Suture Failure Research Articles

Dermal Graft Thickness Over 2 mm and Grafts Oriented Parallel to Skin Tension Lines Increased Graft Strength and Suture Retention: A Biomechanical Study.

To assess the variability in graft biomechanical properties of an acellular human dermal matrix patch. A total of 22 strips obtained from 6 separate graft specimens (AlloPatch HD) were tested. Load elongation properties after cyclic loading, including ultimate load at break, energy at break, and extension at break, were tested and compared by graft thickness. Suture pull-out testing using a simple vertical stitch suture retention test was performed. There was a significant, strong positive correlation between graft thickness and ultimate load to failure, energy at break, and extension at break (P < .01). The association between direction of graft in relation to skin tension lines and ultimate load to failure was also significant (P < .034). The difference in ultimate load to failure from the extremes of graft thickness in this study (1.1 mm vs 3.2 mm) was almost 4-fold (104 N/mm2 vs 402 N/mm2). The suture pull-out testing of 10 dermal graft test strips showed that once the graft thickness reached a threshold thickness of 2 mm, the mode of failure changed from cutting through the graft vertically to tearing the graft diagonally. The tested dermal allograft patch shows great variability in thickness within and between individual patches. This study has revealed that grafts thicker than 2 mm and those used in parallel to skin tension lines exhibit a higher ultimate load to failure. Furthermore, graft thickness over 2 mm influenced the method of suture failure. Caution should be exercised when using grafts less than 2 mm due to lower ultimate load to failure and suture pull-out. Marking the patches in accordance with skin tension lines would help determine the ideal orientation of insertion.

Histologic and immunohistochemical analysis of connective tissue changes in patients with intestinal sutures failure

Objective. To determine the role of connective tissue pathology in the development of intestinal suture failure in order to improve the results of treatment of patients with this complication. Materials and methods. The study included 45 patients with intestinal suture failure who were treated at the Shalimov National Research Center for Surgery and Transplantation of the National Academy of Medical Sciences of Ukraine in 2017–2023. Results. A comprehensive study of fragments of small and large intestine tissues revealed similar morphological changes in patients with phenotypic signs of undifferentiated connective tissue dysplasia and intestinal sutures failure. Immunohistochemical examination of tissues with monoclonal antibodies to α–smooth muscle actin in both groups of patients revealed uneven, focal expression in smooth muscle differentiation cells and fibroblasts; with monoclonal antibodies to type IV collagen – moderate positive expression in the basal membrane of blood vessels, in smooth muscle cells of the muscle layer of the vessel wall, in areas of connective tissue, which meant pathological remodeling of connective tissue. Conclusions. The similar results of histological and immunohistochemical studies in patients with signs of undifferentiated connective tissue dysplasia and intestinal sutures failure confirm the influence of connective tissue pathology on the development of this complication.

Anastomotic leak: genetic aspects of prediction and choice of surgical treatment tactics.

Aim: To improve the treatment results of patients with anastomotic leaks by studying genetic predisposition. Materials and Methods: The object of this prospective study were 17 patients with anastomotic leaks. A group of 80 practically healthy people was tested as control. Real-time PCR was used to investigate polymorphisms: C-1306 →T (MMP2), rs243865 та G303→A (TIMP2), rs9900972.To assess the state of connective tissue metabolism. Free oxyproline in blood serum and the level of glycosaminoglycans (GAG) in urine were studied. Results: Having investigated the relationship of some clinical and laboratory indicators of patients with postoperative complications with the genotypes of the studied polymorphisms, we found data indicating the pathogenetic significance of the C/C allele of the MMP-2 gene (C-1306→T) and the G/G variant of the TIMP gene 2 (G303→A) as a risk factor for the failure of anastomotic sutures, which, unlike other groups of genetic polymorphisms, are statistically reliably accompanied by hypoproteinemia, elevated indicators of markers of protein catabolism, namely free blood oxyproline and urine GAGs. Thus, in the research group with AL, the carriers of the homozygous CC genotype of the MMP2 gene had significantly lower levels of total serum protein. Indicators of urinary GAGs and free oxyproline were almost three times higher than those of carriers of the minor TT genotype. Conclusions: Molecular genetic research is a new promising direction for the development of modern personalized diagnostic criteria and models for predicting the development and course of postoperative abdominal complications, in particular, anastomotic leaks.

