Wound healing in acutely injured fascia

London International Consensus and Delphi study on hamstring injuries part 3: rehabilitation, running and return to sport

Hamstring injuries (HSIs) are the most common athletic injury in running and pivoting sports, but despite large amounts of research, injury rates have not declined in the last 2 decades. HSI often recur and many areas are lacking evidence and guidance for optimal rehabilitation. This study aimed to develop an international expert consensus for the management of HSI. A modified Delphi methodology and consensus process was used with an international expert panel, involving two rounds of online questionnaires and an intermediate round involving a consensus meeting. The initial information gathering round questionnaire was sent to 46 international experts, which comprised open-ended questions covering decision-making domains in HSI. Thematic analysis of responses outlined key domains, which were evaluated by a smaller international subgroup (n=15), comprising clinical academic sports medicine physicians, physiotherapists and orthopaedic surgeons in a consensus meeting. After group discussion around each domain, a series of consensus statements were prepared, debated and refined. A round 2 questionnaire was sent to 112 international hamstring experts to vote on these statements and determine level of agreement. Consensus threshold was set a priori at 70%. Expert response rates were 35/46 (76%) (first round), 15/35 (attendees/invitees to meeting day) and 99/112 (88.2%) for final survey round. Statements on rehabilitation reaching consensus centred around: exercise selection and dosage (78.8%-96.3% agreement), impact of the kinetic chain (95%), criteria to progress exercise (73%-92.7%), running and sprinting (83%-100%) in rehabilitation and criteria for return to sport (RTS) (78.3%-98.3%). Benchmarks for flexibility (40%) and strength (66.1%) and adjuncts to rehabilitation (68.9%) did not reach agreement. This consensus panel recommends individualised rehabilitation based on the athlete, sporting demands, involved muscle(s) and injury type and severity (89.8%). Early-stage rehab should avoid high strain loads and rates. Loading is important but with less consensus on optimum progression and dosage. This panel recommends rehabilitation progress based on capacity and symptoms, with pain thresholds dependent on activity, except pain-free criteria supported for sprinting (85.5%). Experts focus on the demands and capacity required for match play when deciding the rehabilitation end goal and timing of RTS (89.8%). The expert panellists in this study followed evidence on aspects of rehabilitation after HSI, suggesting rehabilitation prescription should be individualised, but clarified areas where evidence was lacking. Additional research is required to determine the optimal load dose, timing and criteria for HSI rehabilitation and the monitoring and testing metrics to determine safe rapid progression in rehabilitation and safe RTS. Further research would benefit optimising: prescription of running and sprinting, the application of adjuncts in rehabilitation and treatment of kinetic chain HSI factors.

Recommendations on postoperative strain and physical labor after abdominal and hernia surgery: an expert survey of attendants of the 41st EHS Annual International Congress of the European Hernia Society

BACKGROUND

There are no valid recommendations or reliable guidelines available to guide patients how long they should refrain from lifting weights or returning to heavy physical labor after abdominal or hernia surgery. Recent studies found that surgeons' recommendations not to be evidence-based and might be too restrictive considering data on fascial healing and incisional hernia development. It is likely that this impairs the patient's quality of life and leads to remarkable socio-economic costs. Hence, we conducted this survey to gather international expert's opinions on this topic.

MATERIALS AND METHODS

At the 41st Annual International Congress of the EHS, attending international experts were asked to complete a questionnaire concerning recommendations on given proposals for postoperative refrain from heavy work or lifting after abdominal surgery and also after hernia repairs.

RESULTS

In total, 127 experts took part in the survey. 83.9% were consultants with a mean experience since specialization of more than 11 years. Two weeks of no heavy physical strain after laparoscopic surgery were considered sufficient by more than 50% of the participants. For laparotomy, more than 50% rated 4 weeks appropriate. For mesh-augmented sublay and IPOM repair of ventral or incisional hernias, more than 50% rated 4 weeks of rest appropriate. For complex hernia repair, 37% rated 4 weeks reasonable. Two weeks after, groin hernia surgery was considered sufficient by more than 50% of the participants.

CONCLUSION

Following groin hernia repair (Lichtenstein/endoscopic technique) and laparoscopic operation, the majority agreed on the proposal of 2 weeks refraining from physical strain. Four weeks of no physical strain were considered appropriate by a majority after laparotomy and open incisional hernia repair. However, the results showed substantial variation in the ratings, which indicates uncertainty even in this selected cohort of hernia surgery experts and emphasizes the need for further scientific evaluation. This is particularly remarkable, because a lack of evidence that early postoperative strain leads to higher incisional hernia rates.

