Heavy Sutures Research Articles

Arthroscopic-Assisted Coracoclavicular Ligament Reconstruction: Clinical Outcomes and Return to Activity at Mean Six-Year Follow-up

Arthroscopic-Assisted Coracoclavicular Ligament Reconstruction: Clinical Outcomes and Return to Activity at Mean Six-Year Follow-up

Acromioclavicular Joint Separation: Repair Through Suture Anchors for Coracoclavicular Ligament and Nonabsorbable Suture Fixation for Acromioclavicular Joint.

ObjectiveTo evaluate the clinical and radiographic outcomes of patients undergoing coracoclavicular (CC) ligament repair by two suture anchors and acromioclavicular (AC) joint (ACJ) fixation using heavy nonabsorbable sutures for the treatment of types III–V ACJ injuries with a minimum of 1‐year follow‐up.MethodsThe clinical and radiographic outcomes of 36 consecutive patients (26 men and 10 women) who underwent anatomic reduction for acute ACJ dislocation using two suture anchors for CC ligament reconstruction and two strands of non‐absorbable stitches for ACJ fixation between December 2013 and December 2018 were reviewed. Two 3.5 mm suture anchors with double‐loaded sutures were separately inserted into the anterolateral and posteromedial portions of the coracoid process. The suture strands were passed through the hole created in the clavicle using 2.0 mm drill and tied over the clavicle. Additional ACJ augmentation using two strands of non‐absorbable heavy sutures was performed in all patients. At 3, 6, and 12 months and last follow‐up visit, the scores on the visual analog scale (VAS), the American Shoulder and Elbow Surgeons (ASES) score, Constant–Murley score, and simple shoulder test (SST) questionnaires were used to provide a final evaluation of shoulder function. Comparison between baseline and treatment results was performed. Radiographic analysis included vertical displacement and horizontal shift.ResultsA total of 29 patients (20 men and nine women) were included in the study. A total of seven, six, and 16 patients had Rockwood type III, type IV, and type V ACJ dislocations, respectively. The mean patient age was 42.8 ± 13.5 years, with a mean follow‐up of 28 months (range, 12–56 months). At the 12‐month follow‐up, the mean ASES score was 92.1 ± 3.5, with a mean pain score of 0.5 ± 0.7 on the VAS and mean Constant–Murley score of 93.0 ± 2.4. The new number of positive answers on the SST was 11.5 ± 0.6. Compared with the baseline, the clinical results improved significantly (P < 0.05). No significant difference could be found between the 6‐ and 12‐month follow‐up evaluations (P > 0.05). Radiographs showed two partial loss of reduction, whereas no horizontal displacement was found in all patients. One patient developed a superficial wound infection 3 weeks postoperation. The wound healed after routine wound care. No neurovascular complications were recorded.ConclusionsCC ligament reconstruction using two suture anchors and ACJ augmentation using two strands of non‐absorbable heavy sutures on high‐grade AC dislocation is a reliable technique for restoring stability to the ACJ and can obtain good to excellent clinical results.

The Kite technique: a new all-arthroscopic technique for the treatment of acute acromioclavicular joint dislocation.

Although many open techniques have been developed, no all-arthroscopic technique has been introduced to reduce acute acromioclavicular joint dislocation (ACJD) and augment both coracoclavicular (CC) ligaments. The Kite technique is the first all arthroscopic technique with this aim. Forty-one consecutive patients [35M-6F; median: 29.2years (range 23-36)] with acute type III and V acromioclavicular joint dislocation were treated with the Kite technique: it consists of positioning three titanium buttons connected by heavy sutures in an 8-strand configuration between clavicle and coracoid to restore the anatomy of CC ligaments. Patients were followed up for a median of 35months (range 30-43months). Median operation time was 70.6min (range 58-82), with no cases of intra-operative complications. At the final follow-up, the median post-operative Constant Score and SST were 94.1 (range 89-98) and 11.6 (range 10-12), respectively. At the final follow-up reduction maintenance was present in 39 patients; in one patient, signs of acromioclavicular joint dislocation recurrence were present 3months post-op. In another patient, medial suture ruptures occurred 4months after surgery with type II acromioclavicular joint dislocation recurrence but with scarce symptoms and full recovery to sport activity. Clavicle osteolysis was observed in four patients. Cosmetics of the arm were judged as excellent in 39/41. All patients, except two, were satisfied with the final result. The kite technique is a safe and reproducible arthroscopic procedure to treat acute ACJD. In daily clinical practice, due to the excellent results and the low complication rate, this technique might be considered by surgeons when operative treatment of an acute acromioclavicular joint dislocation is planned. IV.

