Graft Suture Research Articles

Lateral Meniscus Allograft Transplantation in a Skeletally Immature Patient

Background: Lateral meniscus deficiency in young patients typically results from irreparable lateral meniscus tears, often associated with discoid meniscus. Such cases present a challenging clinical scenario given the known natural history of meniscus deficiency leading to degenerative lateral knee compartment changes. Managing this problem in a skeletally immature patient presents additional clinical and surgical considerations. Indications: Lateral meniscus allograft transplantation (LMAT) is indicated in patients with prior total or subtotal lateral meniscectomy resulting from irreparable lateral meniscus tears, with the goal of providing chondroprotection to the lateral compartment of the knee. Patients are assessed preoperatively for ligamentous stability of the knee, mechanical alignment, and associated chondral injuries to determine whether secondary procedures may be indicated. Technique Description: We present an all-arthroscopic technique for LMAT using small bone plugs in the anterior and posterior meniscus roots secured through 2 separate anatomic root drill tunnels tied over a bone bridge. The meniscus allograft is further secured using an outside-in suture repair technique. Special attention is given to meniscus allograft preparation, anatomic meniscus root identification, and drilling using a minimally disruptive transphyseal technique. Graft passage, suture management, and meniscus fixation and repair are also highlighted. Results: Anticipated outcomes from LMAT in skeletally mature patients are excellent, particularly if preexisting chondral degenerative changes are not present. Prior studies with greater than 7-year follow-up in adolescent patients undergoing meniscus allograft transplantation have shown reoperation rates of less than 6% with no growth disturbances noted, with most patients able to return to their prior level of sport. Computed tomography modeling data using this technique shows a proximal tibial physeal surface area disruption of less than 2.5%; therefore, the risk of growth disturbance is very low. Discussion/Conclusion: The surgical technique demonstrated here offers a safe and effective approach for the management of lateral meniscus deficiency after subtotal lateral meniscectomy for irreparable meniscus tears in skeletally immature patients. The chondroprotective effect of the lateral meniscus can be restored with an anatomically placed lateral meniscus allograft with minimal disruption to the proximal tibial physis.

Reverse graft suturing to avoid Descemet's membrane detachment of glycerol-preserved donor cornea used for therapeutic penetrating keratoplasty during COVID-19 to overcome the tissue shortage - A novel surgical technique.

To overcome tissue shortage during pandemic, we switched to 100% glycerol preservation of the donor cornea, which is economical and provides longer duration of storage than the short and intermediate storage mediums we normally use like McCAREY Kaufman (MK) or cornisol. During our initial few cases of therapeutic penetrating keratoplasty using glycerol preserved donor cornea, we faced spontaneous Descemet’s detachments resistant to air tamponade. We tried reverse graft suturing and successfully reinforced Descemet’s attachment along with air tamponade, in one of the cases after multiple failed air injections. In the subsequent two cases of infective keratitis needing therapeutic penetrating Keratoplasty, we took eight reverse sutures in between the eight cardinals, to anchor the Descemet’s membrane of the graft. Both the grafts showed attached Descemet’s and maintained good graft clarity. The reverse corneal suturing technique has not been described to the best of our knowledge and hope this helps our corneal fraternity.

Allograft contamination during suture preparation for anterior cruciate ligament reconstruction: an ex vivo study.

