Simple Stitch Research Articles

P933 Closing the internal opening with a rectal advancement flap increases the effectiveness of mesenchymal stem cell (MSC) injection in the treatment of complex Crohn's disease anal fistulas

Abstract Background The injection of MSCs into complex anoperineal fistulas of Crohn's disease gives a combined clinical and radiological remission of between 35 and 50% at 12 months. In our department, surgical closure is now done by rectal advancement flap (and no longer with simple stitches) in order to minimize the passage of stools and contamination of the fistula tract. The aim of this study was to compare the remission rate and the quality of life between patients treated with MSC injection using simple stitches versus a rectal flap to close the internal opening. Methods This single-center prospective study included all our consecutive patients who had a MSC injection. The first patients of the series who had closure of the internal opening(s) with stitches (2020- 2022) were compared with those who had a flap (2022-2023). Complete clinical remission was defined by complete closure of the external opening(s) without pain or discharge, and complete radiological remission by a Magnifi-CD score equal to 0 (Hindryckx P, et al. Gastroenterology 2019). Quality of Life was assessed by the Crohn's Anal Fistula Quality of Life scale (CAF-QoL) (Adegbola SO, et al. Gut 2021). Results We included 68 patients (50% women, mean age: 38 ± 13.8 years). The first 42 had stitches and the following 20 had an advancement flap (6 patients had no procedure due to an anal stenosis). The median follow-up was 12 months [6-24]. The overall complete clinical remission was 66.7% at M12: 51.1% [35.5-66.8] in the "stitches" group versus 87.5% [69.7-100.0] in the "flap" group (p = 0.005) (Figure). The difference was noticed early from M1. The mean overall Magnifi-CD MRI score decreased from 15.5 ± 4.7 to 6.5 ± 7.1 at M12 (p < 0.001) with no difference between the 2 groups. However, more patients in the flap group had a Magnifi-CD score of 0: 62.5% versus 38.2%. The CAF-QoL quality of life score improved from 51.3 ± 24.7 to 21.2 ± 20.8 at M12 (p < 0.001) with no significant difference between the 2 groups. The duration of the procedure was longer on average by 19 ± 7 minutes in the "flap" group. There was no difference in the anal incontinence score between the 2 groups. In logistic regression, the advancement flap was significantly associated with complete clinical remission (p = 0.007, HR (95% CI): 2.3 [1.3-4.3]). Conclusion Closing the internal opening with a rectal advancement flap improves the effectiveness of MSC injections with a complete clinical and radiological remission rate of 87.5% and 62.5% respectively, without consequences on anal continence.

Modified Mason-Allen vs Two Simple Stitch Fixation for Medial Meniscus Posterior Root Tears: A Systematic Review and Meta-analysis

Background: Various suture configurations are available for medial meniscus posterior root tear (MMPRT) repair. The modified Mason-Allen (MMA) technique has been proposed as a refixation technique for MMPRT instead of the conventional 2 simple stitches (TSS). This is in view of its superior biomechanical characteristics. Purpose: To perform a systematic review and meta-analysis to compare MMA and TSS configuration techniques for MMPRT repair and identify any differences between the 2 techniques in terms of clinical outcomes, medial meniscal extrusion (MME), and postoperative healing. Study Design: Meta-analysis; Level of evidence, 4. Methods: The Cochrane Controlled Register of Trials, PubMed, Medline, and Embase databases were used to perform a systematic review and meta-analysis using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria with the following search terms: (“meniscus” OR “meniscal injuries”) AND (“Mason-Allen” OR “simple stitch” OR “suture techniques”). Data pertaining to all patient-reported outcome measures, postoperative complications, MME, postoperative healing, cartilage degeneration, and progression of knee osteoarthritis were extracted from each study. The pooled outcome data were analyzed using random- and fixed-effects models. Results: After abstract and full-text screening, 6 clinical studies were included. In total, there were 291 patients; 160 underwent MMA fixation, and 131 underwent the TSS technique. The majority of studies had similar surgical techniques regarding repair technique, suture material, tibial fixation, and number and position of tibial tunnels. There were no differences between the groups in terms of patient-reported outcome measures at 14.2 months. Both techniques were also similar in the degree of postoperative MME and meniscal healing. Conclusion: Both suture configurations were equivalent in terms of clinical outcomes, the extent of meniscal extrusion, and postoperative healing. The TSS technique may offer advantages in terms of faster learning curve and shorter operative time. However, randomized controlled trials with large sample sizes, longer follow-up and assessment of chondral degeneration, and presence of knee osteoarthritis are required to assess whether a true difference exists, as the majority of included studies were limited by their retrospective design.

