Intra abdominal pressure changes in meshplasty and abdominal wall plication techniques in abdominoplasty: a comparative study

Background: Measurement of intra abdominal pressures is used to identify patients at risk of intra-abdominal hypertension and abdominal compartment syndrome after abdominoplasty that may lead to tight closure of the abdomen. This comparative study was aimed at measuring the IAP of patients in groups of meshplasty and abdominal wall plication, intraoperatively and post operatively.Methods: A comparative study was conducted among 34 patients who underwent meshplasty and abdominal wall plication. Each group comprised of 17 patients. All preoperative blood investigations and pre anesthetic evaluations were done. The technique used is decided based on the soft tissue laxity, rectus diastasis and presence of ventral hernias. Intra operatively, IAP was measured soon after the placement of mesh or after Rectus plication and post operatively, IAP was measured within 24 hours. IAP was measured using the intra vesical technique using Foley’s Catheter.Results: Fifty percent of the total patients were in the age group 41-50yrs and 88.2% of the patients were females. No significant variations in IAP, either intraoperative (p=0.051) or post operative (p=0.202), was evidenced in both groups. Post operatively, patient developed minimal complications such as seroma collection, wound infection and respiratory complications, improving on symptomatic treatment and antibiotics.Conclusions: No significant intraoperative or postoperative IAP was found between the two study groups underwent meshplasty and abdominal wall placation techniques.

Contractile Effects of Radiofrequency Energized Helium Plasma on the Fibrous Septal Network

Body contouring with liposuction has evolved significantly from the early approach of simply debulking excess fatty tissue, to affecting the mechanical properties of different tissue types and layers. Operative paradigms have been expanded to apply energy-based technologies intraoperatively to provide more uniform aspiration, selective fatty tissue emulsification in soft and fibrous body areas, minimize trauma to nerves and vessels, expose the fibrous septal network, reduce operator fatigue and help deliver smooth shapes with less discomfort and bruising. Advanced refinements with the delivery of monopolar and bipolar radiofrequency energy for soft tissue heating have been shown to reduce the residual soft tissue laxity that often follows voluminous fat removal. The Renuvion® (Apyx™ Medical, Clearwater, FL) radiofrequency powered helium plasma technology introduces an emerging concept in which the delivery of subdermal thermal energy preferentially coagulates the fascia and fibrous septal network through a conductive helium plasma stream seeking the path of least resistance, which in turn results in collagen contraction and tissue shrinkage that permits re-draping of the skin and enhanced definition. The physics and mechanics of Renuvion® subdermal soft tissue coagulation will be presented, along with clinical applications that have provided the authors more contouring finesse and has augmented liposuction outcomes.

Variability in Coronal Knee Laxity Measured During Computer-Assisted Total Knee Arthroplasty

Principal component analysis on 376 TKA knees presented the distinctive patterns and variabilities in the coronal knee angular laxity throughout the range of motion, measured post-implantation during computer-assisted total knee arthroplasty. The variability in the laxity curves were dominated by the first mode of variation (varus/valgus offset of the laxity envelope) and the second mode of variation (varus/valgus crossing pattern). Further analysis revealed that surgeon-specific impact was associated with the first mode of variation for the laxity curve, and both first and second mode of variation for the size of the laxity envelope. The results shed a light on the characteristics and variabilities of post-implantation soft-tissue laxity under surgical reality and may be used to further understand the clinical implications of intraoperative soft-tissue management.

Soft Tissue Imbalance Resulting from a Simulated Measured Resection Model as Predicted by the Use of Robotic-Assisted Total Knee Arthroplasty Technology

In this study, patients undergoing RA-TKA were critically assessed to understand the accuracy and precision of a simulated MR model used historically in manually instrumented TKA surgery. Using a 3mm threshold of soft-tissue laxity, knees were identified that would have been expected to require the application of a “reactive” CI-TKA surgical technique to achieve adequate soft-tissue balance.

