A comparison of upper abdominal wound closure with monofilament nylon and polyglycolic acid

In a trial of 104 consecutive patients undergoing upper abdominal surgery, 62 wounds were closed with continuous layered nylon and 42 with interrupted mass PGA sutures. All wounds were closed by one surgeon. There was a significantly greater incidence of wound infection (P less than 0.01) and incisional hernia (P less than 0.05) in the group closed with PGA. Wounds closed with PGA took longer to suture (1.00 min/cm) than wounds closed with nylon (0.76 min/cm), a highly significant difference (P less than 0.001). From this study it is recommended that upper abdominal surgical wounds should be closed with a continuous nylon suture.     

Drain entrapment and titanium to ceramic head deposition: Two unique complications following closed reduction of a dislocated total hip arthroplasty

Postoperative dislocation remains one of the most frequent complications following total hip replacement. In this report, a case is presented that illustrates two potential concerns with postoperative dislocation and subsequent closed reduction. The first complication presented in this report is entrapment of a closed drainage system tube in the joint space following closed reduction. The second complication, transfer of metallic debris to a ceramic femoral head from contact with an acetabular shell during closed reduction, was documented by analysis of a femoral head using scanning electron microscopy and energy dispersive x-ray spectrometry. This report emphasizes the need for the surgeon to express caution when relocating a dislocated hip, particularly when a closed drainage system is used postoperatively.     

The management of forearm fractures in children: a plea for conservatism

A retrospective review was undertaken to evaluate the efficacy of primary nonoperative treatment (closed reduction and long-arm casting) along with pins and plaster as a salvage technique for those reduction failures. A total of 730 closed fractures (1987-1993) was compiled, of which 300 required closed reductions and casting. Excluded from the study were teenagers whose growth plates were closed. Of the 300 fractures requiring closed reductions, 22 went on to require remanipulations, and 12 required the use of pins-and-plaster technique to obtain or maintain satisfactory reduction. Complications in the group treated in this manner included two superficial pin infections treated with antibiotics and two forearms with moderate loss of pronation/supination not requiring treatment. We believe that closed reduction of pediatric forearm fractures remains the accepted standard and the technique of pins and plaster should be considered a reliable alternative for the unstable injuries.     

The role of inflammation in bronchial stump healing.

The roles of inflammatory response and closure technique in the development of bronchopleural fistula were evaluated. Canine bronchial stumps closed with 3-0 silk and studied 14 days later were characterized by a dense inflammatory infiltrate. Stumps closed with 3-0 chromic catgut suture showed a moderate inflammatory response with disintegration of suture material. However, stumps closed with the automatic stapling device (TA-30) showed the best healing and a minimal degree of inflammation. These findings correlated well with leakage pressures. The average leakage pressure for the silk closed stumps was 139.44 mm Hg plus or minus 78.9 SD. This was significantly lower (P less than 0.02) than the average leakage pressure for staple closed stumps (251.25 mm Hg plus or minus 82.9 SD). It is concluded that the minimal amount of inflammation following staple closure will be associated with improved bronchial stump healing and a lower incidence of bronchopleural fistula.     

Intramedullary nailing of fractures of the tibia in diabetics

We reviewed 27 diabetic patients who sustained a tibial fracture treated with a reamed intramedullary nail and compared them with a control group who did not have diabetes. There were 23 closed fractures and four were open. Union was delayed until after six months in 12 of the 23 (52%) diabetic patients with closed fractures and ten of the 23 (43%) control patients (p = 0.768). In two patients with diabetes (9%), closed tibial fractures failed to unite and required exchange nailing, whereas all closed fractures in the control group healed without further surgery (p = 0.489). In both the diabetic and control groups with closed fractures two patients (9%) developed superficial infections. There were two (9%) deep infections in diabetic patients with closed fractures, but none in the control group (p = 0.489). Overall, there was no significant difference in the rate of complications between the diabetic patients and the control group, but there was a tendency for more severe infections in patients with diabetes.     