Initial tension at suture fixation affects the suture breakage following medial meniscus posterior root repair: A retrospective cohort study

ObjectivesThis study aimed to investigate whether the initial suture tension when pullout sutures are fixed affects postoperative clinical outcomes following medial meniscus posterior root repair. MethodsThe data of 48 patients who underwent transtibial pullout repair using two simple stitches (outer and inner sutures) with an additional all-inside posteromedial pullout were retrospectively investigated. The patients were sequentially divided into two groups to compare the clinical efficacy of the initial pullout tension (N) when pullout sutures were fixed: the 30 N Group (April 2019 to September 2019, 24 patients) and the 15 N group (October 2019 to February 2020, 24 patients). The rate of suture breakage (suture cutout or rupture) at the second-look arthroscopy at 1 year postoperatively and clinical outcomes at 2 years postoperatively were compared between the two groups. ResultsIn both groups, each clinical score significantly improved at 2 years postoperatively. At the second-look arthroscopy, the rate of posteromedial suture breakage was significantly higher in the 30 N group (19 patients, 79 ​%) than in the 15 N group (10 patients, 42 ​%); the rate of outer suture breakage was also higher in the 30 N group (five patients, 21 ​%) than in the 15 N group (no patients). On comparing 2 years of preoperative clinical scores between the groups categorized according to posteromedial suture breakage, the pain score was significantly higher in the suture breakage group. ConclusionsThe initial tension of pullout repair of the medial meniscus posterior root tear is related to suture breakages. To prevent suture breakage, 15 N is a more initially suitable condition than 30 N. Level of evidenceLevel III.

Enhancing microsurgical skills in neurosurgery residents of low-income countries: A comprehensive guide

Background: The main objectives of this paper are to outline the essential tools, instruments, and equipment needed to set up a functional microsurgery laboratory that is affordable for low-income hospitals and to identify cost-effective alternatives for acquiring microsurgical equipment, such as refurbished or donated instruments, collaborating with medical device manufacturers for discounted rates, or exploring local suppliers. Methods: Step-by-step instructions were provided on setting up the microsurgery laboratory, including recommendations for the layout, ergonomic considerations, lighting, and sterilization processes while ensuring cost-effectiveness, as well as comprehensive training protocols and a curriculum specifically tailored to enhance microsurgical skills in neurosurgery residents. Results: We explored cost-effective options for obtaining microsurgery simulators and utilizing open-source or low-cost virtual training platforms. We also included guidelines for regular equipment maintenance, instrument sterilization, and establishing protocols for infection control to ensure a safe and hygienic learning environment. To foster collaboration between low-income hospitals and external organizations or institutions that can provide support, resources, or mentorship, this paper shows strategies for networking, knowledge exchange, and establishing partnerships to enhance microsurgical training opportunities further. We evaluated the impact and effectiveness of the low-cost microsurgery laboratory by assessing the impact and effectiveness of the established microsurgery laboratory in improving the microsurgical skills of neurosurgery residents. About microsutures and microanastomosis, after three weeks of training, residents showed improvement in “surgical time” for ten separate simple stitches (30.06 vs. 8.65 min) and ten continuous single stitches (19.84 vs. 6.51 min). Similarly, there was an increase in the “good quality” of the stitches and the suture pattern from 36.36% to 63.63%. Conclusion: By achieving these objectives, this guide aims to empower low-income hospitals and neurosurgery residents with the necessary resources and knowledge to establish and operate an affordable microsurgery laboratory, ultimately enhancing the quality of microsurgical training and patient care in low-income countries.

Mediastinitis en cirugía cardíaca. Tasa cero en diez años en centro de referencia para cirugía cardíaca. México

