Is mesh fixation necessary in abdominal hernia repair?

Background: Abdominal hernia repair with implantation of synthetic meshes using the sublay technique has resulted in low recurrence rates and high patient satisfaction. Aim: The purpose of this experimental animal study was to investigate whether mesh fixation is necessary in abdominal hernia repair using a polypropylene mesh in the sublay technique. Methods: Forty-five rats were divided into three groups after creating an abdominal wall defect (CG control group, no mesh implantation; NoFixG mesh implantation without fixation group; SG mesh with suture fixation group) with 15 animals in each group. Endpoints were clinical herniation pressure, hydroxyproline (HP) concentration, mesh shape and number of fibroblasts/collagen fibres of the anchor zone 7, 14 and 90 days after implantation. Results: Herniation pressure, HP content and number of fibroblasts were similar between NoFixG and SG, although significantly higher in these groups than in the CG (P<0.05). Both mesh groups had significantly higher counts of fibroblasts and collagen fibres than the CG. Mesh shrinking occurred in both groups but was less in the SG. Conclusion: Mesh fixation was not mandatory in abdominal hernia repair using this animal model. Received: 18 May 1998; in revised form: 11 August 1998 Accepted: 5 October 1998     

Biomechanical analysis of fracture fixation with external fixator in vivo

Objective: To investigate the different ways of measuring the main axial strain during treatment with an external fixator and to find the suitable compression loaded by the external fixator at an early stage. Methods: Eighteen healthy big-ear rabbits were randomly divided into two groups according to different measuring methods: Group A and Group B. In Group A, a strain gauge was affixed to the external tibial cortex with 502 glue, and in Group B, a bone cement-coated strain gauge was installed on the internal tibial cortex. Groups A and B were divided into two subgroups A1, A2 and B1, B2, respectively, according to the pressure of half of and the same as the body weight. A Z-shaped left mid-shaft tibial osteotomy was performed and fixed by an external fixator. Results: The sealer curves of Group A changed dramatically during the early stage. The trendlines of the internal and external cortex went consistently after reaching the stable stage while the latter strain value was higher than the former. The time for Group B reaching the stable stage was short, but its absolute strain value was less than that of Group A. Before they were pressed to the stable stage, the declined speed of Subgroup A1 was more slowly than that of Subgroup A2 while the results of Subgroups Bl and B2 were same. Group A had an ascending trend after it declined while Group B didn' t have. After they reached the stable stage, both Subgroups Al and A2 had a declining trend while Subgroup A2 was more quickly than Subgroup A1, Subgroup Bl was kept at a definite level while Subgroup B2 fluctuated. Conclusions: The axial strain under external fixator can be measured by bone cement coated-strain gauge in vivo. The data may suggest that half of the body weight load was suitable for external fixator.     

Posterolateral plate fixation with Talarlock® is more stable than screw fixation in ankle arthrodesis in a biomechanical cadaver study

Background

A number of studies report on limitations of the screw arthrodesis in severe malalignment of the hindfoot, neuropathic deformity, poor bone quality and osteoporosis.

What advantages does volar plate fixation have over K-wire fixation for distal radius extension fractures in the elderly?