Managing intra-articular deformity in high Tibial osteotomy: a narrative review

The joint line convergence angle (JLCA) has a normal range between 0° to 2°, which increases in magnitude depending on the severity and stage of osteoarthritis in the knee. The JLCA represents the interaction of the intra-articular deformity arising from the osteoarthritis and the surrounding soft tissue laxity. Therefore, the JLCA has become a vital parameter in analysing the long leg alignment views for corrective planning before osteotomy surgery. Recent studies have considered the influence on how the preoperative JLCA is measured and its influence on achieving accurate postoperative desired correction in high tibial osteotomy surgery. The JLCA also reflects the influence of soft tissue laxity in a lower limb malalignment and many surgeons encourage it to be taken into account to avoid non physiological correction and/or overcorrection with negatively impacted postoperative patient outcome. This present review addressed how to obtain an accurate preoperative measurement of the JLCA, its influence on postoperative deformity analysis and how to reduce errors arising from an elevated preoperative JLCA. We have proposed a formula to help determine the value to subtract from the planned correction in order to avoid an overcorrection when performing a corrective osteotomy. Level of clinical evidence IV, narrative review.

Facelift With Power-Assisted Dissection: A Preliminary Report

Background Subcutaneous elevation of the skin has remained a key component in all facelift techniques. Objectives The aim of this preliminary report was to introduce the ABC facelift as a 3-step method addressing photodamage, soft tissue laxity, and areas of bone and volume loss. Methods The procedure consists of: (A) anatomic and regenerative adipose grafting prior to skin elevation; (B) the use of a Baraf elevator for takedown of perpendicular subcutaneous fibers following hydrodissection of the skin flaps with tumescent solution; and (C) cautery dissection of the superficial muscular aponeurotic system (SMAS) and platysma in the neck. Results Thirty-four patients (31 females; 3 male), aged 50 to 77 years at the date of procedure, underwent an ABC facelift. Dissection of the skin flaps and SMAS elevation were faster than with traditional methods, averaging 10 to 15 minutes per hemiface. Bleeding was reduced (average estimated blood loss, 12 mL) and the skin flaps appeared better perfused with less venous engorgement and ecchymosis than achieved with sharp scissor dissection. In general, patients appeared to have shorter postoperative recovery courses and less social downtime secondary to bruising and edema. Conclusions The ABC facelift addresses facial laxity, volume loss, and skin aging with 3 simple steps: anatomic and regenerative fat grafting, combined with power-assisted dissection of the skin and cautery elevation of the SMAS. The use of more advanced hydrodissection tools to achieve further improvements in layer separation is currently being investigated. Level of Evidence: 4

The effect of anterior cruciate ligament resection on knee biomechanics

Aims The objectives of this study were to assess the effect of anterior cruciate ligament (ACL) resection on flexion-extension gaps, mediolateral soft tissue laxity, maximum knee extension, and limb alignment during primary total knee arthroplasty (TKA). Methods This prospective study included 140 patients with symptomatic knee osteoarthritis undergoing primary robotic-arm assisted TKA. All operative procedures were performed by a single surgeon using a standard medial parapatellar approach. Optical motion capture technology with fixed femoral and tibial registration pins was used to assess study outcomes pre- and post-ACL resection with knee extension and 90° knee flexion. This study included 76 males (54.3%) and 64 females (45.7%) with a mean age of 64.1 years (SD 6.8) at time of surgery. Mean preoperative hip-knee-ankle deformity was 6.1° varus (SD 4.6° varus). Results ACL resection increased the mean extension gap significantly more than the flexion gap in the medial (mean 1.2 mm (SD 1.0) versus mean 0.2 mm (SD 0.7) respectively; p < 0.001) and lateral (mean 1.1 mm (SD 0.9) versus mean 0.2 mm (SD 0.6) respectively; p < 0.001) compartments. The mean gap differences following ACL resection did not create any significant mediolateral soft tissue laxity in extension (gap difference: mean 0.1 mm (SD 2.4); p = 0.89) or flexion (gap difference: mean 0.2 mm (SD 3.1); p = 0.40). ACL resection did not significantly affect maximum knee extension (change in maximum knee extension = mean 0.2° (SD 0.7°); p = 0.23) or fixed flexion deformity (mean 4.2° (SD 3.2°) pre-ACL release versus mean 3.9° (SD 3.7°) post-ACL release; p = 0.61). ACL resection did not significantly affect overall limb alignment (change in alignment = mean 0.2° valgus (SD 1.0° valgus; p = 0.11). Conclusion ACL resection creates flexion-extension mismatch by increasing the extension gap more than the flexion gap. However, gap differences following ACL resection do not create any mediolateral soft tissue laxity in extension or flexion. ACL resection does not affect maximum knee extension or overall limb alignment. Cite this article: Bone Joint J 2020;102-B(4):442–448.