Survivorship and Outcomes of Meniscal Ramp Lesions Repaired Through a Posteromedial Portal During Anterior Cruciate Ligament Reconstruction: Outcome Study With a Minimum 10-Year Follow-up

Background: Several studies have demonstrated suture repair of ramp lesions of the medial meniscus via a posteromedial approach was associated with a significantly lower rate of secondary meniscectomy. However, these studies are not long-term and highlight the need for extended follow-up research to better understand the outcomes over a more extended period. Purpose: To evaluate the long-term results and reoperation rate for the failure of arthroscopic all-inside suture repair of ramp lesions of the medial meniscus via a posteromedial approach during anterior cruciate ligament (ACL) reconstruction. Study Design: Case series; Level of evidence, 4. Methods: All patients who underwent all-inside suture repair of the posterior segment of the medial meniscus (ramp lesion) via a posteromedial approach during ACL reconstruction at a minimum follow-up of 10 years were included in the study. Side-to-side anterior laxity was assessed preoperatively and postoperatively. Pre- and postoperative functional assessment was based on the subjective International Knee Documentation Committee score for activities of daily living and the Tegner activity scale for sporting ability. Reinterventions for meniscal repair failure and other complications were also recorded at the last follow-up. Results: A total of 81 patients met the inclusion criteria for this study. Two patients had an ACL graft rupture with a new ramp lesion and were excluded from the analysis. Additionally, 15 patients were lost to follow-up, leaving a total of 64 patients in the final analysis. The mean follow-up was 124.8 months (range, 122.4-128.4 months). Mean side-to-side difference in anterior laxity significantly improved from 7.4 ± 1.5 mm (range, 5-12 mm) to 0.4 ± 1.3 mm (range, –3 to 4 mm) (P = .01). The mean subjective International Knee Documentation Committee score increased from 64.3 ± 13.4 (range, 34-92) before the operation to 91.1 ± 10.1 (range, 49-100) at the last follow-up (P = .001). The Tegner activity scale score at the last follow-up (6.3 ± 1.6) was lower than that before the trauma (7.1 ± 1.6) (P = .02). Fourteen patients (21.9%) had a failed meniscal repair and were reoperated. The mean time from initial repair to reoperation was 64.5 months (range, 13-126 months), and the median was 60.6 months. The multivariate analysis, including parameters such as lateral tenodesis (hazard ratio [HR], 1.62; P = .50), preoperative Tegner score (HR, 1.66; P = .41), preoperative laxity (HR, 1.75; P = .35), age at surgery (HR, 1.02; P = .97), and number of sutures (HR, 2.38; P = .19), did not reveal any factors associated with suture failure. Conclusion: The results show that arthroscopic repair of ramp lesions of the medial meniscus during ACL reconstruction using a posteromedial approach has a high failure rate at the 10-year follow-up, with half of these suture failures occurring within 5 years after the initial repair.

FUNCTIONAL POSSIBILITIES OF ESOPHAGEAL-GASTIC ANASTOMOSIS IN THE REMOTE POSTOPERATIVE PERIOD ACCORDING TO THE DATA OF THE MORPHO-FUNCTIONAL STUDY

Resume. Purpose: Morpho-functional assessment of the method of endoprosthesis of failure of the esophageal-gastric anastomosis sutures in the distant postoperative period. Introduction. Currently, views on treatment tactics in the case of the inability to suture esophageal anastomoses are contradictory and have diametrically opposite opinions — from extremely gentle to extremely aggressive. Optimism of supporters of palliative resections is due not only to the almost identical mortality with radical operations, which is 4.0-31.6%, but also to the possibility of ensuring 5-year survival of 8.5-15.7% of operated patients. Thus, a number of questions remain relevant, including the study of morpho-functional shifts in tissue cells of the esophageal-gastric anastomosis with the assessment of its functional capabilities in the distant postoperative period based on morphological research. Material and methods. The work was performed in the Department of Surgery of the Gastrointestinal Tract and Esophagus of the State University «IZNG named after V.T. Zaitsev National Academy of Medical Sciences of Ukraine» with the presentation of the results of a morpho-functional study and statistical analysis of the treatment of patients with the development of failure of esophageal-intestinal anastomoses in the postoperative period. All patients were fitted with self-expanding stents, stents from M.I.Tech Co., Ltd. (Korea), covered esophageal HANAROSTENT with an antireflux valve - 14 and Boston Scientific Corp. were used for endoprosthetics. (USA), covered with Ultraflex-2 esophagus. In the long-term period, all patients discharged from the hospital underwent a control X-ray and endoscopic examination every 1-2 months, during which a biopsy was performed and material was taken for the next morphological examination. For light microscopy, tissue fragments of the esophageal-gastric junction were fixed in a 10% solution of neutral formalin for 24 hours at a temperature of +20°C, after which they were dehydrated with ethyl alcohol and embedded in paraffin. Sections were prepared from paraffin blocks and stained with Ehrlich’s hematoxylin and eosin. Research results. The long-term results of endoprosthesis of failed esophageal-gastric anastomosis sutures in 43 stented patients were evaluated. Of great interest is the morpho-functional state of the esophageal-gastric anastomosis in the long term after surgery (3- 24 months), as these terms determine the functional capabilities of the anastomosis. Taking into account that during the research it is possible to detect initial morpho-functional shifts in the tissues of the examined organs, it should be assumed that in the future hypoxia of the stomach and esophagus increases and the degree of expressiveness of these disorders maintains the same sequence. Conclusions. The conducted studies expanded the understanding of the pathogenesis of morpho-functional disorders occurring in the distant postoperative period, confirmed the priority of metabolic disorders in tissue cells in diseases of the gastrointestinal tract, and also allowed to give a prognostic assessment of the functional possibilities of the further development of the gastric process. further tactics of managing patients at the next stage of treatment.