Modified iliac spine wafer osteotomy for exposure during Bernese periacetabular osteotomy.

The Bernese periacetabular osteotomy (PAO) is a well-established procedure for the management of symptomatic hip dysplasia. The associated Smith–Petersen exposure offers excellent visualization of the acetabulum and control of acetabular osteotomy and mobilization. The traditional exposure of the true pelvis involves osteotomy of the iliac wing in order to mobilize the sartorial and inguinal ligament insertion. However, full osteotomy of the iliac spine may necessitate screw fixation if a relatively large segment of bone is included. A known complication with screw fixation of the iliac wing osteotomy involves failure of fixation and screw back out. Moreover, the screw may irritate the patient even in the setting of adequate fixation. A larger osteotomy may also injure the lateral femoral cutaneous nerve (LFCN) as it travels near the anterior–superior spine. To minimize the risk of these potential complications, a wafer osteotomy may be used to develop a sleeve of tissue involving the sartorial insertion. This sleeve also mobilizes the entirety of the LFCN medially and affords protection throughout the procedure. Furthermore, the wafer osteotomy may be re-fixed to the stable pelvis during closure with simple heavy suture fixation alone, avoiding screw insertion or associated removal. Because only a wafer or bone is taken during the spine osteotomy, more bone is available at the anterior–superior iliac spine for fixation of the mobile fragment after repositioning. In this technical note, we describe the wafer osteotomy technique in further detail.

Modified Internal Fixation Technique for Acromio-Clavicular (AC) joint dislocation: The "Hidden Knot Technique".

Acromioclavicular (AC) joint injuries are common and often seen in contact athletes, resulting from a fall on the shoulder tip with adducted arm. This joint is stabilized by both static and dynamic structures including the coracoclavicular (CC) ligament. Most reconstruction techniques focus on CC ligament augmentation as the primary stabilizer of the AC joint. The best surgical technique for some AC joint dislocations is still controversial. In this study, we explained a modification of the CC ligament reconstruction technique described by Wellmann. The method is based on minimally invasive CC ligament augmentation with a flip button/polydioxanone (PDS) repair, typically used for extracortical ACL graft fixation. Patients commonly complain that heavy sutures under the skin in subcutaneous tissue irritate the skin and sometimes require reoperation for suture removal. We present an augmentation technique that resolves this issue by changing the suture knot location to the sub-clavicular position. Level of evidence: II.

MPFL graft fixation in low degrees of knee flexion minimizes errors made in the femoral location.