Effects of suture preparation on graft contamination remain unknown in anterior cruciate ligament reconstruction (ACLR). This study aimed to evaluate the incidence of allograft contamination at different time points of graft preparation and investigate differences in contamination between different sites of the allografts. Fourteen hamstring tendon (HT), 9 quadriceps tendon (QT), and 9 bone-patellar tendon-bone (BTB) allografts were harvested, sterilised, and stored following routine procedures. Graft suture preparation was performed with baseball stitching for soft tissue and bone drilling for bone plug. The time was recorded simultaneously. The graft was kept moist in a standard operating room environment for 30min after the initiation of preparation. The specimens were obtained from the middle and both ends of each graft for culture at three different time points: pre-suturing, post-suturing, and 30min after the initiation of preparation. A total of 192 specimens were transferred to the microbiology laboratory for culture, identification, and semi-quantitative assessment. Culture results were classified as negative, poor, and abundant based on the extent of growth. Contamination level was recorded as low or high corresponding to culture results of poor or abundant. The duration of suture preparation was 348, 301, and 246s for HT, QT, and BTB (P = 0.090). The specimens had a positive culture rate of 41/192 (21.4%), of which 21 were from the ends and 20 from the middle. More positive samples with abundant bacterial growth were detected from the ends than from the middles post-suturing (7/8 vs. 1/7, P = 0.010) and at 30min (6/11 vs. 0/11, P = 0.012). The total graft contamination rate was significantly higher at 30min (19/32, 59.4%) than pre-suturing (4/32, 15.6%) and post-suturing (9/32, 28.1%) (P < 0.001). The contamination rate with abundant bacterial growth was higher post-suturing (7/32, 21.9%) than pre-suturing (0%). No statistically significant differences were found among the three types of allografts. The contamination rate increases significantly at 30min compared with pre-suturing and post-suturing. Suture preparation may have introduced the high-level contamination, to which the ends of the graft were more prone than the middle. Therefore, routine prophylactic decontamination after suture preparation should be considered, especially for the ends of the grafts.

Clinical and quality-of-life outcomes of a combined synthetic scaffold and autogenous tissue graft procedure for articular cartilage repair in the knee

BackgroundInjuries to the articular cartilage of the knee often fail to heal properly due to the hypocellular and avascular nature of this tissue. Subsequent disability can limit participation in sports and decrease quality of life. Subchondral bone perforations are used for the treatment of small defects. Filling out the central portion in larger lesions becomes difficult, and scaffolds can be used as adjuvants, providing a matrix onto which the defect can be filled in completely. Also, autogenous cartilage grafts can be combined, acting as an inducer and improving healing quality, all in a single procedure.MethodsThis observational study evaluated the clinical and quality-of-life outcomes of patients with articular cartilage lesions of the knee undergoing repair via a microfracture technique combined with a synthetic scaffold and autogenous cartilage graft, with transosseous sutures and fibrin glue fixation, at 12 months of follow-up. Secondarily, it assessed whether combined procedures, previous surgical intervention, traumatic aetiology, lesion location, and age affect outcomes. The sample consisted of adult patients (age 18–66 years) with symptoms consistent with chondral or osteochondral lesions, isolated or multiple, ICRS grade III/IV, 2–12 cm2 in size. Patients with corrected angular deviations or instabilities were included. Those with BMI > 40 kg/m2, prior total or subtotal (> 30%) meniscectomy, second-look procedures, and follow-up < 6 months were excluded. Pain (VAS), physical activity (IKDC), osteoarthritis (WOMAC), and general quality of life (SF-36) were assessed.Results64 procedures were included, comprising 60 patients. There was significant improvement (P < 0.05) in VAS score (5.92–2.37), IKDC score (33.44–56.33), and modified WOMAC score (53.26–75.93) after surgery. The SF-36 showed significant improvements in the physical and mental domains (30.49–40.23 and 46.43–49.84 respectively; both P < 0.05).ConclusionsCombination of microfractures, autogenous crushed cartilage graft, synthetic scaffold, and transosseous sutures with fibrin glue provides secure fixation for treatment of articular cartilage lesions of the knee. At 12-month follow-up, function had improved by 20 points on the IKDC and WOMAC, and quality of life, by 10 points on the SF-36. Age > 45 years had a negative impact on outcomes.

Direct Innominate Artery Cannulation versus Side Graft for Selective Antegrade Cerebral Perfusion during Aortic Hemiarch Replacement.