IntroductionMediastinitis is one of the most feared complications of cardiac surgery. It's incidence ranges from 0.9 to 5% and sometimes up to 20%. It is characterized by severe infection, retrosternal abscess, osteomyelitis, and gross sternal dehiscence with high mortality. Material and methodsPatients undergoing median sternotomy for cardiac surgery during a ten years period at the Pemex Hospital in Mexico were reviewed. The variables age, sex, diabetes mellitus, hypertension, body mass index, primary surgery, renal involvement, previous dialysis, type of sternal closure, pre-surgical hospital stay, result of cultures and mortality were studied. ResultsOf 2,242 sternotomies, 33 cases were included. There was an average of 3 cases per year. 24 men and 9 women, the majority between 71 and 80years old, 25 diabetic and 24 hypertensives. 45.3% with normal weight or overweight and 54.5% with grade I-II obesity. 27 had a history of ischemia and 6 had a history of simple valve surgery or mixed procedure, 22.2% had a history of urgent reexploration for bleeding. 44.4% of the patients were nephropaths, 2 on hemodialysis.There were two sternal closure techniques, group1 with simple stitches and group2 with Hemi-Robicsek. Type1 was used in 1499 patients, with 1.8% dehiscence, type2 in 743 patients, with 0.6% dehiscence. ConclusionsPost-sternotomy devastating mediastinal infections are increasingly rare in our hospital. A strict adherence to the technique, the sternal closure that we call Hemi-Robicsek, as well as the early detection of dehiscence for resuturing has led us to zero cases of mediastinitis.

SURGICAL TREATMENT OF AN ABNORMAL UPPER LABIAL FRENUM IN PEDIATRIC DENTISTRY

Introduction: The superior labial frenum corresponds to a thin and triangular anatomical structure that has its formation during the third month of intrauterine life, located from the tubercle of the upper lip to the alveolar process. Abnormal insertion of the roof-labial frenulum is usually indicated for surgical removal. If the surgical procedure is not performed, the frenum causes instability, the main problem being the diastema between the incisors, which many times cannot be treated only by orthodontics. The purpose of correction of the upper labial frenum consists of eliminating excess free tissue between the teeth, in addition to the purpose of improving aesthetics. Objective: To describe a case report of surgical treatment of the upper labial frenum performed on a pediatric patient at a Dental Specialties Center. Case report: Female patient, 11 years old, referred by the orthodontist with indication for surgical treatment of the upper labial frenum. On intraoral physical examination, the presence of persistent roof-labial frenum and diastema between the upper central incisors was observed. In view of the data obtained in the anamnesis and physical examination, we opted for the frenotomy technique with the repositioning of the brake. Intraoral antisepsis and facial antisepsis were performed, followed by terminal infiltrative anesthesia in the anterior superior alveolar nerves, bilaterally. Two oblique incisions were made close to the insertion of the roof-labial frenum and then the repositioning of the. Friction movements were performed between the incisors and simple stitches were used for suturing. After two weeks, the patient returned and the presence of tissue remnant was observed, which was removed using the same anesthetic technique and with the aid of Metzenbaum scissors, without the need for a new suture. Conclusion: Surgical treatments for labial frenum present excellent results and should be chosen according to the individual needs of each patient, always evaluating the risks, benefits and advantages and disadvantages.

Evaluation of laparoscopic skills in medical students.

To evaluate the laparoscopic skills of medical students and identify personal characteristics in terms of greater easiness in performing laparoscopic surgical procedures. This study included medical students in the 6th semester of a Medical School in Brazil who answered 10 questions concerning their habits and characteristics. A laparoscopic platform and an abdominal synthetic model were used to assess surgical skills comprising the three following surgical steps: to pass the needle through the trocar and to place it in the laparoscopic needle holder, to perform a laparoscopic simple stitch in synthetic liver parenchyma and, to perform a laparoscopic surgical knot. The duration of the activity was limited to four minutes and the procedure was monitored by a laparoscopic surgeon. The study included 50 students. Of these, 18% completed the three surgical stages. Steps 1 and 2 were completed by 94% and 88% of students, respectively. No statistically significant variables were found when characteristics of the groups with and without success in the three stages were compared. The group that finished the activity had a faster time completing step 2 than the group that failed (mean time of 115.3 seconds against 157.8 seconds, p=0.03). The minority of students could complete effectively all three surgical steps. No personal traits related to greater surgical skill were identified.

Biomechanical characteristics of different methods of neo-chordal fixation to the papillary muscles.