TRIAL REGISTRATION

Number DRKS00023887.

Recommendations on Postoperative Activities After Abdominal Operations and Incisional Hernia Repair-A National and International Survey

Background: There is no conclusive data on postoperative recommendations after abdominal and hernia surgery, and there is significant variation in the literature on that question. Thus, this study evaluates the status quo of recommendations of postoperative activity restriction after abdominal surgery. Materials and Methods: A national (German) and international survey of general surgeons on postoperative recommendations after abdominal and hernia surgery was pooled and analyzed. Results: A total of 74.6% recommended postoperative reduced activity for 2 weeks or less after laparoscopy. For midline laparotomy, 48.8% considered a reduced activity of 4 weeks or less to be sufficient. A majority from the national survey recommended more than 4 weeks instead (60.2%), whereas only 31.5% from the international survey did so (p = 0.000). In the pooled analysis, 258 of 450 (57.3%) rated 4 weeks or less suitable. However, the recommendations differed significantly between the surveys (4 weeks or less: a national survey, 47.1% vs. international survey, 64.6%; p = 0.000). Conclusion: There was substantial variation in the given recommendations. However, we found no evidence against immediate mobilization, reduced physical activity, and lifting for up to 2 weeks after laparoscopic surgery and for up to 4 weeks after open abdominal surgery and open incisional/ventral hernia repair in uncomplicated and standard cases. There might be individual and socioeconomic benefits to allow patients to return to their whole personal level of activity and work without putting them at risk of complications. Due to lack of evidence, both retrospective and prospective, controlled studies are in need to develop reliable recommendations.

Lack of Standardized Advice on Physical Strain Following Abdominal Surgery

BACKGROUND

In Germany as elsewhere, standardized recommendations are lacking on the avoidance of physical exertion to protect the abdom - inal wall in patients who have recently undergone abdominal surgery. It is unclear how much stress the abdominal wall can withstand and how long the patient should be exempted from work. The goal of this review is to determine whether there are any standardized, evidence-based recommendations for postoperative care from which valid recommendations for Germany can be derived.

METHODS

We systematically searched the literature for evidence-based recommendations on exertion avoidance after abdominal surgery, as well as for information on the extent to which postoperative abdominal wall stress contributes to incisional hernia formation. We then created a questionnaire on recommendation practices and sent it to all of the chiefs of general and visceral surgery services that were listed in the German hospital registry (1078 chiefs of service as of June 2016).

RESULTS

All 16 of the included studies on postoperative exertion avoidance contained low-level evidence that could only be used to formulate weak recommendations ("can," rather than "should" or "must"). Some 50 000 incisional hernia repair procedures are performed in Germany each year, with a reported incidence of 12.8% in the first two years after surgery. The scientifically documented risk factors for incisional herniation are related to techniques of wound closure, the suture materials used, wound infections, and the patient risk profile. From the biological point of view, the abdominal wall regains full, normal resistance to exertional stress 30 days after a laparotomy with uncomplicated healing. Most incisional hernias (>50%) arise 18 months or more after surgery; they are more common in patients who have avoided exertion for longer periods of time (more than 8 weeks). Our questionnaire was returned by 386 surgical clinics. The responses showed that 78% of recommendations were based on personal experience only. The recommendations varied widely; exertion avoidance was recommended for as long as 6 months.

CONCLUSION

The dilemma of a deficient evidence base for postoperative exertion avoidance to protect the abdominal wall should be resolved with the much higher-quality evidence available from hernia research, which concerns the patient population with the biologically least favorable starting conditions. Based on our analysis of the available literature in light of the biomechanical principles of abdominal wall healing, we propose a new set of recommendations on postoperative exertion avoidance after abdominal surgery, with the goal of eliminating excessively protracted exertion avoidance and enabling a timely return to work.

The effect of different suturing materials for abdominal fascia wound closure on the collagen I/III expression ratio in rats

Background

Incisional hernia is a frequent complication of abdominal wall incision and has a high rate of recurrence. Most of the studies stated that non-absorbable sutures decreased incisional hernia incidences, but some stated otherwise. We aimed to compare the collagen type I/III ratio between monofilament non-absorbable sutures and multifilament absorbable sutures for abdominal fascia closure in Wistar albino rats.