Background Selective antegrade cerebral perfusion (SACP) has become our preferred method for cerebral protection during open arch cases. While the initial approach involved sewing a graft to the innominate artery as the arterial cannulation site, our access strategy has since evolved to central aortic cannulation with use of a percutaneous cannula in the innominate for SACP. We hypothesized that SACP delivered via direct innominate cannulation using a 12- or 14-Fr cannula results in equivalent outcomes to cases utilizing a side graft. Methods This was a single-center, retrospective analysis of 211 adult patients who underwent elective hemiarch replacement using hypothermic circulatory arrest with SACP via the innominate artery between 2012 and 2020. Urgent and emergent cases were excluded. Results A side graft sutured to the innominate was utilized in 81% ( n = 171) of patients, while direct innominate artery cannulation was performed in 19% ( n = 40) of patients. Baseline patient characteristics were similar between groups aside from a higher baseline creatinine in the direct cannulation group (1.3 vs. 0.9, p = 0.032). Patients undergoing direct cannulation demonstrated shorter cardiopulmonary bypass time (132.7 vs. 154.9 minutes, p = 0.020) and shorter circulatory arrest time (8.1 vs. 10.9 minutes, p = 0.004). Nadir bladder temperature did not significantly differ between groups (27.2°C for side graft vs. 27.6°C for direct cannulation, p = 0.088). There were no significant differences in postoperative outcomes. Conclusion Direct cannulation of the innominate artery with a 12- or 14-Fr cannula for SACP during hemiarch replacement is a safe alternative to using a sutured side graft. While cardiopulmonary bypass and circulatory arrest times appear improved, this is likely attributable to accumulation of experience and proficiency in technique. However, direct innominate artery cannulation may facilitate quicker completion of these procedures by eliminating the time necessary to suture a graft to the innominate artery.

Labial mucosal epithelium grafting in an ex vivo human donor cornea model

The purpose of the study was to establish a simple ex vivo corneal re-epithelization model and study the labial mucosal epithelium grafting as a potential approach for ocular surface reconstruction. Four human donor corneal buttons were overstored in a corneal cold storage solution at 4 °C for 32–52 days. Four labial oral mucosa strips were dissected from four patients during fornix reconstruction after they signed informed consent. The substantia propria was trimmed off, and the resulting graft was sutured near the corneal limbus with running sutures (thus forming the tissue construct). Constructs were cultured under the standard conditions with the anterior corneal side outwards. After 3 weeks of culture, constructs were removed, washed, and fixed. Sections were stained with hematoxylin and eosin (HE), anti-keratins 4, 13, 19, and p63. Nuclei were counterstained with Hoechst. After the cultivation, all constructs were integral with the attached graft and non-loosened sutures. The native cells were absent in all donor corneas. Histological evaluation demonstrated that the labial mucosal grafts were attached to the Bowman's membrane (BM), and its cellular outgrowths were found to be transit from the graft to the BM over the anterior surface in all constructs. Cells expressed mucosal epithelial keratins 4, 13, and 19, and several were p63-positive in nuclei. In the study, a simple ex vivo corneal re-epithelization model was successfully established. The model was potent in studying the labial mucosal epithelium grafting as an option for autologous ocular surface reconstruction in patients with bilateral limbal stem cell deficiency.

Long sports career and satisfactory clinical outcomes after Meniscal Allograft Transplantation (MAT) in young professional athletes involved in strenuous sports