Suture Tying Force for Cut-Out during Radial Meniscus Tear Repair: A Biomechanical Evaluation of Failure Loads during the Knot-Tying Process.

The purpose of the study was to determine average tensile forces resulting in suture failure while tying a knot during repair of complete radial meniscus tears and to compare the failure tensile force based on meniscus tissue location: the peripheral (red-red) versus inner (white-white). This study was designed as a cadaveric biomechanical study using 24 menisci harvested from fresh frozen cadaveric knees with midbody radial tears. Tears were repaired using 2-0 nonabsorbable suture in both the inner meniscus and the peripheral meniscus. A force gauge was used to measure the tension of a surgeon's knot until failure of either the suture or the meniscus tissue. Statistical analysis was performed comparing suture failure tensile forces between inner and peripheral sutures using 2-sample t test. Suture repairs primarily failed due to meniscal tissue cut-out after suture tensioning (96%). There was no statistical difference in failure mode between medial and lateral meniscus for both the inner (100% cut-out) and the peripheral (92% cut-out; P = 0.703) sutures. The peripheral sutures failed as significantly higher loads (54 ± 26 N) than the inner sutures (36 ± 11 N, P = 0.006). The peripheral meniscus tissue tolerated significantly higher tension at failure (36 ± 7 N) than the inner meniscus (26 ± 7 N, P < 0.001). When tying parallel sutures to repair a radial meniscus tear, suture tensile forces above 30 N may tear through meniscus tissue. Surgeons should not use suture tying forces above 30 N when repairing radial meniscus tears with parallel sutures. The peripheral meniscus can withstand higher knot-tying forces than the inner meniscus, so surgeons should consider tying the peripheral suture before the inner suture.

MINIMALLY INVASIVE TREATMENT OF MECHANICAL STOMACH SUTURE FAILURE IN PATIENTS AFTER LONGITUDINAL RESECTION FOR OBESITY (A CLINICAL CASE)

Sleeve gastrectomy has now become one of the most popular operations in the treatment of morbid obesity. We present a clinical case of minimally invasive treatment of early suture failure after sleeve gastrectomy, from the archive of the authors’ clinical observations. Suture failure occurred on the day 4 after surgery. Endogastroscopy revealed a defect of 12 mm in diameter with infiltration at the edges. The technique of endoscopic sanitation of the abscess cavity and transcutaneous drainage of the abdominal cavity was used. After 14 days, the drainage in the abdominal cavity stopped functioning. Fistulography showed that it was not in the abscess cavity; according to endoscopic fistulography, hermetic sealing was achieved. After 2 months the fistula was completely closed. The patient was discharged with complete recovery. After 6 months, EGD revealed cicatrical changes; body weight loss: 55 kg. This clinical case demonstrated the possibility of combined minimally invasive treatment of a postoperative complication – gastric suture failure after sleeve gastrectomy.

