles. All specimens were loaded to failure.

RESULTS

Cyclically loading polyester suture repairs to 50, 75, 100, or 125 N for 3,000 cycles resulted in mean gapping at the repair site of 3.0 +/- 0.8, 4.9 +/- 1.0, 7.2 +/- 0.9, and 7.9 +/- 0.8 mm, respectively. Cyclically loading the polyblend suture repairs for 3,000 cycles at 75 N, resulted in 3.3 +/- 0.3 mm of gap formation at the repair site, significantly less than polyester suture repairs (p < 0.001). The mean load to failure for polyester suture repair was 222 +/- 19 N and for polyblend suture repair was 582 +/- 49 N, a statistically significant difference (p < 0.001). Gap formation at 100, 1,000, and 2,000 cycles, as a percentage of total gap formation at 3,000 cycles, was 64.3%, 87.5%, and 95.4% for polyester suture and 45.8%, 78.5%, and 90.1% for polyblend repairs. All specimens in all groups failed at the knots during load-to-failure testing.

CONCLUSIONS

Cyclic loading of simulated Achilles tendon repairs using a Krackow, four-core polyester suture technique showed progressive gap formation with increasing load. All repairs failed at the knot, and suture pull-out from tendon was not observed. Polyblend suture repair, when compared to identical repairs with braided polyester suture, resulted in a 260% higher load to failure and 33% less gap formation at the repair site after 3,000 cycles.

CLINICAL RELEVANCE

The use of polyblend suture in a four-stranded Krackow configuration provides stronger repairs with less gap formation, which may provide increased security during early functional rehabilitation.

Comparison and performance characteristics of 3 different knots when tied with 2 suture materials used for shoulder arthroscopy

PURPOSE

To compare the performance of a standard suture material with that of a new material across several arthroscopic knot configurations.

METHODS

Three knots were evaluated (Duncan loop, Weston, and San Diego knots) with the use of 2 suture materials (No. 2 Ethibond [Ethicon, Somerville, NJ] and No. 2 Force Fiber [Stryker Endoscopy, San Jose, CA]). Ten samples were tested for each knot and suture configuration. Samples were pretensioned to 10 N and were mechanically loaded from 10 to 45 N for 1,000 cycles. The number of cycles to 3 mm of loop elongation was recorded as "early" slippage. Intact knots with no evidence of early slippage were then subjected to a load-to-failure test so that the ultimate failure strength of the knot/material could be determined.

RESULTS

Force Fiber knots required a statistically greater number of cycles to reach 3 mm of slippage compared with Ethibond knots (P < .0001). A single Force Fiber knot experienced 3 mm of displacement during cyclic loading; all others survived to 1,000 cycles. One third of all Ethibond knots were displaced to 3 mm during cyclic loading. For Ethibond sutures, no significant differences in ultimate failure strength were observed between knots (average, 143 N across knot types). For Force Fiber sutures, the San Diego knot (279 +/- 41 N) was statistically similar in ultimate failure strength to the Weston knot (254 +/- 41 N), but it was significantly stronger than the Duncan knot (224 +/- 70 N) (P < .03).

CONCLUSIONS

The higher failure loads associated with Force Fiber may allow the surgeon to increase suture tension during knot tying, thereby creating a tighter knot. Loop elongation with Force Fiber occurred at loads that were greater than the typical breakage load for No. 2 Ethibond. Force Fiber is a new material that may be useful for various arthroscopic procedures.

CLINICAL RELEVANCE

Force Fiber provided increased biomechanical stability compared with Ethibond regardless of knot type. The cost benefit of using very strong yet very stiff sutures must be clinically evaluated.

