Bone Anchor Fixation Research Articles

Bone Anchor Fixation in the Repair of Blunt Traumatic Abdominal Wall Hernias: A Western Trauma Association Multicenter Study.

Blunt traumatic abdominal wall hernias (TAWHs) are rare but require a variety of operative techniques to repair including bone anchor fixation (BAF) when tissue tears off bony structures. This study aimed to provide a descriptive analysis of BAF technique for blunt TAWH repair. Bone anchor fixation and no BAF repairs were compared, hypothesizing increased hernia recurrence with BAF repair. A secondary analysis of the WTA blunt TAWH multicenter study was performed including all patients who underwent repair of their TAWH. Patients with BAF were compared to those with no BAF with bivariate analyses. 176 patients underwent repair of their TAWH with 41 (23.3%) undergoing BAF. 26 (63.4%) patients had tissue fixed to bone, with 7 of those reinforced with mesh. The remaining 15 (36.6%) patients had bridging mesh anchored to bone. The BAF group had a similar age, sex, body mass index, and injury severity score compared to the no BAF group. The time to repair (1 vs 1 days, P = .158), rate of hernia recurrence (9.8% vs 12.7%, P = .786), and surgical site infection (SSI) (12.5% vs 15.6%, P = .823) were all similar between cohorts. This largest series to date found nearly one-quarter of TAWH repairs required BAF. Bone anchor fixation repairs had a similar rate of hernia recurrence and SSI compared to no BAF repairs, suggesting this is a reasonable option for repair of TAWH. However, future prospective studies are needed to compare specific BAF techniques and evaluate long-term outcomes including patient-centered outcomes such as pain and quality of life.

OC-077 OPEN REPAIR OF FLANK AND LUMBAR HERNIAS (FLH): 145 CONSECUTIVE REPAIRS AT A HIGH-VOLUME, TERTIARY HERNIA CENTER

Abstract Aim FLH present a surgical challenge due to their anatomic location, proximity to boney structures, and lack of elasticity of the surrounding muscle. With less than 1,000 cases reported, there is no uniform operative management. This is the largest study to date evaluating FLH repair (FLHR). Materials & Methods A prospective, single-center, hernia specific database was queried for patients who underwent open flank or lumbar hernia repair from 2004–2021. Demographics, operative characteristics, and outcomes were evaluated. Standard statistical methods were used. Results 145 patients included 109 flank hernias and 36 lumbar hernias. The hernias resulted from prior surgery (73.3%), blunt trauma (19.7%), or primary defects (7.0%). The mean defect size was 125.7±166.8cm2, 46.9% were recurrent, and 11.0% of patients visited a pain specialist preoperatively. Mesh was commonly synthetic (92.4%), a mean of 755.9±373.4 cm2, and placed in the preperitoneal space (92.7%). Component separation technique was utilized in 16.8% of cases and pelvic bone anchor fixation in 13.8%. Preoperative chronic pain was present in 75% of patients receiving bone anchors and only 6.6% postoperatively. Complete defect closure occurred in each case. Wound infection (8.1%) and mesh infection (1.4%) were uncommon. Prolonged, postoperative discomfort was reported in 22%, half of which had chronic pain preoperatively (p<0.01). Hernia recurrence was 3.4% at 29.3±13.2 months follow-up. Recurrences occurred posteriorly in 3 and in 2 mesh infections requiring explantation. Conclusions Open preperitoneal repair of FLHs with synthetic mesh results in low rates of postoperative complications and hernia recurrence. Postoperative pain correlated closely with preoperative pain.

Effect of difference in fixation methods of tendon graft and the microfracture procedure on tendon-bone junction healing.