Оценка болевого синдрома в реабилитационных мероприятиях после операции по поводу разрыва ахиллова сухожилия

INTRODUCTION. Patients who have been injured need an early start of rehabilitation measures. This is due to the fact that prolonged restriction of motor activity, lack of exercise, vascular and other changes lead to muscle atrophy, limited mobility in joints, impaired metabolic processes in the extremities, loss of functional conditions. AIM. To optimize the complex of measures for early rehabilitation after surgery for Achilles tendon rupture, taking into account the assessment of pain syndrome. MATERIAL AND METHODS. The research work was carried out at the Department of Medical Rehabilitation and Sports Medicine. To implement the tasks set, the following stages were introduced: a critical analysis of domestic and foreign sources, the development of an individual rehabilitation plan with an assessment of pain syndrome. RESULTS AND DISCUSSION. For effective rehabilitation in the postoperative period, it is important to objectively control the patient's pain sensations, gradually increasing the load on the damaged tendon. The pain monitoring and weight load dosing scale based on the visual analog scale has found wide application. Visual analog scale consists of a horizontal line on which the extreme points correspond to 0 points (no pain) and 10 points (maximum unbearable pain). The patient marks a point on this line corresponding to his current pain level. The pain syndrome was assessed on the day of surgery, and then on the 7th, 14th, 21st, 35th, 42nd and 49th days of follow-up after surgery. If by the end of the second week after surgery, the pain syndrome is 0-2 points, this indicates a favorable healing process and the possibility to begin early mobilization of the tendon. During this period, you can gradually increase the weight load on the limb, starting with partial support on the foot. If the pain syndrome persists, it is more than 2 points according to visual analog scale by the end of the second week, which may indicate the development of complications that prevent normal healing: inflammation, failure of sutures, suppuration of the surgical wound. CONCLUSION. The proposed technique using a visual analog scale is a tool for assessing pain and functional status in the preparation of a set of measures for early rehabilitation after surgery for rupture of the Achilles tendon. The assessment of pain symptoms is a determining factor in the introduction of early tendon mobilization. KEYWORDS: Achilles tendon rupture, pain syndrome, early rehabilitation

412. COMPARISON BETWEEN PREOPERATIVE MALNUTRITION, AND SARCOPENIA AND POSTOPERATIVE COMPLICATIONS IN ESOPHAGEAL CANCER PATIENTS

Abstract Background Typical indicators of malnutrition in cancer patients include BMI, CONUT, PNI, and prealbumin, while SMI and PMI are often used as indicators of skeletal muscle mass loss (sarcopenia). Although these indicators have been reported to be associated with surgical outcomes, their combination may be useful in determining the effectiveness of perioperative management because these are closely related during the perioperative period. Methods A total of 132 esophageal cancer patients who underwent esophagectomy between January 2021 and May 2023 were included in this study. Preoperative BMI, CONUT, PNI, prealbumin, SMI (measured by BIA), and PMI (measured by CT imaging) were extracted from clinical record. We also selected BMI and SMI as a new indicator for combined malnutrition and loss of skeletal muscle. Then, we investigated the association between these indicator and postoperative complications (pneumonia, suture failure, total CD Grade ≥II, total CD ≥IIIa), and length of hospital stay. Results The mean age of patients was 67.3 years, 107 were male and 25 were female. Preoperative chemotherapy was administered to 58 patients. Although associations with each single index were found for postoperative pneumonia and low BMI, low SMI, and low PMI, there was no significant association with anastomotic leakage or overall complications. On the other hand, low BMI+SMI was strongly correlated with postoperative pneumonia, overall Grade≥II, and Grade≥IIIa complications. In postoperative hospital stay, low BMI, low PNI, and low SMI as single indicators showed a significant increase in hospital stay, while low BMI+SMI showed further statistically significant increase. Conclusion In patients who underwent esophagectomy, single index for malnutrition and low skeletal muscle mass may be predictors of postoperative complications respectively. However, because perioperative management is inseparable from nutritional therapy and exercise therapy, composite index of BMI and SMI may be better predictor of therapeutic efficacy of perioperative nutrition and exercise therapy.

Tensile testing in feline ventral abdominal coeliotomy closure with different sizes of polydioxanone suture material: a biomechanical study.

The aim of this study was to evaluate, in vitro, the load and type of failure of the sutured ventral abdominal fascia of cats with different sizes of suture material made of polydioxanone (PDX) (2-0, 3-0, 4-0, 5-0 USP). A total of 32 samples of the ventral abdominal wall from 16 cadaveric cats were harvested using an hourglass-shaped template. The samples were sectioned longitudinally along the linea alba and then sutured together in a continuous pattern using four different randomly assigned sizes of pdx suture material (2-0, 3-0, 4-0, 5-0 USP). A universal testing machine was used for linear distraction of the samples. The tensile strength and type of failure were recorded and analysed. Three types of failure were defined: suture material failure (S), suture line failure (T1) and failure of the abdominal wall further away from the linea alba (T2). The frequency of suture material failure decreased with increasing suture size. Suture size 5-0 failed due to a S failure in 6/8 samples, PDX 4-0 failed in 2/8 samples and PDX 3-0 failed in only 1/8 samples. However, PDX 2-0 failed due to only T1 or T2 failures, with both failures being almost equally represented. No statistically significant differences in the load to failure between PDX 2-0, 3-0 and 4-0 were noted (P >0.05). The risk of suture failure increased with decreasing suture size diameter. PDX 2-0 and 3-0 can be used without reservation for the closure of ventral midline coeliotomy in cats. Although there was no statistically significant difference between PDX 2-0, 3-0 and 4-0, PDX 4-0 showed a higher probability for suture breakage and should be used only after careful consideration of the patient while clinical evaluation is pending. Pdx 5-0 cannot be recommended as a safe suture size for this type of surgical closure.