Methods

Forty rats were divided into four groups. Groups 1 and 3 were sutured with monofilament non-absorbable (polyvinylidene fluoride). Groups 2 and 4 were sutured with multifilament absorbable (polyglycolide). Then, groups 1 and 2 were euthanized on day 4 (POD 4), while groups 3 and 4 were euthanized on day 7 (POD 7). Samples of fascia (1 × 0.5 cm) were taken for analysis. Collagen I/III ratios were measured using immunohistochemistry staining methods.

Results

While the expression of collagen I was not significantly different between monofilament non-absorbable and multifilament absorbable at POD 4 and 7 (p = 0.45 and 0.81, respectively), the expression of collagen III reached a significant level with p-values of 0.0003 and 0.0004 for POD 4 and 7, respectively. Moreover, the collagen I/III ratio was also significantly different between the two groups either at POD 4 (0.88 ± 0.23 vs. 0.53 ± 0.08; p = 0.0003) and 7 (1.77 ± 0.65 vs. 1.03 ± 0.28; p = 0.004).

Conclusions

Monofilament non-absorbable sutures show a significantly higher collagen I/III ratio than multifilament absorbable sutures for abdominal fascia closure in rats. Our findings imply that the usage of monofilament non-absorbable sutures might have a beneficial effect on decreasing the incisional hernia occurrence.

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One of the most important factors that influences the occurrence of incisional hernia is suturing material.

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Collagen is a major component of the extracellular matrix and plays an important role in maintaining tissue elasticity and tensility.

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The usage of monofilament non-absorbable sutures might have a beneficial effect on decreasing the incisional hernia occurrence.

The impact of different suturing techniques for abdominal fascia closure on the Interleukin-6 expressions in Rattus norvegicus

OBJECTIVE

Incisional hernia is a frequent complication of midline laparotomy. The suturing technique is an important determinant of the risk of developing an incisional hernia. Moreover, IL-6 has crucial roles in the wound-healing process. We aimed to compare the large stitch vs. small stitch technique for abdominal fascial closure on IL-6 expressions in rats.

RESULTS

Twenty rats were used. The small stitch group received small tissue bites of 5 mm and the large stitch group received large bites of 10 mm. The incisions of fascia were closed by running sutures. Animals were euthanized on days 4 and 7. Histological sections of the tissue-embedded sutures were analyzed for IL-6 expressions. Two-way ANOVA showed that rats in the small stitch group had similar IL-6 expressions on days 4 and 7 to those in the large stitch group (p = 0.36). In conclusion, the IL-6 expressions are similar between the small and the large stitch groups, implying that different suturing techniques might not have an impact on the incisional hernia occurrence.

Hamstring rehabilitation in elite track and field athletes: applying the British Athletics Muscle Injury Classification in clinical practice

Rationale

Hamstring injuries are common in elite sports. Muscle injury classification systems aim to provide a framework for diagnosis. The British Athletics Muscle Injury Classification (BAMIC) describes an MRI classification system with clearly defined, anatomically focused classes based on the site of injury: (a) myofascial, (b) muscle–tendon junction or (c) intratendinous; and the extent of the injury, graded from 0 to 4. However, there are no clinical guidelines that link the specific diagnosis (as above) with a focused rehabilitation plan.

Objective

We present an overview of the general principles of, and rationale for, exercise-based hamstring injury rehabilitation in British Athletics. We describe how British Athletics clinicians use the BAMIC to help manage elite track and field athletes with hamstring injury. Within each class of injury, we discuss four topics: clinical presentation, healing physiology, how we prescribe and progress rehabilitation and how we make the shared decision to return to full training. We recommend a structured and targeted diagnostic and rehabilitation approach to improve outcomes after hamstring injury.

Meta-analysis on Materials and Techniques for Laparotomy Closure: The MATCH Review

BACKGROUND

The aim of this systematic review and meta-analysis was to evaluate closure materials and suture techniques for emergency and elective laparotomies. The primary outcome was incisional hernia after 12 months, and the secondary outcomes were burst abdomen and surgical site infection.

METHODS

A systematic literature search was conducted until September 2017. The quality of the RCTs was evaluated by at least 3 assessors using critical appraisal checklists. Meta-analyses were performed.

RESULTS

A total of 23 RCTs were included in the meta-analysis. There was no evidence from RCTs using the same suture technique in both study arms that any suture material (fast-absorbable/slowly absorbable/non-absorbable) is superior in reducing incisional hernias. There is no evidence that continuous suturing is superior in reducing incisional hernias compared to interrupted suturing. When using a slowly absorbable suture for continuous suturing in elective midline closure, the small bites technique results in significantly less incisional hernias than a large bites technique (OR 0.41; 95% CI 0.19, 0.86).