Displaced supracondylar humeral fractures in children: open reduction vs. closed reduction and pinning

Introduction In the literature the best results for pediatric supracondylar humerus fractures have been achieved by closed reduction and wire fixation. However, in these reports the patient group of open reduction and pinning contained the patients who had had previous ineffective closed reduction trials. This retrospective study compared open and closed reduction with pinning, in which the first group of patients was all consecutively treated with open reduction.Materials and methods The study included 99 children with displaced extension-type supracondylar fractures of humerus who had complete follow-up. Open reduction patients had not had a previous attempted closed reduction. Open reduction and pinning were performed through a posteromedial incision in the first 44 patients and closed reduction and pinning in the subsequent 55 patients. Mean duration surgery was 15 h with open reduction and 17 h with closed reduction. Mean follow up was 35 months with the open reduction and 21 months with closed reduction. Humeral-ulnar angle was compared to the contralateral elbow, clinical flexion deficiency and extension lag, and complications were evaluated.Results At the latest follow-up the open group had an average of 5.1° valgus change and the closed group 3.6° valgus change in humeral-ulnar angle compared to their uninvolved elbow. Average flexion deficiency was 8.61° in the open and 5.25° in the closed group. Average extension lag was 6.23° in the open and 0.6° in the closed group. Functional results were satisfactory in 71% of patients in the open and 93% of those in the closed reduction group. Cosmetic results were satisfactory in 95% of both groups.Conclusions Closed reduction and pinning is superior to open reduction and pinning for the treatment of pediatric supracondylar humerus fractures. In the case of technical insufficiencies open reduction and pinning through a posteromedial incision is an alternative treatment for decreasing the surgical time and complications. Complications was not caused in either group by the delayed surgical timing compared to reports in the literature.     

Acute closed rupture of EHL revisited

Isolated closed injuries to the EHL are rare. Traumatic closed rupture of EHL in the absence of diabetes mellitus, arthritis or local steroid injections is hitherto unreported. We present a case of closed EHL rupture after a hyperflexion injury to the interphalangeal joint of the big toe, successfully managed with surgery, along with review of existing literature.     

Prophylactic closed suction drainage of femoral wounds in patients undergoing vascular reconstruction

Prophylactic closed suction drainage has been advocated in a variety of surgical wounds, but its use in wounds involving vascular anastomoses has not been studied. Fifty patients undergoing lower extremity revascularization that required bilateral groin incisions were randomly assigned to have either the right or left side of the groin drained with a closed suction catheter. The contralateral wound was closed without drainage. Statistically there was no difference between wound closed with drains and undrained wounds in the occurrence of hematomas, seromas, lymphoceles, superficial infections, subcutaneous infections, or graft infections; although serious complications were more frequent in the drained wounds. Prophylactic closed suction drainage appears to offer no advantage over closure without drainage in wounds of the groin resulting from elective vascular operations.     

闭合复位交锁髓内钉治疗胫骨干骨折

目的探讨闭合复位交锁髓内钉治疗胫骨干骨折的临床应用和疗效。方法对21例胫骨干新鲜闭合性骨折患者行闭合复位交锁髓内钉静力性固定。结果经6~29个月随访,21例骨折全部愈合。结论闭合复位交锁髓内钉是治疗胫骨干骨折的理想方法。     

Patient satisfaction after closed reduction of nasal fractures

OBJECTIVE: To evaluate the outcome of closed reduction from a patient's point of view, because there is increasing evidence that closed reduction of nasal fractures fails to address deformities of the cartilaginous nasal framework and the septum. METHODS: We performed a retrospective study of 62 patients who underwent a closed reduction of nasal fracture between July 1, 2002, and June 30, 2005. All patients were interviewed regarding the esthetic and functional outcomes after closed reduction. RESULTS: Eighteen patients (29%) expressed dissatisfaction with the esthetic outcome of the reduction, and 18 (29%) said they would consider further surgery to correct the residual nasal deformity. CONCLUSIONS: A stringent preoperative assessment of the nasal fracture, other nasal deformities, and nasal function is essential before offering patients a simple closed reduction of their nasal fractures. A septorhinoplasty, as the definitive procedure, should be offered to patients when a closed reduction is deemed unable to address all deformities.     

Influence of height on the spatial orientation and equilibrium of the body.