Analysis of molecular mechanisms of regenerative processes in tissues of patients with diabetic foot syndrome

Diabetic foot syndrome (DFS) is a dangerous complication of diabetes mellitus. Despite numerous studies dedicated to the wound healing process in patients with diabetic foot syndrome, surgeries in this pathology are often accompanied by surgical suture failure due to insulin therapy and require repeat surgical intervention. The aim of this study is to analyze the biochemical mechanisms involved in the wound healing process in patients with diabetic foot syndrome. To achieve this goal, articles from foreign databases such as PubMed, MedLine, Google Scholar, and the Russian Index of Scientific Citation (RISC) were selected and analyzed for the period from 2017 to 2023. The search was conducted using keywords such as diabetic foot, wound healing, molecular mechanisms, and their Russian equivalents. A total of 74 publications were identified through the literature search, of which 24 literature sources from 2017 to 2023 were included in the review, corresponding to the direction and purpose of the study. In addition, 18 sources older than 2017 were used to reveal the subject of the study from the references in the literature lists. The literature review discusses various factors that influence the wound healing process: the function of the skin barrier, activity of immune system components, as well as the contribution of hypoxia and endothelial dysfunction to tissue regeneration mechanisms in patients with DFS. Despite the available literature data, it is advisable to search for new factors involved in the development mechanisms of DFS to prevent complications and increase the effectiveness of treatment.

Ex vivo biomechanical evaluation and comparison of lateral femoro-fabella ligament suture and lateral suture with bone anchor for cranial cruciate ligament repair in cats.

To compare the biomechanical properties of lateral femoro-fabella ligament suture (FFLS) and lateral suture with a bone anchor suture (BAS) for management of feline cranial cruciate ligament disease. 12 femurs from 6 mature cat cadavers. The samples were collected from April to June 2023. The specimens had an FFLS and, subsequently, BAS placed and were positioned into a biomechanical testing machine, preloaded from 5 N to 15 N for 100 cycles, and subsequently, a load to suture failure was applied. The displacement at 5 N and 15 N, the total precycle displacement (millimeters), the force at 3 mm displacement and at failure (newtons), the displacement at failure (millimeters), and the stiffness to failure (Newton:millimiter) were recorded. Nonparametric Wilcoxon signed-rank tests were used to compare data between the 2 groups. The displacement at 5 N and 15 N and the total precycle displacement were significantly higher in the FFLS group compared to the BAS group. Additionally, the FFLS group results showed less consistent displacement and marked variability. The force (newtons) at 3 mm displacement was higher in the BAS group. There was no significant difference in force and no significant difference in displacement at failure between the 2 groups. However, the stiffness to failure (N/mm) was significantly higher in the BAS group. BAS represented a more stable and reliable femur attachment for extracapsular suture in cats. To demonstrate the stability and reliability between BAS and FFLS and influence implant selection in the treatment of cranial cruciate ligament rupture in cats with evaluation of biomechanical properties.

Use of a Krackow suture technique with PEEK barrel augmentation for subscapularis repair is stronger than use of a Mason-Allen suture technique