Side-to-end hypoglossal-facial anastomosis via transposition of the intratemporal facial nerve

The technique of facial nerve repair with side-to-end hypoglossal-facial anastomosis is presented and evaluated in five patients who were operated on for facial nerve paralysis after acoustic schwannoma surgery, or had cranial base trauma. The end-to-end hypoglossal-facial anastomosis is accompanied by hemilingual paralysis, with difficulty in swallowing, chewing and speaking. In this new technique, the facial nerve is mobilised in the temporal bone, transected at the second genu and transposed to the hypoglossal nerve where a tensionless side-to-end anastomosis is performed. The hypoglossal nerve is transected in oblique fashion to about one third of its circumference. We were able to achieve a tensionless anastomosis in all patients. The idea is to bring about re-innervation of the previously denervated tissue via a collateral sprouting of axons of the donor nerve through the site of coaptation without sacrificing the innervation of the donor nerve's original targets. With side-to-end hypoglossal-facial anastomosis, two patients attained a House- Brackmann grade of III (one of them with independent movement of eyelids and mouth); one achieved grade IV, another grade V and grade VI. No patient had hemilingual atrophy nor any problems associated with swallowing or chewing.

Comparison of four techniques for the fixation of a collagen scaffold in the human cadaveric knee

OBJECTIVE

Four fixation techniques for a fibrinogen and thrombin coated collagen fleece, used as a scaffold in the cartilage repair, were compared simulating the initial postoperative period in the cadaveric knee joints.

METHODS

Full-thickness chondral lesions were made on the medial femoral condyles of seven human cadaveric inferior extremities. Four scaffolds without seeded chondrocytes were implanted into each lesion using four fixation techniques consecutively: self-adhesion without additional material (SA), fibrin sealant (FS), bone sutures (BS), and periosteal cover (PC). After each implantation 150 cycles of continuous passive motion (CPM) were performed. Two cases were additionally exposed to 50 cycles of 10 and 20 kg loading each after the completion of CPM. The scaffolds were evaluated after every 30 cycles, and the fixation strength was tested after the motion was completed.

RESULTS

All the SA scaffolds were detached before 60 cycles. The other scaffolds remained stable throughout the testing with only minor disruptions. The endpoint fixation strength was higher for BS and PC than for the FS scaffolds. The FS scaffolds were detached as a result of additional load cycles, while the BS and PC scaffolds showed substantial deformations.

CONCLUSION

SA of tested scaffold did not provide sufficient fixation. The FS fixation was easy to perform and assured satisfactory scaffold stability. BS and PC provided excellent scaffold stability, but the techniques were difficult and caused additional injuries. Regardless of the fixation technique used, the tested collagen scaffold may not be exposed to loading in the initial postoperative period.

Capillary activity of surgical sutures and suture-dependent bacterial transport: a qualitative study

OBJECTIVE

To evaluate the multitude of new synthetic absorbable sutures (both monofilament and multifilament) in comparison with older materials with regard to capillarity and bacterial transport.

METHODS

Sutures of United States Pharmacopoeia (USP) 4-0 thickness were arranged in a three-chamber system under sterile conditions. Either a colorant (liquid transport evaluation) or bacteria (bacterial transport evaluation) were added to the contamination chamber, and movement of colorant or bacteria was evaluated for as long as 30 days.

RESULTS

None of the monofilament sutures transported colorant or bacteria. Colorant transport was found on the pseudomonofilament and multifilament sutures between the first and the fifth day. Escherichia coli were transported on the majority of the multifilament sutures, although no transport was found on silk or polyester sutures. Bacterial transport was most often evident in tests using the motile Proteus mirabilis.

CONCLUSIONS

All multifilament and pseudomonofilament suture designs allowed transport of colorants and bacteria to some degree. The movement of fluids and bacteria did not depend on the absorptive capacity of the sutures, coating, or the presence of an open suture end.

Old habits tie hard: an in vitro comparison of first-throw tension holding in Polyglycolic acid (Dexon S) and Polyglactin 910 (Coated Vicryl)

PURPOSE

To compare the first-throw tension holding property of two braided absorbable sutures commonly used in oculoplastic surgery.

