TREATMENT OF ARTERIAL TRAUMA IN PATIENTS OF VARIOUS AGES

Aim. To identify the differences in arterial trauma (AT) treatment in patients of different ages. Materials and methods. The hospital medical records of 222 patients with AT who were treated in the Lviv Regional Clinical Hospital between 1992 and 2019 were studied. The following patterns were analyzed: age, etiology and mechanism of injury, type of AT, topography, symptoms, type of diagnosis, method of treatment. Patients were divided into seven age groups according to V. Quinn (1994): infants, early childhood, childhood, adolescents, young adults, adults and the elderly. Patients received one of three types of treatment – conservative, surgical or endovascular. Surgical treatment was further divided into simple operations (ligation or suture repair) and complex operations (end-to-end anastomosis or replacement). Results. Conservative treatment was used in 7.66±1.78%, surgical in 90.99±1.92% and endovascular in 1.35±0.77% of clients. The percentage of conservative treatment was higher among the infants (88.9±10.48%) and lower among the young adults (0.9%), as compared to the average. Among the operated patients, simple operations were performed in 48.45±3.59%, and complex operations in 51.55±3.59%. The distribution of different types of simple and complex operations between different age groups was similar. Regression analysis confirmed the influence of age factor, along with the type of AT, on the choice of treatment of patients. In addition, atherosclerotic changes were found in 20% of the adults and 50% of the elderly patients in the AT area. Conclusions. The age category of the patient makes an impact of the treatment method for patients with AT. Differences were related to the children of their first years of life, who were often managed conservatively. In the adults and the elderly, arterial damage may coincide with atherosclerotic changes in the blood vessels

The Transosseous Internal Four Strand Technique: A New All-Inside Technique for Zone 1 Flexor Tendon Repairs

Background: Multiple techniques for the repair of flexor tendon injuries in zone 1 have been proposed over time. While pull-out suture techniques and bone anchor seem to be stronger than internal suture techniques, they are associated with a higher complication rate. We therefore developed an alternative internal suture repair with similar biomechanical stability to those of pull-out sutures and bone anchors. Methods: Twenty porcine distal phalanges and deep flexor tendons were randomized to 2 groups of 10 each. The tendons were transsected at the level of the distal interphalangeal joint. In group 1, repairs were performed with a well-established intraosseous suture repair and in group 2 with our new multistrand technique. The repairs were biomechanically tested with linear distraction until failure. Results: We recorded a significantly higher 2-mm gap force (2GF)—and thus higher stability—of the repairs in group 1 in comparison to group 2. With a 2GF of more than 50 N, our suture technique allows for a modern early active motion rehabilitation protocol. Breakage of the suture construct occurred at random places in the repair in both groups. No pull-outs were noted. Conclusions: This study presents a strong transosseous multistrand repair technique for flexor tendon repair in zone 1 that is simple and fast to perform and should have enough strength to withstand early active motion rehabilitation.

Distal Insertion Rupture of Lateral Ankle Ligament as a Predictor of Weakened and Delayed Sports Recovery after Acute Ligament Repair: Mid- to Long-Term Outcomes of 148 Cases