BackgroundIn total shoulder arthroplasty, the subscapularis tendon is routinely mobilized, by tenotomy, peel, or lesser tuberosity osteotomy, to visualize the joint and allow proper implant positioning. Careful mobilization of the subscapularis is undertaken to achieve an anatomic tension-free repair. This cadaveric study tests the biomechanical differences of 2 repair techniques of the subscapularis peel (SP) compared to the classically described technique. We hypothesize that adaptation of this SP technique using a custom-designed polyether-ether-ketone (PEEK) barrel in the bicipital groove may further stabilize suture repair of the subscapularis. MethodsTwenty paired cadaveric shoulder specimens underwent SP and repair via transosseous suture fixation. The PEEK barrel used was a laboratory prototype designed for the study (Catalyst OrthoScience, Naples, FL, USA). Five specimens were repaired using a traditional Mason-Allen suture; their paired shoulders were repaired using the PEEK barrel and a Mason-Allen suture. Five specimens were repaired using the Krackow suture; their paired shoulders were repaired using the PEEK barrel and a Krackow suture. Mechanical testing was performed using a uni-axial materials testing system with primary outcome of gap displacement and secondary outcomes of maximum load to failure and method of failure. ResultsThe Krackow repair method with and without PEEK augmentation was significantly stiffer than the Mason-Allen repair method with and without PEEK augmentation (P < .001 across all groups). Adding augmentation changed the strength of the Mason-Allen repair without achieving statistical significance (P = .0925). Intergroup differences in cyclic displacement were not statistically significant. The Krackow repair methods had higher mean maximal load at failure than the Mason-Allen repairs of 534 ± 108 N and 266 ± 98 N, respectively (P < .001). Maximum load at 5 mm displacement was significantly different across groups (P = .004). Methods of failure in the Mason-Allen technique groups included knot and tendon failure, and in the Krackow technique groups included suture failure and lesser tuberosity fracture. ConclusionRepairing the subscapularis with a Krackow suture is significantly stronger than a Mason-Allen repair in stiffness as well as load to failure. The results reported here compare a Krackow suture with a more common Mason-Allen suture configuration, and demonstrate the application of PEEK augmentation to subscapularis repair techniques. This study can guide surgeon selection of an ideal subscapularis repair technique for stemmed or stemless total shoulder arthroplasty.

Usefulness of Probing Sensor Device for Evaluating Meniscal Suture and Scaffold Implantation.

Appropriate suture tension is a key factor in successful meniscal repair. This study aimed to clarify the appropriate value of meniscal stabilization with suture repair based on a probing procedure for healthy porcine menisci and a novel meniscal scaffold. After evaluating the reliability of the probing sensor, meniscal vertical tear and partial meniscectomy models were developed, in which suture repair and meniscal scaffold implantation were performed at suture intervals ranging between 20 and 2.5 mm. The residence forces at each interval were evaluated using a probing sensor. Moreover, a tensile test was conducted to evaluate the displacement and presence or absence of gaps. We found that normal and meniscal scaffolds should be fixed within 5 mm of suture interval. The probing residence forces required were at least 1.0 N for vertical tears and 3.0 N for meniscal scaffolds. These findings may be taken into consideration to reduce suture failure following meniscal tear repair and stabilizing meniscal scaffold fixation.

Absorbable Sutures Repair Without Meniscopexy, Results in Superior Outcomes for Discoid Lateral Meniscus With Meniscocapsular Anterior Detachment in Children.

Despite the fact that meniscocapsular anterior detachment is the most common location of instability in children with a Discoid Lateral Meniscus (DLM), there is a lack of consensus about the type of repair that should be utilized for stabilization. The aim of this study was to determine the best fixation method for anterior detachment of DLM in children. Our hypothesis was that excessive rigidity with fixation would restrict meniscal mobility and increase the rate of failure or prevent full knee flexion. This study was a retrospective single-center study consisting of 51 consecutive knees (45 children) with menico-capsular anterior detachment that underwent stabilization and minimal saucerization of the meniscus between 2007 and 2018. We aimed to compare the need for revision surgery and knee flexion between the different types of fixations utilized; namely we compared meniscopexy using anchors on the tibia (n=30) with outside-in arthroscopic soft tissue fixation (n=21), and absorbable (n=18) and nonabsorbable sutures (n=33) were compared. The mean age at surgery was 10.4 years (3 to 17) with a mean follow-up of 52 months (18 to 148). The group of knees treated with absorbable sutures had a significantly better rate of full knee flexion (15/18) compared with the nonabsorbable group (17/33) ( P =0.03). Despite the absence of significance ( P =007), there was a lower rate of revision surgery due to suture failure in the soft tissue fixation group (0 revision operations) compared with the meniscopexy group (5 revision operations). For anterior meniscocapsular detachment of DLM, it is recommended to perform soft tissue fixation with absorbable sutures, as this technique resulted in better knee flexion and a lower rate of revision surgery when compared with meniscopexy and nonabsorbable suture fixation. Level III-retrospective case studies.

Comparison of Suture Types and Techniques in Achilles Tendon Repair: An Ex Vivo Biomechanical Animal Experiment.