To evaluate the appropriate amount of knee flexion in which to secure the graft during medial patellofemoral ligament (MPFL) reconstruction. Heavy suture was used to simulate graft tissue during MPFL reconstruction on eight fresh-frozen cadaveric knees. The sutures were passed through two transverse patellar tunnels and draped over a Kirschner wire at Schöttle's point on the femur. Suture displacement at the location of the wire was measured during knee range of motion from 0 to 135°. The wire's location was then moved to 3 additional locations (1cm proximal, 1cm distal, and 1cm anterior), and the measurements were repeated. Using Schöttle's point, the suture length did not vary throughout all ranges of knee flexion. The distal location resulted in a greater distance between attachment points (i.e. graft tightened) if the measurements began with the knee flexed and then brought into extension. Conversely, with the proximal location, the opposite occurred as the knee was extended (i.e. graft loosened). For all locations other than Schöttle's point, the amount of initial knee flexion for fixation was directly related to the amount of suture length change when the knee was brought into extension. For non-anatomic femoral MPFL graft fixation locations, suture length (and thus graft length) in full extension becomes increasingly altered if the graft is secured in high degrees of knee flexion. Thus, graft fixation in lower degrees of knee flexion is recommended to minimize over or under tensioning the graft when the knee goes into extension if the graft position is placed in a non-anatomic location. To avoid this problem, fluoroscopy should be used to locate the anatomic footprint of the MPFL insertion. While recognizing the limitations of cadaveric research, this study is the first to provide any data to corroborate the widely used practice of securing the MPFL in lower degrees of knee flexion.

Open Reduction Internal Fixation of Distal Clavicle Fracture With Supplementary Button Coracoclavicular Fixation

Distal clavicle fractures are common, and no standard treatment exists. Many different surgical modalities exist. This report describes an open reduction internal fixation technique that achieves both plate and coracoclavicular stabilization using a button device. A precontoured superior-lateral plate is secured to the clavicle. A 3.2-mm spade-tipped drill bit is drilled across the clavicle and coracoid, passing through 4 cortices. The button is loaded onto an insertion device, passed across the 4 cortices, and captured on the undersurface of the coracoid under fluoroscopic guidance. This construct is linked to the distal clavicle plate by heavy sutures using a second button that sits in the plate. The lateral locking holes are then filled to finalize fixation. This technique provides for a simplified way to achieve coracoclavicular stabilization when using a plate for fixation of distal clavicle fractures.

Impact of tendon suturing on the interference fixation strength of quadrupled hamstring tendon grafts

Interference screw fixation of soft tissue grafts has been a widely used fixation technique for cruciate ligament reconstruction. Suturing of the graft construct prior to graft fixation has been proposed to increase fixation strength; however, the effect on mechanical properties has not been well characterized. The goal of this study was to determine whether uniform suturing of the tendon graft affects (1) ultimate fixation strength of the hamstring tendon graft and (2) motion of the tendon in the bone tunnel during cyclic loading when comparing sutured grafts vs. unsutured grafts. Eight pairs of matched mature porcine tibias (age <2years) and eight paired fresh-frozen human quadrupled hamstring tendon grafts were used. One quadrupled graft from each pair was placed into one of two groups. In the group A a single cerclage suture 3cm from the doubled end of the graft was placed to join the four tendon strands. In group B a heavy suture was used to tightly unite the four strands of tendon graft to provide a better grip for the interference screw during fixation. The grafts were placed in tibial bone tunnels that matched the graft's diameter and fixed with an interference screw. The looped end of the graft and the attached tibia were rigidly fixed in a material testing machine. The graft constructs were subjected to 100 cycles of 20-250N load, followed by a load-to-failure test. In addition, a motion analysis system was used during cyclic testing to better determine the amount of elongation at the graft-tunnel interface. Statistical analysis of the failure load and stiffness and the overall elongation following cyclical loading was performed using the Wilcoxon rank sum test. Level of significance was set at p<0.05. Elongation at the tendon-bone interface during sub-maximal cyclic loading was 2.4±1.4mm (unsutured) vs. 2.0±0.7mm (sutured) (p>0.05). Failure load of the grafts without sutures (634±86N) was significantly lower than with the sutures (837±183N). Ultimate stiffness of group A (283±34N/mm) was lower than that of group B (331±51N/mm); however, this was not statistically significant (p=0.051). This study confirms that suturing of the graft construct before interference screw fixation may increase ultimate failure load. However, an improvement of structural properties in response to cyclic loading with sub-maximal loads could not be confirmed. Clinicians using interference screw fixation may suture the graft to improve fixation strength; however, suturing does not appear to allow a more aggressive rehabilitation after surgery.