BackgroundThere are generally two methods of fixation for tendon grafts used in ligament reconstruction: bone tunnel fixation and anchor fixation. The microfracture (Mf) procedure is a technique to induce bleeding from the bone marrow, and the bleeding may contain cells with differentiation potential. However, few studies have compared the effects of the Mf procedure with those of the fixation methods. This study aimed to evaluate the effectiveness of the Mf procedure on two tendon graft fixation methods: histological, gene expression, tendon graft thickness, and mechanical. We especially focused our investigation on junction healing of tendon grafts and bone in the two fixation methods.MethodsWe used 20 rabbits to evaluate tendon and bone healing in a peroneal tendon graft model. The rabbit models were divided into five groups according to the combination of peroneal tendon graft fixation method and Mf technique as follows: control group (C, n = 4), bone tunnel fixation without Mf procedure group (BT − Mf, n = 4), bone tunnel fixation with Mf procedure group (BT + Mf, n = 4), anchor fixation without Mf procedure group (A − Mf, n = 4), and anchor fixation with Mf procedure group (A + Mf, n = 4). All animals were sacrificed at 4 weeks postoperatively. The specimens underwent histological evaluation, mRNA analysis, tendon graft thickness at the tendon-bone junction, and biomechanical testing.ResultsHistological evaluation of the BT + Mf and A + Mf groups showed healing with fibrocartilage formation at the tendon graft-bone junction. The mRNA expression showed significant increase in type 2 collagen, Scleraxis, and SRY-box9 in the BT + Mf and A + Mf groups. In biomechanical tests, the BT + Mf and A + Mf groups showed significantly increased tensile strength compared with the BT − Mf and A − Mf groups (BT + Mf group, 21.6 ± 1.7 N; A + Mf group, 22.5 ± 2.3 N vs. BT − Mf group, 12.3 ± 2.4 N; A − Mf group, 11 ± 2.3 N).ConclusionThe Mf procedure resulted in fibrocartilage formation at the tendon-bone junction in the BT and anchor fixation and improved the fixation strength at 4 weeks.

Hybrid laparoscopic and open repair of post-nephrectomy flank hernia

Surgical repair of flank hernia is not routinely performed, due to perceived technical difficulties with the surgery and risk of recurrence, or the misconception that flank hernia is solely due to a denervation injury. Due to the rareness of flank hernia in the literature, there is no general consensus on the best method of surgical repair. We present the case of a patient with a symptomatic large flank hernia following open nephrectomy, in which a hybrid technique of open and laparoscopic flank hernia repair with sublay mesh and bone anchor fixation was successfully performed with good outcome. This case highlights the benefits of the hybrid approach, which allowed a laparoscopic assessment of the defect and adhesiolysis, followed by the open repair which enabled adequate mesh overlap, fixation to surrounding tissues and bone anchor fixation.

Bone Anchor Suture Tape Fixation Technique for the Treatment of Calcaneal Avulsion Fractures

Category:Hindfoot, TraumaIntroduction/Purpose:Surgical treatment of avulsion fractures of the calcaneus has a reported fixation failure rate as high as 23%, and there is much controversy surrounding the best method of treatment for these fractures. We present a technique for fixation of calcaneal avulsion fractures utilizing a bone anchor suture tape fixation technique that can be utilized with or without additional standard internal fixation.Methods:Five patients (2 male, 3 female), with an average age of 73 years old, presenting with a closed extraarticular avulsion fracture of the calcaneus, are included in this case series. Patients underwent bone anchor and suture tape fixation of fracture by a single foot and ankle-fellowship trained orthopaedic surgeon. Patients were additionally assessed pre-operatively, using the contralateral uninjured limb, for gastrocnemius equinus; and if present, patients underwent a gastrocnemius recession. If appropriate, a single compression lag screw and washer inserted perpendicular to fracture line was utilized for additional fixation. Outcomes observed were time to radiographic consolidation, failure of fixation, reoperation rate, presence of post-operative infection, and return to previous function.Results:Of the included patient cohort, all fractures went on to union, and there were no failures of fixation. There was one removal of a compression screw and washer due to hardware pain, and one superficial infection, which resolved with local wound care. All patients went on to weight-bearing as tolerated within 8 weeks post-operatively. Radiographic consolidation was observed at approximately 12 weeks. 4 out of 5 patients returned to previous function, with 1 patient expiring due to unrelated causes prior to determination of final function.Conclusion:Use of a bone anchor suture tape fixation technique appears to hold promise and warrants further investigation for its potential utilization as a reliable technique for fixation for avulsion fractures of the calcaneus. Our technique increases the distribution of surface area forces over the cortical bone while incorporating multiple points of fixation, including through the Achilles tendon insertion, neutralizing the distraction forces of the tendon directly.