PURPOSE: The purpose of this retrospective study was to compare the outcome of open reduction and internal fixation (ORIF) followed immediately by physiotherapy and of percutaneous K-wire-fixation and casting for unstable distal radius fractures in elderly patients, considering the results both in general, for all such fractures, and selectively for A3 and C2 fractures. METHODS: Follow-up examinations were performed 26 (18-48) months after surgery in 43 patients (median age 67 (60-83) years) treated with K-wire fixation and 9 (5-17) months after surgery in 46 patients (median age 76 (60-90) years) treated with ORIF, and the outcome of each was recorded as Disabilities of the Arm, Shoulder and Hand (DASH), Gartland-Werley and Castaing scores; the radiological loss of correction was also assessed. Statistical analysis was performed first without reference to the specific type of fracture for the K-wire- and the total ORIF -groups, and then selectively for A3 and C2 -fractures only; in the second analysis the patients were divided into three groups: KD, ORIF with and ORIF without angular stability. RESULTS: The Garland-Werley and Castaing scores do not indicate any significant difference between the procedures specified. According to the Garland-Werley score 37 patients (86%) treated by K-wire fixation and 39 (85%) treated by ORIF achieved "excellent" and "good" results; according to the Castaing score there were 33 (77%) "good" results after K-wire fixation and 34 (74%) good results after ORIF. The radiological loss of correction (K-wire fixation/ORIF) as measured by the radial inclination (median 2/2.5 degrees), the palmar tilt (median 3/5 degrees) and the radial shortening (median 1/1 degrees mm) do not differ significantly. Suboptimal radiological results do not always correlate with results that are only "fair" or "poor". The non-fracture-specific DASH score suggests a higher degree of patient satisfaction after K-wire fixation (7 [0-87] points) than after ORIF (17 [0-82] points), which is not confirmed by fracture-specific evaluation. There is a significantly earlier return to the "activities of daily living" (4 as against 8 weeks) after ORIF. CONCLUSION: All the treatments compared are suitable for the treatment of A3 and C2 fractures. The important advantages of ORIF are the early functional physiotherapy without casting and without obligatory second surgery and the earlier return to "activities of daily living", which are all of decisive importance for older patients, who are the ones most frequently affected.     

Tibial Pilon fractures Internal plate fixation versus external wire fixation

A M ED LIN E search w as conducted to identify studiepublished betw een January 1998and January 2004usininternal plate fixation or external wire fixation for treatm ent of tibial Pilon fractures.The search strategy identified 20articles thatreportedoutcom…     

The role of intramedullary fixation in ankle fractures – A systematic review

Background

Ankle fractures are one of the most commonly occurring fractures in the elderly population. The overall incidence has been reported to be up to 184 fractures per 100,000 persons per year, of which 20–30% occur in the elderly. Medical co-morbidities, osteoporosis, suboptimal skin quality and poor toleration of non-weight bearing status all contribute to difficulties in managing these injuries in this population. Intramedullary implants are advantageous as they utilise smaller incisions, minimise soft tissue disruption and may allow early weight bearing. This systematic review aims to analyse the use of both fibula nails and talo-tibial-calcaneal (TTC) implants in the management of fragility ankle fractures.

Cementless cup fixation in total hip arthroplasty after 5–8 years

A series of 199 total hip arthroplasties was performed using a porous-coated, hemispherical press-fit acetabular cup. At a mean follow-up of 91.5 months 158 cups were available for clinical and radiological review. The mean age of the patients at the time of the index arthroplasty was 62.5 years. The mean Harris Hip score at final follow-up was 87.3. No shells were revised although eccentric polyethylene wear prompted liner replacement in two cases. Osteolysis was noted in six cases but predominantly in relation to the femoral stem. Focal pelvic osteolytic lesions were rare. All the cups were classified as stable on radiography.     

Is there a place for external fixation in humeral shaft fractures?

There is a good indication for unilateral axial dynamic external fixation in fractures of the humeral shaft when the fracture appears in the distal third or in cases of bilateral fractures. A non-union or a posttraumatic paralysis of the radial nerve may be indications for external fixation as well as fractures associated with multiple injuries. Further indications include osteitis, infected non-union and comminuted fracture. There is maximum protection of the soft tissue with this method of treatment. External fixation combines the advantages of conservative and operative treatment by influencing callus formation by dynamizing, distraction or compression. Minimizing soft tissue damage facilitates the decision for early exploration of the radial nerve in cases of palsy. A safer positioning technique of the distal screws of the fixator is described.     

Radiographic and clinical analysis of cementless acetabular fixation in total hip arthroplasty

Tofruetancloc nthisoitpnru sac.rttih oOrnorpig ltaiensctahylln y(i,qTuH emAa)jfoo irrs a Td HweteAelrli-o etrseatctaehbdnliiqs huheeidpsutilized bone cement for fixation,but loosening rate ofthe acetabular component was very high because ofbone cement tec…     

Does a longer delay in fixation of talus fractures cause osteonecrosis?