Several techniques have been described for neo-chordal fixation to the papillary muscles without any reported clinical differences. The objective of this study is to compare in vitro the biomechanical properties of four of these common techniques. We studied the biomechanical properties of expanded polytetrafluoroethylene neo-chordal fixation using four techniques: nonknotted simple stitch, nonknotted figure-of-eight stitch, knotted pledgeted mattress stitch, and knotted pledgeted stitch using commercially available prefabricated loops. Neo-chordae were submitted to a total of 20 traction-relaxation cycles with incremental loads of 1, 2, and 4 N. We calculated the elongation, the force-strain curve, elasticity, and the maximum tolerated load before neo-chordal failure. The elongation of the neo-chordae was lowest in the simple stitch followed by the figure-of-eight, the pledgeted mattress, and he commercially prefabricated loops (p < .001). Conversely, the elastic modulus was highest in the simple stitch followed by the figure-of-eight, the pledgeted mattress, and the prefabricated loops (p < .001). The maximum tolerated load was similar with the simple stitch (28.87 N) and with the figure-of-eight stitch (31.39 N) but was significantly lower with the pledgeted mattress stitch (20.51 N) and with the prefabricated loops (7.78 N). In vitro, neo-chordal fixation by nonknotted simple or nonknotted figure-of-eight stitches resulted in less compliance as opposed to the use of knotted pledgeted stitches. Fixation technique seemed to influence neo-chordal biomechanical properties, however, it did not seem to affect the strength of the suture when subjected to loads within physiological ranges.

PE24 - A simple stitch to aid dorsal vein complex ligation with subsequent completion of robot assisted radical prostatectomy at sustained low-pressure pneumoperitoneum

PE24 - A simple stitch to aid dorsal vein complex ligation with subsequent completion of robot assisted radical prostatectomy at sustained low-pressure pneumoperitoneum

The stability of repaired meniscal root can affect postoperative cartilage status following medial meniscus posterior root repair

BackgroundTranstibial pullout repair yields beneficial clinical outcomes in patients with medial meniscus (MM) posterior root tear. However, the relationship between repaired meniscal root healing status and postoperative clinical outcomes remains unclear. We aimed to evaluate changes in articular cartilage damage and clinical scores after pullout repair using two simple stitches (TSS). MethodsThirty-three patients who underwent pullout repair using TSS were assessed. Healing status was assessed by a semi-quantitative second-look arthroscopic scoring system comprising three evaluation criteria (width of bridging tissues, stability of the repaired root, and synovial coverage), 1 year postoperatively. MM medial extrusion (MMME) and cartilage damage were assessed preoperatively and 1 year postoperatively. The medial compartment was divided into 8 zones (A-H) for comparison of preoperative and 1-year postoperative cartilage damage. Clinical outcomes were evaluated using the Knee Injury and Osteoarthritis Outcome score, Lysholm score, International Knee Documentation Committee scores, and visual analogue scale pain score. ResultsAlthough cartilage damage did not aggravate significantly in most medial compartment areas, MMME progressed at 1 year postoperatively. No statistical differences were observed in cartilage damage between the central-to-medial area of the medial femoral condyle and the medial tibial plateau area at 1 year postoperatively. Regarding semi-quantitative healing scores, the stability score was significantly correlated with the International Cartilage Repair Society grade at 1 year postoperatively. All 1-year and 2-year clinical scores significantly improved compared with the preoperative scores. ConclusionRegarding TSS repair, stability of repaired meniscal root negatively correlated with cartilage damage in the medial compartment loading area. All 1-year and 2-year clinical scores significantly improved than those of the preoperative scores. Achieving MM stability is crucial for suppressing cartilage degeneration. Level of evidenceIV case series study.

Effectiveness of an inexpensive short-term theoretical-practical course on videosurgery for surgeons in training

BackgroundThe rapid development of video surgery and minimally invasive surgical techniques prompted many studies on the methods of teaching these techniques to young surgeons in training. However, the characteristics of a short-term course that is both easily accessible and efficient for this group of surgeons remain controversial. To investigate this issue, a short-term training method was proposed for first year surgery residents, using inexpensive handmade wooden simulation boxes with the students smartphones as cameras. Its effectiveness was evaluated, as well as possible factors that could influence student performance, such as gender and previous experience with video games.MethodsThirty-six first-year General Surgery residents, entering in 2019 and 2020, participated in the study: 21 were males and 15 were females with ages between 22 and 29 years old, (mean 25.47 years). All participants performed a pre-established exercise (placing two simple stitches using a laparoscopic simulator), which was timed and scored. They then participated in a short theoretical-practical course, consisting of an initial lecture followed by 4 exercises on handcrafted wooden laparoscopic video surgery simulators. Afterwards, they were asked to repeat the same exercise from the first step. Finally, they answered a questionnaire that included questions on previous videogame experience. The data were tabulated and submitted to statistical analysis.ResultsIn the pre-training exercise, 15 (41.66%) participants were able to perform the two simple stitches in the simulator box within the maximum time limit of 5 minutes. After the short course, 22 (61.11%) of participants were able to perform the complete exercise. Improvement in the time to complete the practical exercise was statistically significant (p = 0.0296) after participating in the theoretical-practical course. A better pre- and post-training performance was demonstrated by the 17 participants with experience with video games (p = 0.0116), and a better post-training performance was demonstrated by female participants (p = 0.0405).ConclusionThis short-term inexpensive theoretical-practical course in laparoscopic training for surgeons in training was effective in reducing the execution time of a laparoscopic stitch in a simulation box. Previous experience with video games and/or female gender appear to be associated with improved performance.

