Does expanded polytetrafluoroethylene mesh really shrink after laparoscopic ventral hernia repair?

BACKGROUND

The shrinkage of mesh has been cited as a possible explanation for hernia recurrence. Expanded polytetrafluoroethylene (ePTFE) is unique in that it can be visualized on computed tomography (CT). Some animal studies have shown a greater than 40% rate of contraction of ePTFE; however, very few human studies have been performed.

STUDY DESIGN

A total of 815 laparoscopic incisional/ventral hernia (LIVH) repairs were performed by a single surgical group. DualMesh Plus (ePTFE) (WL Gore & Associates, Newark, DE) was placed in the majority of these patients using both transfascial sutures and tack fixation. Fifty-eight patients had postoperative CTs of the abdomen and pelvis with ePTFE and known transverse diameter of the implanted mesh. The prosthesis was measured on the CT using the AquariusNet software program (TeraRecon, San Mateo, CA), which outlines the mesh and calculates the total length. Data were collected regarding the original mesh size, known linear dimension of mesh, seroma formation, and time interval since mesh implantation in months.

RESULTS

The mean shrinkage rate was 6.7%. The duration of implantation ranged from 6 weeks to 78 months, with a median of 15 months. Seroma was seen in 8.6% (5) of patients. No relationship was identified between the percentage of shrinkage and the original mesh size (P = 0.78), duration of time implanted (P = 0.57), or seroma formation (P = 0.074). In 27.5% (16) of patients, no shrinkage of mesh was identified. Of the patients who did experience mesh shrinkage, the range of shrinkage was 2.6-25%.

CONCLUSIONS

Our results are markedly different from animal studies and show that ePTFE has minimal shrinkage after LIVH repair. The use of transfascial sutures in addition to tack fixation may have an implication on the mesh contraction rates.

The Littler line method and the area under a Gaussian curve: a new method of assessing digital range of motion

A new method of measuring digital range of motion (the Littler line method) is presented. When a Gaussian curve is centered over the Littler line and the appropriate area under the curve is computed, this area can provide a measure of the functional range of motion regained by an injured digit. Seventeen children (24 digits) with flexor tendon injuries were evaluated at an average follow-up period of 58 months (range, 12-121 months). The Littler line/Gaussian curve method was found to be more reproducible than total active motion, particularly in zone I and II injuries. This method can serve as a more meaningful functional assessment tool than a linear measurement such as total active motion, because it emphasizes digital motion in the mid-ranges of digital motion. (J Hand Surg 2001;26A:23-30.

Madelung's deformity. Surgical correction through the anterior approach

A resurgence of interest in Madelung's deformity has developed recently because of improved operations for correction of the deformity, identification of the genetic loci for the condition in certain syndromal variants, identification of an anterior ligamentous structure tethering the carpus, and preventive treatments in growing children. The process is reviewed in this article and a new surgical technique is presented. The procedure is performed by way of an anterior incision that is more cosmetically appealing. The release of an anterior ligamentous structure described by Vickers is performed simultaneously with a dome shaped osteotomy of the radius. The fragments, once alignment is corrected, are stablized with temporary pin fixation and a long arm cast until the bone has healed.

The spectrum of presentation of silent sinus syndrome

The general clinical, ophthalmologic, and radiologic features of three patients with silent sinus syndrome are presented. All three patients were treated surgically. The cases of these patients illustrate the spectrum of presentation of silent sinus syndrome, including enophthalmos, hypophthalmos, transient vertical diplopia, lid retraction, lagophthalmos, and blurred vision. All patients had sinus disease, and all patients improved after surgery using functional endoscopic sinus surgery techniques. The protean manifestations of silent sinus syndrome can be identified, thereby allowing appropriate management.

Trigger finger in children

At the Texas Scottish Rite Hospital for Children, 239 trigger digits in 176 children were seen and treated surgically over a 10-year period. Trigger fingers accounted for 33 (14%) of these digits in 18 (10%) of the patients. In 8 of 18 patients (44%) the fingers continued to trigger after A-1 pulley release. In children, trigger fingers are different from trigger thumbs. Trigger fingers in children are uncommon and have variable causes, and an A-1 pulley release alone will not always correct the triggering. Additional treatments, such as resection of one or both limbs of the sublimis tendon or an A-3 pulley release, may be required. An awareness of other contributing factors and readiness to explore the entire flexor mechanism should help prevent failure of surgical treatment.

