Vertical Mattress Research Articles

Cosmetic outcomes of cesarean section scar; subcuticular suture versus intradermal buried suture.

ObjectiveThe objective of the study was to compare cosmetic outcomes and overall satisfaction rate of cesarean section scar between conventional subcuticular suture and intradermal buried vertical mattress.MethodsPatients were enrolled to the study by chart review. A scar assessment was obtained retrospectively through a telephone survey. The patient component of the patient and observer scar assessment scale (POSAS) was utilized along with the overall satisfaction of the patient regarding their cesarean section scar and their willingness to choose the same skin closure technique when anticipating their next cesarean section.ResultsA total of 303 cases of cesarean section was recruited, 102 finished telephone surveys were calculated for the analyses. Subcuticular suture was regarded as control group (n=52) and intradermal buried suture as test group (n=50). The PSAS score of the test group (mean, 21.8) was lower than that of the control group (mean, 28), with a statistical significance (P=0.02). Overall satisfaction rate did not differ between the two groups. Two parameters of the PSAS score and the level of overall satisfaction showed significant correlation (Pearson's r, −0.63; P<0.01).ConclusionWe suggested the use of intradermal buried vertical mattress as a cosmetically superior skin closure method for application in cesarean sections over subcuticular stitch.

Reconstruction of a Traumatic Cleft Earlobe Using a Combination of the Inverted V-Shaped Excision Technique and Vertical Mattress Suture Method.

Traumatic cleft earlobes are a common problem encountered by plastic and reconstructive surgeons. Various techniques have been reported for the repair of traumatic cleft earlobes. Usually, the techniques of split earlobe repair are divided into two categories, namely straight- and broken-line repairs. Straight-line repair is simple and easy, but scar contracture frequently results in notching of the inferior border of the lobule. It can be avoided by the broken-line repair such as Z-plasty, L-plasty, or a V-shaped flap. Between April 2016 and February 2017, six patients who presented with traumatic cleft earlobe underwent surgical correction using a combination of the inverted V-shaped excision technique and vertical mattress suture method. All the patients were female and had a unilateral complete cleft earlobe. No postoperative notching of the inferior border the lobule occurred during 6–16 months of follow-up. Without the use of a broken-line repair, both the patients and the operators attained aesthetically satisfactory results. Therefore, the combination of the inverted V-shaped excision technique and vertical mattress suture method is considered useful in the treatment of traumatic cleft earlobes.

Hughes Abdominal Repair Trial (HART)—abdominal wall closure techniques to reduce the incidence of incisional hernias: feasibility trial for a multicentre, pragmatic, randomised controlled trial

ObjectivesIncisional hernias are common complications of midline abdominal closure. The ‘Hughes Repair’ combines a standard mass closure with a series of horizontal and two vertical mattress sutures within a single...

A novel technique for modified all-inside repair of bucket-handle meniscus tears using standard arthroscopic portals

BackgroundBucket-handle meniscus tears (BHMT) are often displaced and unstable. The inside-out technique of repairing such tears is currently the gold standard. All-inside repair with meniscal fixators is getting increasingly popular. Shortcomings of the inside-out technique include neurovascular complications, especially saphenous nerve palsy, and retention of a non-resorbable suture which can result in discomfort to patient, granuloma formation, and a foci of infection. Hence, the purpose of this project was to innovate a novel all-inside technique to precisely reduce and fix BHMT while avoiding neurovascular complications and retention of a non-resorbable suture.MethodsRoutine arthroscopic portals were created on a patient’s left knee with a displaced BHMT. Through the anteromedial portal, a conjoint pseudo double lumen cannula was inserted. Two limbs of a reduction suture were passed through the cannula, one over the “femoral” surface of the meniscus, one over the “tibial” surface of the meniscus anterior to the biceps femoris tendon, with the knee flexed at 20° to avoid injury to the saphenous nerve. Suture limbs were passed out percutaneously and tensioned.ResultsAnatomic reduction was ensured under arthroscopic visualization with ease. All inside repair was performed using the vertical mattress suture configuration. Reduction sutures were subsequently removed by cutting flush to the skin and pulling on one suture limb. The patient was back to full activities with minimal discomfort 8 months post-operatively.ConclusionThe technique described is superior to existing techniques for the following reasons: (1) Reduction of the displaced meniscal tear is “extra-meniscal,” avoiding further trauma to a damaged meniscus. (2) Tensioning of the two suture limbs created promotes better control of reduction through tensioning. (3) Risk of discomfort, infection, and neurovascular damage caused by a retained suture is reduced. (4) No additional portals/equipment is required. We encourage this novel technique to be attempted by surgeons.