To assess the return to sport rate of young professional athletes, to analyze their careers in terms of matches played and league participation over a minimum period of 6years after Meniscal Allograft Transplantation (MAT), as well as to assess the long-term clinical subjective outcomes and satisfaction. Thirteen professional athletes (ten soccer and one basketball players, one fencer and one wrestler) with a mean age at surgery of 23.4 ± 4.0 underwent MAT (six medial, seven lateral). The time required to return to sport, post-operative performance level and the number of reoperations were evaluated. At an average follow-up of 9.0 ± 2.8years, Lysholm, KOOS and Cincinnati scores were administered and collected. Thirteen patients (100%) returned to sports practice after an average period of 11.8 ± 3.8months. Nine athletes (69%) returned to sports at the same pre-injury level. Overall, 93%, 85%, 62% and 55% were active until the 3rd, the 5th, the 7th and the 9th season after MAT, respectively. Seven patients (54%) underwent a reoperation after MAT, where only two of them (15%) were related to graft problems (one meniscectomy and one graft suture). Of the ten athletes that completed subjective evaluation, the mean Lysholm score was 72 ± 15 (0% "Excellent", 10% "Good", 60% "Fair", 30% "Poor"). Of the athletes with lower scores, one suffered from patellar tendon rupture, one from post-operative infection and one from a previous femoral fracture. The mean Cincinnati knee score was 77 ± 18, while the average KOOS values were 60 ± 34 for sports. Meniscal Allograft Transplantation (MAT) in young professional athletes involved in strenuous activities allowed all patients to return to pre-injury sport and in nearly 70% of cases at their pre-injury level. After five seasons following MAT, 85% of patients were still active or playing more than 20-30 matches per season. On the other hand, nearly 50% underwent at least one reoperation and only 70% of patients were rated as "Good", or "Fair" using the Lysholm score. IV.

Biomechanical comparison of two medial patellofemoral ligament reconstruction techniques: Quadriceps tendon fixation versus single-tunnel patella fixation with gracilis autograft did not differ in load to failure and stiffness

BackgroundThe purpose of this study was to evaluate the ultimate failure load and stiffness of two patellar fixation techniques for medial patellofemoral ligament (MPFL) reconstruction: (1) quadriceps tendon fixation (QT), (2) single tunnel (STG) patella fixation with gracilis autograft. MethodsA total of 16 fresh-frozen cadaveric knees (eight matched pairs) were randomized into two groups (QT vs. STG). The MPFL reconstructions were subjected to cyclic loading for 10 cycles to 30 N and then tested to failure at a constant displacement rate of 15 mm/min using a materials-testing machine (MTS 810 Universal Testing System). Failure mode, ultimate failure load and stiffness were recorded for each cadaveric specimen. ResultsThere was no significant difference in mean ultimate failure load among groups (P = 0.35). The STG group failed at a mean ultimate load of 190.04 N [standard deviation (SD) 23.18] and the QT group failed at 206.24 N (SD 37.99).The STG group had a mean stiffness of 21.38 N/mm (SD 1.44). This was not significantly higher than the mean stiffness value achieved for the QT group at 20.36 N/mm (SD 1.3) (P = 0.19). In the QT group all reconstructions failed due to tendon rupture at the patella attachment. The reason for failure in the STG group was the graft–suture connection. ConclusionsThis cadaver study showed no statistically significant difference in biomechanical performance of the evaluated patella fixation techniques, in terms of maximum load to failure and stiffness. Both techniques are reliable in terms of biomechanical properties and could offer additional surgical solutions.

Comparison of dural grafts and methods of graft fixation in Chiari malformation type I decompression surgery

Suboccipital decompression with duraplasty is a widely accepted method for treating patients with Chiari malformation type I. However, important details of the duraplasty technique are still controversial. This retrospective study analyzes clinical and radiological outcomes after surgery depending upon the type of graft and methods of graft fixation. Seventy consecutive decompressions with duraplasty were analyzed. Two types of grafts, nonautologous (Non-AutoG; 60.0%) and autologous (AutoG; 40.0%), and two methods of graft fixation, suturing (S; 67.1%) and gluing (G; 32.9%), were used in four different combinations: (Non-AutoG+S: 31.4%; Non-AutoG+G: 28.6%; AutoG+S: 35.7%; AutoG+G: 4.3%) according to surgeon preference. The mean follow-up was 63.4 months. According to gestalt and Chicago Chiari Outcome Scales, satisfactory results were obtained in 72.9% and 78.6% of cases, respectively, in the long term. The outcomes were not related to the kind of graft (p = 0.44), fixation method (p = 0.89) or duraplasty pattern (p = 0.32). Decreased syringomyelia was observed in 88.9% of cases, and no associations with the kind of graft (p = 0.84), fixation method (p = 1) or duraplasty pattern were found (p = 0.96). Pseudomeningocele occurred 5 times more often in the Non-AutoG group than in the AutoG group (52.4% vs. 10.7%; p < 0.05), whereas their formations were not related to the fixation method (p = 0.34). Three cases (12.0%) required reoperation with reduraplasty. Autologous and nonautologous dural grafts can be sutured or glued with similar clinical results; however, the use of nonautologous grafts is linked with a much higher risk of pseudomeningocele formation.