Quantitative kinetic and kinematic gait variables after percutaneous achilles tendon repair: Indications for rehabilitation

s / Gait & Posture 37 (2013) S1–S31 S5 ion are lack of foot posture, i.e. lack of support reaction, weakness of plantarflexors, especially of the soleus, and excessive length of triceps surae (post-surgical, post-toxin o due to structural failure). The excessive length of triceps surae affects the plantar flexion — knee extension mechanism to extend the knee, which may result in quadriceps failure and finally in crouch gait with high fatigue. Methods: We selected three children with type-2 diplegia and with the following clinical and instrumental (gait-analysis) charac- teristics: delay of heel-off in terminal stance, absence of push-off; reduced speed with shorter steps, reduced knee extension under load, resulting in crouch gait due to impairment of the foot plan- tar flexion and knee extension mmechanism. Segmental analysis: reduced activity of the triceps surae (M1/5), normal passive ankle ROM, absent active ankle ROM in plantarflexion, inability to raise on the toes. Orthoses used: Anti-talus AFOs from cast, in Estruse. The patients underwent surgical shortening of the Achilles tendon; one with bilateral procedure and two with unilateral procedure. The surgical technique consists in a full cut of the Achilles ten- don approximately in the middle. Both edges are then overlapped and grasped with heavy sutures, keeping the ankle in a 20◦ plan- tar flexion [2]. Post-surgical treatment consists of a lower leg cast in equinus without weight bearing for 6 weeks. Weight bearing is resumed with a second walking cast made at 90◦, to be worn for 4 weeks, followed by AFO. Results: We reviewed the patients 6 months after the surgi- cal procedure. Post-surgical gait-analysis (after 6 months) did not show significant differences from pre-surgical assessment con- cerning foot progression, delayed heel lift in terminal stance and weight-bearing knee extension deficit. The only difference was an increased gait speed and length. The activity of the triceps surae (M3/5) had recovered clinically, the active ROM in plantar flexion was improved, as was the ability to raise on the toes with support. As a consequence, anti-talus AFOs were abandoned. Discussion: The literature describes various surgical techniques whichmay be used to shorten the Achilles tendon. These make use of the same procedures suggested for a traumatic tendon lesion of a previously normal muscle. We know that in CP muscles can be spastic andweak at the same time, and that surgical procedures can alsobe influencedby the tenodenic effect. Aperiodof only6months was probably insufficient to highlight significant changes between pre-surgical and post-surgical gait-analysis. We could nonetheless assess a clinical and functional improvement highlighted by an increased active ROM in plantar flexion and abandonment of AFOs.

Laparoscopic repair of secondary parahiatal hernia with incarceration of the stomach: a case report

IntroductionParahiatal hernia is an extremely rare subtype of hiatal hernia, which in turn is a type of diaphragmatic hernia in adults, and only a few cases have been reported to date. We report the case of a patient who suffered from gastric incarceration through an anatomically separate diaphragmatic defect, immediately lateral to a structurally normal esophageal hiatus, that developed after treatment of a malignant mesothelioma.Case presentationA 70-year-old Japanese man, who had undergone treatment for a left malignant pleural mesothelioma a year ago at another hospital, was referred to our institution following a 4-day history of epigastric pain. Esophagogastroscopy demonstrated a normal esophagogastric junction, with remarkable stenosis and active gastric ulcer of the gastric body. Histopathological examination of the gastric biopsy specimen confirmed a gastric ulcer. Furthermore, computed tomography revealed a large fluid-filled structure in the retrocardiac space. On the basis of preoperative data, we decided to attempt laparoscopic repair for the gastric volvulus. During surgery, gastric and omental herniation was observed within a peritoneal lined defect immediately lateral to the esophageal hiatus. Dissection near the esophageal hiatus revealed a discrete extrahiatal defect 3cm in diameter immediately adjacent to the left crus of the diaphragm. The parahiatal defect was closed using interrupted nonabsorbable heavy suture. The patient’s postoperative course was uneventful, and anastomotic leakage was not observed at postoperative barium swallowing.ConclusionsAlthough preoperative diagnosis of parahiatal hernia is difficult, a laparoscopic approach can be a useful therapeutic procedure not only for paraesophageal hernia but also for parahiatal hernia.