Two-Port Endoscopic Fetal Closure of Myelomeningocele

Introduction: Open neural tube defects are a common congenital abnormality with significant consequences for affected children and their families. Issues include paraplegia, walking difficulties, bowel and bladder incontinence, and hydrocephalus. The 2011 Management of Myelomeningocele Study established fetal closure as a treatment option.1 Fetal closure reduces the incidence of hydrocephalus and improves motor outcomes compared with conventional postnatal closure. Open prenatal closure, however, necessitates hysterotomy and significantly increases the risk of preterm delivery and uterine dehiscence.2 Endoscopic approaches eliminating the need for hysterotomy have been described.3–5 Here we demonstrate our two-port endoscopic technique. Materials and Methods: The mother is at 26 weeks gestation and ultrasonography work-up has revealed a myelomeningocele defect of the fetus at the L3-S1 levels. A transverse abdominal opening is made for uterine exposure. Two ports are placed 6 cm apart with ultrasound guidance into the fundus of the uterus. A total of 300 cc of amniotic fluid are removed and the uterus is insufflated with humidified CO2 gas. The fetus and myelomeningocele defect are observed under endoscopic guidance. Endoscopic closure of the myelomeningocele is done in two major steps. First, the neural placode is released through sharp circumferential dissection of the arachnoid lying between the neural placode margin and the junctional zone. Second, the defect is closed primarily with interrupted vertical mattress sutures. Closure is facilitated with the use of relaxing flank incisions and retention sutures. Results: The child was born term at 39 weeks through vaginal delivery. Her neurologic examination demonstrates intact spinal function inclusive of the S1 level. Conclusions: Endoscopic fetal closure of myelomeningocele is technically feasible and can be accomplished through a two-port technique utilizing single layer closure. The avoidance of hysterotomy with this method may reduce the risk of preterm delivery and uterine dehiscence. No competing financial interests exist. Runtime of video: 6 mins 19 secs Related Presentations: Podium Presentation (ID 83697), IPEG's 26th Annual Congress for Endosurgery in Children, July 20, 2017, London, England.

Arthroscopic Treatment of Type 1B Triangular Fibrocartilage Complex Tear by “Outside-In” Repair Technique Using Transcapsular Transverse Mattress Suture

Triangular fibrocartilage complex (TFCC) injuries are increasingly recognized as a cause of ulnar-sided wrist pain. Palmer grouped these tears into either traumatic or degenerative, with various subclassifications. Magnetic resonance imaging (MRI), arthrogram, and arthroscopy are the methods used to establish the diagnosis. Several arthroscopic methods of TFCC repair including outside-in, inside-out, and all-inside techniques have been described. The outside-in repair, which involves piercing the TFCC via the ulnar side of the wrist, has been described by several authors, but the technique varies among authors with respect to instrumentation and subtle surgical modifications. The purpose of this article was to present the technique of arthroscopic outside-in repair using transverse mattress suture for type 1B TFCC tear by modifying classic vertical mattress sutures into sutures that pass completely through the disc.