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

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

Reconstruction of Large Upper Eyelid Defects Using the Reverse Hughes Flap Combined With a Sandwich Graft of an Acellular Dermal Matrix.

To investigate the usefulness of the reverse Hughes flap procedure combined with a sandwich graft of an acellular dermal matrix for reconstruction of large full-thickness defects of upper eyelids after cancer excision. Clinical data were obtained from patients who underwent upper eyelid reconstruction using a reverse Hughes flap combined with a sandwich graft of an acellular dermal matrix (AlloDerm) as a tarsal substitute. The tarsoconjunctival flap of the donor lower eyelid was mobilized to reconstruct the posterior lamella, and acellular dermal matrix was grafted onto the tarsoconjunctival flap. A skin-orbicularis muscle flap superior to the defect was advanced to cover the acellular dermal matrix graft, followed by application of lid crease formation sutures to prevent postoperative entropion. The tarsoconjunctival pedicle was divided 3-8 weeks after the surgery. Six patients with sebaceous carcinoma were included, and all had ≥70% full-thickness upper eyelid defects after tumor excision. After a median follow-up of 40 months (range 6-62 months), all 6 showed satisfactory functional and cosmetic outcomes. Tumor recurrence, exposure keratopathy, upper eyelid entropion, persistent use of bandage contact lenses, lower eyelid deformity, and dermal matrix-related complications were not observed by the last follow-up. Reverse Hughes flap combined with a sandwich graft of an acellular dermal matrix as a tarsal substitute was successful in reconstructing large upper eyelid defects. Acellular dermal matrix graft and lid crease formation sutures enhance marginal stability and prevent postoperative entropion of the reconstructed upper eyelid.

The Evolution and Role of the Bursal Acromial Reconstruction

Background: Massive, irreparable rotator cuff tears (RCTs) remain a challenging clinical problem with numerous described treatment options. Bursal acromial reconstruction (BAR) represents a promising and evolving technique for a subset of patients with irreparable RCTs. Indications: BAR is indicated for patients with massive, irreparable RCTs with a primary complaint of pain, well-compensated shoulder function, and minimal radiographic degenerative changes of the glenohumeral joint as an alternative to reverse total shoulder arthroplasty or superior capsular reconstruction. Technique Description: Positioning per surgeon preference and diagnostic arthroscopy is performed. Subacromial decompression with a minimal and gentle acromioplasty is performed, followed by assessment of RCT repairability. If the tear is deemed irreparable, acromial measurements in the medial-lateral and anterior-posterior dimensions are obtained. Two pieces of acellular dermal allograft are cut to the acromial dimensions and affixed together using fibrin glue. The reactive side (facing the acromion), medial, and anterior sides of the graft are labeled. Two suture tapes are passed through the corners of the graft and self-locked and run diagonally in a cruciate configuration using an antegrade suture passer. Medial and lateral #2 fiberwire sutures are placed in a luggage-tag configuration. Neviaser (posterior), middle, and anterior acromioclavicular joint portals are created for medial sided suture passage. Medial graft sutures are shuttled through the respective medial portals and the graft is pulled into the subacromial space. The lateral sutures are then removed from percutaneous posterolateral, middle lateral, and anterolateral portals along the acromial edge. Medial sutures are retrieved using a suture grasper subcutaneously on top of the acromion through the percutaneous lateral portals. The sutures are tied through the lateral portals, starting with the medial-lateral sutures, and the knots are buried. Postoperatively, patients are progressed through passive, active-assisted, and active range of motion between weeks 2 and 6 and strengthening is progressed at 6 weeks. Results: Clinical results are lacking in the literature, but anecdotal results in our institution have demonstrated promising early outcomes. Discussion/Conclusion: BAR represents a promising alternative in the array of surgical options for treatment of irreparable RCTs.