Fractures in Brief: Olecranon Fractures

Olecranon fractures are relatively common injuries, accounting for approximately 10% of upper extremity fractures in adults [26]. These fractures may result from a direct blow to the proximal ulna, or indirectly, via the forceful contraction of the triceps against resistance (typically, during a fall onto an outstretched hand). Less commonly, the olecranon may fracture when the elbow is hyperextended, as the bone is impacted against the olecranon fossa of the distal humerus. For unstable injuries, operative fixation typically is required. Even after recovery, loss of ROM is not uncommon. This article provides an overview of olecranon fractures in adults; therefore, discussion of olecranon fractures in skeletally immature patients is beyond the scope of this article.

All-Arthroscopic Weaver-Dunn-Chuinard Procedure With Double-Button Fixation for Chronic Acromioclavicular Joint Dislocation

We described a novel all-arthroscopic technique of coracoclavicular ligament reconstruction and reported the early clinical and radiologic results of this procedure. We performed all-arthroscopic coracoclavicular ligament reconstruction in 10 consecutive patients (8 men and 2 women; mean age, 41 years) with a symptomatic chronic and complete acromioclavicular (AC) joint dislocation (Rockwood type III or IV). Four patients had undergone surgery previously: two had initial pinning of the acute AC joint separation, and two had a subsequent Mumford procedure. The surgical technique, performed entirely by arthroscopy, consisted of (1) rerouting the coracoacromial ligament with a bone block harvested from the tip of the acromion in a socket created in the distal clavicle (Chuinard's modification of the Weaver-Dunn procedure) and (2) augmenting the reconstruction with 2 titanium buttons connected by a heavy suture in a 4-strand configuration (Double-Button fixation; Smith & Nephew Endoscopy, Andover, MA). Patients were prospectively followed up for a mean of 12.8 months (range, 6 to 20 months). One patient had a superficial infection of the superior (clavicular) portal, which resolved with oral antibiotics. At the most recent review, all patients were satisfied or very satisfied with the cosmesis, and 9 of 10 returned to previous sports, including contact and overhead sports. All symptoms resolved (pain, shoulder weakness, paresthesia). The mean postoperative University of California, Los Angeles modified AC rating score was 16.5 points (range, 13 to 18 points) out of 20 points. The mean Subjective Shoulder Value improved from 36% (range, 0% to 70%) preoperatively to 82.5% (range, 70% to 100%) postoperatively (P = .005). The bone block was totally healed in the medullary canal in 8 cases and partially healed in 2. No loss of reduction was observed in any of the patients. Our study shows that severe chronic symptomatic AC joint separations, defined as Rockwood types III through V, can be repaired entirely by arthroscopy safely and effectively by transferring the coracoacromial ligament with a bone block in the distal clavicle. The bone block transfer (Weaver-Dunn-Chuinard procedure) has the advantage of making the repair easier and stronger, and it provides bone-to-bone healing by use of free, autologous vascularized tissue. Double-Button fixation has the advantage of maintaining the reduction during the biological healing process. Although the durability of the reconstruction remains unproven, in our short-term follow-up we observed no loss of reduction and the functional and cosmetic results were uniformly good. Level IV, therapeutic case series.