Comparable Outcomes After Bucket-Handle Meniscal Repair and Vertical Meniscal Repair Can Be Achieved at a Minimum 2 Years’ Follow-up

Background: Meniscal tears can lead to significant pain and disability, necessitating surgical treatment. Nondisplaced vertical tears are usually smaller in size and can be repaired in most cases; however, bucket-handle tears are usually larger and displaced, and the repair of these tears can be challenging. Purpose/Hypothesis: The purpose was to report the outcomes after inside-out vertical mattress suture meniscal repair of bucket-handle tears and to compare these outcomes with those of patients who underwent repair of nondisplaced vertical meniscal tears with a minimum of 2 years’ follow-up. The hypothesis was that the outcomes of bucket-handle tear repair would be comparable with those of nondisplaced vertical meniscal tear repair. Study Design: Cohort study; Level of evidence, 3. Methods: Patients who underwent inside-out repair of a bucket-handle meniscal tear or a nondisplaced vertical meniscal tear with a minimum 2 years’ follow-up were included in this study. Patients were excluded if they had a diagnosis of a meniscal root tear, underwent a concomitant procedure for a chondral injury, or underwent previous surgical treatment of the same meniscus. Subjective questionnaires were administered preoperatively and postoperatively, including the Lysholm score, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Short Form–12 (SF-12) physical component summary (PCS) and mental component summary (MCS), the Tegner activity scale, and patient satisfaction. Results: Thirty-two patients underwent repair for vertical meniscal tears (mean, 7 sutures), while 38 patients underwent repair for bucket-handle meniscal tears (mean, 11 sutures), with a mean follow-up of 3.1 years (range, 2-6 years). There were no significant differences in the preoperative outcome scores between the 2 groups. Significant improvements in patient-reported outcome scores from preoperatively to postoperatively were found in both groups. A direct comparison of the bucket-handle tear group to the vertical tear group did not exhibit significantly different SF-12 PCS scores (54.0 vs 51.6, respectively; P = .244), SF-12 MCS scores (55.3 vs 52.5, respectively; P = .165), WOMAC scores (8.1 vs 9.0, respectively; P = .729), Lysholm scores (84.6 vs 80.8, respectively; P = .276), Tegner scores (5.5 vs 5.5, respectively; P = .970), and patient satisfaction scores (7.4 vs 7.7, respectively; P = .570). Additionally, a comparison of acute and chronic bucket-handle tears demonstrated no significant difference in outcome scores. Conclusion: The repair of bucket-handle meniscal tears with multiple vertical mattress sutures using an inside-out technique yielded improved results and low failure rates, comparable with outcomes after repair of nondisplaced vertical meniscal tears. The findings of this study support repairing bucket-handle meniscal tears with multiple vertical mattress sutures when possible.

Inside-out Meniscal Repairs in the Setting of Multiligament Reconstruction in the Knee: Does Meniscal Repair Affect Outcomes and Failure Rates?

Objectives:The purpose of this study was to assess outcomes and failure rates of meniscal repair in patients who underwent multiligament reconstruction compared to patients who underwent multiligament reconstruction but lacked meniscal tears. We hypothesized that the outcomes of meniscal repair associated with a concomitant multiligament reconstruction would significantly improve from preoperatively to postoperatively at a minimum of 2 years following the index surgery. Secondarily, we hypothesized that this cohort would demonstrate similar outcomes and failure rates compared to the cohort who did not have meniscal pathology at the time of multiligament reconstruction.Methods:Inclusion criteria for the study included radiographically confirmed skeletally mature patients over 16 years of age who underwent multiligamentous reconstruction of the knee without previous ipsilateral osteotomy, intraarticular infection, or fracture. Patients were included in the experimental group if they underwent inside-out meniscus suture repair with a concurrent multiligament reconstruction. Those included in the control group (multiligament reconstruction without a meniscal tear) underwent multiligament reconstruction, but did not have any type of meniscal surgery. Lysholm, WOMAC, SF-12 PCS and MCS, Tegner Activity scale and patient satisfaction were recorded preoperatively and postoperatively. Failure of the meniscal repair was defined as a re-tear of the meniscus that was confirmed arthroscopically.Results:There were 43 patients (16 females, 27 males) in the meniscal repair group and 62 patients in the control group (25 females, 37 males). Follow-up was obtained in 93% of patients with an average follow-up of 3.0 years (range, 2.0 to 4.7 years). There was a significant improvement between all preoperative and postoperative outcome scores (p<.05) for both groups. The multiligament plus meniscal repair group had significantly lower preoperative Lysholm and Tegner scores (p=0.009, p=0.02, respectively). There were no significant differences between any other outcome score at preoperative status. There was no significant difference in any postoperative outcome score at a minimum two-year follow up between the two groups.Conclusion:Good to excellent patient reported outcomes were reported for both groups with no significant differences in outcomes between cohorts. Additionally, the failure rate for an inside-out meniscal repair with a concomitant multiligament reconstruction was low, regardless of meniscus laterality and tear characteristics. The use of multiple vertical mattress sutures and the biological augmentation resulting from intra-articular cruciate ligament reconstruction tunnel reaming may be partially responsible for the stability of the meniscus repair construct and thereby contribute to the overall improved outcomes and a low failure rate of meniscal repair despite lower preoperative Lysholm and Tegner scores in the meniscal repair group.