Construct Levels to Anchored Levels Ratio and Rod Diameter Are Associated With Implant-Related Complications in Traditional Growing Rods

IntroductionIn addition to patient characteristics, consideration of length of construct to number of anchored levels ratio and rod diameter should be a part of preoperative planning to minimize implant-related complications (IRCs). IRCs including rod breakage, anchor dislodgement, and pullout are among the most common adverse events in traditional growing rods (TGRs). The current study hypothesized that anchor type and configuration are associated with IRC. MethodsPatients with (1) age ≤10 years at surgery; (2) spine-based dual TGR; (3) minimum 2-year follow-up; and (4) available imaging. Cephalad and caudal foundations were grouped based on the number of instrumented levels and anchor type. All radiographs were reviewed. Based on the results, a “construct levels / anchored levels” (CL/AL) ratio was calculated, which is the number of levels spanned by instrumentation divided by the number of levels with bone-anchor fixation. Receiver operating characteristic curve was used to define the CL/AL threshold. Results274 patients divided into patients with complications (IRC+, n = 140) and without complications (IRC–, n = 134) groups. Mean follow-up was 6.3 years (2.1–18.0 years). No significant differences in age, gender, body mass index, ambulatory status, etiology, primary curve size, T1–S1 height, coronal and sagittal balance, and rod material were observed between the two groups. Comparative analysis showed that connector type, presence and location of crosslinks, number of levels instrumented, number and type of anchors, presence of pelvic fixation, and mirroring of cephalad and caudal foundations were not different. However, maximum kyphosis and rod diameter were significantly different. The CL/AL ratio threshold was 3.5. Multivariate analysis of kyphosis, rod diameter, and CL/AL ratio showed a significant association with IRC (p < .05). Discussion and ConclusionAlthough patient characteristics like kyphosis have been proven to be associated with instrumentation failure, it is a combination of characteristics that include rod diameter and CL/AL ratio that showed significant correlation with IRC. Validation of the CL/AL ratio is recommended.

Maxillary protraction with bimaxillary bone anchor and mini rigid surgical fixation plates in patient with Bilateral Cleft Lip and Palate Sequelae: Case report

The objective is to evaluate the effects of maxillary protraction by means of a bimaxillary bone anchorage as well as its progress by fixing mini plates in patients with Bilateral Cleft Lip and Palate Sequela, based on the protocol of Clerck and Cha et al. HGO CM La Raza and the Technological University of Mexico UNITEC.

Bone anchor fixation method of an incarcerated Petit hernia in an elderly lady: Optimal management of a rare case

Background: The first reported lumbar hernia was in 1731. Since then, only about 300 cases have been reported in the literature. Approximately 20% of lumbar hernias are congenital and the remainder are acquired. They commonly occur in males, more frequently on the left side, and the majority are reported in the sixth-to-seventh decade of life. Based on the anatomical defect, lumbar hernias are classified into two types: superior (Grynfeltt-Lesshaft) and Inferior (Petit). Petit hernias are less common and their proximity to bone can make them more difficult to repair. Several methods for optimal repair have been proposed. Since 2004, only 7 reports advocated surgical management using the bone anchor fixation method. Case description: A 79-year-old obese female presented to the outpatient clinic with a 1-year history of moderate right lumbar pain. Examination revealed a tender bulge in the posterior lumbar region. CT of the abdomen & pelvis revealed a 6.6 cm × 7.4 cm defect in the right posterolateral abdomen incorporating parts of the right ascending colon. She was diagnosed with right-sided Petit lumbar hernia and underwent an open hernia repair with iliac crest anchor fixation and mesh implantation. The postoperative course was uneventful and the patient was discharged in a stable condition. Conclusions: Lumbar hernias represent a rare clinical phenomenon, especially in females. A protruding mass in the lumbar region with localized abdominal pain and radiographic evidence of posterior abdominal wall defect should raise suspicion for a lumbar hernia. Predisposing factors such as old age, obesity and conditions that increase intra-abdominal pressure increase the risk of lumbar hernia. There is a current dilemma centered on the optimal type of surgical approach and repair technique. In our case, an open repair using the bone anchor fixation technique led to excellent results.