Background Surgical repair has been considered for ankle sprain patients with high sports demanding to achieve stronger ankle stability and allow for an earlier return to sports. However, there is a lack of systematic research regarding arthroscopic treatment followed by ligament repair for severe acute ankle sprain. The purpose of this study was to analyze the mid- to long-term outcome of arthroscopy followed by open anatomic lateral ankle ligament repair surgery for acute lateral ankle sprain and the impact of ligament rupture site on the outcome. Methods 166 professional or semi-professional athletes with clinically- and radiologically-confirmed grade III acute lateral ankle ligament injuries underwent ankle arthroscopy followed by open anatomic ligament repair. Intra-articular lesions and rupture site of the lateral ankle ligament were treated and explored under arthroscopy. Simple suture repair was performed for mid- substance ligament rupture (middle group), while suture repair with anchors were used for the ruptures near the ligament attachment site on the fibular (proximal group), talar or the calcaneal side (distal group). The evaluation parameters included VAS score, AOFAS score, Tegner score, time to return to sports and resumption of pre-injury sports level at final follow-up, sprain recurrence and range of motion (ROM). Results The mean follow-up duration was 64.5 (range, 37–132 months) months and 148 (89.2%) patients were evaluated at final follow-up. Intra-articular lesions were treated under arthroscopy in 63 (43%) patients. The average time to return to pre-injury sports activity was 4.37 ± 1.10 months and 17 (11.5%) patients complaint sprain recurrence after operation. There were 71 (48%) cases in the proximal group, 46 (31%) cases in the middle group and 31 (21%) cases in the distal group respectively. The proximal group achieved shortest time to return to sports (4.14 ± 1.09 months) and highest resumption proportion of pre-injury sports level (94% ± 11%) at final follow-up, followed by middle group (89% ± 15%, 4.61 ± 0.93 months, respectively) and distal group (87% ± 13%, 4.53 ± 1.29 months, respectively) (p =0.008, p =0.04, respectively). At final follow-up, all of the VAS score, AOFAS score and the Tegner score were significantly improved from the pre-operative level (p < 0.001). 18 (12%) patients reported mild ROM restriction and 7 (4.7%) patients experienced transient skin numbness. Conclusions Ankle arthroscopy followed by open anatomic ligament repair is a reliable procedure for patients with high sports demands after severe acute ankle sprains. Rupture near the talar or calcaneal side weakened the sports resumption and delayed about 2 weeks of sports recovery.

Intrinsic Tendon Regeneration After Application of Purified Exosome Product: An In Vivo Study

Background: Tendons are primarily acellular, limiting their intrinsic regenerative capabilities. This limited regenerative potential contributes to delayed healing, rupture, and adhesion formation after tendon injury. Purpose: To determine if a tendon’s intrinsic regenerative potential could be improved after the application of a purified exosome product (PEP) when loaded onto a collagen scaffold. Study Design: Controlled laboratory study. Methods: An in vivo rabbit Achilles tendon model was used and consisted of 3 groups: (1) Achilles tenotomy with suture repair, (2) Achilles tenotomy with suture repair and collagen scaffold, and (3) Achilles tenotomy with suture repair and collagen scaffold loaded with PEP at 1 × 1012 exosomes/mL. Each group consisted of 15 rabbits for a total of 45 specimens. Mechanical and histologic analyses were performed at both 3 and 6 weeks. Results: The load to failure and ultimate tensile stress were found to be similar across all groups ( P ≥ .15). The tendon cross-sectional area was significantly smaller for tendons treated with PEP compared with the control groups at 6 weeks, which was primarily related to an absence of external adhesions ( P = .04). Histologic analysis confirmed these findings, demonstrating significantly lower adhesion grade both macroscopically ( P = .0006) and microscopically ( P = .0062) when tendons were treated with PEP. Immunohistochemical staining showed a greater intensity for type 1 collagen for PEP-treated tendons compared with collagen-only or control tendons. Conclusion: Mechanical and histologic results suggested that healing in the PEP-treated group favored intrinsic healing (absence of adhesions) while control animals and animals treated with collagen only healed primarily via extrinsic scar formation. Despite a smaller cross-sectional area, treated tendons had the same ultimate tensile stress. This pilot investigation shows promise for PEP as a means of effectively treating tendon injuries and enhancing intrinsic healing. Clinical Relevance: The production of a cell-free, off-the-shelf product that can promote tendon regeneration would provide a viable solution for physicians and patients to enhance tendon healing and decrease adhesions as well as shorten the time required to return to work or sports.

Simultaneous traumatic dislocation of the posterior tibial tendon and long peroneal tendon: a case report

Background Viewing the existing literature, one can find several documents about dislocation of the peroneal tendons. Clinical findings, diagnostics, and therapy are well described. Instead, the list of documents describing dislocations of the posterior tibial tendon is short. We found no case in which a dislocation of both long peroneal tendon and posterior tibial tendon is described. Case presentation We present a case of a 29-year-old male patient who sustained an ankle injury after a fall at a boulder gym. He admitted himself with severe pain, tenderness, and swelling of his left ankle. Dislocation of the posterior tibial tendon and simultaneous dislocation of the long peroneal tendon was diagnosed using x-ray, computed tomography, and magnetic resonance imaging. Transosseous suture repair with periosteal augmentation of the flexor retinaculum was performed at the medial malleolus. At the lateral malleolus, transosseous suture was used to repair the superior retinaculum. The ankle was immobilized following surgery. The patient underwent physical therapy afterwards. The treatment resulted in good recovery, and the patient returned to the same level of performance at rock climbing. Conclusion Our novel finding is that simultaneously sustained dislocations of the posterior tibial tendon and the long peroneal tendon may occur and can be successfully treated as if each injury is treated individually. Level of evidence Level V, case report.

