Subcutaneous Fixation Research Articles

Subcutaneous fixation model for complex stenting of recurrent laryngotracheal stenosis

BackgroundA straight silicone stent can be used to treat proximal benign tracheal stenosis in non-surgical candidates. However, stent migration is a common complication when placed at a particular location and can lead to major complications. This case series of laryngotracheal stenosis reports a fixation method for straight silicone stents in the subglottic trachea (Stage 3 of the McCaffrey classification).MethodsThe medical charts of these patients scheduled for straight silicone stent placement with suture fixation between 2014 and 2020 at the CHU UCL Namur Hospital (Belgium) were retrospectively reviewed. The procedure was performed using a rigid bronchoscope. Details of the procedure were obtained from medical records.ResultsThis case series included six patients (males: 4, females: 2). The median patient age was 59 years. Two suture fixations were placed following previous silicone stent migration episodes, whereas the others were placed proactively to avoid this risk. All fixations were performed by the device Freka® Pexact II ENFIt®, originally developed for gastropexy in endoscopic gastrostomy. The sutures were subcutaneously buried.ConclusionsDuring the 6-month follow-up period, complications such as fixation issues and stent migration were reported despite the off-label use of the treatment. The straight silicone stent fixation technique used in this case series was simple and effective for securing the stent in upper benign tracheal stenosis.

Introduction and comparision of three different fixation methods in the suprahepatic space in laparoscopy-assisted ventriculoperitoneal shunt for hydrocephalus

Ventriculoperitoneal shunt (VPS) placement is the standard procedure in the management of hydrocephalus. The introduction of laparoscopy allows better visualization during the operation and a more reliable placement of the peritoneal terminal of the catheter, which significantly decreases postoperative obstruction and malposition rates. However, the fixation methods of the peritoneal terminal of the catheter have not been previously discussed. The indications, techniques, and complications were compared between conventional VPS and laparoscopy-guided VPS. Furthermore, same analyses were performed within the laparoscopy-guided VPS group subdivided by three different techniques of the fixation of the peritoneal terminal of catheter, including suture and ligature, titanium clip fixation, and subcutaneous fixation. A total of 137 patients with hydrocephalus who received VPS treatment was retrospectively studied, 85 of which were laparoscopy-guided, and 52 were not. The distal ends of the catheters were all placed in the suprahepatic space. At least one year (mean 28.6 months) follow-up was given postoperatively. The average duration of the whole operation was 45 min for suture and ligature, 40 min for titanium clip fixation, and 30 min for the subcutaneous fixation, respectively. Six patients (4.4%) had obstructive of the ventricular catheter in total. The success rates for the laparoscopy-assisted VPS procedure and the conventional VPS procedure were 87.1% (74/85) and 80.8% (42/52), respectively. Within subgroups of the laparoscopy-assisted VPS divided by fixation methods, the procedures were successful in 85.2% (23/27) of suture and ligation, 82.1% (23/28) of titanium clip fixation, and 93.3% (28/30) of subcutaneous fixation, respectively. Two patients had dislocated shunt tube in peritoneal end in laparoscopy group, all in the titanium clip fixation subgroups. The laparoscopy-assisted VPS insertion is an ideal shunt method for its effectiveness and lesser complication rate after operation. The subcutaneous fixation method of the peritoneal terminal of catheter might be the optimal fixation technique.

Biomechanical evaluation of seven fixation methods to treat pubic symphysis diastasis using finite element analysis