Arthroscopic refixation of TFCC by bone screw anchor

The goal of this operation technique is astable refixation of the triangular fibrocartilage complex (TFCC) to the fovea ulnaris. The stability of the distal radio-ulnar joint (DRUJ) should be re-established. The patients pain and the feeling of instability should be reduced. Lesions of the foveal component of the TFCC resulting in DRUJ instability. Combined lesions of both components of the TFCC. Complete detachment of the TFCC from the ulna either without fracture of the styloid process of the ulna or with fracture (floating styloid). Severe lacerations of the TFCC and clinically relevant arthrosis of the DRUJ. Severely osteoporotic bone. Following diagnostic arthroscopy and performance of stability control of the TFCC with a palpation hook, reduction of the DRUJ with supination position of the wrist. Bone anchor fixation through the direct foveal portal (DF). Under arthroscopic control through the 3/4 portal, the suture from the DF portal is placed through the TFCC. Pull out and tie the strands through the 6U portal. Restriction of rotation of the forearm in aMunster cast or special cast brace for 6weeks. Self-controlled exercise of the wrist after 6weeks. Physiotherapy and strength building 8weeks postoperatively. Clinical studies of this technique showed asignificant amelioration of pain perception, improved range of motion and DASH score in all patients after anchor fixation. The results are comparable to other techniques. All patients returned to work after the operation. Accordingly, using this technique avery good stabilization of the DRUJ with low complications can be achieved.

Numerical Methodology to Evaluate the Effects of Bone Density and Cement Augmentation on Fixation Stiffness of Bone-Anchoring Devices.

Bone quality is one of the reported factors influencing the success of bone anchors in arthroscopic repairs of torn rotator cuffs at the shoulder. This work was aimed at developing refined numerical methods to investigate how bone quality can influence the fixation stiffness of bone anchors. To do that bone biopsies were scanned at 26-μm resolution with a high-resolution microcomputer tomography (micro-CT) scanner and their images were processed for virtual implantation of a typical design of bone anchor. These were converted to microfinite element (μFE) and homogenized classical FE models, and analyses were performed to simulate pulling on the bone anchor with and without cement augmentation. Quantification of structural stiffness for each implanted specimen was then computed, as well as stress distributions within the bone structures, and related to the bone volume fraction of the specimens. Results show that the classical method is excellently correlated to structural predictions of the more refined μFE method, despite the qualitative differences in local stresses in the bone surrounding the implant. Predictions from additional loading cases suggest that structural fixation stiffness in various directions is related to apparent bone density of the surrounding bone. Augmentation of anchoring with bone cement stiffens the fixation and alters these relations. This work showed the usability of homogenized FE (hFE) in the evaluation of bone anchor fixation and will be used to develop new methodologies for virtual investigations leading to optimized repairs of rotator cuff and glenoid Bankart lesions.

Bone Anchor Fixation in Abdominal Wall Reconstruction: A Useful Adjunct in Suprapubic and Para-iliac Hernia Repair

Suprapubic hernias, parailiac or flank hernias, and lumbar hernias are difficult to repair and are associated with high-recurrence rates owing to difficulty in obtaining substantive overlap and especially mesh fixation due to bone being a margin of the hernia. Orthopedic suture anchors used for ligament reconstruction have been used to attach prosthetic material to bony surfaces and can be used in the repair of these hernias where suture fixation was impossible. A prospective, single institution study of ventral hernia repairs involving bone anchor mesh fixation was performed. Demographics, operative details, and outcomes data were collected. Twenty patients were identified, with a mean age 53 (range: 35-70 years) and mean body mass index 28.4 kg/m(2) (range 21-38). Ten lumbar, seven suprapubic, and three parailiac hernias were studied. The majority were recurrent hernias (n = 13), with one to seven previously failed repairs. The mean hernia defect size was very large (270 cm(2); range: 56-832 cm(2)) with average mesh size of 1090 cm(2) (range 224-3640 cm(2)). Both Mitek GII (Depuy, Raynham, MA) and JuggerKnot 2.9-mm (Biomet, Biomedical Instruments, Warsaw, IN) anchors were used, with an average of four anchors/case (range: 1-16). Mean operative time was 218 minutes (120-495). There were three minor complications, no operative mortality, and no recurrences during an average follow-up of 24 months. Pelvic bone anchors permit mesh fixation in high-recurrence areas not amenable to traditional suture fixation. The ability to safely and effectively use bone anchor fixation is an essential tool in complex open ventral hernia repair.

