Prospective Outcomes of a Biological Resurfacing Arthroplasty with Fascia Lata Autograft (BioJoint) for the Treatment of Osteoarthritis of the Midtarsal Joint Complex

OBJECTIVE

To determine the clinical, safety, and radiological outcomes after biological resurfacing arthroplasty for the treatment of osteoarthritis (OA) of one or more joints of the midtarsal joint complex.

DESIGN

All prospectively followed patients with OA to one of or multiple joints of the midtarsal joint complex who were operated with a biological resurfacing arthroplasty with a fascia lata autograft (BioJoint procedure) were included. A total of 7 patients were included (5 males, 2 females), with a median age of 52 (interquartile range [IQR] 44-55) years. The primary outcome was the Numeric Rating Scale (NRS) for pain during walking 2 years postoperatively. Range of motion (ROM), revision rates, and complications were assessed. A postoperative MRI scan was performed to assess progression of OA, graft position and ingrowth, and the degree of bone marrow edema.

RESULTS

There was a 100% follow-up of the patients (median follow-up: 33 [IQR 26-33] months). The NRS during walking improved from 6 preoperatively to 2 at 2 years postoperatively (P < 0.05). There were no reoperations nor severe complications. The limitations in the ROM remained limited in the majority of the cases. MRI at 2 years of follow-up showed no progression of OA, reduced bone marrow edema, and no loosening of the grafts.

CONCLUSION

Biological resurfacing arthroplasty with a fascia lata autograft (BioJoint procedure) for OA to one or more joints in the midtarsal joint complex showed clinically relevant pain reduction during walking, improvement in clinical and radiological outcomes, and proved to be safe and durable.

Reconstruction of the severe Achilles tendon and soft-tissue loss with the bi-pedicled conjoined flap and vascularized fasciae latae: A consecutive case series of 15 patients

BACKGROUND

Historically, the segmental loss of the Achilles tendon with overlying soft-tissue defects had been frequently reconstructed with the composite anterolateral thigh (ALTP) flap, including the iliotibial tract or fasciae latae. This study aimed to present our modified combination using the bi-pedicled conjoined flap with vascularized fasciae latae, for the approximately total reconstruction of the Achilles tendon and extensive soft tissue.

METHODS

From May 2015 to March 2018, 15 patients (9 male and 6 female) with a mean age of 36 years (ranged, 18-52 years) underwent microvascular Achilles tendon reconstruction. Harvested on the abdomen and groin, the conjoined flap was chimeric with the vascularized fasciae latae. Primary donor-site closure was accomplished in all patients. A standard assessment of the functional and esthetical outcomes was completed.

RESULTS

Mean follow-up time was 42 months (ranged, 32-48 months). The average dimension of the conjoined flap was 25 × 14 cm (ranged, 18 × 10-35 × 18 cm), and the average size of the folded fasciae latae was 15 × 6 cm (ranged, 12 × 5-25 × 8 cm). At the last follow-up, the Thompson test was negative in all patients. The mean American Orthopedic Foot and Ankle Society (AOFAS) score was 91.0. The mean Achilles tendon total rupture score (ATRS) was 18.5. The mean Vancouver Scar Scale (VSS) score was 3.0.

CONCLUSIONS

The composite bi-pedicled flap including vascularized fasciae latae provides an alternative approach with great functional and esthetic outcomes, in selected patients who suffered severe Achilles tendon and skin defects. The one-stage procedure facilitates better rehabilitation postoperatively.

Management of Avascular Necrosis (AVN) of Femoral Head by Core Decompression with Tensor Fascia Lata (TFL) Muscle Pedicle Bone Graft

Avascular necrosis (AVN) of femoral head is an increasingly common cause of musculoskeletal disability. Most of the cases caused by steroid induced and traumatic but idiopathic cause are not also uncommon. Almost all the patients presented with pain at the hip, limping gait, restricted movement and difficulty in waking and squatting and becomes disabled. Core decompression and muscle pedicle bone graft at stage IIA, IIB and III provides painless and mobile life. Core decompression supplemented with bone graft to enhance mechanical support and augment healing. We have started a prospective study for the treatment of AVN of Femoral head at stage IIA, IIB and III by core decompression and Tensor fascia lata muscle pedicle bone graft in the department of Orthopaedic surgery Bangabandhu Seikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from January 2009 to December 2019. Aim of the study was to assess the effectiveness of core decompression and tensor fascia lata muscle pedicle bone graft in the treatment of AVN of femoral head at stage IIA, IIB and III. A total 48 patients and 65 hips were operated. Out of 48 patients, male was 30(62.50%) and female was 18(37.5%). Male-Female ratio was 1.66:1. Age of the patients ranging from 20 years to 50 years, mean age 36±4.65 years. According to aetiology corticosteroid induced was 47/65 (72.31%), idiopathic was 8(12.31%), post traumatic was 4(6.15%), ITP was 2(3.08%), ALL was 2(3.08%), and alcohol induced was 2(3.08%) of femoral head involvement. According to Ficat and Arlet's staging, stage IIA hip involvement was 28/65(43.08%), stage IIB was 32(49.23%) and stage III was 5(07.69%). All patients were treated with core decompression along with tensor fascia lata (TFL) muscle pedicle bone graft. All patients were followed clinically and radiologically at regular interval. Follow up period was 6 months to 10 years. Harris hip score (HHS) was used for evaluation of clinical outcome. Among the 65 hips, 24(36.92%) was excellent outcome (HHS >90), 30(46.15%) was good outcome (HHS: 80-90), 7(10.78%) was fair outcome (HHS: 70-79) and 4(6.15%) was poor outcome. For valid statistical analysis excellent and good results were grouped as satisfactory that was 54(83.07%) and fair and poor results were grouped as unsatisfactory that was11(16.93%), p value is <0.001 that is significant. It has been concluded that core decompression and TFL muscle pedicle bone graft is a pain relieving, head preserving procedure and improve hip function for the management of AVN of femoral head in stage IIA, IIB and III.

Free vascularized fascia lata flap for total columella reconstruction

INTRODUCTION

Despite their relatively small size, columellar defects, including both external and internal elements, are exceedingly difficult to reconstruct. Local, regional, and distant flaps have been described for reconstruction. Herein, we present a novel technique for reconstruction of the columella using vascularized free fascia lata from the anterolateral thigh with structural replacement and skin grafting.

METHODS

This novel technique utilizes a small anterolateral thigh flap, formed into vascularized fascia lata without the overlying subcutaneous fat or skin. The fascia lata is inset into the columellar and caudal septal defect after a cartilage framework is constructed and is microsurgically anastomosed to either distal facial or angular vessels. A skin graft from the ALT donor site is then secured over the fascia.

RESULTS

This technique has been applied successfully in patients with either isolated columella or in multi-subunit reconstruction following total rhinectomy with no flap or reconstructive failures. Given the low morbidity of flap harvest and minimal access incisions, this has been reliably accomplished with short (1-2 day) hospital stays.