BackgroundPubic symphysis diastasis (PSD) hinders the connection between bilateral ischia and pubic bones, resulting in instability of the anterior pelvic ring. PSD exceeding 25 mm is considered disruptions of the symphyseal and unilateral/bilateral anterior sacroiliac ligaments and require surgical intervention. The correct choice of fixation devices is of great significance to treat PSD. This study aimed to evaluate the construct stability and implant performance of seven fixation methods to treat PSD using finite element analysis.MethodsThe intact skeleton-ligament pelvic models were set as the control group. PSD models were simulated by removing relevant ligaments. To enhance the stability of the posterior pelvic ring, a cannulated screw was applied in the PSD models. Next, seven anterior fixation devices were installed on the PSD models according to standard surgical procedures, including single plates (single-Plate group), single plates with trans-symphyseal cross-screws (single-crsPlate group), dual plates (dual-Plate group), single cannulated screws, dual crossed cannulated screws (dual-canScrew group), subcutaneous plates (sub-Plate group), and subcutaneous pedicle screw-rod devices (sub-PedRod group). Compression and torsion were applied to all models. The construct stiffness, symphyseal relative micromotions, and von Mises stress performance were recorded and analyzed.ResultsThe construct stiffness decreased dramatically under PSD conditions. The dual-canScrew (154.3 ± 9.3 N/mm), sub-Plate (147.1 ± 10.2 N/mm), and sub-PedRod (133.8 ± 8.0 N/mm) groups showed better ability to restore intact stability than the other groups (p < 0.05). Regarding regional stability, only single-plate fixation provided unexpected regional stability with a diastasis of 2.1 ± 0.2 mm (p < 0.001) under a compressive load. Under a rotational load, the single-crsPlate group provided better regional angular stability (0.31° ± 0.03°, p < 0.001). Stress concentrations occurred in the single-Plate, sub-Plate, and sub-PedRod groups. The maximum von Mises stress was observed in the single-plate group (1112.1 ± 112.7 MPa, p < 0.001).ConclusionThe dual-canScrew fixation device offers ideal outcomes to maintain stability and prevent failure biomechanically. The single-crsPlate and dual-Plate methods effectively improved single-Plate device to enhance regional stability and disperse stresses. The subcutaneous fixation devices provided both anterior pelvic ring stability and pubic symphysis strength.

Development of a method for serial intravesical administration of drugs in experiment

The technical difficulties of serial intravesical administration of drugs are a significant problem in preclinical studies of the effectiveness of local chemotherapy for superficial bladder cancer. The aim of the study was to develop and evaluate the effectiveness of the method of serial intravesical administration of drugs in the experiment. The study included 49 Wistar rats of both sexes. Five proposed methods of intravesical administration of drugs were investigated: retrograde catheterization of the urinary bladder under anesthesia, method of transcutaneous puncture of the urinary bladder in rats, intraoperative puncture of the bladder, method of subcutaneous fixation of the bladder for subsequent puncture in the experiment, method of serial intravesical administration of drugs in female rats using special catheter. The obtained data were processed using a package of statistical programs SPSS 20.0 for Windows. The disadvantage of the first technique is its trauma – each insertion of the catheter is accompanied by trauma of the urethral mucosa and associated pain. The manipulations were failed because of edema of the urethral mucosa. The manipulation should be performed under general anesthesia. The second technique also requires general anesthesia. The aggressive cytostatic action of Doxorubicin prevented the closure of the puncture hole and caused the development of complications. Sealing the bladder with a collagen plate when performing the third technique prevents the release of the drug into the abdominal cavity, however, the adhesion of the tissues of the surrounding organs to the plate promotes the formation of an adhesive conglomerate and makes further manipulations impossible. The withdrawal of the bladder from the abdominal cavity during the implementation of the fourth technique, theoretically, should have helped to avoid the complications observed during the third technique. However, insufficiently reliable fixation of the urinary and adhesions in the area of the implanted ring make this technique such that it does not correspond to the tasks set. The fifth method was the only one proposed that met all the assigned tasks. This technique made it possible to perform a series of 5 intravesical injections of Doxorubicin without general anesthesia and without the development of postoperative complications from the postoperative wound and abdominal cavity. The proposed method of serial intravesical administration of drugs in female rats using a special catheter makes it technically easy to perform serial intravesical administration of drugs without the use of general anesthesia and without the development of complications from the postoperative wound and abdominal cavity.

Results of surgical treatment of De Quervain's tenosynovitis: 80 cases with a mean follow-up of 9.5 years.