Dynamic magnetic resonance imaging before and 6 months after laparoscopic sacrocolpopexy

The objective of this study was to correlate dynamic magnetic resonance imaging (MRI) with Pelvic Organ Prolapse Quantification (POP-Q) measurements and pelvic floor symptoms in order to determine the value of dynamic MRI for evaluating vaginal vault prolapse both before and 6 months after laparoscopic sacrocolpopexy. This was a prospective, single-center cohort study in 43 patients who underwent a modified laparoscopic sacrocolpopexy/hysteropexy operation using bone-anchor fixation and synthetic mesh. The study included dynamic MRI, POP-Q staging, and validated questionnaires before and 6 months after laparoscopic sacrocolpopexy. To assess MRI data, the pubococcygeal reference line and specifically defined anatomical landmarks for the separate compartments were used. Differences between pre- and postoperative measurements were evaluated with the Wilcoxon signed-rank test, and correlations at the 0.05 level were considered to be significant (Pearson correlation, two tailed). At 6 months, a statistically significant improvement was seen in POP-Q staging for all compartments. Dynamic MRI measurements only revealed a significant improvement after surgery for the apical compartment. The correlation between (changes in) MRI measurements, POP-Q measurements, and validated questionnaires was poor. The value of dynamic MRI for evaluating and documenting changes in vaginal vault support and position after laparoscopic sacrocolpopexy is limited due to the poor correlation with both POP-Q staging and pelvic floor symptoms.

Laparoscopic sacral colpopexy versus total vaginal mesh for vault prolapse; comparison of cohorts

The surgical treatment of vaginal vault prolapse can either be performed by the vaginal or the abdominal (laparoscopic) route. The objective of this study was to compare the laparoscopic sacral colpopexy (LSC) and total vaginal mesh (TVM) for vaginal vault prolapse. This study compared a prospective cohort of LSC with bone-anchor fixation and mesh limited to the apex to a prospective cohort of TVM as treatment modalities in patients with a symptomatic vaginal vault prolapse (pelvic organ prolapse-quantification (POP-Q) point C ≥ −3). Primary outcome was failure in the apical compartment after 6 month follow-up, defined as POP-Q stage ≥ II with prolapse complaints or re-treatment in apical compartment. Based on an overall failure in all compartments of 23 % in the LSC group and 57 % in the TVM group, 29 patients would be needed in each group with a power of 80 % and alpha 0.05. Ninety-seven women were included, 45 LSC and 52 TVM. The failure rate of symptomatic vault prolapse was 1 (2 %) in each group (p = 0.99). The failure rate (POP stage ≥ II) in any compartment was 23 (51 %) in the LSC group and 11 (21 %) in the TVM group (p = 0.002). Each technique had its own type of complications. Short-term failure rates in the apical compartment after TVM and LSC were similar. In case of anterior or posterior prolapsed, additional mesh insertion or additional vaginal colporrhaphy is indicated in LSC surgery.

Sequential urodynamic assessment before and after laparoscopic sacrocolpopexy

Controversial data are available as to whether to perform a simultaneous abdominal or vaginal colposuspension operation in laparoscopic sacrocolpopexy procedures. We wanted to evaluate the effect of a modified laparoscopic operation technique on urodynamic parameters and lower urinary tract symptoms. Prospective single center cohort study. Teaching hospital. Forty-nine consecutive patients who underwent a modified laparoscopic sacrocolpopexy/hysteropexy operation using bone anchor fixation and synthetic mesh, performed by the same laparoscopic surgeons. Pre- and postoperative multichannel urodynamic evaluation and validated questionnaires. The same urologist, blinded to the results of the questionnaire survey, interpreted all urodynamic evaluations. The effects of surgery on pelvic anatomy and patient satisfaction, urodynamic observations and diagnoses and symptom scores in validated questionnaires. Forty-two patients consented to pre- and postoperative urodynamic evaluation. Laparoscopic sacrocolpopexy successfully corrected vaginal vault prolapse in all 42 patients with urodynamic evaluation six months after surgery. The bladder volume at first desire to void was significantly increased and the maximal detrusor pressure at voiding phase was significantly decreased. In the questionnaires, irritative and storage voiding symptoms were significantly decreased. The results of the study demonstrate that there are no adverse urodynamic findings following this modified technique for laparoscopic sacrocolpopexy. The statistically significant urodynamic improvements are in accordance with the scores on the Urogenital Distress Inventory questionnaires. These results do not support a simultaneous routine prophylactic colposuspension procedure.