Pediatric Airway Surgery: Advances in Evaluation and Endoscopic Management

Pediatric airway evaluation and surgery have evolved over time to involve less invasive techniques in order to facilitate quicker recovery and potentially less discomfort. Over the past decade, new indications, techniques, and data have emerged to support the use of these techniques routinely. In this article, we present techniques for evaluation and outcomes for endoscopic management of the pediatric larynx and review relevant recent publications relevant to pediatric endoscopic airway surgery. Laryngeal ultrasound has been shown to be an effective modality for evaluating vocal fold motion and potentially for evaluating laryngeal lesions. Innovations in surgical techniques include epiglottopexy for supraglottic obstruction, new airway balloons for dilating subglottic stenosis, and endoscopic cricoid split with or without a cartilage graft and vocal fold suture lateralization for bilateral vocal fold immobility. Less invasive techniques of diagnosis and management are viable options for pediatric airway patients and may replace or serve as adjuncts to traditional modalities.

Florida Sleeve Operative Technique

The Florida sleeve is a useful aortic root remodeling technique for cardiothoracic surgeons to have in their armamentarium that entails encompassing the sinuses while narrowing the aortic annulus and sinotubular junction to preserve the aortic valve. This technique is a valuable alternative to root replacement in appropriately chosen patients. The Florida sleeve is particularly advantageous for aortic valve salvage in cases of offset coronary arteries and bicuspid aortic valve. It has even become a useful option in carefully selected aortic dissection patients. Specific attention must be paid to inspection of the coronary artery relationship to commissures, circumferential dissection below the coronaries to allow passage of the sleeve graft and subcommissural suture placement to secure the graft in place. The Florida sleeve is a useful aortic root remodeling technique for cardiothoracic surgeons to have in their armamentarium that entails encompassing the sinuses while narrowing the aortic annulus and sinotubular junction to preserve the aortic valve. This technique is a valuable alternative to root replacement in appropriately chosen patients. The Florida sleeve is particularly advantageous for aortic valve salvage in cases of offset coronary arteries and bicuspid aortic valve. It has even become a useful option in carefully selected aortic dissection patients. Specific attention must be paid to inspection of the coronary artery relationship to commissures, circumferential dissection below the coronaries to allow passage of the sleeve graft and subcommissural suture placement to secure the graft in place. Aortic Sinuses Resection or External Support to Treat Aortic Root Aneurysm?Operative Techniques in Thoracic and Cardiovascular SurgeryVol. 26Issue 2PreviewThe modified Bentall procedure was the standard surgical treatment for aortic root aneurysm until 3 decades ago when an operation was introduced to preserve the aortic valve in these patients.1 We coined the term “aortic valve sparing operations” to differentiate them from aortic valve repair and proposed a classified in 2 basic types: reimplantation of the aortic valve and remodeling of the aortic root.2 Aortic valve sparing operations became increasingly more popular over time but were deemed complex and surgeons continued to search for simpler alternatives to preserve the native aortic valve in patients with aortic root aneurysms. Full-Text PDF

Chronic Tibial Tunnel Infection Following ACL Reconstruction: A Case Report and Review of the Literature