Near Disappearance of Splenorrhaphy as an Operative Strategy for Splenic Preservation After Trauma

Background Splenorrhaphy was once used to achieve splenic preservation in up to 40% of splenic injuries. With increasing use of nonoperative management and angioembolization, operative therapy is less common and splenic injuries treated operatively are usually high grade. Patients are often unstable, making splenic salvage unwise. Modern surgeons may no longer possess the knowledge to perform splenorrhaphy. Methods The records of adult trauma patients with splenic injuries from September 2014 to November 2018 at an urban level I trauma center were reviewed retrospectively. Data including American Association for the Surgery of Trauma splenic organ injury scale, type of intervention, splenorrhaphy technique, and need for delayed splenectomy were collected. This contemporary cohort (CC) was compared to a historical cohort (HC) of splenic injuries at a single center from 1980 to 1989 (Ann Surg 1990; 211: 369). Results From 2014 to 2018, 717 adult patients had splenic injuries. Initial management included 157 (21.9%) emergent splenectomy, 158 (22.0%) angiogram ± embolization, 371 (51.7%) observation, and only 10 (1.4%) splenorrhaphy. The HC included a total of 553 splenic injuries, of which 313 (56.6%) underwent splenectomy, while splenorrhaphy was performed in 240 (43.4%). Those who underwent splenorrhaphy in each cohort (CC vs HC) were compared. Conclusion The success rate of splenorrhaphy has not changed. However, splenorrhaphy now involves only electrocautery with topical hemostatic agents and is used primarily in low-grade injuries. Suture repair and partial splenectomy seem to be “lost arts” in modern trauma care.

OV07 LAPAROSCOPIC HIATAL HERNIA MESH-SUTURE REPAIR

Aim “A new original laparoscopic operative technique was used to suture paraesophageal hernia (PEH) with the strips of mesh. Material and Methods The Mercilen (MercilenTM) mesh suture was used to close large hiatal hernia. The strips of mesh, instead of normal thread, were applied to close the gap between diaphragm’s crura in 12 patients with hernia defect more than 5 cm. Mesh suture were tighten as a simple laparoscopic intracorporeal knot. The surgical technique and surgical outcomes are presented. Results 12 patients underwent a laparoscopic PEH suturing with Mercilen strips of mesh. We recorded no recurrence or dysphagia at 6 and 12 months follow-up. Conclusions Mesh-sutured repairs of diaphragm’s hernia support the concepts of force distribution and resistance to suture pull through. The new original technique avoids using the sheet of mesh and enables to reduce the amount of dangerous complications connected with mesh and its fixation. Mesh-sutured closures of hiatal hernias seem to be safe and effective in tension closure of large hiatal defects. Further investigations are needed to evaluate the results. Using the mesh suture technique for the closure of large PEH, we protect the cruras from being cutting through. Besides, the mesh stripes and its knots produce tissue scarring around the esophagus making the suture line stronger.

