Continuous abdominal fascial closure: a randomized controlled trial of poly(L-lactide/glycolide)

[Effectiveness evaluation of three-dimensional printed titanium-alloy prosthesis reconstruction after distal tibia tumor segment resection]

Objective

To evaluate the feasibility and short-term effectiveness of three-dimensional (3D) printed titanium-alloy prosthesis reconstruction after the distal tibia tumor segment resection.

Methods

The clinical data of 6 patients with bone defect after distal tibia tumor segment resection treated with 3D printed titanium-alloy prosthesis reconstruction and tibiotalar joint fusion between January 2020 and December 2021 were retrospectively analyzed. There were 2 males and 4 females; the age ranged from 12 to 35 years, with an average of 18.5 years. Among them, 4 cases were osteosarcoma, 1 case was Ewing sarcoma, and 1 case was giant cell tumor of bone. The Enneking staging was stage ⅡA in 3 cases, stage ⅡB in 2 cases, and stage Ⅲ in 1 case. The disease duration was 2-5 months (mean, 3.2 months). All patients received preoperative neoadjuvant therapy, and patients with osteosarcoma and Ewing sarcoma started chemotherapy at3 weeks after operation. The systemic and local tumor conditions and prosthesis conditions were evaluated regularly after operation. The Musculoskeletal Tumor Society (MSTS) score and the American Orthopaedic Foot and Ankle Society (AOFAS) score were used to evaluate the lower extremity and ankle function.

Results

All patients were followed up 8-26 months, with an average of 15.6 months. There was no local recurrence and distant metastasis during the follow-up. The ankle joints of 5 cases were all in 90° functional position at last follow-up, and there was no complication such as prosthesis loosening and fracture; the ankle joint fusion was stable, the local bone ingrowth was good, and the daily activities could be completed, but the ankle range of motion was limited and the ankle joint was stiff. The MSTS score ranged from 22 to 26, with an average of 24, and 3 cases were evaluated as excellent and 2 cases were good; the AOFAS score ranged from 71 to 86, with an average of 80.6, and 4 cases were evaluated as good and 1 case was fair. One patient had severe periprosthetic infection at 2 months after operation, resulting in failure of prosthesis implantation, pain in limb movement, and poor ankle function; MSTS score was 12, AOFAS score was 50, and both were evaluated as poor; distraction osteogenesis was performed after removal of prosthesis and infection control, at present, it was still in the process of distraction osteogenesis, and local osteogenesis was acceptable.

Conclusion

Using 3D printed titanium-alloy prosthesis and tibiotalar joint fusion to reconstruct the bone defect after distal tibia tumor segment resection has satisfactory mechanical stability and function, and is one of the effective distal tibial limb salvage methods.

Synthetic biodegradable alternatives to the use of the amniotic membrane for corneal regeneration: assessment of local and systemic toxicity in rabbits

AIM

The aim of this study was to assess the local and systemic response to poly-lactic co-glycolic acid (PLGA) 50:50 membranes, developed as synthetic biodegradable alternatives to the use of human donor amniotic membrane in the treatment of limbal stem cell deficiency.

METHODS

PLGA membranes of 2  cm diameter and 50  µm thickness were placed on one eye of rabbits and secured in place using fibrin glue and a bandage contact lens, suturing the eye close with a single stitch. Control animals were treated identically, with the absence of the membranes. Plain and microfabricated electrospun membranes (containing micropockets which roughly emulate the native limbal niche) were examined over 29 days. All animals were subjected to a detailed gross and histopathological observation as well as a detailed examination of the eye.

RESULTS

Application of the membranes both with and without microfabricated pockets did not adversely affect animal welfare. There was complete degradation of the membranes by day 29. The membranes did not induce any significant local or systemic toxicity. Conjunctival congestion and corneal vascularisation were noted in a few control and PLGA-treated animals. Intraocular pressure was normal and the retinal status was unaltered. The ocular surface was clear and intact in all animals by the end of 29  days.

CONCLUSION

Membranes of 50:50 PLGA can be safely applied to rabbit corneas without inducing any local or systemic toxicity and these break down completely within 29 days.

Suture choice to reduce occurrence of surgical site infection, hernia, wound dehiscence and sinus/fistula: a network meta-analysis

BACKGROUND

There are many options and little guiding evidence when choosing suture types with which to close the abdominal wall fascia. This network meta-analysis investigated the effect of suture materials on surgical site infection, hernia, wound dehiscence and sinus/fistula occurrence after abdominal surgery. The aim was to provide clarity on whether previous recommendations on suture choice could be followed with confidence.

METHODS AND METHODS

In February 2017, the Cochrane Central Register of Controlled Trials, Medline, EMBASE and Science Citation Index Expanded were searched for randomised controlled trials investigating the effect of suture choice on these four complications in closing the abdomen. A reference search of identified trials was performed. Prisma guidelines and the Cochrane risk of bias tool were followed in the data extraction and synthesis. Two review authors screened titles and abstracts of trials identified. A random effect model was used for the surgical site infection network based on the deviance information criterion statistics.

RESULTS

Thirty-one trials were included (11,533 participants). No suture material reached the predetermined 90% probability threshold for determination of 'best treatment' for any outcome. Pairwise comparisons largely showed no differences between suture types for all outcomes measured. However, nylon demonstrated a reduction in the occurrence of incisional hernias with respect to two commonly used absorbable sutures: polyglycolic acid (odds ratio, OR 1.91; 95% confidence interval, CI, 1.01-3.63) and polyglyconate (OR 2.18; 95% CI 1.17-4.07).

CONCLUSIONS

No suture type can be considered the 'best treatment' for the prevention of surgical site infection, hernia, wound dehiscence and sinus/fistula occurrence.