CONCLUSION

Rapid and aesthetically acceptable reconstruction of total nasal columella defects in isolation or with additional nasal subunit reconstruction, is possible utilizing this novel technique. Here we discuss pearls and pitfalls of its use following surgical resection of malignancy.

Fascia lata packing and tension suturing for symptomatic pseudomeningocele after recurrent cervical intradural tumour resection

In recurrent posterior cervical intradural tumour resections, serious complications can be developed. The dural can become affected by inflammatory factors or removed during tumor resection; if cerebrospinal fluid (CSF) leakage cannot be stopped by duraplasty, artificial meninges or fascia repair, large pseudomeningocele can develop posteriorly within the soft tissue of the neck. When the pressure of the CSF cannot be maintained steadily, persistent clinical symptoms can occur, such as postural headache or central fever. Moreover, the skin can also be penetrated in a few patients even after extension of the drainage duration, lumbar cistern drainage or skin suturing, leading to the induction of life-threatening intra-cranial infections. Is there a simple and effective surgical method to address this scenario? The aim of this study was, therefore, to investigate the effectiveness of fascia lata packing and tension suturing in the treatment of symptomatic pseudomeningocele after recurrent posterior cervical intradural tumour resection. In our study, nine consecutive spinal surgery patients were recruited from January 2008 to January 2018. All pseudomeningoceles were combined with postural headache, central neurological fever or wound non-union. There were 3 cases of melanocytoma, 3 cases of nasopharyngeal carcinoma metastasis, 2 cases of breast cancer metastasis, and 1 case of spinal canal lymphadenoma. Standard patient demographics, diagnosis, post-operative symptoms, wound healing time, and the largest pre- and last follow-up pseudomeningocele area on axial MRI sections were recorded. All cases were followed-up successfully, from 12 to 24 months, with an average of 15.3 months. Our observations indicate that all wounds healed successfully. The wound union time was 20.7 days on average. After wound union, these patients became symptom free. The largest cerebrospinal fluid area on axial MRI sections improved significantly from 42.9 ± 5.01 cm² at p re-operation to 6.6 ± 1.89 cm² at 1 year post-operation (P < 0.05); Our data indicate that .the proposed procedure is simple, safe and effective. And more importantly, it allows rapid closure of any cerebrospinal fluid leakage pools.

Medial patellofemoral ligament reconstruction in children: A comparative randomized short-term study of fascia lata allograft and gracilis tendon autograft reconstruction

BACKGROUND

Many surgical procedures have been described to treat recurrent patellar dislocation, but none of these techniques has been successful in all patients. The goal of the study was to evaluate the results of medial patellofemoral ligament reconstruction in children. Two operative procedures were evaluated; a fascia lata allograft and an autologous gracilis graft.

METHODS

Forty-four children (27 girls and 17 boys) between 13 and 17 years of age with unilateral recurrent patellar dislocation underwent medial patellofemoral ligament (MPFL) reconstruction. Patients were operated in two orthopedic centers. The 1st group contained 22 patients and surgery was performed using a fascia lata allograft. In the 2nd group of patients which also contained 22 children and autologous gracilis graft was used. The mean age of the patients was 14.9 years and the mean follow-up was 24 months. Preoperatively, all patients were evaluated clinically (Kujala score questionnaire) and radiologically. The same evaluation was used 18 to 30 months postoperatively to estimate the results of our treatment.

RESULTS

In 1st group of children operated with cadaver allografts, the Kujala score significantly improved from 73.91 points preoperatively to 94.50 points postoperatively (P < .001). The average duration of operating procedure was 1 hour and 35 minutes. As shown by subjective symptoms, the results in 95% of patients were rated as good or very good. All children returned to full activity. Similar results were obtained in patients in 2nd group, where MPFL was reconstructed with ipsilateral gracilis tendon. Kujala score increased from 70.77 points preoperatively to 94.32 postoperatively (P < .001). Our results were estimated as good or very good in 93% of patients. All patients that were operated returned to full activity. However, median duration of operation was longer and lasted 1 hour and 55 minutes.

CONCLUSIONS

Both techniques were effective in the short-term (18-30 months) in treatment of recurrent patellar dislocation. The use of cadaver allograft spares the hamstring muscles and reduces the time of surgery. Therefore, such study appears to be useful because it provides valuable information that would help to guide treatment of this condition in children. Level of evidence II-2.

Acetabular cup revision combined with tensor facia lata reconstruction for management of massive abductor avulsion after failed total hip arthroplasty

We report on 17 patients with massive abductor avulsions after total hip arthroplasty (THA) treated with medialization of the acetabular component and tensor fascia lata (TFL) reconstruction. All patients had severe limp, positive Trendelenburg sign, and avulsion of the abductor insertion confirmed on MRI. Mean age was 69 years (range, 50-83 years), and mean follow-up period was 36 months (range, 18-78 months). After surgery, 9 patients had no limp (47%), 8 patients had a mild limp, and abductor power improved from mean 2.5/5 to mean 3.8 (P < 0.0001). At latest follow-up, the Harris Hip Score was excellent in 6 hips (37%), good in 7 (43%) hips, and fair or poor in 3 (23%). Two patients with mild limp were not satisfied with their procedure.

Pelvic deformity secondary to tensor fascia lata tightness associated with desmoid tumor

The iliotibial band is a thick, condensed fascia that, when contracted, leads to a hip flexion, abduction, and external rotation contracture in addition to other joint contractures. Iliotibial band tightness occurs secondary to iliotibial band friction syndrome, which commonly occurs at the lateral femoral epicondylar region. However, a proximal cause of iliotibial band/tensor fascia lata friction syndrome leading to a secondary hip contracture is swelling around the hip; this swelling being a desmoid tumor has not been explicitly described in the literature. The authors present a rare case of a hip contracture in a 28-year-old active man who presented with a functionally disabling hip flexion contracture of 20° with further flexion possible up to 130°, a 45° abduction contracture, and a 20° external rotation contracture with further rotation possible up to 40° with a bony hard swelling in the left gluteal region. Ober’s test was positive. Opposite hip and spine examinations were normal. The goals of treatment were to establish the causality between the 2 and to diagnose the etiology of the gluteal mass. Radiographs were normal, with only a pelvic obliquity evident. Magnetic resonance imaging revealed an extra-articular mass abutting the iliac blade. Histopathology confirmed the mass to be a desmoid tumor in the left gluteal region. A wide surgical excision of the mass was performed with negative margins; no postoperative radiotherapy was administered. After rigorous physiotherapy, the hip deformity disappeared at 6 months and there was no evidence of recurrence at 2.5-year follow-up, with the patient able to sit cross-legged and squat.