Surgery is indicated in De Quervain's tenosynovitis only after failure of medical treatment, often due to individual anatomical variants. We use Le Viet's technique, to avoid tendon instability. The aim of the present study was to evaluate long-term results, with the hypothesis that this surgical technique is reliable, providing lasting results. All patients operated on between 1993 and 2015 were included, and results were assessed by telephone questionnaire at a minimum 1-year's follow-up. Surgical technique was systematically as described by Le Viet, with subcutaneous fixation of the retinaculum flap. Any anatomical variants were specified. In 26 cases, a concomitant pathology was treated in the same step. In addition to demographic data, the study looked for: pain on VAS, functional impairment, tendon dislocation, and satisfaction. There were no intra- or immediate postoperative complications. Of the 89 patients, 74 (80 wrists) were successfully recontacted: 68 women and 6 men, with a mean age of 48.5 years (range, 19-71 years). The 15 patients lost to follow-up showed initial progression comparable to the rest of the population. A supernumerary septum was found in 50 cases, and an abductor pollicis longus tendon with multiple slips in 35 cases. There were no recurrences. Functional impairment was absent in 68 wrists, moderate in 8 and significant in 4, including 3 with associated diseases. Mean VAS was 0.76 (range, 0-10). No patients reported tendon dislocation or neuroma. Patients were very satisfied in 72 cases, satisfied in 6 and dissatisfied in 2 cases with associated diseases. Results in the present series, with a mean follow-up of 9.5 years, were favorable, with total regression of functional impairment in 85% of cases and a satisfaction rate of 97.5%. There were no cases of tendon dislocation, neuroma, or recurrence. Residual problems were all related to associated diseases, whether pre-existing or with subsequent onset. Le Viet's technique gives reliable, lasting results without complications or recurrence. IV, retrospective study.

Biomechanical characteristics of fixation methods for floating pubic symphysis

BackgroundFloating pubic symphysis (FPS) is a relatively rare injury caused by high-energy mechanisms. There are several fixation methods used to treat FPS, including external fixation, subcutaneous fixation, internal fixation, and percutaneous cannulated screw fixation. To choose the appropriate fixation, it is necessary to study the biomechanical performance of these different methods. The goal of this study was to compare the biomechanical characteristics of six methods by finite element analysis.MethodsA three-dimensional finite element model of FPS was simulated. Six methods were used in the FPS model, including external fixation (Ext), subcutaneous rod fixation (Sub-rod), subcutaneous plate fixation (Sub-plate), superior pectineal plate fixation (Int-sup), infrapectineal plate fixation (Int-ifa), and cannulated screw fixation (Int-scr). Compressive and rotational loads were then applied in all models. Biomechanical characteristics that were recorded and analyzed included construct stiffness, micromotion of the fracture gaps, von Mises stress, and stress distribution.ResultsThe construct stiffness of the anterior pelvic ring was decreased dramatically when FPS occurred. Compressive stiffness was restored by the three internal fixation and Sub-rod methods. Unfortunately, rotational stiffness was not restored satisfactorily by the six methods. For micromotion of the fracture gaps, the displacement was reduced significantly by the Int-sup and Int-ifa methods under compression. The internal fixation methods and Sub-plate method performed well under rotation. The maximum von Mises stress of the implants was not large. For the plate-screw system, the maximum von Mises stress occurred over the region of the fracture and plate-screw joints. The maximum von Mises stress appeared on the rod-screw and screw-bone interfaces for the rod-screw system.ConclusionsThe present study showed the biomechanical advantages of internal fixation methods for FPS from a finite element view. Superior stabilization of the anterior pelvic ring and fracture gaps was obtained by internal fixation. Subcutaneous fixation had satisfactory outcomes as well. Sub-rod fixation offered good anti-compression, while the Sub-plate fixation provided favorable anti-rotational capacity.