The Use of Mitek Bone Anchors for Synthetic Mesh Fixation to Repair Recalcitrant Abdominal Hernias

Repair of recurrent abdominal hernias is a surgical challenge. These patients usually present to the plastic surgeon as a last resort for treatment. Such recalcitrant hernias cause enormous morbidity and constitute a financial burden to any health service. It is important to explore novel and potentially effective repair methods. We report on a technique using overlay prolene mesh fixed to bone by Mitek anchors. All patients who had Mitek bone anchor fixation of synthetic mesh, to repair recurrent iatrogenic abdominal hernias between 2003 and 2010 by one surgeon (C.M.M.), were retrospectively reviewed. The indications, operative details, and clinical outcomes were documented. A total of 7 patients (6 females, 1 male) aged 35 to 60 (average 53) years were included in the study. The causes of herniation were previous surgical incisions (3) and abdominal flap harvests (4). They had had a median of 3 hernia repairs before referral to plastic surgery. The operations lasted for a mean of 6 hours (range, 3-10½ hr). There were no major intra- and postoperative problems although 1 patient requested removal of 2 of his 8 Mitek anchors because of persistent localized pain and tenderness. After a mean follow-up of 24 months (range, 4-34), only 1 patient developed a recurrent lower abdominal bulge. Our single operator series demonstrated that Mitek bone anchor fixation of prosthetic mesh reinforcement of abdominal wall hernia repair is an effective treatment technique associated with a low morbidity. This method of recalcitrant hernia repair may be a useful addition to the armamentarium of the plastic surgeon.

Laparoscopic sacrocolpopexy with bone anchor fixation: short-term anatomic and functional results

Introduction and hypothesisThe aim of this study was to evaluate short-term anatomic and functional outcomes and safety of laparoscopic sacrocolpopexy with bone anchor fixation.MethodsA prospective cohort study of women undergoing laparoscopic sacrocolpopexy between 2004 and 2009. Anatomic outcome was assessed using the pelvic organ prolapse quantification score (POP-Q). Functional outcomes were assessed using the Urogenital Distress Inventory, Defecatory Distress Inventory, and the Incontinence Impact Questionnaire preoperatively and at 6 months postoperatively. The Wilcoxon signed rank test was used to test differences between related samples.ResultsForty-nine women underwent laparoscopic sacrocolpopexy. The objective success rate in the apical compartment was 98%, subjective success rate was 79%. One mesh exposure (2%) was found. One conversion was necessary due to injury to the ileum.ConclusionsLaparoscopic sacrocolpopexy with bone anchor fixation is a safe and efficacious treatment for apical compartment prolapse. It provides excellent apical support and good functional outcome 6 months postoperatively.

Laparoscopic lumbar hernia repair with bone anchor fixation

Lumbar hernias are rare defects of the posterolateral abdominal wall. Surgical repair of lumbar hernias is challenging because they are bounded inferiorly by the iliac bone, which makes adequate mesh fixation difficult. We demonstrate a method of a laparoscopic lumbar hernia repair utilizing bone anchor fixation at the inferior border. The patient is a 37-year-old male who had been in a motor vehicle collision and presented with a large left lumbar hernia and nonspecific abdominal pain. The patient had a Petit-type hernia that was bordered by the external oblique muscle, the latissimus dorsi, and the iliac crest. We opted to perform a laparoscopic mesh repair. Two Mitek GII QuickAnchor sutures were placed in the anterior superior iliac crest to provide inferior fixation of the mesh, with sufficient overlap of the mesh to prevent recurrence. The remainder of the mesh was fixed with standard laparoscopic tacks and sutures under good visualization to avoid damage of underlying structures. The patient did well postoperatively and left the hospital on the first postoperative day. He has had no signs of recurrence at follow-up. The anatomic features of lumbar hernias create several challenges. A number of surgical approaches for lumbar hernia repair have been described, including laparoscopic and open methods as well as intraperitoneal and preperitoneal approaches and the use of flaps to cover the defects. However, limited fixation points for the mesh can lead to high recurrence rates. Bone anchors have been used in a variety of surgical disciplines, including orthopedics, plastic surgery, and gynecologic surgery, with low complication rates of bone pain or infection. We demonstrated a method that utilizes bone anchor fixation in a laparoscopic approach to overcome the challenge of inferior fixation. This securely repairs the hernia with good coverage of the defect while maintaining the benefits of the minimally invasive approach.