Anatomical reconstruction of the patellar tendon using the fascia lata attached to the iliac bone following resection for soft tissue sarcoma: a case report

A new reconstruction of the patellar tendon was performed in a 43-year-old patient who lost tendon and tibial tuberosity after a wide tumor resection for low-grade myofibroblastic sarcoma of the parapatellar tendon. In this technique, the patellar tendon was anatomically reconstructed using a fascia lata attached to the iliac bone. The iliac bone was fixed to the tibial bony trough with absorbable screws, and the fascia lata was fashioned into three branches: the central branch was folded through the tunnel in the patella, and the medial and lateral branches were tagged to the medial and lateral retinaculum, respectively, around the patella. The skin defect was covered by the bilateral head of the gastrocnemius flap and a split-thickness skin graft. At the 3-year follow-up, the active range of motion of the knee joint was 0 to 110 degrees. The functional result according to the Musculoskeletal Tumor Society scoring system was 97%. Radiographs showed that the grafted bone was united well to the tibial bone, and the grafted fascia was confirmed as a dark band on MRI. There was no evidence of disease and no complaint of the donor site. This procedure allows for the reconstruction of the patellar tendon in the original location. To our knowledge, this reconstructive procedure of the patellar tendon using the fascia lata attached to the iliac bone has never been reported in English literature.

Endoscopic repair of cerebrospinal fluid rhinorrhoea in a developing country

The objectives of the study was to determine the causes and outcome of endoscopic repair of cerebrospinal fluid (CSF) leak in a developing country. A total of five patients were recruited in the study. The age of patients ranged from 8 to 65 years. Four patients were male and one was female. In two cases of iatrogenic injury, the first was in the sphenoid sinus. The second was following functional endoscopic sinus surgery (FESS). Fascia lata was used to repair all cases. Beriplast was used as sealing agent in four cases and clotted blood was used in remaining case. Despite the small number, CSF rhinor rhoea was resolved in all cases. The patients were followed up for 2.5 to 6.5 years. Endoscopic repair is a viable option even in developing countries. It is cost effective and has a very low morbidity rate with no mortality at all.

Results of levator excision followed by fascia lata brow suspension in patients with congenital and jaw-winking ptosis

AIM

The purpose of the study was to examine the results of frontalis brow suspension after levator excision in patients with ptosis, and to determine whether satisfactory cosmetic results can be achieved with this procedure.

METHODS

A retrospective case notes review of 13 patients (21 lids) undergoing levator weakening and frontalis brow suspension using autogenous fascia lata was performed. Seven patients (14 lids) were affected by the Marcus Gunn jaw-winking phenomenon. These had bilateral levator muscle excision. Five patients (5 lids) had unilateral congenital levator dystrophy (isolated congenital ptosis) with poor levator function. These had levator muscle excision on the normal side only. One patient (2 lids) had congenital aberrant regeneration of the third nerve. This patient had bilateral levator muscle excision. A successful result in terms of lid height was defined as a lid height within 1 mm of the desired height.

RESULTS

During the first post-operative month, 11 out of 21 lids were undercorrected by more than 1 mm, whilst 10 achieved a satisfactory lid height. At subsequent follow-up visits, 18 lids were within 1 mm of the desired height and only 3 lids of 2 patients remained undercorrected by more than 1 mm and required further surgery. There were no overcorrections.

CONCLUSIONS

Excision of the levator muscle followed by brow suspension ptosis correction can reliably produce satisfactory cosmetic results with good symmetry of lid movement and position. It is used selectively in the normal upper lid in congenital ptosis with poor levator function and in both upper lids in synkinetic ptosis.

[Analysis of treatment results 389 patients with congenital blepharoptosis]

PURPOSE

Retrospective analysis of the results in the treatment of congenital blepharoptosis.

MATERIAL AND METHODS

We retrospectively reviewed the records of 389 patients with blepharoptosis who underwent surgical treatment in the Hospital of Plastic Surgery in Polanica-Zdrój, from January 1976 to January 2005. The age of patients, degree of malformation and unilateral or bilateral occurrence of ptosis, was analyzed. Moreover, we studied treatment results of patients with blepharoptosis treated in our hospital and patients treated elsewhere, before admission to our hospital.

RESULTS

218 patients from 327 operated in our hospital had levator muscle resections. After 6 months of observation 39 patients were qualified for surgical re-correction. 12 months after surgery 4 patients had recurrence of ptosis. Frontalis suspension technique with using the temporal fascia, was performed in 109 patients. After 6 months observation, 8 patients were qualified for surgical re-correction.

CONCLUSIONS

For patients with maintained function of the levator muscle the most effective and physiological procedure, is the muscle shortening. Frontalis suspension technique with use of the temporal fascia should be limited to treat failure cases and patients with poor or absent function of the levator muscle.

[Orbitoblepharophimosis syndrome--own clinical experience in treatment of 60 patients]

PURPOSE

The orbitoblepharophimosis syndrome is an autosomal-dominant congenital malformation involving the orbitopalpebral region. The condition is associated with orbital phimosis, upper eyelid ptosis, epicanthus and telecanthus.

MATERIAL AND METHODS

We retrospectively reviewed the records of 60 patients with blepharophimosis who underwent surgery in the Hospital of Plastic Surgery in Polanica Zdrój from January 1975 to January 2006. The study population consisted of 23 (38.3%) females and 37 (61.7%) males patients whose age at the time of first surgical stage ranged from 1 to 48 years (mean 8 years). Surgical management consisted of epicanthus correction using modified technique of Mustardé followed by eyelid suspension to the frontalis muscle with using temporal fascia. In patients with orbitoblepharophimosis type II, correction of the lower lid ectropion and antimongoid slanting palpebral fissures, were performed before or after Mustardé procedure.

RESULTS

In our series of 60 patients, good result of treatment was obtained in 80.1% and satisfactory in 18.3% of patients. Poor outcome was obtained only in one patient with orbitoblepharophimosis type II.

CONCLUSIONS

Orbitoblepharophimosis management should consists of gradual and complex surgical treatment. During the first stage epicanthus correction is performed. As a second stage, blepharoptosis is treated by frontalis suspension technique with using temporal fascia.

Arthroscopic bursectomy with concomitant iliotibial band release for the treatment of recalcitrant trochanteric bursitis

Trochanteric bursitis with lateral hip pain is a commonly encountered orthopaedic condition. Although most patients respond to corticosteroid injections, rest, physical therapy (PT), stretching, and anti-inflammatory medications, those with recalcitrant symptoms may require operative intervention. Studies have explored the use of the arthroscope in the treatment of these patients. However, these reports have not addressed the underlying pathology in this chronic condition. We believe that the iliotibial band must be addressed and is the main cause of pain, inflammation, and trochanteric impingement leading to the development of bursitis. We report a new technique for arthroscopic trochanteric bursectomy with iliotibial band release. Our technique involves 2 incisions--one 4 cm proximal to the greater trochanter along the anterior border of the iliotibial band, and the other 4 cm distal and along the posterior border. The 30 degrees arthroscope is introduced through the inferior portal, and a cannula is introduced through the superior portal. A 5.5-mm arthroscopic shaver is inserted through the superior cannula to clear off the surface of the iliotibial band, so that it may be adequately visualized. A hooked electrocautery probe is then used to longitudinally incise the iliotibial band until it no longer rubs, causing impingement over the greater trochanter.