The ideal suture technique and type in tendon repair remain unclear. This biomechanical study aimed to assess the biomechanical characteristics of three techniques-modified Kessler (mKE), modified Krackow (mKR), and modified tension Bunnell (mtBU)-in sheep Achilles tendon tear repair using three suture types-polypropylene, polyester, and ultra-high-molecular-weight polyethylene (UHMWPE)-which are also compared. Sixty-three Achilles tendons harvested from sheep were transversely hacked as a replacement for rupture in a standardized measure and repaired using mKE, mKR, and mtBU techniques with No. 2 polypropylene, polyester, and UHMWPE sutures. Biomechanical parameters, such as Young's modulus, ultimate strength, and strength to the 5-mm gap, were recorded for statistical analysis. The mtBU technique with UHMWPE use resulted in increased ultimate strength, strength to 5-mm gap, Young's modulus, and quantity of specimens with low clinical failure modes compared with the other techniques with other suture materials. Furthermore, mtBU has the lowest thickness at the repair side of the tendons. This approach showed tendon failure during maximal traction testing, whereas the mKE and mKR techniques had polyethylene and polyester suture failures. The UHMWPE suture was significantly superior to the other sutures in each technique in terms of strength and durability. The mtBU technique using UHMWPE suture showed better biomechanical results, implying that this repair might be more appropriate to obtain early mobilization after tendon ruptures.

Short-term and long-term results of robot-assisted esophagectomy in cT3br/T4b esophageal cancer at initial diagnosis: Comparison with conventional thoracoscopic surgery.

284 Background: Conversion surgery in patients with locally advanced esophageal cancer that is not resectable at first time and has responded to prior therapy remains unclear. Recently, the usefulness of RAMIE for locally advanced esophageal cancer has begun to be discussed. In this study, we first analyzed the short- and long-term results of RAMIE, then examined the results of conversion RAMIE in T3br/T4b patients, and compared them with those of conversion using conventional MIE. Methods: Short-term and long-term postoperative outcomes were analyzed in 203 cases of robot-assisted esophageal cancer resection between 2020/1 and 2023/08. In addition, 33 patients with T3br/T4b who were initially diagnosed with cT3br/T4b and who underwent RAMIE after prior treatment were selected and compared to 48 cT3br/T4b cases with conventional MIE performed at the same time. Results: The mean age of RAMIE patients was 66.2 years, male to female ratio 170:33, preoperative treatment including NAC 150:53, and Clinical Stage I:II:III:IV 41:27:97:38. Surgical outcomes included thoracic surgery time of 200.3 min and total blood loss of 154.4 ml. Perioperative outcomes were Clavien-Dindo Grade 1 or higher: suture failure 4.4%, pneumonia 13.3%, and recurrent nerve palsy 16.7%. Long-term prognostic analysis (MST: 483.6days) showed 3yOS:97.6/94.1/80.3/70.9% and 3yDFS:96.2/87.2/66.2/52.4% in cStage I/II/III/IV. Especially in cStage II/III patients, 3yOS: 81.5%, 3yDFS: 71.4%. Long-term outcomes were not significantly different from those of conventional thoracoscopic procedures performed at the same time. Perioperative outcomes in cT3br/cT4b patients at initial presentation were pneumonia: 18.1%, recurrent nerve palsy rate: 12.1% (excluding complicated resection cases), and these 3yOS:66.2% and 3yDFS:48.7%. The 3yOS:52.7% and 3yDFS:40.3% of cT3br/T4b cases in the usual MIE showed a favorable trend in RAMIE (p=002). Of the 38 patients with recurrence after RAMIE surgery, 19 were local/regional and 19 were distant. Of these, 5/6/5/3 were brain/lung/liver/LN+others as the first site of distant metastasis. Conclusions: The short- and long-term results of RAMIE in our department, including T3br/T4, were described, and the short-term and long-term results of RAMIE were considered acceptable. In terms of recurrence, local/regional disease control was considered to be relatively good.

Strength of small-bites abdominal wall closure using different suturing methods and materials in an experimental animal model.