Timing of traumatic lumbar hernia repair: is delayed repair safe? Report of two cases and review of the literature

Fewer than 100 cases of traumatic lumbar hernias are described in the English literature. The herniation has been described as a consequence of a combination of local tangential shearing forces combined with an acute increase in intra-abdominal pressure secondary to sudden deceleration sustained during blunt abdominal trauma. Delayed diagnosis is not uncommon, as nearly a quarter of these are missed at initial presentation. These hernias are best managed by operative intervention; however, there is no well-defined treatment strategy regarding either the timing or the type of repair. Several approaches, including laparoscopy, have been described to repair these defects. Various techniques, including primary repair, musculoaponeurotic reconstruction, and prosthetic mesh repair, have been described. These repairs are usually complicated because of the lack of musculoaponeurotic tissue inferiorly near the iliac crest. We describe here two cases of traumatic lumbar hernia managed by initial watchful waiting and subsequent elective repair using a combined laparoscopic and open technique and one with and one without bone anchor fixation.

Outpatient Perineal Sling in Adolescent Boys With Neurogenic Incontinence

Management for urinary incontinence in boys with sphincteric incompetence secondary to a neurogenic etiology is a challenge. Minimally invasive approaches have inconsistent efficacy and may require multiple treatments. Open bladder neck reconstruction requires inpatient hospitalizations and can be associated with a high complication rate. To overcome some of these shortcomings we placed a polypropylene male perineal sling in male adolescents with neurogenic sphincteric incontinence. We retrospectively reviewed the outcome in our initial 6 patients. Six patients 14 to 20 years old underwent placement of a polypropylene male perineal sling on an outpatient basis. Followup was 27 to 39 months (median 33). All patients had a history of myelomeningocele and underwent urodynamics showing normal compliance, adequate capacity and sphincteric incompetence. A suburethral sling was placed on an outpatient basis through a small perineal incision. Sling tension was adjusted for maximal urethral compression while still permitting uncomplicated urethral catheter passage. All 6 patients reported immediate complete continence after sling placement. Two slings were removed after local infection developed and 1 was replaced. Another sling required revision secondary to incomplete bone anchor fixation. No patients had urethral erosion. All 5 patients with a sling currently in place were fully continent on intermittent catheterization every 3 hours and they reported excellent satisfaction with the procedure. Our retrospective study suggests that the male urethral sling may be an outpatient option for neurogenic incontinence secondary to sphincteric incompetence. Long-term followup in our initial 6 patients shows encouraging durability. Continued study is required to determine strategies that might decrease the complication rate of this approach.

Tendon Graft—Ulna Fixation in Distal Radio-Ulnar Joint Stabilisation; Biomechanical Comparison of three Graft-Bone Fixation Methods

A common distal radio-ulnar joint (DRUJ) stabilisation procedure uses a tendon graft running from the lip of the radial sigmoid notch to the ulnar fovea and through a bony tunnel to the ulnar shaft, before being wrapped round the distal ulna and sutured to itself. Such graft fixation can be challenging and requires a considerable tendon length. The graft length could be reduced by fixing the graft to the ulna using a bone anchor or interference screw. The aim of this study was to compare the strength of three distal ulna graft fixation methods (tendon wrapping and suturing, bone anchor and interference screw). Four human cadaveric ulnae were used. A tendon strip was run through a tunnel in the distal ulna and secured by: (1) wrapping round the shaft and suturing it to itself, (2) a bone anchor and (3) an interference screw in the bone tunnel. Load to failure was determined using a custom-made apparatus and an Instron machine. Maximum failure load was highest for the bone anchor fixation (99.3 +/- 23.7 N) followed by the suturing (96.2 +/- 12.1 N), and the interference screw fixation (46.9 +/- 5.6 N). There was no significant difference between the tendon suturing and bone anchor methods, but the tendon suturing was statistically significantly higher compared to the interference screw (P = 0.028). In performing anatomical stabilisation of the DRUJ fixation of the tendon graft to the distal ulna with a bone anchor provides the most secure fixation. This may make the stabilisation technique less demanding and require a smaller tendon graft.