Simple alternative to the Wright needle in frontalis sling surgery

The Wright needle is a widely used instrument for insertion of fascia lata or a synthetic material during frontalis suspension surgery; however, difficulties in handling this instrument are frequently encountered by many surgeons. We describe an 18-gauge needle with a 4/0 monofilament polypropylene suture as an alternative to the Wright needle for placement of the sling material in frontalis suspension surgery. Less slippage and easier control of the needle's direction and depth of tissue penetration result in more accurate placement of the material and a reduction in damage to the surrounding tissues.

Blepharophimosis-ptosis-epicanthus inversus syndrome: objective analysis of surgical outcome in patients from a single unit

BACKGROUND

The aim was to objectively assess surgical outcome in blepharophimosis-ptosis-epicanthus inversus syndrome (BPES).

METHOD

Retrospective review of 14 consecutive patients with BPES. Mustardé double z plasty (at about age 4) and autogenous fascia lata Crawford brow suspension (9-12 months later) were used in all. One consultant performed all operations. Patient photographs were scanned and magnified for analysis. Preoperative and postoperative intercanthal distance, vertical palpebral aperture and cosmetic outcome were measured. Values were converted into ratios.

RESULTS

Bilateral (mildly asymmetrical) ptosis and symmetrical epicanthic folds were found in all preoperatively. Seventy-one per cent had severe folds. Preoperative intercanthal distance ratio range was 1.26-1.60 (non-BPES=1.0). Median reduction post surgery was 26% (P=0.001, Wilcoxon's signed ranks test). Patients with largest preoperative ratio displayed greatest correction (P=0.029). Mustardé technique completely abolished all epicanthic folds and unmasked prominent caruncles in all. Fifty per cent had mild scarring postoperatively in the medial canthal region. Median change in marginal reflex distance ratio (right)=22.2% (P=0.012), left=18.2% (P=0.008), Wilcoxon's signed ranks tests. Postoperatively all had formed eyelid creases with improved upper lid position symmetry.

CONCLUSIONS

This is the first known study objectively assessing surgical outcome in BPES. Mustardé double z plasty and Crawford autogenous fascia lata brow suspension are an effective surgical combination in the treatment of this syndrome, with overall cosmetic benefit.

Fasciotomy closure using simultaneous vacuum-assisted closure and hyperbaric oxygen

Fasciotomies performed for compartment syndrome and ischemic vascular disease often requires closure in 2 to 4 weeks by skin graft. This leaves the patient with an unsightly scar and a limb with reduced strength. The use of vacuum-assisted closure (VAC) and hyperbaric oxygen therapy (HBOT) quickly reduce the edema and permit earlier closure with adjacent skin. A study of three trauma patients with compartment syndrome, fasciotomies, and the use of the VAC and HBOT to close the fasciotomy wounds with adjacent skin is presented. The pathophysiology of compartment syndrome and ischemia-reperfusion syndrome is discussed. These patients had closure of the fasciotomy wounds in 3 to 18 days. The simultaneous use of HBOT and VAC accelerates the reduction of edema in a synergistic fashion, permitting early closure of fasciotomy wounds.

Surgical treatment of abdominal wall tumor seeding after percutaneous transhepatic biliary drainage

Occasional cases of malignant seeding of cancer cells along the catheter tract, particularly affecting the skin, have been reported after percutaneous biliary drainage. Although radical resection of the abdominal wall may achieve long-term postoperative survival, reconstruction of large abdominal defects that cannot be closed primarily is problematic. We describe the successful surgical repair of a full-thickness defect of the abdominal wall using a free tensor fascia lata musculofasciocutaneous flap anastomosed to the intraabdominal gastroepiploic vessels.

Giant combined microdissected thin thigh perforator flap

Despite recent advances in reconstructive surgery, extremely wide and thin flap coverage has rarely been reported. Recently, the authors developed a technique for transferring a very wide and thin flap from the thigh area using microdissection. In this procedure, both perforators of the anterolateral thigh flap and the tensor fasciae latae perforator flap were microdissected simultaneously and these two perforator flaps were elevated in combination based on the common pedicle of the vessels. In this report, the detailed technique of the procedure is described along with a discussion of the safety of this giant flap in consideration of 60 clinical experiences of microdissected thin tensor fasciae latae perforator and anterolateral thigh flaps.

[Designing a surgical device for harvesting autologous fascia lata grafts as a minimal invasive procedure]

AIMS

Fascia lata is used in different shapes and sizes as a graft material in surgical procedures. The conventional method of harvesting a fascia lata graft is through a long skin incision on the lateral aspect of the thigh. Minimal invasive procedures have been established to reduce the disadvantages of an extensive surgical approach for obtaining the autotransplant. However, they do not facilitate to suture the remaining fascia after harvesting the transplant and therefore bear the risk of a symptomatic herniation of the muscle belly. The aim of this study was to design a surgical device to harvest a fascia lata graft and close the resulting fascia defect as a minimal invasive procedure.

MATERIALS AND METHODS

The prototype was tested in 11 human cadaver specimens. It was introduced subcutanously via two small skin incisions. The device contained a special fixation- and working mechanism which enabled the fascial closure using a continuous suture. After the harvest procedure, both the transplant and the sutured fascia lata were examined.

RESULTS

The experiments demonstrated the suitability of this method for minimal invasive harvesting of fascia lata. The removed transplants complied in all experiments with the expected dimensions. The continuous suture of the femoral fascia ran with accurate gaps between the sutures and constant tension without dehiscence. Neither the transplant nor the tissue in the region of harvest have shown unduly macroscopic damage due to the use of the device.

CONCLUSION

The designed prototype can be used for harvesting a fascia lata graft and repairing the resulting defect minimal invasively. Clinical implementation seems possible. However, improvements could be made mainly concerning the handling of the device.

Transvaginal repair of enterocele and vaginal vault prolapse using autologous fascia lata graft

BACKGROUND

The aim was to describe the operative technique of transvaginal repair of enterocele and apical prolapse using autologous fascia lata and report intra- and postoperative complications and long-term outcome.

METHODS

A retrospective chart review of 74 consecutive patients who had repair of a symptomatic enterocele and vaginal vault prolapse or uterine prolapse from January 1987 to August 1999. All patients were followed for a minimum of 3 months and 61 were available for long-term evaluation at 18-106 months (median 52 months).

RESULTS

Intra- and postoperative complications were few. Pelvic examination at long-term follow-up disclosed a recurrence rate for enterocele of 1.7%, vaginal vault prolapse of 8.3%, and cystocele of 15%. Ninety-one per cent were subjectively satisfied with the relief of mechanical vaginal symptoms. Only 35% (6/17) were cured of constipation. Out of the 22 women who were sexually active after the procedure, 12 (54%) experienced improved quality.