O31 SUTURE OR MESH REPAIR FOR THE SMALLEST UMBILICAL HERNIAS: A NATIONWIDE DATABASE STUDY

Aim High level evidence recommends the use of mesh for umbilical hernias with defects &gt;1 cm to reduce recurrence rates without increasing the risk of postoperative complications. For umbilical hernias with defect width ≤1 cm, the literature is sparse. The aim of the study was to assess outcomes after suture and mesh repair of umbilical hernias with defect width &lt;1 cm on a nationwide basis, and to evaluate outcomes after onlay mesh repair specifically. Material and Methods By merging data from the Danish Hernia Database and the National Patients Registry from January 2007 until December 2018, patients receiving elective repair of an umbilical hernia with defect width ≤1 cm were identified. Available data included details about comorbidity, surgical technique, 90-days readmission, 90-days reoperation and reoperation for recurrence. Results A total of 7,849 patients were included, of whom 25.7% (2,013/7,849) underwent mesh repair. The cumulative 5-year incidence of reoperation for recurrence was significantly decreased after mesh repair 3.1% (95% C.I. 2.1-4.1) compared with suture repair 6.7% (95% C.I. 6.0-7.4), P &lt; 0.001. Onlay mesh repairs had the lowest cumulative risk of recurrence at 5 years 2.0% (95% C.I. 0.6-3.5). For onlay mesh repairs, readmission 7.9%, (65/826)) and reoperation (3.9% (32/826)) rates within 90-days were comparable to suture repairs (6.5% (381/5,836) and 3.3% (192/5,836), P = 0.149 and P = 0.382, respectively. Conclusions Even for the smallest umbilical hernias, mesh repair significantly decreased the recurrence rate. Onlay mesh repair was associated with the lowest risk of recurrence without increasing early complications.

P121 ONLAY MESH FOR TREATMENT OF SMALL UMBILICAL HERNIAS IN ADULTS - A SINGE CENTER INVESTIGATION

Aim Previous studies on the repair of small umbilical hernias have suggested a lower recurrence rate with mesh compared to suture repair. A remaining important question is in what anatomical position the mesh should be placed. The purpose of this study was to investigate the outcome of using a standardized 4x4 cm onlay-mesh for umbilical hernias ≤2cm. Material and Methods A retrospective study was conducted at a single institution in Sweden on all umbilical hernia repairs during 2015-2019. The follow up time was at least four months. Patients were identified using the hospital medical record database. Repairs performed with suture, sublay, ventral patch or laparoscopic mesh positioning were excluded. Patient’s demographics, comorbidities, intra – and postoperative details were considered. Primary outcome was surgical site complications within 30 days. Secondary outcome was recurrence. Results 80 patients were repaired with a small onlay-mesh for an umbilical hernia ≤ 2 cm and were included for statistical analysis. Median (range) follow-up time was 29.0 (4.3-50.1) months. Median age was 46 (26-76) years old. Median body mass index was 28 (19-38) kg/m2. Men to female ratio was 2.1. 4 patients were identified with a surgical site postoperative complication; 3 with seroma and 1 with superficial wound infection. 3 of these were given antibiotics. 2 patients were treated with wound opening bedside. There were no registered cases of a recurrence. Conclusions Repairing small umbilical hernias with a small onlay-mesh was safe with a low surgical site complication rate. Randomized trials are needed to assess weather mesh reduce recurrences in umbilical hernia repairs ≤2cm.

P073 SYNCHRONOUS VERSUS DELAYED SURGICAL TREATMENT OF MORBID OBESITY AND VENTRAL HERNIA. PRELIMINARY RESULTS OF A RETROSPECTIVE SINGLE CENTER STUDY

Aim The worldwide increase in morbid obese patients raises controverises regarding the best timing of treatment for concomitant ventral hernias (VH). We present the preliminary experience at a referral center for bariatric surgery (BS): synchronous versus delayed ventral hernia repair (S-VHR, D-VHR) have been compared. Material and Methods From 2009, 40 consecutive morbid obese patients eligible for BS presented with concomitant VH. Symptoms and characteristics of the VH were evaluated to choose between S-VHR (28 patients), primary (n = 12) or mesh augmented (n = 16), and D-VHR (12 patients). 90-day postoperative complications and hernia recurrence were evaluated. Results 3 patients out of 16 in the mesh group experienced superficial surgical site infections. 4 patients in the D-VHR had a bowel incarceration within 20 days after BS and required emergency surgery with mesh implantation. No complications occurred in the primary repair group. The recurrence rate was around 19% in both groups of the S-VHR. Nonetheless the group that received mesh repair had a significant higher mean value of the defect. In the D-VHR cohort 1 patient was lost at follow up while 3 patients were not operated on due to inadequate weight loss. No recurrences occurred in the 4 patients requiring emergency surgery. Conclusions: D-VHR is associated with worse early postoperative outcomes; primary suture repair should be considered in preventing bowel incarceration but synchronous mesh repair is preferred in large symptomatic hernias for its acceptable postoperative morbidity and hernia recurrence at 1 year.