Use of a Trochanteric Flip Osteotomy Improves Outcomes in Pipkin IV Fractures

The optimal surgical approach for combined femoral head and acetabular fractures (Pipkin IV) is controversial because of their rarity and lack of definitive reports. Surgical dislocation with trochanteric flip osteotomy (TFO) allows simultaneous exposure of the acetabulum and femoral head. We protected the obturator internus and inferior capsule during repair with a heavy suture at the inferior extent of the traumatic capsulotomy. We retrospectively reviewed 12 patients with Pipkin IV fractures treated using this approach during a 6-year period. The minimum followup was 24 months (mean, 47 months; range, 24-71 months). Clinical outcomes were measured using the Merle d'Aubigné-Postel and Thompson-Epstein scoring scales. Radiographically, all patients achieved healing of their acetabular fractures; 11 achieved healing of the femoral head fracture and osteonecrosis developed in one patient. The average Merle d'Aubigné-Postel score was 15.6 of 18; using the Thompson-Epstein score, 10 of the 12 patients had good or excellent outcomes, one had a fair outcome, and one had a poor outcome. Trochanteric flip osteotomy allowed for simultaneous exposure and repair of both lesions in Pipkin IV fractures. Using a uniform surgical protocol with TFO rendered clinical results comparable to previously reported outcomes in series of isolated femoral head fractures. Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Hemiarthroplasty for Humeral Head Fractures.

Replacement of the fractured humeral head with a modular prosthesis. The procedure aims at an adequate reconstruction of shape and function of the shoulder. Displaced three- and four-part fractures of the proximal humerus that cannot be reduced and internally fixed. Fracture can be reduced and adequately internally fixated. Noncompliant patient. In beach-chair position, the fractured humeral head is removed via a deltopectoral approach. The Aequalis modular fracture prosthesis can be positioned by two methods: (i) a fracture jig optimizing height and retroversion of the prosthesis, (ii) under additional intraoperative fluoroscopy. Healing of the tuberosities can be promoted by cancellous grafts taken from the fractured head. These are fixed by four heavy sutures running horizontally and two sutures running vertically. 13 out of 22 patients treated by primary hemiarthroplasty (within 10 days after the fracture) and 34 out of 50 patients treated by secondary arthroplasty could be assessed after a mean follow-up of 40 (15-70) and 44 (8-98) months, respectively. The absolute Constant score amounted to 45 and 50 points, respectively, and the relative score to 56% in both groups. The majority of patients was free of pain or suffered less pain than before the operation (secondary arthroplasty; p < 0.001). In contrast to these, only satisfactory, objective results, self-assessment was good or better than before (secondary prostheses; p < 0.001). In both groups, prognostic factors were the size and position of the tuberosities (p < 0.001).

Proximal Humeral Nonunions

Nonunions of the proximal humerus, although uncommon, are challenging for even the experienced upper extremity specialist. The bone quality is typically poor, and the proximal bone stock is limited. These patients often possess multiple comorbidities contributing to the development of the nonunion. Although many treatment options exist, results have been mixed with no definitive surgical technique identified. The technique presented is a safe and reliable method for treatment of nonunions of the proximal humerus using an inlay fibular strut allograft, compression through the nonunion site with heavy suture, and secure fixation with a fixed-angle locked plate.

Primary and Revision Acromioclavicular Joint Reconstruction

Injury of the acromioclavicular (AC) joint can occur as the result of direct or indirect trauma. The treatment of these injuries has remained controversial. The first reported surgical procedure for internal fixation of AC dislocation was performed by Cooper in 1861 using silver wire to secure the AC joint. Since then, a wide variety of techniques have been used. In 1972, Weaver and Dunn described an open technique involving resection of the distal clavicle and reconstruction of the coracoclavicular (CC) ligament by transferring the acromial end of the coracoacromial ligament to the intramedullary shaft of the distal clavicle. More recent surgical modifications of these techniques have incorporated augmentation of the coracoclavicular reconstruction with heavy suture fixation, as well as tissue augmentation with tendon auto or allograft. This article describes our technique for acromioclavicular reconstruction using tendon allograft combined with suture augmentation.