FIXING DEVICE FOR CLOSING AND COUPLING AN INTRAVENOUS CATHETER

skin fixing devices in peripheral, central or arterial catheters have several important drawbacks: site infection, stacking of material in the anatomical area which is very annoying for the patient and medical staff risk when fixating stitches are used. to develop a fixing device that simplifies presently used systems, favoring asepsis and motility. the device herein described is composed by a mechanical fixation, a closing system and coupling for intravenous catheters. The system has a thin circular piece with at least two holes for subcutaneous fixation, one or several conducts for lumina and a hollow cylindrical part in one side, screwed exteriorly and flat inside, with an oriented protuberance. A watertight plug with one or several thin tubes that adapt to the lumina, a positional slot, a handle and a solid screwed tap for perfect closure are available for at home use. An intermediate plug with one or several lumina and a screwed hollow plug are provided for in hospital use. the above described device is intended to be used in two settings: in hospital and at home. It is supposed to reduce the risk of infection and stacking of the anatomical site where cutaneo us puncture with fixation of peripheral, central or arterial catheters is performed.

Principles of Structural Rhinoplasty in South East Asian Noses

Principles of Structural Rhinoplasty in South East Asian Noses

Surgical Technique: A Percutaneous Method of Subcutaneous Fixation for the Anterior Pelvic Ring: The Pelvic Bridge

Management of pelvic ring injuries using minimally invasive techniques may be desirable if reduction and stability can be achieved. We present a new technique, the anterior pelvic bridge, which is a percutaneous method of fixing the anterior pelvis through limited incisions over the iliac crest(s) and pubic symphysis. An incision is made over each anterior iliac crest and a 6- to 8-cm incision is centered over the symphysis. Either a locking reconstruction plate or a spinal rod is placed through a subcutaneous tunnel overlying the external oblique fascia in the subcutaneous tissue, and fixation into the iliac crest and pubis is achieved to effect stability. A randomized controlled trial comparing anterior pelvic external fixation (APEF) versus anterior pelvic internal fixation (APIF) for unstable pelvic ring injuries was begun in October 2010. Patients with unstable pelvic ring injuries were enrolled and followed with respect to fracture reduction, surgical pain, complications, and functional outcome scores. As of January 2012, 23 patients met inclusion; however, 12 patients refused participation because of the possibility of external fixation, leaving 11 patients (four male, seven female) enrolled. At 6-month followup, there was a single pin tract infection in the APEF cohort and no complications or pain in the APIF cohort. This clinical experience lends support to the use of a new minimally invasive technique to stabilize the anterior pelvis, particularly given the resistance on the part of patients to consider external fixation. Level II, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Repairing the Loss of Areas of the Palpebromalar Region: A Modified Mustardé Skin Flap Technique