Self-Directed Interactive Video-Based Instruction Versus Instructor-Led Teaching for Myanmar House Surgeons: A Randomized, Noninferiority Trial

To compare self-directed interactive video-based instruction (IVBI) with instructor-led teaching in the acquisition of basic surgical skills by House Surgeons at University of Medicine 1, Yangon. A prospective, 1:1 randomized controlled trial was conducted. Participants were randomized into 2 teaching arms: (1) self-directed IVBI or (2) instructor-led teaching. Self-directed IVBI participants were provided with a portable DVD player that could play, fast forward, rewind, and skip through skills modules. Participants in the instructor-led teaching group were taught in small groups by standardized instructors. Pretesting and posttesting of 1-handed knot tie, 2-handed knot tie, vertical mattress suture, and instrument tie was performed using the Objective Structured Assessment of Technical Skills (OSATS). Students randomized to self-directed IVBI completed an exit survey to assess satisfaction. Demographic data were collected of all participants. University of Medicine 1, Yangon, Myanmar. Fifty participants were randomly selected from 78 eligible House Surgeons who were enrolled in their basic surgery rotation. Demographic characteristics and baseline skills were comparable in participants randomized to IVBI and instructor-led teaching. Mean OSATS score increased from pretest to posttest in both groups (p < 0.001). The mean posttest OSATS score of the IVBI group was 0.72 points below that of the instructor-led teaching group (90% CI: -3.8 to 5.2), with the 90% CI falling below the a priori noninferiority margin, satisfying criteria for noninferiority. More than 90% of students marked either "agree" or "strongly agree" to the following statements on the exit survey: further expansion of IVBI into other skills modules and integration of IVBI into training curriculum. IVBI is noninferior to instructor-led teaching of surgical skills based on OSATS scores. House Surgeons highly rated self-directed IVBI. Self-directed IVBI has the potential to significantly reduce the personnel required for skills teaching and may serve as a long-term learning adjunct in low-resource settings.

Utility of Dynamic Sonographic Evaluation of Left Knee Pain &amp; Locking in a Softball Catcher

HISTORY: An 18 year-old softball catcher presenting with a 3 year history of left progressive postero-lateral knee discomfort with associated knee locking when squatting or deep knee flexion. Onset was 3 years ago when she was in a squat position during a softball game. She had been avoiding aggravating activities and initially sought medical care 3 months ago, presenting to an orthopedic specialist’s clinic. Following a negative MRI, she was referred to our clinic for diagnostic ultrasound of the knee. She reported no reliable way to reproduce locking, but, when locking does occur, she must manually unlock herself. Previous treatment included 8 weeks of physical therapy without benefit. PHYSICAL EXAMINATION: No discoloration or swelling of the left knee. Non-antalgic gait. Valgus alignment with dynamic valgus on single leg squat. Posterior lateral joint line tenderness. No other focal tenderness. Full and symmetric bilateral knee active range of motion without pain, except in terminal flexion. Negative McMurray’s, cruciate and collateral ligament testing and dial test. 9/9 Beighton criteria. DIFFERENTIAL DIAGNOSIS: 1. Meniscocapsular separation 2. Lateral meniscus injury 3. Proximal tibiofibular ligament injury 4. Popliteus muscle/tendon injury 5. Anteriolateral complex sprain 6. PFL injury TEST AND RESULTS: MRI: Subtle irregularity of posterior superior meniscocapsular fascicle deemed secondary to volume-averaging artifact. Otherwise, no discrete pathology was noted. Ultrasound: No discrete lesion of entirety of lateral meniscus on static exam. Development of a separation (3.1mm) between posterior knee capsular tissue and posterior outermost fiber of left lateral meniscus when knee is in near full flexion. FINAL WORKING DIAGNOSIS: left postero-lateral meniscocapsular separation TREATMENT AND OUTCOMES: Management options (expectant management, injection options to mitigate pain, and a surgery) were discussed. Patient elected surgical fixation of lateral meniscus. Arthroscopic fixation of lateral meniscus with 2 vertical mattress sutures using a FasTFix device was performed. After 4 weeks of bracing to allow proper surgical healing, she was able to start using an elliptical at 6 weeks and jogging at 9 weeks. She remains void of pre-surgical pain and locking at 16 weeks post-operatively.