METHODS

The study was an in vitro experimental model. 6/0 Polyglycolic acid (Dexon S) and 6/0 Polyglactin 910 (Coated Vicryl) were compared using an experimental model to determine first-throw knot security. A polypropylene suture (Surgipro 2) was included as a benchmark to judge the apparatus by, ensuring that our experiment could be designed independently of the test suture materials. Increasing metric loads were applied to the first double throw of a surgical knot. Each suture was tested to the point of knot slipping and the critical tension recorded. All the sutures were kept wet during use. Three variations of the experiment were undertaken: experiment 1 -- two metal loops brought together by the test suture; experiment 2 -- two strips of tissue brought together by the test suture; and experiment 3 -- a knot tied over a metal bar coated in tissue. The tissue used was processed cross-linked porcine dermal collagen (Permacol). Each experiment was repeated three times for each suture type and the mean value taken.

RESULTS

Experiment 1: Dexon S 12.2 g (11, 12, 13.5), Coated Vicryl 2.5 g (2.5, 2.5, 2.5) and Surgipro 2 2.3 g (2, 2, 3); experiment 2: Dexon S 33.33 g (30, 35, 35), Coated Vicryl 25 g (25, 25, 25) and Surgipro 2 5 g (5, 5, 5); experiment 3: Dexon S 100 g (100, 100, 100), Coated Vicryl 56.667 g (60, 55, 55) and Surgipro 2 5 g (5, 5, 5).

CONCLUSIONS

Dexon S-braided absorbable suture has significantly better first-throw knot security when compared with Coated Vicryl. This is an important property when suturing tissues under tension as it minimizes slippage before the locking throw is tied.

Operative Standardisierung bei randomisiert kontrollierten Studien in der Chirurgie

BACKGROUND

INSECT is an internationally registered, three-armed, multicentre, intraoperatively randomised model trial of the Study Centre of the German Surgical Society. The interventions being compared are running suture technique with slowly absorbable monofilament suture material (PDS vs MonoPlus) and interrupted technique with a braided, rapidly absorbable suture material (Vicryl). The primary endpoint is the rate of incisional hernias 1 year postoperatively.

MATERIAL AND METHODS

A total of 25 surgeons from 24 different institutions at all levels of care evaluated the theoretical and practical sessions of the surgical investigator meeting using 25 criteria, including course organisation, content, and speaker evaluation, and a categorical grading system from 1 (very good) to 6 (insufficient).

RESULTS

Distribution of the 625 grades was: very good (1) n=367, good (2) n=207, satisfactory (3) n=39, adequate (4) n=2, and "No statement" n=10. The average score for the investigator meeting was 1.5.

CONCLUSION

The participants felt they were successfully prepared theoretically and practically for trial interventions and conduct by attending the meeting. Clear explanation of the measures for treatment equivalence before and during trials is mandatory in randomised controlled surgical trials.

Suture holding capacity of the Achilles tendon during the healing period: an in vivo experimental study in rabbits

BACKGROUND

Early motion and weightbearing is known to promote the healing of Achilles tendon repair. It is important to be informed about the repair strength for a secure rehabilitation. There are reports about the initial repair strength of Achilles tendons; however, they are mainly in vitro studies that represent the time zero strength of the repair. Softening of the tendon observed during the biological process of the tendon healing, which may effect the suture holding capacity and in turn the repair strength of the tendon has not been evaluated before.

METHODS

In the current study, the suture holding capacity of rabbit Achilles tendon was observed at various times during the healing period.

RESULTS

The suture holding capacity of the tendon at the end of the first and third weeks after surgery was found to be similar within 30% of the control tendon. However, at the end of the fourth week it was doubled reaching 65% of the control tendon.

CONCLUSIONS

Intrinsic tendon insufficiency which causes a decrease in the suture holding capacity of the tendon may lead to pull-out of the suture material during the postoperative third week. This period is precarious for early motion and weightbearing since the suture holding capacity of the tendon doubled relative to the previous three weeks.