CONCLUSION

Repair of the posterior compartment defect and suspension of the vaginal vault using autologous fascia lata graft provides acceptable intra- and postoperative complication and long-term results.

Results of Partial Fasciectomy for Dupuytren Disease in 261 Consecutive Patients

Many different surgical techniques are still being used for Dupuytren disease. The outcome of 558 consecutive operations with 1 technique was reviewed. Distinct subgroups were made to detect risk factors for a poor outcome and complications. The mean follow-up time was 7.3 years. Younger patients (first surgery before 45 years) were operated significantly more than older patients (after 45 years). Results of contracted proximal interphalangeal (PIP) joints were significantly worse than other joints. The overall complication rate was 26%. Nerve lesions occurred in 7.7%. Young age proved to be a prognostic factor for the total number of operations. The contracted PIP joints will lead to more complications and poorer result. The risk at nerve lesion, necrosis, and infection are higher for recurrent surgery. These findings can be used in advising patients.

Composite anterolateral thigh-fascia lata flap: a good alternative to radial forearm-palmaris longus flap for total lower lip reconstruction

BACKGROUND

Major defects of the lower lip are challenging to the reconstructive surgeon. The major goals in treating total lower lip defects are reconstruction of the external skin and mucosal lining and maintenance of oral competence and sphincter function. The authors describe reconstruction of total lower lip and larger full-thickness defects including the cheek and commissure by means of a composite anterolateral thigh-fascia lata free flap.

METHODS

The flap was harvested with 5-cm fascial extensions at the superior and inferior margins. The flap was folded over the fascia lata to restore the intraoral lining and cover the external skin defect. Fascia lata extensions were divided longitudinally into two fascial strips at both margins of the flap. Two strips were tunneled through the orbicularis muscle in the upper lip and sutured to each other and to the orbicularis muscle. The remaining two strips were anchored to the zygomatic bone periosteum by permanent sutures. This procedure was used in 11 patients.

RESULTS

In all cases, disease was advanced squamosus cell carcinoma. The patients' ages ranged from 37 to 72 years. Nine patients had cancer of the lower lip and two patients had a buccal cancer involving the lip. The entire lower lip, bilateral modiolus, and part of the cheek were resected in all patients, and mandibulectomy was performed in three patients. Flap survival was 100 percent. One patient died 10 days after the operation because of cardiopulmonary arrest. At the end of the 1-year follow-up period, all patients had good oral continence at rest and had achieved sufficient oral competence when eating. Eight patients were able to resume a regular diet and two patients could eat a soft diet.

CONCLUSIONS

This flap is a good choice for reconstruction of the extensive head and neck defects. We think that anterolateral thigh-fascia lata composite flap has maximum reconstructive capacity and minimal donor-site morbidity. This flap has many advantages over the radial forearm flap and should replace to the composite radial forearm palmaris longus tendon flap when total lower lip reconstruction is concerned.

Endoscopic iliotibial band release for external snapping hip syndrome

PURPOSE

The external snapping hip syndrome is caused by slippage of the iliotibial band over the greater trochanter. Most cases are treated conservatively but if this fails, open surgical treatment is commonly performed by Z-plasty or by creating a defect on the iliotibial band. We present a series of 11 hips that were surgically treated by an endoscopic technique.

TYPE OF STUDY

Prospective consecutive series of patients.

METHODS

Diagnosis of external snapping hip syndrome was clinical in all cases and anteroposterior pelvis radiographs were taken to evaluate the hip joint. Endoscopic release was performed with the patient in the lateral decubitus position without traction using 2 portals, the superior trochanteric and inferior trochanteric. A standard 4-mm, 30 degrees arthroscope was introduced at the inferior trochanteric portal over the iliotibial band. A needle was placed at the proximal trochanteric portal and visualized endoscopically. The portal was then established and subcutaneous tissue resection was performed with radiofrequency (RF) probes and a shaver until the iliotibial band was identifiable and released with a vertical cut made using an RF hook probe. The arthroscope was introduced into the space created under the iliotibial band and a transverse cut at the middle of the vertical release was then made, creating a cross-shape. Next the 4 resulting flaps were resected to make a diamond-shaped defect.

RESULTS

Between September 2001 and December 2003, we treated 11 patients, 9 female (1 bilateral) and 1 male with an average age of 26 years, for external snapping hip syndrome using an endoscopic technique. At an average 2-year follow-up, we had 1 patient with nonpainful snapping. The rest of the patients in the series had no complaints and returned to their previous level of activity.

CONCLUSIONS

We present a reproducible endoscopic technique for the treatment of external snapping hip syndrome. Our results are comparable to those reported for open procedures.

LEVEL OF EVIDENCE

Level IV.

LONG-TERM URINARY CONTINENCE RATES AFTER SIMPLE SLING INCISION FOR RELIEF OF URINARY RETENTION FOLLOWING FASCIA LATA PUBOVAGINAL SLINGS

PURPOSE

We examined long-term urinary continence rates in patients after midline simple sling incision for urinary retention following suburethral fascia lata slings.

MATERIALS AND METHODS

A retrospective review was completed of 13 women undergoing a simple sling incision for catheter dependent obstruction after suburethral sling surgery more than 4 years previously. Urinary continence was evaluated by use of the Groutz-Blaivas anti-incontinence surgery response score. The scores were statistically compared as binary categories at mean 111-day and 60.8-month followup.

RESULTS

A total of 13 women underwent a simple sling incision for catheter dependent urinary retention after sling surgery, and 11 patients (mean age 73.4 years) were available for long-term followup (60.8 months). The simple sling incision procedure was completed an average of 65 days (range 36 to 235) after original sling placement. Mean post-void residual urine volume at least 1 month after sling surgery was 289 ml (range 75 to 500). At a mean followup of 60.8 months, no patient required catheterization. Of 11 patients 5 wore no pads. There was no statistical difference in leakage episodes per day (p = 1.0), pads per day (p = 0.3), or patient perceived condition (p = 0.3) during long-term followup. The mean Groutz-Blaivas score did not change statistically during the 5-year followup period (p = 0.6).

CONCLUSIONS

Midline simple sling incision provides relief of catheter dependent obstruction following fascia lata sling surgery while preserving urinary continence in the majority of patients during a 5-year followup period.

Epimysium and perimysium in suturing in skeletal muscle lacerations

BACKGROUND

Direct muscle belly trauma is common. Selecting optimal methods for surgical repair of muscle disruption is difficult because reliable methods have not been established. Suturing tendon offers strong repairs, but epimysium and perimysium, the connective tissues that coalesce to form tendons, offer unknown repair strength. The purpose of this study was to compare biomechanical properties of repaired muscle in transected muscle bellies with epimysium and perimysium.

METHODS

The authors surgically repaired with figure-eight stitches in both epimysium and perimysium groups. Individual stitches were placed in lacerated quadriceps bellies from a euthanized pig and were tensioned on a biomechanical machine. Maximum loads and strains were measured, and failure mechanisms were recorded.