Multistep Approach for Improved Aesthetic and Functional Outcomes for Lower Extremity Wound Closure After Mohs Micrographic Surgery.

Lower extremity wounds present a major clinical challenge. This paper introduces a new multistep approach for improved aesthetic and functional outcome for lower extremity wound closure after Mohs micrographic surgery. In this prospective case series, 12 consecutive patients undergoing Mohs micrographic surgery for cutaneous malignancies of the lower extremities underwent closure assisted by elastic bandages, proper positioning with 45° flexion of the knee, buried vertical mattress sutures, and careful eversion, using a premium angled stapler. Assessment of cosmetic outcome was performed by 2 blinded observers, using the Hollander Wound Evaluation Scale. The mean age was 73 ± 9 years with most patients having at least one comorbidity. Six patients (50%) underwent resection of a basal cell carcinoma and 5 patients (42%) underwent resection of a squamous cell carcinoma and 1 patient (8%) underwent resection of a keratoacanthomatous carcinoma. There were no wound complications, and at the 3- to 6-month follow-up, 11 of the 12 wounds (92%) had an optimal Hollander Wound Evaluation Scale score of 6. This new approach to lower extremity wounds provides excellent cosmetic outcome with no reported complications.

Cross Vertical Mattress Suturing with Basilar Tightening During the Correction of Inverted Nipple in 30 Cases.

To investigate the efficacy of cross vertical mattress suturing with basilar tightening during the correction of inverted nipple. Thirty patients with inverted nipples underwent cross vertical mattress suturing with basilar tightening. The postoperative results were recorded. All the patients were followed up for 6months to 2years. The results of 28 cases were satisfactory, and there was no recurrence. Two patients relapsed, and a mild depression was formed. They were satisfied with the results after the second correction. The method of cross vertical mattress suturing with basilar tightening has been applied to treat inverted nipple, with minimal trauma, which provides a reliable guarantee for a long-term effect. It is worthy to be widely used in clinical practice. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Outcomes of Inside-out Meniscal Repair in the Setting of Multiligament Reconstruction in the Knee