Comparable Torque to Failure Using the Simple Stich Versus the Figure-of-Eight Configuration for Hip Capsular Closure Following an Interportal Capsulotomy: A Cadaveric Study

To measure and compare the torque to failure and stiffness of the capsular repair construct consisting of four-suture simple stitches to a two-figure of eight stitches repair construct in external rotation following an interportal capsulotomy. Six pairs of fresh-frozen cadaveric hemipelves were divided into two capsular repair groups. All hips underwent a 40-mm interportal capsulotomy from the 12 o'clock position to the 3 o'clock position. Capsular closure was performed using either the two stitches in a figure of eight or with four simple stitches. Afterward, each hemipelvis was securely fixed to the frame of a mechanical testing system with the hip in 10° of extension and externally rotated to failure. Significance was set at P < .05. The average failure torque was 86.2 ± 18.9 N·m and 81.5 ± 8.9 N·m (P=.57) for the two stitches in a figure of eight and the four simple stitches, respectively. Failure stiffness was also not statistically different between groups and both capsular closure techniques failed at similar degrees of rotation (P= .65). Hip capsular repair using either the four simple stitch or two-figure of eight configurations following interportal capsulotomy demonstrated comparable failure torques and similar stiffness in a cadaveric model. Adequate and comprehensive capsular management in hip arthroscopy is critical. Capsular repair following capsulotomy in femoroacetabular impingement surgery has been associated with higher patient-reported outcomes when compared to capsulotomy without repair. Therefore, determining which capsular closure construct provides the higher failure torque is important.

Influence of a novel suturing technique on periodontal health of mandibular second molar following impacted third molar surgery: a split-mouth randomized clinical trial

BackgroundSurgical extraction of the third molar is the most common surgical procedure in the oral surgery field and is associated with several complications. This study aimed to compare the effects of a newly presented suturing technique with the routine suture after surgical removal of the third molar on the postoperative complications.Materials and methodsThis randomized clinical trial was designed as a split-mouth double-blinded investigation. Twenty patients were involved in the current study. After the surgical removal of the third molar, the new suturing technique was used to close the wound on one side of the patient randomly (case side), and the other side was sutured by the routine simple interrupted stitches (control side). Pain, edema, trismus, pocket depth, and the attachment loss of the distal of the second molar were assessed following the surgery. The data were statistically analyzed and compared between the sides.ResultsPain and edema following the surgery in the control side were significantly less than in the case side. The pocket depth and the gingival attachment loss of the distal aspect of the second molar in the case side were significantly less than in the control side. No case of dry socket was observed in the case side.ConclusionIt seems that the newly presented suturing technique is able to keep the wound margins close to each other and may be helpful in reducing the periodontal complication of the second molar following the surgical removal of the impacted third molars.

Can a Two Simple Stitches Method Provide Secure Fixation Strength in Biceps Tenodesis?: Biomechanical Evaluation of Various Suture Techniques.