Open reduction and internal fixation of unstable distal radius fractures with a low-profile plate: a multicenter study of 73 fractures

A study of acute, dorsally displaced, unstable (high-energy) fractures of the distal radius was conducted to determine the safety and efficacy of a new low-profile plate for unstable distal radius fractures. Thirteen surgeons in 11 US cities participated in the study. A minimum follow-up period of 1 year was required to be included in the study. Seventy-three fractures in 71 patients met this criterion. Each fracture was treated according to a prospective protocol. An autogenous bone graft was used in 64 fractures. All procedures were completed using a radiolucent sterile traction table. No external fixators were used either during or after the operation. After bone grafting and while in traction, a fracture reduction clamp with a template preshaped to the normal contour of the dorsal radial metaphysis molded the fracture into reduction and then allowed precision drilling of the holes for the plate. Active wrist motion began at an average of 14 days. Satisfactory open reduction was obtained in 93% of the fractures and maintained in 88%. Ninety-five percent of the fractures demonstrated good or excellent outcomes using a standardized evaluation. Eighty-one percent of the outcomes were rated as excellent. This initial report demonstrates that the method is a safe and effective treatment for acute, unstable, dorsally displaced fractures of the distal radius.

Iliac crest bone grafting and Herbert screw fixation of nonunions of the scaphoid with avascular proximal poles

Between 1989 and 1991, 137 nonunions of the scaphoid were treated by the senior author, who noted that 26 of these nonunions had an avascular proximal pole (no punctate bleeding from the bone at the time of surgery). All 26 nonunions were treated with iliac crest bone grafting and Herbert screw fixation. Of these 26 patients, 17 were followed for more than 1 year after their surgery (average follow-up period, 31 months). The average time from injury to surgery was 31 months. Of the 17 patients included in this study, 12 were treated with a palmar approach to the nonunion, 5 with a dorsal approach. The 12 nonunions that occurred at either a midwaist or distal location were approached through a palmar modified Russe incision and treated with interpositional corticocancellous iliac crest bone graft in addition to the Herbert bone screw. The five nonunions with a very small proximal fragment were approached through a dorsal incision and treated with cancellous iliac crest bone graft and Herbert screw fixation. All patients were immobilized after operation in a short-arm thumb spica cast for 3 months and were then allowed active range of motion of their wrists. Return to full activity was permitted once preoperative wrist motion was restored. Radiographic union, as defined as bridging trabeculae of bone present in all x-ray films, occurred in nine patients, an incomplete union or persistent fibrous union in seven, and a nonunion in one patient. Using the scaphoid outcome score, an assessment scale based on pain, occupation, wrist motion, strength, and patient satisfaction, functional results were graded as excellent in six patients, good in five patients, fair in four patients, and poor in two patients. The average range of motion of the wrist did not significantly improve after surgery, but the average grip strength of the injured hand increased by 29 lbs. There were no intraoperative complications. However, three patients required further operative procedures including radial styloidectomy, pin removal, and carpal tunnel release. No patient has required either a proximal row carpectomy or wrist arthrodesis. Previously published results of avascular proximal pole scaphoid nonunions suggest that union cannot be obtained and functional results are uniformly poor. In contrast, the functional and x-ray results of our patients are markedly improved over these previous studies--emphasizing the importance of iliac crest bone grafting, rigid internal fixation, and appropriate postoperative immobilization.

Injection injuries to the median and ulnar nerves at the wrist

Carpal tunnel syndrome is often treated nonoperatively with temporary wrist immobilization and local steroid injections. A direct injection into a peripheral nerve can result in permanent damage. Two cases of median nerve injection injury and one involving the ulnar nerve are presented; all were treated with neurolysis and debridement of the injected material. At follow-up ranging from 1 to 11 years, all patients showed significant improvement, but with some functional loss. The literature is confusing because of the variety of injection techniques used for the treatment of carpal tunnel syndrome, some of which put the median nerve at risk. We recommend that the injection be made midway between the palmaris longus tendon and the flexor carpi ulnaris tendon just proximal to the proximal edge of the transverse carpal ligament in a line with the superficialis tendon of the ring finger. The injection should be stopped and redirected if the patient experiences paresthesia of any kind.