Sir: First described by Mustardé in 1971, the advancement-rotation temporojugal skin flap has been used largely for the loss of areas of the cheek, the temple, and the inferior eyelid.1 Reconstruction by a temporojugal flap using a deep plane sub–superficial musculoaponeurotic system (SMAS) flap, as first described by Barton and Zilmer and popularized by Kroll et al., is used when there is loss of temporojugal substances, or even the external canthus, where the SMAS is well-defined and separable.2,3 However, the role of the SMAS is weak in the palpebromalar region. In effect, the palpebromalar region is the sum of two aesthetic units: the palpebro-orbital region, where the orbicularis oculi muscle plays the role of the SMAS; and the malar region, which is essentially constituted of subcutaneous fatty tissue.4 Consequently, we propose our temporojugal skin flap associated with a malar lift adapted for use in the case of loss of the palpebromalar area. This technique is of special interest in elderly patients, where the risk of ectropion is increased because of a defective skin-SMAS system. Our technique consists of the following: Resection of the tumor according to the Mohs' technique. Lesion repair after finding the margins of healthy tissue using biopsy excisions and microscopy: make the incision starting from the inferior eyelid in line with the lacrimal point, then make one upward and outward line starting from the lateral canthus and curving toward the tip of the eyebrow, then toward the temple and descending to 2 cm below the ear lobe. Then, move 1 cm forward perpendicularly. Incision and broad dissection of the subcutaneous fat above the SMAS plane. Rotation of the skin flap upward and inward. Malar lift: separation of the subperiosteum of the malar fat pad and then fixation the periosteum of the margo orbitalis (Fig. 1).Fig. 1.: Malar lift: subperiosteum dissection.Prior placement of the inferior eyelid under tension using lateral canthopexy: remove the inferior canthal lateral tendon from its orbital attachments, totally free the inferior eyelid and create a neotendon, which is then reinserted in the orbital periosteum at the desired position. Subcutaneous fixation of the cutaneous-fat skin flap at the temporal aponeurosis to give anchorage points. Cutaneous closure by separate points. At the end of surgery, the cutaneous coverage is satisfactory and the stasis of the inferior palpebral region is conserved (Fig. 2).Fig. 2.: Conservation of the stasis of the inferior palpebral region.The aim is to achieve a deep plane with vertical traction, which is fixed firmly to the periosteum.2,3,5 Use of the sub-SMAS is feasible for the loss of substance of the temporal or the external canthus. However, the SMAS is limited to the lower palpebral and malar regions with the loss of central or paracentral substance. With the same purpose as deep dissections, we propose a subperiosteal detachment of the malar region with vertical traction. Associated with a classic lateral canthopexy, the malar lift provides major support for the inferior eyelid. This technique should be used for the reconstruction of large defects of the inferior eyelid and the malar region. DISCLOSURE The authors have no financial or commercial interests to disclose. Sophie Converset-Viethel, M.D. Philippe Kestemont, M.D. Jose Santini, M.D. Alexandre Bozec, M.D. Nicolas Guevara, M.D. Head and Neck Surgery Department University Hospital Nice, France

Subcutaneous Fixation of Gastrostomy Tube Is Superior to Temporary Fixation

The placement of gastrostomy tubes (GTs) in infants and children to provide enteral access over the past decade has shifted toward a minimally invasive, safer direction with the development of various new techniques. We have developed a modified technique, utilizing subcutaneous (S.C.) tunneling stay sutures to prevent complications, such as GT dislodgment and wound infection. The aim of this study was to identify and describe complications of the modified procedure and compare it with the standard laparoscopic GT placement. A retrospective 4-year review of 153 patients who underwent laparoscopic GT placement was conducted. Eighty-nine patients underwent the modified S.C. tunneled technique, and 64 patients had standard U-stitch with temporary fixation. The overall complication rate was significantly higher with the temporary fixation group (20%) versus the modified technique group (2.5%). Six patients from the temporary group and 2 patients from the modified group developed cellulitis. Seven patients underwent reoperation secondary to GT dislodgment in the temporary group. No patients were identified with tube-related pressure necrosis or procedure-related deaths. S.C. placement of stay sutures in the modified technique is associated with a lower complication rate than temporary fixation. The modified technique should be the preferred approach when performing laparoscopic GT insertion.

Percutaneous Endopyelotomy and Results: Korth Technique

Endoscopic incision of ureteral strictures has become an important component of the urologic armamentarium. Despite different techniques and stenting times applied for the procedures, the rates of long-term favorable outcomes have proved to range consistently from 72% to 89% for both secondary and primary hydronephrosis. Cold-knife incision combined with 3 weeks of stenting has been utilized at our institution from the beginning. The results have been as favorable as those from other groups. However, stenting times are the subject of controversy. In a prospective trial, a newly designed stent for internal reflux-free drainage and subcutaneous fixation was applied in 53 patients and left indwelling for 6 months. Whereas such long-term stenting using the Endostent seemed to produce less favorable overall results, stenting for 3 weeks proved sufficient in lower-grade hydronephrosis secondary to small stenotic ureteral segments. Although stenoses recurred in 12% of our cases, 90% of these recurrences could be treated endoscopically. All but two recurrences became evident within the first 6 months after stent removal. After a mean follow-up of 20.2 +/- 19.6 months, the outcomes have remained unchanged even on late reexamination.

Subcutaneous fixation with screws for fractures of the hip

Subcutaneous fixation with screws for fractures of the hip