Introduction: Rupture of the anterior cruciate ligament (ACL) is a common injury in active people and one of the most common knee injuries in sports. Foreign body granuloma with concomitant infection is a rare complication in ACL surgery. Very few cases have been reported on it. We present a young patient with a chronic discharging sinus at a surgical site on the tibia in a diabetic patient and its successful management. Case Report: A thirty-two-year-old male presented to us with a persistent discharging sinus at the surgical site following an Anterior Cruciate Ligament (ACL) reconstruction two years back. Since then, he developed wound infection at the incision site created for graft harvesting, which kept on discharging sero-purulent discharge even with several antibiotics and local dressing courses. There was no stiffness or instability in the knee. We did a follow-up arthroscopic evaluation of the joint and debridement of the wound. A portion of hamstring graft and non-absorbable suture with unhealthy granulation tissues were found subcutaneously during the surgery. A partially resorbed bioscrew with unhealthy granulation tissue was observed in the tibial tunnel. After thorough debridement of the site, the wound completely healed. Conclusion: Surgical site infection and foreign body granuloma should be considered and treated accordingly if the patient presents with persistent discharging sinus at the surgical site in ACL reconstruction Keywords: Anterior cruciate ligament reconstruction, ACL, Surgical site infection, Tibial tunnel.

SUTURELESS VERSUS SUTURED CONJUNCTIVAL AUTOGRAFT FOR SURGICAL TREATMENT OF PTERYGIUM

Background: Pterygium is a degenerative ocular surface disorder with wing-shaped fibrovascular growth of the subconjunctival tissue onto the cornea. Objectives: The purpose of this study was to compare the surgical outcomes of sutureless technique versus graft suturing technique for conjunctival autograft fixation following pterygium excision. Patients and Methods: This prospective interventional case study included 20 eyes with pterygium requiring surgical excision. Operated eyes were divided into 2 equal groups. group A, where the conjunctival auto graft was placed without using sutures and with placing a tight bandage for 24 hours after excision, and group B where the conjunctival auto graft was fixed by 8/0 nylon sutures. Results: The surgical time for group A was significantly less as compared to group B. Postoperative symptoms were seen in less number of patients and were of shorter duration in group A as compared to group B. Recurrence rate and conjunctival granuloma formation rate for group A and for group B were statistically insignificant. Visual acuity and astigmatism showed improvement in both group with no statistically significant difference between both divided groups. Conclusion: Suture-less and glue free limbal conjunctival autograft was safe, effective, economical, option for pterygium surgery.

The use of fibrin glue during aqueous shunt surgery.

To examine the safety and economic effect of using fibrin glue to reduce suturing of a donor patch graft and in conjunctival closure during aqueous shunt implantation. Retrospective interventional case series of 150 patients from a single institution including historical controls from before the introduction of the change in technique. The surgery was performed by multiple glaucoma surgeons. One hundred and fifty eyes of 150 patients were identified. The mean age was 54.3 ± 21.1 years. Previous surgery included: cataract extraction (34.7%), trabeculectomy (36%) and retinal surgery (15.3%). All operations were carried out by either a consultant (57%) or fellow (43%). A Baerveldt Glaucoma Implant (Advanced Medical Optics, Santa Ana, California, USA) was used in 149 eyes. Conventional surgery (CS) was performed for 91 eyes and fibrin glue (FG) was used for 59 eyes. Compared with conventional surgery (CS) in which the donor patch graft and conjunctiva were sutured, use of fibrin glue (FG) reduced the overall mean operating time by 11.2 min ± 6.4 min (P = 0.031), though much less for consultants (8.5 min ± 6.2 min) (P = 0.16) than fellows (32.9 min ± 7.2 min) (P < 0.0001). There were four cases of conjunctival dehiscence-three in the FG group and one in the CS group (P = 0.30). Only one patient required re-suturing in the FG group. The use of fibrin glue is safe and effective during aqueous shunt implantation. We have shown that the mean operating time can be reduced significantly with the use of fibrin glue which has significant implications for resource utilisation.