Suture-Button Syndesmosis Fixation

Syndesmosis screws have significant problems including loosening, breakage, the need for removal, and late diastasis. A new technique of syndesmosis fixation is proposed in this study, in which a heavy suture is placed across the syndesmosis, which has been looped and tightened through cortical button anchors on either side of the ankle. Indirect placement of the medial button avoids a medial incision. Sixteen patients had this suture-button fixation in a prospective clinical study. Mean American Orthopaedic Foot and Ankle Society ankle scores were significantly better in patients who had suture-button fixation than in a comparative group of 16 patients who had syndesmosis screw fixation at 3 months (91 versus 80, respectively) and at 12 months postoperatively (93 versus 83, respectively). Return to work was faster (2.8 months in patients who had suture-button fixation versus 4.6 months who had syndesmosis screw fixation), and no patients who had suture-buttons required secondary surgery for implant removal. Axial computed tomography scanning at 3 months showed maintenance of reduction. Suture-button fixation is simple, safe, and effective. Patients have had improved outcomes and faster rehabilitation, without needing routine implant removal. It may become the treatment of choice in patients with a syndesmosis injury.

Distraction Osteogenesis (Callotasis) for Pelvic Closure in Bladder Exstrophy

The success of urogenital reconstruction in bladder exstrophy is dependent on how successfully the pelvic ring can be closed. In patients with this disorder, the pubic bones are short and separated. A two-component plate-rod combination was designed to widen the pelvic ring using distraction osteogenesis (callotasis). After a middiagonal iliac osteotomy, two components of the implant are connected with two bolts passing through the iliac bone. After 10 days, the rods outside the skin are approximated gradually. When the pubic bones get close, they are fixed by heavy nonabsorbable sutures. The current study included 14 patients who were operated on between 1990 and 1996. The mean followup was 6 years. No neurologic or vascular complications developed. Successful tension-free closure of the abdominal wall was achieved in all but one patient. Urogenital reconstruction was done in the second stage. In all but one patient, the bladder was closed in one stage of urogenital reconstruction. In one patient (7%), a deep infection developed for which the patient needed early implant removal resulting in failure of the urogenital reconstruction. The described method addresses the pathoanatomy of the pelvic ring. The diameter of the pelvic ring can be widened and the pubic bones can be approximated without a significant increase in tension.

The subcutaneous Achilles tendon rupture: comparison of three surgical techniques

The authors report their experience with subcutaneous Achilles tendon rupture: its frequency, the morbidity of the different surgical treatments and the related results at different periods of time from the end of treatment. The study population consists of 55 patients who were treated in the Orthopedic and Traumatologic Clinic of the University of Padova from 1994 to 2000. Twenty-four patients were treated with heavy suture of Silverskiöld, modified by Vigliani; 22 with end-to-end ‘placed’ suture; and 9 with the modified percutaneous suture according to Ma and Griffith. All 55 patients have been seen with an average follow-up of 3 years and 6 months (range from 1 year to 5 years and 9 months) from surgery. The results have been satisfactory in all the patients with the same score, regardless of the surgical technique applied. Of the three main surgical techniques examined, the one with the least morbidity is the end-to-end ‘placed’ suture.

Brow or forehead fixation with sutures only: a preliminary communication.

Fixation of the brow, although not technically difficult, can be a time-consuming process. Screws, whether permanent or absorbable, are occasionally associated with minor undesirable problems. We present a technique of brow suspension that is quick, simple, and free of the problems associated with fixation to the calvarium. It involves the use of sutures only. A heavy PDS suture is passed (with the aid of an awl) from the dermis of the brow or forehead that needs to be fixed to the dermis of a small incisional wound located 5-8 cm away. This suture suspension technique has proven to be quick and easy to execute. It has provided satisfactory fixation of the forehead/brow without problems of suture reaction. The cost of calvarial screws has been eliminated. When brow or forehead fixation is necessary, suspension with sutures to the dermis of a more superior location is an excellent method to accomplish the task quickly and easily. Long-term follow-up of a large series of patients will be necessary to validate the initial impression of this new technique.