BackgroundThe purpose of this study was to compare the initial fixation strength between four different suture methods for the long head of the biceps.MethodsForty-eight fresh frozen porcine flexor hallucis longus tendons (mean width at suture site, 8.5 ± 0.9 mm) and phalanx bones were randomly assigned to one of the four arthroscopic biceps tenodesis techniques: simple stitch (SS), mattress suture (MS), lasso-loop (LL), and two simple stitches (2SS). A biceps tenodesis was performed according to the four techniques using all-suture type suture anchors (1.9-mm SUTUREFIX anchor with No. 1 ULTRABRAID sutures). Biomechanical evaluations were performed to test load to failure (N), stiffness (N/mm), stress (N/m2), and mode of failure.ResultsAs for the SS, MS, LL, and 2SS, the mean load to failure was 50.9 ± 14.61 N, 82.3 ± 24.8 N, 116.2 ± 26.7 N, and 130.8 ± 22.5 N (p < 0.001), respectively; mean stiffness was 6.1 ± 1.3 N/mm, 6.7 ± 2.6 N/mm, 7.8 ± 1.4 N/mm, and 8.1 ± 4.2 N/mm, respectively (p = 0.258); and mean stress was 0.7 ± 0.3 N/m2, 1.4 ± 0.8 N/m2, 2.9 ± 0.7 N/m2, and 2.7 ± 0.8 N/m2, respectively (p < 0.001). All the failures happened by the suture cutting through the tendon along its longitudinal fibers.ConclusionsNeither the SS nor the MS method was enough to securely fix the biceps tendon with a significantly lower mechanical strength; however, the 2SS method showed similar initial fixation strength as the LL technique.

Arthroscopic Transosseous Repair of a Medial Meniscal Posterior-Root Tear.

(1) Preoperative evaluation, including patient history, examination, and imaging (i.e., radiographs and magnetic resonance imaging). (2) Preparation and positioning. The patient is placed in the supine position, and anteromedial and anterolateral portals are created. (3) Placement of sutures. Two simple cinch sutures are placed into the posterior horn, within approximately 5 mm of each other. (4) Footprint decortication. Remove articular cartilage from the native root insertion site. (5) Drilling of the transosseous tibial tunnel. Introduce a tibial tunnel guide over the decorticated base, set guide to 45° to 50°, place a 2-cm vertical incision over an anteromedial tibial guide footprint, advance a 2.4-mm guide pin through the guide, and overream to 5 mm. (6) Passing of the sutures with use of a looped suture passer introduced retrograde through the tibial tunnel to retrieve sutures. (7) Anchor placement and fixation. Apply maximum suture traction, drill a second aperture 0.5 to 1.0 cm distal to the original aperture on the anteromedial aspect of the tibia, pass the suture ends through the anchor, and fix the anchor into the aperture. (8) Repair evaluation and closure. Note the position and stability of the meniscal root relative to the native footprint. Standard closure in layers is performed. If the patient experiences no relief from nonoperative treatment, an MMPRT can be treated operatively via partial meniscectomy or repaired via direct suture-anchor repair or indirect transosseous (transtibial) repair. Direct repair utilizes a suture anchor inserted at the root site5. Variations of the present technique include different suture configurations or numbers of tunnels. Although several suture configurations have been described, the simple cinch stitch (utilized in the present procedure) has been shown to be better at resisting displacement than the locking loop stitch6. Moreover, it has been suggested that simple stitches are less technically difficult and more able to resist displacement because they require less tissue penetration than other stitches7. Lastly, procedures that utilize a single versus a second transtibial tunnel have been shown to be equivalent in cadaveric studies8. The desired results of MMPRT repair include anatomic reduction, preservation of meniscal tissue and knee biomechanics, and preservation of hoop stress, which improve activity, function, and symptoms and mitigate degenerative changes and the risk of progression to total knee arthroplasty. At a minimum of 2 years after transosseous repair, the Lysholm, Western Ontario and McMaster Universities Osteoarthritis Index, 12-Item Short Form, and Tegner activity scale were significantly improved8,9. Previous studies have shown significant improvement in the Hospital for Special Surgery and Lysholm scores without radiographic osteoarthritis progression at the same minimum follow-up10. Lastly, in the longest-term follow-up study to date, transosseous repair survivorship was reported to be 99% at 5 years and 92% at 8 years, with failure defined as conversion to total knee arthroplasty11. Pearls○ Decorticate the native meniscal root down to bleeding bone.○ Consider fenestration or percutaneous release of the medial collateral ligament in order to further open a tight medial compartment.○ A self-retrieving suture passer allows the use of standard arthroscopy portals.○ A multiuse variable-angle tibial tunnel drill guide allows point-to-point placement over the native meniscal root insertion.○ A guide with a tip may be easier and more accurate to control.○ Consider different guides when drilling the tibial tunnel, according to the anatomy of the patient.○ A low-profile guide may provide better clearance along the condyles.○ Utilize a cannula when shuttling sutures through the tibial tunnel in order to prevent a soft-tissue bridge.○ With anchor fixation, consider drilling over a guide pin and tapping when the bone is hard.○ Study preoperative imaging to evaluate the amount of arthritis present. Evaluate all compartments on magnetic resonance imaging for additional pathology.Pitfalls○ Obliquity of the tibial tunnel can cause the guide pin and reamer to enter too anteriorly.○ Patient failure to adhere to postoperative rehabilitation and restrictions can lead to unfavorable outcomes.○ The use of lower-strength sutures may increase the risk of fixation failure.