Microsurgical robotic suturing of sural nerve graft for sympathetic nerve reconstruction: a technical feasibility study.

Endoscopic thoracic sympathectomy (ETS) may provide a permanent surgical cure for primary palmar hyperhidrosis. Unfortunately, some patients can experience intensive post-operative compensatory sweating (CS) that ultimately impairs quality of life. Sympathetic nerve reconstruction (SNR) may be used to counteract severe post-operative CS through the restoration of sympathetic pathways. In this case series, we describe the technical feasibility of a robot-assisted micro-peripheral nerve reconstruction method for achieving SNR in patients with post-operative CS. Between January 2017 and May 2019, seven cases with severe post-operative CS underwent robot-assisted SNR using a sural nerve graft. We report the pre-operative assessment, the surgical technique, and the clinical outcomes of the study patients. The study sample consisted of five men and two women (median age: 41 years). Primary hyperhidrosis affected the face in one case and the palms in six patients. The median time between ETS and SNR was 20 years. All robotic surgery procedures were successfully accomplished, and neither conversion to open surgery nor the creation of additional ports were required. Sural nerve grafts (median length: 8 cm) were used in all cases, and the median operating time was 10.5 h. There was no operative mortality, with the median length of post-operative hospital stay being 4 days. One patient developed a post-operative pneumothorax-which was treated conservatively. Our case series demonstrates the safety and clinical feasibility of microsurgical robot-assisted sural nerve grafting for achieving SNR in patients with post-operative CS.

Comparative Study to Evaluate the Outcome of Sutures Versus Sutureless in Attachment of Conjunctival Autograft for Pterygium Excision

Background: Suturing of conjunctival graft is a traditional technique for pterygium excision surgery. Owing to its many disadvantages &amp; complications many newer techniques like autologous fibrin glue have been introduced &amp; accepted as an alternative method of graft adhesion. Methodology: The present study was conducted at the Department of Ophthalmology, MMIMSR, Mullana (Maharishi Markandeshwar Deemed to be University) in the time period extending between December 2017 and January 2019. 100 eyes of patients of either sex with primary pterygium were selected and divided into 2 groups of 50 each in Group 1- patient underwent conjunctival auto graft with 10-0 ethilon sutures while in Group 2 suture less conjunctival auto graft was done with patient’s own blood fibrin. Results: Parameters such as mean operating time, presenting complaints like pain, watering, burning and foreign body sensation, complications &amp; recurrence were compared between the two groups on postoperative Day 1, Day 7, 2 weeks, 1 month, 2 month, 3 month &amp; 6th month. Statistical significant difference (p&lt;0.01) was found between the suture and sutureless surgery for pterygium in relation to post-operative discomfort grading. There was a significant difference (t = 22.149, p = 0.001) in the duration of surgery for GROUP I surgery. Conclusion: Conjunctival auto graft with autologous serum is a safe and fast method. It is equally effective as conventional sutured autograft technique. Post operative discomfort is significantly less in this method. It also prevents suture related complications.

Thrombosis of the brachial artery - a rare and devastating complication after a simple closed posterolateral elbow dislocation.

Dislocation of the elbow joint is the second most common dislocation after the shoulder joint. Although this pathology is relatively common, concomitant vascular injuries are rare. We present a case of a patient who sustained a fall on his arm with an outstretched elbow that resulted in a closed simple posterolateral elbow dislocation and delayed thrombosis of the brachial artery followed by two revascularisation surgeries. The physician must always maintain a high index of suspicion for a concomitant vascular injury before and after closed reduction of the elbow joint and have in mind that complete ischemia without any pulsations could be absent because the elbow is surrounded by rich collateral anastomoses. Suspicion should be even stronger in the presence of bony lesions or open injuries. A team of trauma and vascular surgeons has to work hand in hand as surgical treatment with a saphenous graft or direct suture is the first method of choice with the prior requirement of a stable elbow joint.