RESULTS

Loads and strains for repairs with epimysium were higher than those for repairs with perimysium. Failure mechanisms were significantly different between groups.

CONCLUSION

These data showed that epimysium incorporation into suturing improves capacity to bear forces compared with perimysium incorporation.

Sonographic assisted diagnosis and treatment of bilateral gastrocnemius tendon rupture in a Labrador retriever repaired with fascia lata and polypropylene mesh

This case report describes a four-year-old, eighty-five pound, male neutered Labrador retriever that was admitted with unilateral lameness and clinical findings consistent with a unilateral gostrocnemius tendon rupture. A prior history of trauma was not identified. Ultrasonagraphic evaluation revealed bilateral gastrocnemius tendon defects in which approximately 80% of the tendon was ruptured on the clinically normal side, yet mechanical function and anatomical length were not apparently altered. Bilateral surgical repair was performed utilizing primary tendon reconstruction, supported by fascia lata, autograft and polypropylene mesh. The repairs were protected with rigid costs for two weeks following surgery, and replaced with orthotics through the complete recovery period. Orthotics provided semi-rigid support and allowed removal for controlled intermittent physical therapy. This surgical repair technique, combined with orthotic support, allowed for early mobilization and good ultimate outcome for a complicated bilateral condition.

Neurolysis for meralgia paresthetica: an operative series of 45 cases

BACKGROUND

Failure of symptom relief after neurolysis for meralgia paresthetica (MP) is reported frequently, yet systematic outcome analysis is limited in the modern literature. The present operative series of 45 cases aims to address this issue.

METHODS

From 1996 to 2000, all patients who had neurolysis for MP by our senior author were enrolled in the study. Nerve entrapment was confirmed preoperatively by electrophysiological studies or a positive response to local anesthetic and steroid injection. Attention to the anatomical variability of the lateral femoral cutaneous nerve was made during nerve exploration. Decompression of the nerve was performed at the level of the iliac fascia, the inguinal ligament, and the fascia of the thigh distally. The outcome of surgery was assessed 6 weeks after the procedure followed by 3 monthly intervals if symptoms persisted. Telephone interviews were conducted to assess long-term results.

RESULTS

Forty-five decompressive procedures were performed in 42 patients over the 5-year period. The average duration of symptoms was 31 (2.5-180) months. All patients were followed for an average of 4.1 years. Complete and partial symptom improvements were noted in 33 (73%) and 9 (20%) cases, respectively. No recurrence was reported. Analysis of clinical variables demonstrated that the duration of symptoms preoperatively did not affect the rate of complete symptom relief, but obese patients (body mass index > 30) was 6 times more likely to have (odds ratio 6.16, P = 0.04) incomplete relief after surgery at long-term follow-up.

CONCLUSION

High success rate was recorded in our series of 45 cases. Prolonged duration of symptoms did not preclude favorable outcome but obesity had a negative association with good outcome.

The role of epimysium in suturing skeletal muscle lacerations

BACKGROUND

Direct muscle trauma is a common and disabling clinical problem. Surgical muscle repair is difficult to evaluate because reliable repair techniques have not been established scientifically. The purpose of this study was to assess the biomechanical properties of epimysium, the collagenous tissue sheath that surrounds muscles in the body.

STUDY DESIGN

We surgically repaired transected porcine muscle bellies with and without epimysium. For both groups, 25 figure-eight stitches in lacerated quadriceps bellies from a euthanatized pig were loaded under tension on a biomechanical machine (model 8521S, Instron Company). Maximum loads and strains were measured and mechanisms of failure recorded.

RESULTS

The mean load for repairs with epimysium (25.1 N) was significantly higher (p = 0.034) than that for repairs without epimysium (21.2 N). The mean strain for repairs with epimysium (10.4%) was significantly higher (p < 0.001) than that for repairs without epimysium (7.3%). The mechanisms of failure were also different. Among epimysium repairs, 15 stitches avulsed muscle transversely, and 10 stitches tore out longitudinally from the muscle. In the nonepimysium group, 1 suture avulsed muscle and 24 sutures tore out. Muscle was the weakest element in each test.

CONCLUSIONS

These data showed that epimysium incorporation into suturing improves the capacity of repairs to bear force. These findings fill a knowledge gap and may improve outcomes of muscle suturing. By focusing the experiment on biomechanical properties of muscle stitching, this study showed the key role epimysium plays in muscle suturing.

An In Vitro Study to Determine the Effectiveness of a Patellar Ligament/Fascia Lata Graft and New Tibial Suture Anchor Points for Extracapsular Stabilization of the Cranial Cruciate Ligament-Deficient Stifle in the Dog

OBJECTIVE

(1) To determine whether an extracapsular patellar ligament/fascia lata graft would provide stability in the cranial cruciate ligament (CrCL)-deficient stifle comparable with that of the intact stifle. (2) To determine if different tibial anchor points would enhance stability of the CrCLdeficient stifle when compared with the standard fabellar-tibial suture (FTS) placement.

STUDY DESIGN

Experimental.

ANIMALS

Twenty-eight canine cadaver hind limbs.

METHODS

Stifles were mounted in a jig and tested between loads of -65 and 80 N. After testing the intact CrCL, 4 stabilization techniques were tested after CrCL transection: lateral graft technique (LGT) and 3 FTS with different tibial anchor points.

RESULTS

There were no significant differences in displacement between the LGT and standard FTS, between the LGT and the intact CrCL, or between the FTS and the intact CrCL, in either the Securos or the Screw-washer experiments. Stiffness of the intact CrCL was significantly greater than that of any stabilization technique and the cut CrCL. The standard FTS showed the least displacement of all suture stabilization techniques. Differences in stiffness were not significant between the suture stabilization techniques.

CONCLUSIONS

Securely anchored, the LGT results in a reduction in drawer motion similar to that of the intact CrCL and the standard FTS. Altering the tibial anchor point for the FTS does not improve stiffness or enhance stabilization of the CrCL-deficient stifle.

CLINICAL RELEVANCE

The LGT could be used for the treatment of CrCL ruptures in the dog. A clinical study is recommended.

Pubovaginal sling using cadaveric allograft fascia for the treatment of female urinary incontinence

OBJECTIVES

The technique and outcomes of patients treated with allografts or autografts as pubovaginal sling are compared.

METHODS

Fascia lata was included among the tissues harvested from brain-dead patients considered for multiple organ donation. After informed consent, segments of allograft (group A) cadaveric fascia lata autografts (group B) were compared with used for sling operations in 60 women from 37 to 73 years of age (mean 53.4 years), who presented with stress incontinence requiring a pubovaginal sling.