The pulp plasty: a composite graft for complete syndactyly fingertip separations

Composite grafts of skin and subcutaneous fat harvested from the glabrous non-weight-bearing areas of the foot were used to graft 34 fingertips after separation of 23 complete syndactyly webs in 13 patients. Simple complete syndactylies accounted for 17% and complex complete syndactylies accounted for 83%; synonychia was encountered in 70%. Follow-up averaged 13.9 months (minimum, 2 months, maximum 33 months). All patients had 100% take of the composite graft. Subjective gradings were 94% good, 6% fair, and there were no poor results. This technique provides a relatively normal contour and satisfactory pad to the fingertip.

The scaphoid allograft: a new operation for treatment of the very proximal scaphoid nonunion or for the necrotic, fragmented scaphoid proximal pole

This is a preliminary report of eight cases in which an allograft was used to replace half of the scaphoid. The indications for the procedure include the following: (1) Severe necrosis with fragmentation of the proximal pole, (2) Very proximal pole nonunion with small (less than 20% of the bone), unreconstructable proximal fragments, and (3) One case of severely comminuted intra-articular fracture of the scaphotrapezial joint and basal joint of the thumb caused by a gunshot wound. The Herbert scaphoid screw was used to provide rigid fixation. Follow-up ranged from 8 to 30 months. The result was good in six of eight patients. It should be emphasized that this is a preliminary report of the early experience with a new operation for salvage of difficult scaphoid fracture problems.

Silicone rubber carpal implants: a study of the incidence of late osseous complications

This clinical review of 53 silicone rubber carpal implants done by the senior author (P. R. C.) between 1976 and 1983 determines the incidence of so-called "silicone rubber synovitis." Although previously reported in small series, the true incidence of this complication of wear of the implant has not been documented. In this study late radiographic follow-up demonstrated lytic lesions adjacent to the carpal implants in 75% of the scaphoid implants, 55% of the lunate implants, and 75% of the scapholunate implants. In patients with x-ray film evidence of lytic lesions, more than half (56%) complained of pain, and more than one fourth (27%) have already had revision surgery. In every patient who had reoperation in this study, the histologic examination of the tissue in the wrist showed a chronic granulomatous process identical to that previously reported in cases of so-called "silicone rubber synovitis". These "lytic lesions" must be differentiated from "degenerative cysts" that are a part of the natural progression of degenerative arthritis. Four cases were submitted for mass spectrophotometric analysis, and the positive identification of the silica atom was made in all four. This study shows that the wear of carpal bone implants of silicone rubber and subsequent "silicone rubber synovitis" are common occurrences and not rare as has been previously inferred from isolated case report studies. This study suggests that implantation of these implants in young, healthy individuals is rarely indicated, and careful follow-up of patients who already have these implants in place is important.(ABSTRACT TRUNCATED AT 250 WORDS)

Injuries to the major nerves of the hand

This article outlines methods that can be used in the emergency department or in the physician's office to establish the presence of injury to a peripheral nerve in the upper limb. This includes motor and sensory tests that require equipment no more sophisticated than a paper clip but that give accurate, reproducible, clinically useful information.

Crush injury of the upper limb. Early and late management

The care of the patient with a crushed upper limb requires accurate assessment, carefully planned and executed surgical procedures, diligence, and reassessment. Often, a long period of rehabilitation is also needed. The quality of care rendered by the surgeon and therapist often affects the patient's functional end result and his chance to regain his ability to provide for himself independently.

Ununited fracture of the hook of the hamate

Of nine ununited fractures of the hook of the hamate, eight were treated by surgical excision of the fragment. All eight patients had relief from persistent pain and regained the preinjury level of function. This fracture occurs frequently in athletes and is often not diagnosed because it can be demonstrated only by special roentgenographic views. It is concluded that this fracture may be less rare than is commonly believed and that surgical excision permits early return of function, especially in athletes and laborers who must be able to grip hard objects strongly.