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Polycarpou A, Chopko TC, Glasgow AE, McCarthy SR, Hilliker DR, Wilder RT, Klinkner DB. One-year Results of Minimally Invasive Sutured Fixation of the Slipped Ribs in the Pediatric Population. J Pediatr Surg 2024; 59:1703-1707. [PMID: 38522977 DOI: 10.1016/j.jpedsurg.2024.02.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 02/07/2024] [Accepted: 02/21/2024] [Indexed: 03/26/2024]
Abstract
PURPOSE Costal cartilage resection with or without rib resection is the gold standard surgery for slipping rib syndrome. Minimally invasive restoration of normal anatomy via nonabsorbable sutures has been described in the adult population with encouraging results. We sought to assess the efficacy of minimally invasive sutured fixation of the hypermobile rib in the pediatric population. METHODS A retrospective review was performed at Mayo Clinic involving 31 pediatric patients diagnosed with slipped rib syndrome. Minimally invasive sutured open reduction internal fixation was performed between 2020 and 2022. The standardized Örebro Musculoskeletal Pain Screening Questionnaire was given at dedicated time points pre- and post-operatively to assess efficacy. Significance was determined via the Wilcoxon rank sum test. RESULTS SRS was diagnosed clinically in 31 patients (24 females, 7 males, 1220 years-old). Symptoms were present for an average of 18.9 months and patients had seen an average of 4.7 specialists. Traumatic causes were identified in three patients and eight patients had hypermobility. At one month follow up, there were no surgical complications and patients reported significantly less pain (p < 0.001). Preoperative analgesics reduced by 80%. Ultimately, seven patients underwent a second operation; three patients underwent a third operation; one patient underwent five total operations. Recurrent pain was reported in six patients. Only nine patients followed-up at 1-year post-operation. CONCLUSION Pediatric patients with SRS demonstrated an early positive response to suture fixation without costal cartilage excision. Reoperation and recurrent pain, however, remain significant in this population. LEVEL OF EVIDENCE Level IV. TYPE OF STUDY Case series with no comparison group.
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Affiliation(s)
- Andreas Polycarpou
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Trevor C Chopko
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Amy E Glasgow
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Sarah R McCarthy
- Mayo Clinic College of Medicine & Science, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA; Department of Psychiatry and Psychology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Daniel R Hilliker
- Mayo Clinic College of Medicine & Science, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA; Department of Psychiatry and Psychology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Robert T Wilder
- Mayo Clinic College of Medicine & Science, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA; Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Denise B Klinkner
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA; Mayo Clinic College of Medicine & Science, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Abstract
INTRODUCTION An ideal ligature should tighten readily and remain tight. Ligature failure can be a critical complication of invasive procedures in human and veterinary surgical practice. Previous studies have tested various knots but not the constrictor knot. METHODS A new test bench was employed to compare six ligatures using four suture materials. As tension in a ligature is not readily measured, the study employed a surrogate measurement: the force required to slide a ligature along a rod. Benchmark values tested each suture material wrapped around the rod to establish the ratio between this force and the ligature tension for each material. Each ligature was tested first during tightening and then again afterwards. The benchmark ratios were employed to calculate the tensions to evaluate which ligature and which suture material retained tension best. RESULTS The model provided consistent linear relationships between the tension in the suture and the force required to pull the ligature along the rod. The constrictor knot retained tension in the ligature best (55-107% better than the next best ligature). Among the suture materials, polydioxanone had the greatest ability to retain the tension in a ligature and polyglactin the least. CONCLUSIONS The constrictor knot showed superior characteristics for use as a ligature, and should be introduced into teaching and clinical practice for human and veterinary surgery. The new test bench is recommended for future testing of ligatures as well as objective comparison of suture materials.
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