RESULTS

At a mean follow-up of 36 months (range = 22 to 44 months), 40% of group A patients were cured and 28% were improved. At a mean follow-up of 33 months (range = 24 to 41) 70% of group B patients were cured and 20% improved (P <.05). There were no adverse outcomes of sling erosion or infection in either group. Placement of allograft sling took an average of 62 minutes while the mean duration of sling placement requiring fascial harvest was 81 minutes (P <.05). The mean duration of hospital stay was shorter in the allograft (1.25 days) than the autograft (2.48 days) group (P <.05).

CONCLUSION

Use of allografts was associated with a shorter operative time and duration of hospital stay compared to an autograft, but the 3-year continence rate was lower in the autograft group.

Comparison of cosmetic results in frontalis sling operations: the eyelid crease incision versus the supralash stab incision

PURPOSE

In addition to ptosis, the lack of eyelid crease is one of the main cosmetic problems of patients with poor levator function. In this study, we aimed to evaluate the effect of the incision site on ptosis correction and eyelid crease formation in frontalis sling operations.

MATERIALS AND METHODS

Photographs and charts of 27 patients (45 eyelids) who underwent frontalis sling operations were retrospectively reviewed. All patients had congenital ptosis with poor levator function ranging from 0 to 4 mm. In group I (15 eyelids), 3 supralash eyelid skin incisions were performed and the sling material was threaded along the tarsal surface. In group 11 (30 eyelids), the eyelid crease approach was used with the suturing of the sling material directly to the tarsus.

RESULTS

Although lid contour and lid crease symmetry were good in 46.6% of the cases in group I, eyelid crease formation was not satisfactory in any of the cases. Lid contour and lid crease symmetry were good in 76.6% of the cases in group II.

CONCLUSION

Our results indicated that the eyelid crease approach provided better functional and cosmetic results than did the supralash stab incision in frontalis sling operations. The passage of the sling material behind the orbital septum by direct visualization in the eyelid crease approach is one of the main factors affecting the surgical success of the frontalis sling operation.

Histological study of experimental reconstructive materials for repair of lateral skull base and dura mater defects in dogs

OBJECTIVE

In order to assess the reconstructive properties of fascia lata, superficial fascia lata and bone morphogenetic protein (BMP) in skull base surgery, lateral skull base bone and dura mater defect models were established in dogs

MATERIAL AND METHODS

As a repair material we selected fascia lata, either alone or in combination with BMP, for reconstructing large cranial defects in dogs. Twenty dogs undergoing a 3.0 x 4.0 cm2 full-thickness excision of the parietal bone were divided into four equal groups as follows: fascia lata reconstruction; fascia lata reconstruction plus BMP; controls; and fascia lata reconstruction plus BMP with direct exposure of fascia lata. The implants were harvested at 2-15 weeks and examined histologically. Results-Treated and untreated implants were quite different: formation of new bone occurred in the dogs treated with BMP whereas the unreconstructed controls demonstrated only a bridge of fibrovascular connective tissue.

CONCLUSION

The results of this study suggest that it is better to combine BMP and reconstructive material for the treatment of bone defects.

The enhanced frontalis sling for blepharoptosis repair

PURPOSE

To describe a simple modification of the frontalis sling procedure.

DESIGN

Interventional case reports.

METHODS

The fascia lata strips are passed superiorly with a Richard-Allan needle rather than trimmed at the central incision in the inferior forehead.

RESULTS

Satisfactory and stable eyelid positions have been achieved in six patients.

CONCLUSIONS

Increasing the area of contact between the fascia lata strips and the frontalis muscle should enhance the muscle's action in elevating the ptotic eyelid.

[Repair of skin defect after resection of cutaneous malignant tumor]

OBJECTIVE

To investigate the clinical effects of repairing skin defect after resection of cutaneous malignant tumors.

METHODS

From 1984 to 2001, cutaneous malignant tumors of 38 patients were resected and diagnosed pathologically. There were 12 cutaneous squamous cancer, 14 carinal cutaneous fibrosarcomas, 2 in situ cancers, 1 wart like cancer, 4 eczematoid cancers, and 5 deteriorative chronic ulcers. The biggest skin defect was 14 cm x 20 cm in size. Skin defects were repaired with flaps, myocutaneous flaps, free skin grafts and suturations. There were 4 gastronomies flaps, 6 latissimus flaps, 2 tensor fascia lata myocutaneous flaps, 1 transverse recuts abdominis myocutaneous flap, 5 plantaris medialis flaps, 3 random flaps, 12 free skin grafts and 5 suturings.

RESULTS

All the operations succeed. Among 21 cases followed up for 3 to 12 years, 19 healed and 2 relapsed, but the 2 patients healed after second operation.

CONCLUSION

Thorough resection of tumor is the key to eradicate malignant tumor. The method to repair skin defect after resection should be chosen according to the patients individually.

Medium-term follow-up of transvaginal suburethral slings: variance in outcome success using two different evaluation methods

OBJECTIVES

To compare Groutz-Blaivas' Simplified Urinary Incontinence Outcome Score (SUIOS) with retrospective chart review for medium-term evaluation of transvaginal suburethral slings.

METHODS

A total of 127 consecutive women underwent transvaginal suburethral sling surgery using In-fast bone screw technology, with a fascia lata graft, from April 1997 to September 1998 (30-month follow-up), performed by a single method. Retrospective evaluation of the patients' office charts was compared with the outcome data determined by the previously validated SUIOS.

RESULTS

Of the 107 available patients, 65 (61%) responded. When evaluating the patients' charts retrospectively, we obtained a complete cure of urinary stress incontinence in 59 (91%), improvement in 3 (4.5%), and complete failure in 3 (4.5%) of the 65 women. Of the 65 patients, 9 (13.5%) reported urge incontinence. The overall urge de novo rate was 9% (6 of 65). On the basis of the SUIOS, 24 (37%) were cured, 22 (34%) had good results, and 10 (15%) of the 65 women had a fair response. By SUIOS, 21 (60%) of 35 patients with mixed incontinence continued having urge incontinence episodes postoperatively compared with 16 (53%) of 30 patients without documented preoperative urge incontinence who developed de novo urge incontinence postoperatively (P <0.05).

CONCLUSIONS

Despite extensive preoperative counseling, patients perceive any kind of postoperative urinary incontinence as a poor outcome. However, we, as physicians, regard success as cure of the stress component when the surgical intervention is concerned. A validated simplified urinary incontinence score represents a more objective account of the outcome.

Extensor hallucis longus tendon rupture repair using a fascia lata allograft

The authors present a case of a traumatic extensor hallucis longus tendon rupture sustained 2 days after hallux valgus and hammer toe correction. The ruptured tendon, separated by a 6-cm defect, was repaired using a fascia lata allograft. This case demonstrates a serious complication of a commonly performed procedure and a salvage technique useful for dealing with large tendon defects.

[Auricular reconstruction with Medpor framework and temporal-parietal fascia flap]

OBJECTIVE

In search of a simpler and safer technique for auricular reconstruction with good appearance.

METHODS

Medpor implant was used as auricular framework, and covered by temporal fascia flap and skin graft.