English

BACKGROUND One of the most common emergency diseases is traumatic vascular injury. The damage mechanism is linked to the environment and the time frame. The treatment of vascular injury is evolving in tandem with the passage of time. In short, vascular injury treatment ranges from simple to complex, and from simple to diverse. Patients suffering from vascular injury can now benefit from advanced medical equipment. Traditional treatments, on the other hand, continue to play an important role. It remains to be seen which treatment method will be adopted as the standard. Traumatic vascular injury is an emergency in surgery, mainly characterized by damage to veins and arteries. Haemorrhage (commonly from truncal vascular injuries) and ischemia (typical of peripheral arterial injuries) are the main clinical manifestations of vascular injuries. If vascular trauma has not been treated in time, it may cause disability or even death, especially for limb vascular surgery. There are many difficulties in diagnosis and treatment of vascular injuries, which have brought many challenges to the surgeons since the 20th century. Vascular trauma accounts for 3 % of all traumatic injuries. Vascular injury may lead to severe complications, so early diagnosis and timely treatment are critical. The purpose of this study was to assess the clinical profile of emergency extremity vascular cases at Trivandrum medical college. METHODS The demographic details, aetiology, mode of injury, limb and structures involved, concomitant injuries, clinical finding, delay in reaching trauma centre and surgical intervention done were recorded in a planned proforma and analysis was done. In this retrospective cross-sectional study, a total of 67 patients with extremity vascular emergencies referred to and called for intraoperative assistance in cardiovascular and thoracic surgery, Trivandrum Medical College over a period of 2 years from January 2018 to December 2019were included. RESULTS The mean age was 44 (SD 16.2) years with male to female ratio being 10.1 : 1.0. Trauma was the most common aetiology of vascular emergency (76.1 %). Out of the total study population, lower extremity emergencies (82 %) were high compared to upper extremity emergencies (18 %). Popliteal and superficial femoral arteries were the most common sites of injury in lower extremity, whereas radial and brachial arteries were the most common arteries involved in the upper extremity. Vessels were seen contused in majority of patients (46.3 %) followed by thrombosis, transection and rupture. No patients presented with venous injuries. But tendon and nerve injuries were present in 36 patients (53.7 %). Average time delay in reaching trauma center was 3 hours. Simple injuries to arteries were repaired with simple stitches as direct repair in 2 patients (2.99 %) and end to end anastomosis was done in 19 patients after resecting the injured segment. CONCLUSIONS Majority of the affected patients belonged to younger age group with trauma being the predominant aetiology. This may be due to the increase in incidence of road traffic accidents and other industrial accidents. Road safety measures are needed and awareness among public should be increased to reduce these types of injuries. All patients presented to our centre could be managed by performing emergency vascular surgeries, owing to timely reporting to hospital and by better use of imaging modalities. KEY WORDS Extremity Vascular Surgery, Anastomosis, Embolectomy

Comparison of two simple stitches and modified Mason-Allen suture for medial meniscus posterior root tear based on the progression of meniscal posterior extrusion: A retrospective cohort study.

Purpose: Medial meniscus (MM) posterior root (PR) tear leads to severe MM posterior extrusion (PE), resulting in rapid knee cartilage degeneration. MMPR repairs are recommended to reduce MMPE, especially during knee flexion. However, the difference in MMPE between different repair techniques remains unknown. This study aimed to investigate preoperative and postoperative MMPE following several pullout repair techniques. We hypothesized that a technique using two simple stitches (TSS) would be more useful than FasT-Fix-dependent modified Mason-Allen suture (F-MMA) to prevent the progression of MMPE in knee extension. Methods: This retrospective study included 35 patients who underwent MMPR repair. To compare MMPE, patients were divided into two groups according to the use of F-MMA while grasping the posterior capsule and TSS without grasping it. Open magnetic resonance imaging was performed at 10° and 90° knee flexion preoperatively, and at 3 and 12months postoperatively, and the MMPE of both groups was evaluated. Results: A significant difference was observed between preoperative and 3-month postoperative MMPE at 90° knee flexion in both groups (p < .01). A significant difference was observed in 3- and 12-month postoperative MMPE at 10° knee flexion between both groups (p = .04/.02), whereas no significant difference in the preoperative MMPE at 10° knee flexion was observed between them (p = .45). Conclusions: Both repairs were found to be useful to reduce MMPE in knee flexion. Further, F-MMA repair increased MMPE in knee extension, unlike TSS repair. These findings suggest that TSS might have more advantages for load distribution when standing or walking.