Background: Limited evidence exists for meniscal repair outcomes in a multiligament reconstruction setting. Purpose/Hypothesis: The purpose of this study was to assess outcomes and failure rates of meniscal repair in patients who underwent multiligament reconstruction compared with patients who underwent multiligament reconstruction but lacked meniscal tears. The authors hypothesized that the outcomes of meniscal repair associated with concomitant multiligament reconstruction would significantly improve from preoperatively to postoperatively at a minimum of 2 years after the index surgery. Secondarily, they hypothesized that this cohort would demonstrate similar outcomes and failure rates compared with the cohort that did not have meniscal lesions at the time of multiligament reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: Inclusion criteria for the study included radiographically confirmed skeletally mature patients of at least 16 years of age who underwent multiligamentous reconstruction of the knee without previous ipsilateral osteotomy, intra-articular infections, or intra-articular fractures. Patients were included in the experimental group if they underwent inside-out meniscal suture repair with concurrent multiligament reconstruction. Those included in the control group (multiligament reconstruction without a meniscal tear) underwent multiligament reconstruction but did not undergo any type of meniscal surgery. Lysholm, Western Ontario and McMaster Universities Osteoarthritis Index, Short Form–12 physical component summary and mental component summary, Tegner activity scale, and patient satisfaction scores were recorded preoperatively and postoperatively. The failure of meniscal repair was defined as a retear of the meniscus that was confirmed arthroscopically. Results: There were 43 patients (16 female, 27 male) in the meniscal repair group and 62 patients (25 female, 37 male) in the control group. Follow-up was obtained in 93% of patients with a mean of 3.0 years (range, 2.0-4.7 years). There was a significant improvement between all preoperative and postoperative outcome scores (P < .05) for both groups. The meniscal repair group had significantly lower preoperative Lysholm and Tegner scores (P = .009 and P = .02, respectively). There were no significant differences between any other outcome scores preoperatively. The failure rate of the meniscal repair group was 2.7%, consisting of 1 symptomatic meniscal retear. There was no significant difference in any postoperative outcome score at a minimum 2-year follow-up between the 2 groups. Conclusion: Good to excellent patient-reported outcomes were reported for both groups with no significant differences in outcomes between the cohorts. Additionally, the failure rate for inside-out meniscal repair with concomitant multiligament reconstruction was low, regardless of meniscus laterality and tear characteristics. The use of multiple vertical mattress sutures and the biological augmentation resulting from intra-articular cruciate ligament reconstruction tunnel reaming may be partially responsible for the stability of the meniscal repair construct and thereby contribute to the overall improved outcomes and the low failure rate of meniscal repair, despite lower preoperative Lysholm and Tegner scores in the meniscal repair group.

Developing Cognitive Task Analysis–based Educational Videos for Basic Surgical Skills in Plastic Surgery

To describe the development of cognitive task analysis (CTA)-based multimedia educational videos for surgical trainees in plastic surgery. A needs assessment survey was used to identify 5 plastic surgery skills on which to focus the educational videos. Three plastic surgeons were video-recorded performing each skill while describing the procedure, and were interviewed with probing questions. Three medical student reviewers coded transcripts and categorized each step into "action," "decision," or "assessment," and created a cognitive demands table (CDT) for each skill. The CDTs were combined into 1 table that was reviewed by the surgeons performing each skill to ensure accuracy. The final CDTs were compared against each surgeon's original transcripts. The total number of steps identified, percentage of steps shared, and the average percentage of steps omitted were calculated. Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada, an urban tertiary care teaching center. Canadian junior plastic surgery residents (n = 78) were sent a needs assessment survey. Four plastic surgeons and 1 orthopedic surgeon performed the skills. Twenty-eight residents responded to the survey (36%). Subcuticular suturing, horizontal and vertical mattress suturing, hand splinting, digital nerve block, and excisional biopsy had the most number of residents (>80%) rank the skills as being skills that students should be able to perform before entering residency. The number of steps identified through CTA ranged from 12 to 29. Percentage of steps shared by all 3 surgeons for each skill ranged from 30% to 48%, while the average percentage of steps that were omitted by each surgeon ranged from 27% to 40%. Instructional videos for basic surgical skills may be generated using CTA to help experts provide comprehensive descriptions of a procedure. A CTA-based educational tool may give trainees access to a broader, objective body of knowledge, allowing them to learn decision-making processes before entering the operating room.

Allgöwer-Donati Versus Vertical Mattress Suture Technique Impact on Perfusion in Ankle Fracture Surgery: A Randomized Clinical Trial Using Intraoperative Angiography.