RESULTS

Ear reconstruction was successfully achieved in 19 cases, the newly formed ears all had good appearance after edema disappeared 1 or 2 months postoperatively.

CONCLUSION

Medpor is a kind of good implant material because it is steady in nature, easy to be sculptured. Temporal fascia flap is rich in blood supply, tough and tensile in biomechanics. So the combination of Medpor implant framework with temporal fascia flap is preferable in auricular reconstruction.

Abdominal sling surgery--artificial sacro-uterine ligament

Abdominal sling surgery is defined as attachment of either the connective tissue graft (fascia lata) or some synthetic material (Mersilene) to the anterior wall of the exposed vaginal vault following total hysterectomy or to the posterior wall of the uterine cervix in total and subtotal uterine prolapse, whereas the other end is attached to the anterior longitudinal ligament extending along the anterior surface of the vertebrae. Our analysis comprised 45 operations: 20 cases of vaginal vault prolapse following vaginal hysterectomy; 7 cases of vaginal vault prolapse following HTA: 2 cases of prolapse following subtotal hysterectomy; 3 cases of nondefined TH; 2 cases following Burch operation; 1 following Kocher; 1 following Manchester, 1 following Neugebauer-Le Fort operation in which HTA was performed 2 times. Abdominal sling operation was associated with the following surgical procedures: sling in 13 cases, sling + douglasorrhaphy in 16 cases, sling + douglasorrhaphy + colpoperineoplastics in 6 cases, sling + colpoperineoplastics in 9 cases and sling + marshall marcetti in 1 case. Recurrence of enterocele was recorded in 5 patients in whom closure of the douglas pouch had not been performed. This procedure was therefore later included into our approach to the operation. The abdominal sling operation has been a logical and physiologic approach to surgical therapy of genital prolapse, particularly of the vaginal vault prolapse following total hysterectomy. This operation ensures subsequent normal sexual relations.

Spigelion hernia: fascia lata repair is an alternative option in absence of prolene mesh

Spigelian hernia is rare. Seven cases of Spigelian hernia are presented. These include two recurrent Spigelian hernias. Incisional hernias through Spigelian aponeurosis after Pfannensteil incision are not included. Clinical examination is the mainstay of diagnosis. The true incidence is possibly higher, as a low Spigelian hernia is not recognised and often diagnosed as a direct inguinal hernia. Ultrasound scanning is recommended, as it is non-invasive and easily available and can detect the hernial orifice in the Spigelian fascia at an early stage. Recurrence of Spigelian hernia took place in two cases through the site of prolene stitch of a previous repair. Hernioplasty with tension free fascia lata graft/prolene mesh was carried out in all cases. The cost of fascia lata graft is only a scar in the thigh. In a mean follow-up of 3.1 -year no patient has reported back with recurrence This is the ideal substitute for the patients in developing countries where synthetic meshes are still not freely available.

Coxa saltans externa treated with Z-plasty of the iliotibial tract in a military population

Coxa saltans, or snapping hip, can be attributable to a number of causes. Coxa saltans externa typically occurs when the thickened portion of the iliotibial band snaps over the greater trochanter as the hip is flexed. This condition generally resolves with a course of nonoperative treatment. We have treated three patients with Z-plasty of the iliotibial band, which has the highest published success rate in the English language literature. Only one of three patients was able to return to full activities postoperatively. In our small series, this method of surgical treatment in an active duty military population yielded less than optimal results.

A case of chronic expanding hematoma in the tensor fascia lata

We describe a patient in whom a chronic expanding hematoma was pathologically confirmed by examination of the resected specimen. It developed gradually in the left lateral thigh, which had been bruised 8 months before, but had produced no mass-related symptoms initially. Computed tomography (CT) showed the mass to be homogeneous with capsule formation, whereas ultrasonography showed it to resemble a multilocular cyst. The lesion was treated by complete excision of a perifascial mass. Grossly, a well-circumscribed, fusiform mass with a soft cystic center and a fibrous pseudocapsule was observed. Histologically, the mass was composed of necrotic debris, fibrin and blood clots. This was surrounded by a rim of hyalinized fibrous tissue with a chronic inflammatory infiltrate and granulation tissue with sprouting new capillaries. CT was unable to discriminate the chronic expanding hematoma from other soft tissue masses, ultrasonography being needed to reveal its characteristics in this case.

Autologous, cadaveric, and synthetic materials used in sling surgery: comparative biomechanical analysis

OBJECTIVES

To compare the biomechanical properties of allografts, autografts, and synthetic materials used in sling surgery using the Instron tensinometer.

METHODS

The sling grafts we studied consisted of autologous tissues (dermis, rectus fascia, and vaginal mucosa), cadaver tissues (decellularized dermis and freeze-dried, gamma-irradiated fascia lata), and synthetics (Gore-Tex and polypropylene mesh). The sling grafts were constructed into two types of slings: full strip sling (FSS) versus patch suture sling (PSS). The slings were loaded onto the Instron tensinometer and uniaxially loaded in tension until failure. From the load deformation curve, the mechanical properties of the sling grafts were compared.

RESULTS

A total of 140 sling grafts were analyzed. In rank order for the FSSs, cadaver allografts had the strongest tensile strength followed by the synthetics and autologous tissues (P <0.05). The tensile strength of the FSSs was greater than for the PSSs for all groups (P </=0.001). In rank order for the PSSs, the synthetics and dermal tissues (autograft and allograft) had the highest tensile strength followed by cadaver fascia lata, rectus fascia, and vaginal mucosa (P <0.05).

CONCLUSIONS

The tensile strength of the FSS was greater than that of the PSS for the autograft, allograft, and synthetic tissues. The autograft and allograft tissues were significantly weaker as a PSS. The synthetics were more durable as a PSS compared with the organic tissues. When a PSS is constructed from autograft and allograft tissues, the risk of suture pull-through and recurrent stress incontinence must be considered.

[The tensor fascia lata racket shape myocutaneous island flap]

OBJECTIVE

To provide a racket shape tensor fascia lata myocutaneous island flap according to the anatomical form and blood supply of the tensor fascia lata.

METHODS

Four tensor fascia lata racket shape myocutaneous island flaps were used in four patients clinically. All 4 flaps were for repairing abdominal defect.

RESULTS

Three of the four flaps survived without complication. In one of the four flaps, skin necrosis at the distal tip was noted and needed additional skin graft.

CONCLUSIONS

The tensor fascia lata racket shape myocutaneous island flap is a convenient island flap. The island flap designed like racket shape has two benefits than the conventional rectangular island flap: 1. The narrow proximal part of the flap is like a extended pedicle, which makes the broad distal part of the flap can easily be transposed to the recipient site. 2. The donor defect of the narrow proximal part can be closed directly, which lessens the size of skin graft for the donor defect. The cause of skin necrosis at the distal tip of one flap is mainly due to that the length of the flap exceeds the distal end of the middle one third of the lateral thigh.