Increased Bite Distance From the Edge Lowers Risk of Pullout of Simple Sutures from Acellular Dermal Allograft

PurposeTo investigate whether pullout strength in the acellular dermal allograft matrix (ADM) used for superior capsule reconstruction depends on the distance from the edge of the graft.MethodsADM used for superior capsule reconstruction was obtained and cut into 30 squares. Two sutures were placed through the center of each graft by using a loaded Keith needle and forming a simple stitch. The grafts were divided into 3 groups of 10 grafts with a distance of 5 mm, 10 mm or 15 mm from the closest edge of the graft, respectively. The grafts were then preloaded to 5 N and pulled to failure at a rate of 12 mm/s on an MTS 858 MiniBionix servohydraulic mechanical test frame. The load to failure was recorded as well as the stiffness of each graft.ResultsThe mean load to failure was 34.5 N (SD 7.89) for the 5 mm grafts, 31.7 N (SD 5.99) for the 10 mm grafts, and 66.2 N (SD 18.4) for the 15 mm grafts. There was a significant difference (< 0.0001) between the large grafts (15 mm) and the 2 smaller grafts (10 mm, 5 mm). There was no significant difference in stiffness between the groups of graft (P 0.40).ConclusionPlacing the suture at least 15 mm from the edge of the graft increases the graft’s ultimate yield strength to suture pullout.Clinical RelevanceThe depths of the suture in ADM could improve pullout strength for constructs of superior capsular reconstructions.

Extra-articular Soft Arthroscopic Latarjet Technique: More Versatility and Closer Reproducibility of Classic Latarjet Procedure than Its Intra-articular Counterpart

The recent innovative concept of dynamic anterior stabilization of the shoulder by long head of biceps tendon for anterior gleno-humeral instability management has gained growing popularity among shoulder surgeons. Different techniques using this concept have been reported. Nevertheless, these techniques share common steps of tenotomy, re-routing, trans-subscapularis transfer and bony glenoid fixation of long head of biceps. Lately, a simplified procedure of intra-articular soft arthroscopic Latarjet technique has been introduced to refer to soft tissue tenodesis of long head of biceps to subscapularis tendon by 2 simple stitches of nonabsorbable sutures following Bankart repair. For more technical simplicity and closer reproducibility of gleno-humeral restabilization mechanisms of Latarjet procedure; the current Technical Note describes the extra-articular soft arthroscopic Latarjet technique, whereby long head of biceps is retrieved to the subpectoral region following intra-articular tenotomy; whip-stitched; rerouted deep to pectoralis major; and passed within subscapularis window into the gleno-humeral joint, where it is sutured over itself around upper subscapularis tendon. The currently reported technique offers potential advantages of versatility, steep learning curve, low cost (no hardware), feasibility of concurrent gleno-humeral restabilization procedures, and technical easiness of revision management; however; it is nonanatomic and should be biomechanically and clinically investigated to validate its long-term versatile utility.

Outpatient treatment for colostomy stenosis; report of 3 cases.

Introduction and importanceStenosis of the colostomy occurs in 2–15% of patients and, they are the cause of serious discomfort for the patient due to the difficulty in evacuation, as well as the need for new surgical interventions. The purpose of this work demonstrates an outpatient surgical treatment that can be performed in the office.Case presentationThree patients with definitive colostomy who suffered progressive stenosis are presented. Under local anesthesia, one or two triangular segments, with their bases on the colostomy, which included the thickened and hardened skin, are removed to expand the diameter of the stoma. The mucosa of the colon is sutured to healthy skin with Vicryl 3/0 simple stitches.This method has been used in three patients older than 60 years with permanent colostomy who presented with progressive stenosis 6–7 months after surgery. The average follow-up at 14.5 months was satisfactory, without restenosis.DiscussionStoma stenosis is a complication that occurs in up to 15% of cases and requires reconstruction, most of which are carried out in the operating room.The triangular stenoplasty presented is effective and is performed under local anesthesia in the office.ConclusionTriangular-section stenoplasty of a stenosed permanent colostomy is an effective outpatient treatment.