The sway of the center of gravity for 30 seconds with a stabilometer was examined in 30 volunteers under 3 visual conditions (eyes open with and without fixation and eyes closed) at heights of 0, 1, and 2 m and under 2 visual conditions (eyes open with fixation and eyes closed) at a height of 10 m 22 cm. Eight of the subjects had acrophobia. The sway worsened at 10 m 22 cm but showed no change at 1 or 2 m. The acrophobic group became clearly worse at 10 m 22 cm. In another group of 12 volunteers, the subjects were guided to the roof with the eyes closed, and sway was measured. Sway was also measured with the eyes uncovered and open and again with the eyes closed. The first measurement with the eyes closed showed worse sway, and the second with the eyes open was better, except in 2 subjects who were acrophobic.     

Closed reduction of constrained total hip arthroplasty

Many surgeons use acetabular components with constrained polyethylene liners to improve stability in patients with a history of hip dislocation. Considering that the reported incidence of hip dislocation in patients with constrained components is 4% to 29%, it generally is recognized that open reduction would likely be necessary in cases of redislocation. Recent reports have indicated that closed reduction of constrained total hip arthroplasty is possible in some cases. However, it is unknown whether closed reduction damages the constrained polyethylene liner and predisposes patients to additional dislocations. The current study evaluated the integrity of the polyethylene constraint mechanism after in vitro simulation of hip dislocation and closed reduction. After lever-out dislocation and reduction, 76% of the capture mechanism strength was maintained without additionally damaging the polyethylene liner. Also reported is the technique for closed reduction in patients with constrained components and a clinical series of six patients who had successful closed reduction. These patients remain stable without any additional dislocations 7 to 72 months after reduction. These data suggest that closed reduction of Poly-Dial constrained polyethylene liners can be successful without predisposing patients to additional dislocations.     

Postoperative pyothorax

Twenty-five cases of pyothorax occurred in a series of 1281 thoracotomies. Almost all cases of pyothorax without bronchopleural fistula were successfully treated by closed drainage and irrigation alone. On the other hand, patients with pyothorax and fistula who were treated only with closed drainage almost all had a poor outcome. When pyothorax with fistula was treated by closed drainage and irrigation followed by further procedures such as open window thoracostomy, muscle plombage and/or omentopexy, treatment was successful. It is concluded that pyothorax without fistula may be cured by closed drainage and irrigation alone, but that pyothorax with fistula requires operative intervention such as open window thoracostomy or omental flap as soon as possible.     

Distal femoral physeal problem fractures

Treatment options in the past for distal femoral physeal fractures have varied from closed reduction to open reduction with internal fixation to balanced skeletal traction. In this study, ten patients with distal femoral physeal fractures treated with closed reduction and casting or skeletal traction are reviewed. Seven fractures lost position in comparison with original reduction films. Nine patients developed subsequent deformity. No consensus exists regarding the use of open versus closed treatment with internal fixation. This review of closed treatment yielded a high rate of unacceptable results. Initial anatomic reduction with rigid fixation of physeal injuries about the ankle has been demonstrated to decrease the incidence of growth deformity. The authors' experience and a review of the literature suggest that a similar approach is applicable to distal femoral physeal fractures.     

Coronary Arteriovenous Fistula

A coronary artery fistula to the coronary sinus in a 58-year-old woman with angina pectoris is described. Two big fistulas from the right coronary artery had a common opening which was closed with 5 mattress sutures buffered with teflon pearls and a dacron patch. A small fistula between the left coronary artery and the coronary sinus was closed with 2 mattress sutures. An atrial septal defect was also encountered and closed. The patient survived the operation and is now free of angina pectoris.     

Closed-loop titration of propofol guided by the bispectral index

This review analyzes the clinical studies concerning the automated perfusion, or closed-loop, of propofol guided by the bispectral index (BIS). To carry out the maintenance of general anaesthesia by a closed loop propofol-BIS is feasible as shown by studies comprising few low risk patients. We showed that induction of anaesthesia is feasible with a closed loop, haemodynamic stability being similar to a manual titration. A second study, bearing on the whole of the anaesthesia of patients ASA I to III undergoing very diverse surgical acts, showed that the closed loop propofol-BIS was more precise than a manual perfusion. This confirms that the closed loop propofol-BIS is not an esoteric research and that it represents a tool with a future for the clinician.     