CONCLUSIONS

There is no high-quality evidence available concerning the best suture material or technique to reduce incisional hernia rate when closing a laparotomy. When using a slowly absorbable suture and a continuous suturing technique with small tissue bites, the incisional hernia rate is significantly reduced compared with a large bites technique.

Fascia and Primo Vascular System

The anatomical basis for the concept of acupuncture points/meridians in traditional Chinese medicine (TCM) has not been resolved. This paper reviews the fascia research progress and the relationship among acupuncture points/meridians, primo vascular system (PVS), and fascia. Fascia is as a covering, with common origins of layers of the fascial system despite diverse names for individual parts. Fascia assists gliding and fluid flow and holds memory and is highly innervated. Fascia is intimately involved with nourishment of all cells of the body, including those of disease and cancer. The human body's fascia network may be the physical substrate represented by the meridians of TCM. The PVS is a newly found circulatory system; recent increased interest has led to new research and new discoveries in the anatomical and functional aspects of the PVS. The fasciology theory provides new insights into the physiological effects of acupuncture needling on basic cellular mechanisms including connective tissue mechanotransduction and regeneration. This view represents a theoretical basis and means for applying modern biomedical research to examining TCM principles and therapies, and it favors a holistic approach to diagnosis and treatment.

Pseudomonas aeruginosa wound infection involves activation of its iron acquisition system in response to fascial contact

BACKGROUND

Wound infections are traditionally thought to occur when microbial burden exceeds the innate clearance capacity of host immune system. Here, we introduce the idea that the wound environment itself plays a significant contributory role to wound infection.

METHODS

We developed a clinically relevant murine model of soft tissue infection to explore the role of activation of microbial virulence in response to tissue factors as a mechanism by which pathogenic bacteria cause wound infections. Mice underwent abdominal skin incision and light muscle injury with a crushing forceps versus skin incision alone followed by topical inoculation of Pseudomonas aeruginosa. Mice were sacrificed on postoperative Day 6, and abdominal tissues were analyzed for clinical signs of wound infection. To determine if specific wound tissue components induce bacterial virulence, P. aeruginosa was exposed to the skin, fascia, and muscle.

RESULTS

Gross wound infection caused by P. aeruginosa was observed to be significantly increased in injured tissues versus noninjured (80% vs.10%) tissues (n = 20 per group, p < 0.0001). Exposure of P. aeruginosa to individual tissue components demonstrated that fascia significantly induced bacterial virulence as judged by the production of pyocyanin, a redox-active phenazine compound known to kill immune cells. Whole-genome transcriptional profiling of P. aeruginosa exposed to the fascia demonstrated activation of multiple genes responsible for the synthesis of the iron scavenging molecule pyochelin.

CONCLUSION

We conclude that wound elements, in particular fascia, may play a significant role in enhancing the virulence of P. aeruginosa and may contribute to the pathogenesis of clinical wound infection.

Factors related to post-tonsillectomy pain in adults

OBJECTIVE

Assessment of factors related to pharyngeal anatomy and surgical technique as possible causes of post-tonsillectomy pain.

MATERIALS AND METHODS

This was a prospective observational study that included 42 patients undergoing tonsillectomy with cold and monopolar electric device dissection. We recorded duration of the entire operation, duration of electrocautery use, tonsil size and postoperative pain and discomfort assessed using a visual analogue scale (VS) and a 40-item questionnaire (QoR-40, Quality of Recovery), along with sequelae on returning to normal diet, weight loss and hospital stay. Correlations among quantitative variables were obtained by mean of lineal regression coefficients.

RESULTS

Duration of surgery was 22.66 ± 7.07 minutes, removing tonsils with a volume of 6046.07 ± 3866.20 mm(3) and an electrocautery use time of 66.14 ± 37.77 seconds, applying 1984.24 ± 1133.32 joules per patient. The most frequently observed Mallampati classification and tonsil size scores were stages II and III. The VS score increased and QoR-40 decreased at 24 hours and 7 days, but differences were statistically non-significant. Joule amount used for electrocautery was the parameter that correlated the best with discomfort status as measured via assessment scores, analgesic and corticosteroid requirements, weight loss and hospital stay. Pain was higher in subjects submitted to peritonsillar surgical aggression.

CONCLUSIONS

Improved use of electrodissection techniques, limiting and focusing the application of its energy, and preservation of peritonsillar mucosa are factors that may lower post-tonsillectomy pain levels.