7. Herzklappenersatz durch autologe Fascia lata

Ohne Zusammenfassung     

Fascia lata aortic valve reconstruction: long-term results in 33 patients

Aortic valve reconstruction with autologous fascia lata was performed in 33 patients (mean age 35 years) in 1966 and 1967. Eighty-two per cent had cusp extension rather than replacement, while 33% required additional intracardiac procedures. There were seven hospital deaths (21%) and 11 late deaths (33%), a total mortality of 54% over four years. Six late deaths followed reoperation for recurrent incompetence, and two other patients survived reoperation. Endocarditis (rickettsial, fungal, and bacterial) occurred in five cases, all required reoperation for incompetence, and four died. Sixty-nine per cent of the survivors of operation left hospital with competent valves and did better than the 31% with leaking valves in terms of late deaths, endocarditis, and reoperation for incompetence. Of the 15 patients (45%) still alive, 13 still have their original fascial valve, and of these only two (or perhaps three) have no diastolic murmur. Seven have insignificant murmurs and three have aortic incompetence. These poor results, particularly in the long term, make us sceptical about current enthusiasm for fascia lata heart valves.     

Fascia lata allograft bridging of a rotator cuff tear in a rabbit animal model

Purpose:

Despite advances in surgical treatment options, large rotator cuff (r-c) tears still represent a challenge for orthopedic surgeons. The purpose of this study was to evaluate the temporary and spatial histological incorporation of fascia lata allografts, used for bridging artificially created defects of the r-c.

Materials and Methods:

Seventy-two rabbits were divided into two groups and a supraspinatus tendinous defect was created. Half of the rabbit population underwent repair only, while in the other half, the defect was bridged utilizing fascia lata allograft. The animals were euthanized at 2, 4, and 6 weeks postoperative. Half of the specimens were evaluated histologically and the other half underwent mechanical testing.

Results:

There was an increased remodeling activity, fibroblastic in growth and strong presence of collagen fibers observed at 6 weeks on both groups. A gradually increasing mechanical strength was noticed by week 6 and increased toughness was also found at the same time period. There was no significant difference observed between the two groups regarding their histological and mechanical properties.

Conclusions:

In the difficult scenario of a large irreparable tear where the simple suture of the remaining r-c is impossible, allograft bridging, could be used with satisfactory results.

Clinical Relevance:

Treatment Study, Level 1.     

Fascia lata sling cystourethropexy for the management of female urinary incontinence

Pubovaginal sling cystourethropexy has rapidly become one of the primary surgical treatment options for women with urinary incontinence. The procedure has evolved over time with regard to clinical indications, patient selection criteria and surgical techniques. This article reviews the historical development of pubovaginal sling cystourethropexy, including recent technical advances. The selection of graft materials is considered and the utility of fascia lata emphasized. Clinical results and potential complications of the procedure are also reviewed.     

Fascia lata plasty in recurrent posterior dislocation after total hip arthroplasty

With a soft-tissue plasty, stability could be obtained in 17 of 22 patients with unstable hips after total hip arthroplasty. While in 16 of 18 patients with a posterior instability stability was achieved, only 1 of 3 patients with a unstable hip for dislocation in all directions was successfully treated. No stability could be achieved in one patient with a hip which dislocated anteriorly. The method described should only be used for posterior recurrent dislocations after total hip arthroplasty.     

Retrieved human allografts : a clinicopathological study.

BACKGROUND: We studied seventy-three massive preserved human allografts, retrieved from two to 156 months after implantation, to provide insight into the mechanisms of their repair. METHODS: The specimens were studied with radiographic and histological techniques that permitted time-related quantitative analysis of the reparative mechanisms of union, cortical repair, soft-tissue attachment, fracture, and characteristics of the allograft-cement interface and the articular cartilage. RESULTS: Union at cortical-cortical junctions occurred slowly (approximately twelve months) by host-derived external callus that bridged the junction and filled the gap between abutting cortices. The bone in the gap did not undergo stress-oriented remodeling even after many years, and, when the union was intentionally disrupted, failure occurred at the cement line that marked the allograft-host junction. Repair of the necrotic graft matrix was both external and internal. External repair consisted of the apposition of a thin seam of host bone on the outer surface of the graft, coating about 40% of the surface at one year and 80% at two years. Internal repair was confined to the ends and the periphery of the cortices and penetrated so slowly that only 15% to 20% of the graft was repaired by five years, after which deeper repair seldom occurred. Graft fractures in specimens retrieved soon after fracture showed only necrotic bone adjacent to the fracture site, whereas those retrieved after fracture-healing showed a marked increase in internal repair of the bone about the fracture site. When bone cement had been used to fix a prosthesis, there was no evidence of bone resorption or loosening of the device. The osteoarticular specimens showed no survival of chondrocytes in the articular cartilage. However, the architecture of the acellular cartilage was well preserved after two to three years and occasionally after as many as five years. Late degenerative changes in the articular cartilage coincided with subchondral revascularization and fragmentation, and the articulating surfaces became covered by a pannus of fibrovascular reparative tissue. Degenerative changes in articular cartilage occurred earlier and were more advanced in specimens retrieved from patients with an unstable joint than in those retrieved from patients with a stable joint. CONCLUSIONS: Repair of massive human allografts is an indolent process that follows a fairly predictable course during the first few years and is influenced by other biological activities, such as fracture repair, supplementary autografting, and tumor recurrence.     

Subacute necrotizing sialadenitis: a clinicopathological study.

OBJECTIVE: To report cases of extra-palatal subacute necrotizing sialadenitis (SANS), an uncommon condition that usually affects palatal minor salivary glands, and to characterize the etiopathogenesis, clinical features, and histology of this lesion. STUDY DESIGN: Retrospective reviews of records for patients with SANS diagnosed between 1999 and 2005; only cases with complete clinical history and histology were included in the study. RESULTS: Five cases (3 women, 2 men) were identified. The majority of patients presented with painful 1.0 to 1.5 cm swellings, with sudden and rapid increase in size. Two cases occurred in the buccal mucosa, 2 on the ventral surface of tongue, and 1 on the upper lip. Histology showed acinar necrosis surrounded by a dense polymorphous inflammatory infiltrate with focal exuberant tissue eosinophilia. Ductal atrophy was seen with minimal squamous metaplasia. In all the cases, healing occurred without any further treatment in 3 weeks. No recurrence was observed. CONCLUSION: SANS is an uncommon, inflammatory condition of unknown etiology affecting minor salivary glands. SANS appears to be a self-limiting process that has distinct characteristic clinical and histologic features. Nevertheless, SANS shares some of the histologic features of early necrotizing sialometaplasia (NS), suggesting a possible relationship between the 2 conditions. Additional reporting of SANS would be helpful in better defining the condition and its delineation from NS.     

Fascia lata composite graft for right ventricular outflow tract and pulmonary artery reconstruction: Surgical technique

Because there is no `ideal' method for the complete correction of some of the more complex congenital cardiac abnormalities, a technique of making a composite graft of autologous fascia lata has been developed.

Three types of grafts are described, all of them being based on the same general principle. The composite graft comprises a conduit, which serves to enlarge or reconstruct the outflow tract of the right ventricle and the main pulmonary artery, and an inner valve attached inside it, which provides the conduit with a one-way flow mechanism.

The technique of preparing these composite grafts is outlined and the surgical implantation of the grafts in the right ventricular outflow is described.

Since November 1969, fascia lata composite grafts have been used in 18 patients with a variety of complex congenital heart malformations with very good early results.