Using small instead of large bites for laparotomy closure results in lower incidence of incisional hernia, but no consensus exists on which suture material to use. This study aimed to compare five different closure strategies in a standardized experimental setting. Fifty porcine abdominal walls were arranged into 5 groups: (A) running 2/0 polydioxanone; (B) interlocking 2/0 polydioxanone; (C) running size 0 barbed polydioxanone; (D) running size 0 barbed glycolic acid and trimethylene carbonate; (E) running size 0 suturable polypropylene mesh. The small-bites technique was used for linea alba closure in all. The abdominal walls were divided into a supra- and infra-umbilical half, resulting in 20 specimens per group that were pulled apart in a tensile testing machine. Maximum tensile force and types of suture failure were registered. The highest tensile force was measured when using barbed polydioxanone (334.8N ± 157.0), but differencesdid not reach statisticalsignificance. Infra-umbilical abdominal walls endured a significantly higher maximum tensile force compared to supra-umbilical (397N vs 271N, p < 0.001). Barbed glycolic acid and trimethylene carbonate failed significantly more often (25% vs 0%, p = 0.008). Based on tensile force, both interlocking and running suture techniques using polydioxanone, and running sutures using barbed polydioxanone or suturable mesh, seem to be suitable for abdominal wall closure. Tensile strength was significantly higher in infra-umbilical abdominal walls compared to supra-umbilical. Barbed glycolic acid and trimethylene carbonate should probably be discouraged for fascial closure, because of increased risk of suture failure.

Refixation of the anterior cruciate ligament: A biomechanical analysis of suture techniques in a porcine model.

Refixation of acute anterior cruciate ligament (ACL) tears represents an increasingly popular treatment option. Systematic evaluations of various suture technique parameters are still pending. We therefore aimed to evaluate the mechanical pull-out outcomes of various suture methods for optimization of ACL refixation. Sixty fresh knees from mature domestic pigs were dissected and the femoral attachment of the ACL was peeled off. The 60 knees were divided in 10 groups and sutured as follows: (A) one suture (1, 2, 4 and 6 passes), (B) two sutures (2, 4 and 6 passes each; sutures knotted together as a loop) and (C) two sutures (2, 4 and 6 passes each, sutures knotted separately). The pull-out test was conducted using a validated electrodynamic testing machine. First occurrence of failure, maximum pull-out load and stiffness were measured. Suture failure was defined as pull-out of the ACL. Two-point fixation, using two sutures, with at least two passes, showed the most favourable biomechanical stability. The maximum pull-out load was significantly higher with two sutures (529.5 N) used compared to one (310.4 N), p < 0.001. No significant differences were found for maximum pull-out loads between two-point fixation versus one-point fixation but stiffness was significantly higher with two-point fixation (107.4 N/mm vs. 79.4 N/mm, p < 0.001). More passes resulted in higher maximum pull-out loads. The results suggest using two independent sutures, refixed separately and at least two suture passes, is appropriate for ACL refixation. More suture passes provide additional strength but are technically challenging to achieve during surgery. Level IV.

Biomechanical Comparison of the Simple Suture Technique, Meniscal Matrix-Assisted Repair, and a Novel Meniscus Cap Suture Technique for Complex Meniscal Repair.

Meniscal repair is the gold standard for simple morphology tears. However, when the morphology and chronicity of the tear are less favorable, the success of the standard techniques is reduced. To compare meniscal repair augmented by a new bioresorbable implant (Meniscus Cap) versus a traditional simple suture technique and the currently available augmented repair collagen matrix meniscus wrapping technique. It was hypothesized that the Meniscus Cap suture technique would increase ultimate failure load and less displacement during cyclic loading. Controlled laboratory study. A total of 80 fresh porcine menisci were harvested. Complex tears were created in 60 menisci, and 20 intact menisci were tested as the control group. Repairs were performed on the 60 meniscal tears using 1 of the 3 techniques (20 menisci each): an inside-out H-suture group (SS), the collagen matrix wrapping technique (CMW), and the Meniscus Cap bioresorbable implant group (CM). The menisci were subjected to 500 loading cycles from 4 to 20 N at a frequency of 1 Hz, and the total displacement was recorded. Then, the specimens underwent load to failure testing at a rate of 3.15 mm/s, and the failure mode was noted. After 500 cycles of cyclic loading, there were no significant differences in displacement between the controls and CM group (0.524 vs 0.448 mm; P = .95). The displacement after the CM was significantly smaller compared with the CMW and the SS (0.448 vs 1.077 mm [P = .0009] and 0.448 vs 0.848 mm [P = .04], respectively). The ultimate load to failure was significantly greater for the controls and the CM group compared with the SS and CMW groups (controls, 1278.7 N and CM, 628.5 N vs CMW, 380.1 N and SS, 345.1 N; P < .05). The failure mode was suture breakage (suture failure) for all repairs. In a porcine specimen meniscal repair model, the biomechanical properties of a novel Meniscus Cap repair technique were superior to that of the simple suture and CMW techniques. The results suggest that the Meniscal Cap repair technique may provide sufficient primary stability of the meniscal fixation even in the cases of complex meniscal tears.