Closure methods for laparotomy incisions for preventing incisional hernias and other wound complications

BACKGROUND

Surgeons who perform laparotomy have a number of decisions to make regarding abdominal closure. Material and size of potential suture types varies widely. In addition, surgeons can choose to close the incision in anatomic layers or mass ('en masse'), as well as using either a continuous or interrupted suturing technique, of which there are different styles of each. There is ongoing debate as to which suturing techniques and suture materials are best for achieving definitive wound closure while minimising the risk of short- and long-term complications.

OBJECTIVES

The objectives of this review were to identify the best available suture techniques and suture materials for closure of the fascia following laparotomy incisions, by assessing the following comparisons: absorbable versus non-absorbable sutures; mass versus layered closure; continuous versus interrupted closure techniques; monofilament versus multifilament sutures; and slow absorbable versus fast absorbable sutures. Our objective was not to determine the single best combination of suture material and techniques, but to compare the individual components of abdominal closure.

SEARCH METHODS

On 8 February 2017 we searched CENTRAL, MEDLINE, Embase, two trials registries, and Science Citation Index. There were no limitations based on language or date of publication. We searched the reference lists of all included studies to identify trials that our searches may have missed.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared suture materials or closure techniques, or both, for fascial closure of laparotomy incisions. We excluded trials that compared only types of skin closures, peritoneal closures or use of retention sutures.

DATA COLLECTION AND ANALYSIS

We abstracted data and assessed the risk of bias for each trial. We calculated a summary risk ratio (RR) for the outcomes assessed in the review, all of which were dichotomous. We used random-effects modelling, based on the heterogeneity seen throughout the studies and analyses. We completed subgroup analysis planned a priori for each outcome, excluding studies where interventions being compared differed by more than one component, making it impossible to determine which variable impacted on the outcome, or the possibility of a synergistic effect. We completed sensitivity analysis, excluding trials with at least one trait with high risk of bias. We assessed the quality of evidence using the GRADEpro guidelines.

MAIN RESULTS

Fifty-five RCTs with a total of 19,174 participants met the inclusion criteria and were included in the meta-analysis. Included studies were heterogeneous in the type of sutures used, methods of closure and patient population. Many of the included studies reported multiple comparisons.For our primary outcome, the proportion of participants who developed incisional hernia at one year or more of follow-up, we did not find evidence that suture absorption (absorbable versus non-absorbable sutures, RR 1.07, 95% CI 0.86 to 1.32, moderate-quality evidence; or slow versus fast absorbable sutures, RR 0.81, 95% CI 0.63 to 1.06, moderate-quality evidence), closure method (mass versus layered, RR 1.92, 95% CI 0.58 to 6.35, very low-quality evidence) or closure technique (continuous versus interrupted, RR 1.01, 95% CI 0.76 to 1.35, moderate-quality evidence) resulted in a difference in the risk of incisional hernia. We did, however, find evidence to suggest that monofilament sutures reduced the risk of incisional hernia when compared with multifilament sutures (RR 0.76, 95% CI 0.59 to 0.98, I2 = 30%, moderate-quality evidence).For our secondary outcomes, we found that none of the interventions reduced the risk of wound infection, whether based on suture absorption (absorbable versus non-absorbable sutures, RR 0.99, 95% CI 0.84 to 1.17, moderate-quality evidence; or slow versus fast absorbable sutures, RR 1.16, 95% CI 0.85 to 1.57, moderate-quality evidence), closure method (mass versus layered, RR 0.93, 95% CI 0.67 to 1.30, low-quality evidence) or closure technique (continuous versus interrupted, RR 1.13, 95% CI 0.96 to 1.34, moderate-quality evidence).Similarily, none of the interventions reduced the risk of wound dehiscence whether based on suture absorption (absorbable versus non-absorbable sutures, RR 0.78, 95% CI 0.55 to 1.10, moderate-quality evidence; or slow versus fast absorbable sutures, RR 1.55, 95% CI 0.92 to 2.61, moderate-quality evidence), closure method (mass versus layered, RR 0.69, 95% CI 0.31 to 1.52, moderate-quality evidence) or closure technique (continuous versus interrupted, RR 1.21, 95% CI 0.90 to 1.64, moderate-quality evidence).Absorbable sutures, compared with non-absorbable sutures (RR 0.49, 95% CI 0.26 to 0.94, low-quality evidence) reduced the risk of sinus or fistula tract formation. None of the other comparisons showed a difference (slow versus fast absorbable sutures, RR 0.88, 95% CI 0.05 to 16.05, very low-quality evidence; mass versus layered, RR 0.49, 95% CI 0.15 to 1.62, low-quality evidence; continuous versus interrupted, RR 1.51, 95% CI 0.64 to 3.61, very low-quality evidence).

AUTHORS' CONCLUSIONS

Based on this moderate-quality body of evidence, monofilament sutures may reduce the risk of incisional hernia. Absorbable sutures may also reduce the risk of sinus or fistula tract formation, but this finding is based on low-quality evidence.We had serious concerns about the design or reporting of several of the 55 included trials. The comparator arms in many trials differed by more than one component, making it impossible to attribute differences between groups to any one component. In addition, the patient population included in many of the studies was very heterogeneous. Trials included both emergency and elective cases, different types of disease pathology (e.g. colon surgery, hepatobiliary surgery, etc.) or different types of incisions (e.g. midline, paramedian, subcostal).Consequently, larger, high-quality trials to further address this clinical challenge are warranted. Future studies should ensure that proper randomisation and allocation techniques are performed, wound assessors are blinded, and that the duration of follow-up is adequate. It is important that only one type of intervention is compared between groups. In addition, a homogeneous patient population would allow for a more accurate assessment of the interventions.