The purpose of this study was to evaluate which primary wound closure technique for ankle fractures affords the most robust perfusion as measured by laser-assisted indocyanine green angiography: Allgöwer-Donati or vertical mattress. Prospective, randomized. Level 1 Academic Trauma Center. Thirty patients undergoing open reduction internal fixation for ankle fractures were prospectively randomized to Allgöwer-Donati (n = 15) or vertical mattress (n = 15) closure. Demographics were similar for both cohorts with respect to age, sex, body mass index, surgical timing, and OTA/AO fracture classification. Skin perfusion (mean incision perfusion and mean perfusion impairment) was quantified in fluorescence units with laser-assisted indocyanine green angiography along the lateral incision as well as anterior and posterior to the incision at 30 separate locations. Minimum follow-up was 3 months with a mean follow-up 4.7 months. Allgöwer-Donati enabled superior perfusion compared with the vertical mattress suture technique. Mean incision perfusion for Allgöwer-Donati was 51 (SD = 13) and for vertical mattress was 28 (SD = 10, P < 0.0001). Mean perfusion impairment was less in the Allgöwer-Donati cohort (12.8, SD = 9) compared with that in the vertical mattress cohort (23.4, SD = 14; P = 0.03). One patient in each cohort experienced a wound complication. The Allgöwer-Donati suture technique offers improved incision perfusion compared with vertical mattress closure after open reduction internal fixation of ankle fractures. Theoretically, this may enhance soft tissue healing and decrease the risk of wound complications. Surgeons may take this into consideration when deciding closure techniques for ankle fractures. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Use of a Partial-thickness Flap for Guided Bone Regeneration in the Upper Jaw.

Guided bone regeneration (GBR) aims to restore adequate bone volume for the placement of implants in an ideal location. In this article, we analyze different surgical techniques for tissue management during GBR and a modified partial-thickness surgical approach. In a year's time span, five patients were enrolled in the study: Four women and one man (aged 44-59 years). In four patients, a GBR with simultaneous implant placement was adopted, whereas in another patient, a delayed implant placement was done. The flap was of full thickness and overturned on the side palatal with the aim of a retractor, thus exposing the bone crest. The graft material was covered and protected with a resorbable collagen membrane (Geistlich Bio-Gide®, Switzerland). The periosteal layer of the flap was then positioned above the resorbable membrane without traction. The sutures as vertical mattress were then positioned. Each patient received an intramuscular betamethasone dose (4 mg/50 kg) and antibiotic therapy for 7 days (amoxicillin + clavulanic acid 1 gm every 12 hours) and was instructed to maintain oral hygiene and appropriate wound cleaning. The patients were recalled at different times to monitor the healing. No cases of tissue dehiscence were observed during the period of wound healing. One patient, however, showed a delayed exposure 4 months after surgery. This occurrence was managed without complications for the patient. The design of proposed flap seems to be effective in controlling the risk of dehiscence during the healing time in the GBR. The vascular supply was rarely compromised. The results we obtained are encouraging even if further studies on this technique are needed. Lateral partial-thickness flaps seem to be effective in controlling tissue tension and consequently the risk of dehiscence. The incision vestibularly performed should favor the soft tissue healing.

Repair of Torn Avascular Meniscal Cartilage Using Undifferentiated Autologous Mesenchymal Stem Cells: From In Vitro Optimization to a First-in-Human Study

Meniscal cartilage tears are common and predispose to osteoarthritis (OA). Most occur in the avascular portion of the meniscus where current repair techniques usually fail. We described previously the use of undifferentiated autologous mesenchymal stem cells (MSCs) seeded onto a collagen scaffold (MSC/collagen‐scaffold) to integrate meniscal tissues in vitro. Our objective was to translate this method into a cell therapy for patients with torn meniscus, with the long‐term goal of delaying or preventing the onset of OA. After in vitro optimization, we tested an ovine‐MSC/collagen‐scaffold in a sheep meniscal cartilage tear model with promising results after 13 weeks, although repair was not sustained over 6 months. We then conducted a single center, prospective, open‐label first‐in‐human safety study of patients with an avascular meniscal tear. Autologous MSCs were isolated from an iliac crest bone marrow biopsy, expanded and seeded into the collagen scaffold. The resulting human‐MSC/collagen‐scaffold implant was placed into the meniscal tear prior to repair with vertical mattress sutures and the patients were followed for 2 years. Five patients were treated and there was significant clinical improvement on repeated measures analysis. Three were asymptomatic at 24 months with no magnetic resonance imaging evidence of recurrent tear and clinical improvement in knee function scores. Two required subsequent meniscectomy due to retear or nonhealing of the meniscal tear at approximately 15 months after implantation. No other adverse events occurred. We conclude that undifferentiated MSCs could provide a safe way to augment avascular meniscal repair in some patients. Registration: EU Clinical Trials Register, 2010‐024162‐22. Stem Cells Translational Medicine 2017;6:1237–1248

The Buried Half Horizontal, Half Vertical Mattress Suture: A Novel Technique for Wound Edges of Unequal Lengths.