This retrospective study investigated active duty soldiers with delayed definitive fixation of combat-related talus fractures. The authors predicted a longer delay to internal fixation and a correlation between the timing of fixation and development of osteonecrosis and posttraumatic arthritis. The Joint Theater Trauma Registry was queried by ICD-9 codes for talus fractures. Soldiers, ages 18 to 40, with talus fracture between 2001 and 2008 were included. Radiographs identified the injury type, Hawkins sign, osteonecrosis, and posttraumatic arthritis. Mean time to fixation was 12.9 days. Hawkins sign was observed in 59% of fractures at a mean of 7 weeks. No correlation was found between osteonecrosis or posttraumatic arthritis and open fractures, comminuted fractures, or timing of fixation. Average follow-up was 16 months. This case series has the longest mean time to fixation by more than threefold. There was no correlation of delayed timing of fixation and development of osteonecrosis or posttraumatic arthritis.     

Intraarticular distal radial fractures External fixation versus open reduction with internal fixation

Results of three randomized controlled trials, class of evidenceⅡ, comparing external fixation (EF) with open reduction and internal fixation (ORIF) for the treatment of intraarticular distal radial fractures described no consistent benefit of one treatment over another. Only grip strength was significantly better with EF compared with ORIF in two studies. There was a suggestion of fewer complications, more rapid return of function, and better functional outcome with EF, but these results were not consistent across studies. No statistically significant differences in rates of infection or reflex sympathetic dystrophy were seen between treatment groups. Larger, methodologically sound randomized controlled trials are needed to determine whether treatment with EF is indeed preferable to ORIF.     

Biomechanical analysis of bicondylar tibial plateau fixation: how does lateral locking plate fixation compare to dual plate fixation?

OBJECTIVES: This study is designed to test the comparative strength of lateral-only locked plating to medial and lateral nonlocked plating in a cadaveric model of a bicondylar proximal tibial plateau fracture. METHODS: Ten matched pairs of human cadaveric proximal tibia specimens were used for biomechanical testing. Cyclic loading using a materials testing device simulated initial range of motion and load bearing following surgical repair. Subsidence of the medial and the lateral condyles was measured following 10,000 cycles from 100N to 1,000N; the maximum load to failure on the medial condyle for both plate constructs was also measured. RESULTS: On the lateral side, dual plating (DP) allowed an average of 0.68 +/- 0.14 mm of subsidence, compared with 1.03 +/- 0.27 mm for the fixed-angle plate (FAP) (P = 0.077). On the medial side, DP allowed an average of 0.78 +/- 0.15 mm of subsidence, compared with 1.51 +/- 0.32 mm for the FAP (P = 0.045). No significant difference was found in the maximal load to medial condyle fixation failure between either plating construct (P = 0.204). CONCLUSIONS: The results of this study demonstrate that dual-plate fixation allows less subsidence in this bicondylar tibial plateau cadaveric model when compared to isolated locked lateral plates. This may raise concerns about the widespread use of isolated lateral locked plate constructs in bicondylar tibial plateau fractures.     

Stability of Lisfranc injury fixation in Thiel Cadavers: Is routine fixation of the 1st and 3rd tarsometatarsal joint necessary?

BackgroundThere is debate as to whether a home run screw (medial cuneiform to 2nd metatarsal base) combined with k-wire fixation of the 4th & 5th tarsometatarsal joints is sufficient to stabilise Lisfranc injuries or if fixation of the 1st and 3rd tarsometatarsal joints is also required. Unlike the 2nd, 4th and 5th tarsometatarsal joints, stabilisation of the 1st and 3rd requires either intra-articular screw or an extra-articular plate which risk causing chondrolysis and/or osteoarthritis.The aims of this cadaveric study were to determine if routine fixation of the 1st and 3rd tarsometatarsal joints is necessary and to determine if a distal to proximal home run screw is adequate.MethodsUsing 8 Theil-embalmed specimens, measurements of tarsometatarsal joint dorsal displacement at each ray (1st–5th) and 1st–2nd metatarsal gaping were made during simulated weight bearing with sequential ligamentous injury and stabilisation to determine the contribution of anatomical structures and fixation to stability.ResultsAt baseline, mean dorsal tarsometatarsal joint displacement of the intact specimens during simulated weight bearing (mm) was: 1st: 0.14, 2nd: 0.1, 3rd:0, 4th: 0, 5th: 0.14. The 1st–2nd intermetatarsal gap was 0 mm. After transection of the Lisfranc ligament only, there was 1st–2nd intermetatarsal gaping (mean 4.5 mm), but no increased dorsal displacement. After additional transection of all the tarsometatarsal joint ligaments, dorsal displacement increased at all joints (1st: 4.5, 2nd: 5.1, 3rd: 3.6, 4th: 2, 5th: 1.3). Stabilisation with the home run screw and 4th and 5th ray k-wires virtually eliminated all displacement. Further transection of the inter-metatarsal ligaments increased mean dorsal displacement of the 3rd ray to 2.5 mm. K-wire fixation of the 3rd ray completely eliminated dorsal displacement.ConclusionsThe results of this cadaveric study suggest that stabilising the medial cuneiform to the 2nd metatarsal base combined with stabilisation of the 4th and 5th tarsometatarsal joints with K-wires will stabilise the 1st and 3rd tarsometatarsal joints if the inter-metatarsal ligaments are intact. Thus 3rd TMTJ stability should be checked after stabilising the 2nd and 4/5th. Provided the intermetatarsal ligaments (3rd–4th) are intact, the 3rd ray does not need to be routinely stabilised.     