Closed depressed skull fracture in childhood reduced with suction cup method: case report

A closed depressed skull fracture in a child was reduced with a suction cup. This method keeps the fracture closed and leaves no scar.     

Closed suction or penrose drainage after partial nephrectomy: does it matter?

PURPOSE: Prospective studies in the general surgery literature have shown fewer wound related complications with closed suction drainage than with open passive drainage. Nevertheless, some urologists avoid closed suction drains after partial nephrectomy mainly because of a theoretical increased risk of a prolonged urinary leak or delayed hemorrhage. MATERIALS AND METHODS: We reviewed the records of 184 patients who underwent 197 consecutive partial nephrectomies at our institution. Closed suction or open passive (Penrose) drainage was used based on surgeon preference. Drain type was compared with duration of use and the incidence of relevant complications. RESULTS: A Penrose drain was used in 37.6% (74 of 197) of partial nephrectomies and a closed suction drain was used in 62.4% (123). Clinical characteristics were equivalent between both groups, including age, body mass index, tumor size (mean 3.1 cm), number of renal tumors excised, estimated blood loss and operative time. There was no statistically significant difference in the duration of drainage between the Penrose group (mean 7.1 days) and the closed suction group (7.8 days). While we found variation in the incidence of relevant complications by drain type, none of these differences was statistically significant. Complications included prolonged urinary drainage in 7.6% of cases (8.9% closed suction, 5.4% Penrose), wound infection or perinephric abscess in 3.6% (2.4% closed suction, 5.4% Penrose) and delayed hemorrhage in 1.5% (2.4% closed suction, 0 Penrose). CONCLUSIONS: No statistically significant differences in postoperative morbidity were observed between the use of closed suction or Penrose retroperitoneal drains after partial nephrectomy.     

Does open reduction increase the chance of infection during intramedullary nailing of closed tibial shaft fractures?

OBJECTIVE: To evaluate whether an open technique used to obtain reduction during intramedullary nailing of closed tibial shaft fractures increases the risk of infection, compared to closed reduction and nailing. SETTING: University level 1 trauma center. DESIGN: Retrospective database analysis. PATIENTS/PARTICIPANTS: One hundred seventeen patients with 119 fractures from our trauma database who had sufficient follow-up and met study criteria. The patients were grouped by open versus closed reduction. Only OTA fracture types 42 A to C were included in this study. INTERVENTION: Locked reamed intramedullary nailing for closed tibial shaft fractures accomplished through either open or closed reduction. MAIN OUTCOME MEASUREMENT: The presence or absence of infection as determined by the clinical presentation (erythema, warmth, purulent drainage, fevers, chills, increased pain at the fracture site), indicative laboratory work (complete blood count, erythrocyte sedimentation rate, C-reactive protein), and/or positive culture. RESULTS: There were 85 males and 32 females. The average age was 35.7 years; the average follow-up was 14.3 months. Of the 119 fractures, 79 had closed reduction whereas 40 had open reduction. The open reductions consisted of 13 with a formal incision (>1 cm in length), 22 with percutaneous incisions, and 5 with fasciotomies. There were no infections in the closed reduction group and 2 infections (5%) in the open reduction group. This difference was not statistically significant (P=0.1). The average time to union was 7.0 months in closed reductions and 7.3 months in open reductions. By latest follow-up, 107 fractures had reached union (89.9%), 1 had not (0.8%), and 11 were lost to final follow-up (9.2%). CONCLUSIONS: Limited open techniques can greatly facilitate the reduction of closed tibial shaft fractures but raise concern for infection through exposure of the fracture site. This study found that the rate of infection for open versus closed reductions was higher but not statistically different. Judicious use of open reduction techniques during intramedullary nailing of closed tibia fractures seems to have a minimal risk of infection.     

PDS II (polydioxanone) is the monofilament suture of choice for subcuticular wound closure following breast biopsy.

In a randomized study of 120 patients having a local anesthetic breast biopsy, wounds closed with subcuticular PDS II were cosmetically superior to those closed by Prolene.