The Buried Half Horizontal, Half Vertical Mattress Suture: A Novel Technique for Wound Edges of Unequal Lengths.

The Use of Three Different Suturing Techniques for Wound Closure of Mucoperiosteal Flaps After Surgical Removal of Impacted Lower Wisdom Teeth (Comparative Study)

Aims: The aim of the study is to determine the effects of different suturing techniques on post-operative complications (pain and swelling) following the removal of impacted lower wisdom teeth. Materials and Methods: Sixty medically fit patients were randomly selected with an age range between 16–42 years of both sexes. They were divided into 3 groups. These patients had impacted lower third molars indicated for surgical extraction. The first group comprised of twenty patients, the flap would be closed by simple interrupted suturing technique, and in the second group (20 patients) by vertical mattress suturing technique, and anchoring suture techniques for the third group (20 patients). All groups will be compared by clinical assessment to determine post-operative complications including pain and swelling. Results: In all treatment groups, pain (on VAS) reached its peak on the first post-operative day then faded away. In all groups, swelling was most severe in the first post-operative day and gradually decreased, with the anchor suturing technique showing significant difference of swelling at day three Conclusions: Changing the method of suturing appear to have no effect on the degree of pain, swelling following surgical removal of impacted mandibular third molars.

Clinical analysis of 54 cases of large area soft tissue avulsion in the lower limb

ObjectiveTo assess the clinical curative effect of different treatment methods for large area avulsion injury in the lower limb. MethodsBetween January 2010 and December 2013, 54 patients with large area avulsion injury in the lower limb were treated in the trauma center of our hospital, including 34 males and 20 females with a mean age of 35.7 years (range, 16–65 years). The injury mechanism was traffic accident in 44 cases, hitting by heavy objects in 8 cases, and fall from height in 2 cases, involving 31 thighs, 19 legs and 4 feet involved. The sizes of the avulsed wounds ranged from 10 cm × 15 cm to 50 cm × 30 cm. There were 16 cases combined with hemorrhagic shock, 5 with femoral fractures, and 7 with tibiofibula fractures. Averagely the patients were sent to our hospital within 3.5 h (range, 1.5–10 h) after injury. For the 54 patients, three different surgical strategies were performed based on the wound area and condition of the avulsed skin: in Group A, 24 patients were treated by debridement and preservation of subcutaneous vascular network + vertical mattress suture of full thickness skin flap + tube drainage; in Group B, 25 patients were treated by split-thickness skin flap meshing and grafting + vacuum sealing drainage (VSD); and in Group C, the other 5 patients were treated by debridement and VSD at stage I + reattachment of autologous reserved frozen split-thickness skin graft at stage II. ResultsAll the 54 patients recovered and were discharged eventually, without any deaths or amputees. In each group, there were no statistical differences (all p > 0.05) among different injury sites in terms of survival rate and length of hospital stay, except for the infection rate, which was much higher (p = 0.000) at the leg area than that at the thigh (32.54% ± 2.97% vs. 2.32% ± 2.34% in Group A and 50.00% ± 0.00% vs. 0 in Group C) or the foot (50.00% ± 0.00% vs. 0 in Group C). Moreover comparison of the three surgical methods showed a significant different (all p < 0.05) between each other for all the three assessed parameters, i.e. flap survival rate, length of hospital stay, and infection rate. ConclusionTreatment choices for skin avulsion on the lower limb should be based on the viability of the avulsed skin flap and the location of the wound. Proper choice can not only reduce the economic burden caused by using VSD, but also shorten the long hospital stay due to repeated wound dressing change or second stage surgery.