Prophylactic contralateral fixation in slipped upper femoral epiphysis: is it safe?

Prophylactic stabilization with internal fixation of the asymptomatic hip in unilateral slipped upper femoral epiphysis is controversial. We present a retrospective analysis of 65 patients who had prophylactic fixation of the uninvolved hip at the same time as their opposite slipped femoral physis. None had an underlying systemic or endocrine abnormality and the average age was 12.5 years (range 11-15 years). A single 7.0 mm cannulated cancellous screw was used in all patients. The average time to fusion was 18 months (range 6-36 months) and duration of follow up ranged from 5 to 8 years (mean 6.5 years). None of the patients had implant removal and at latest review did not show any evidence of chondrolysis, avascular necrosis, premature physeal arrest or secondary arthrosis in the prophylactically fixed hip. One patient (1.5%) developed a superficial wound infection, which was successfully treated by antibiotics. This study demonstrates the safety of prophylactic fixation using a single cannulated cancellous screw and we recommend it for prevention of delayed slip and hence secondary osteoarthrosis.     

Femoral fractures in the polytrauma patient Early fracture fixation versus damage control orthopedics

AMEDLINEsearchwasconductedtoidentifystudiespublishedfromJanuary1999toDecember2003thataddressedthetimingoffemurfixationanddamagecontrolorthopedicsinthepolytraumapatient.Fromalistofsevenarticles,fourwerecomparativestudiesthatmadetheappropriatecomparison.StudiesStudy1BrundageSI,McGhanR,JurkovichGJ,etal(2002)Timingoffemurfracturefixation:effectonoutcomeinpatientswiththoracicandheadinjuries.JTrauma;52(2):299-307.Study2ScaleaTM,BoswellSA,ScottJD,etal(2000)Externalfixationasabridgetointr…     

Neuromuscular scoliosis and pelvic fixation in 2015: Where do we stand?

Neuromuscular scoliosis is a challenging problem to treat in a heterogeneous patient population. When the decision is made for surgery the surgeon must select a technique employed to correct the curve and achieve the goals of surgery, namely a straight spine over a level pelvis. Pre-operatively the surgeon must ask if pelvic fixation is worth the extra complications and infection risk it introduces to an already compromised host. Since the advent of posterior spinal fusion the technology used for instrumentation has changed drastically. However, many of the common problems seen with the unit rod decades ago we are still dealing with today with pedicle screw technology. Screw cut out, pseudoarthrosis, non-union, prominent hardware, wound complications, and infection are all possible complications when extending a spinal fusion construct to the pelvis in a neuromuscular scoliosis patient. Additionally, placing pelvic fixation in a neuromuscular patient results in extra blood loss, greater surgical time, more extensive dissection with creation of a deep dead space, and an incision that extends close to the rectum in patients who are commonly incontinent. Balancing the risk of placing pelvic fixation when the benefit, some may argue, is limited in non-ambulating patients is difficult when the literature is so mottled. Despite frequent advancements in technology issues with neuromuscular scoliosis remain the same and in the next 10 years we must do what we can to make safe neuromuscular spine surgery a reality.