Repair of a coccygeal hernia with a biological mesh.

Coccygeal herniation after coccygectomy is rare. Little is known about the management of this complication. We present a case of a 44 year old women with a coccygeal herniation 7 years after coccygectomy. She was treated two times for an infected pilonidal sinus with incision and drainage. After the last incision and drainage she had complaints of a painful swelling in the sacral area and difficulty with evacuation of her stools. A defaecography showed a coccygeal herniation. An additional MRI of the pelvic region showed a defect with a diameter of approximately 38mm. We performed a hernia repair with a biological mesh (Strattice™ surgical mesh, LifeCell Corporation USA) via a sacral approach. Her recovery was complicated by a small wound dehiscence without clinical signs of infection. The sacral wound healed per secundam. Her complaints had completely disappeared. A defaecography 2 months after surgery showed no residual herniation. To our knowledge, it is the first reported case of a coccygeal hernia repair with a biological Strattice™ surgical mesh.

Subtalar dislocation: two cases requiring surgery and a literature review of the last 25 years.

BACKGROUND: Subtalar dislocations are uncommon, representing ~1% of all traumatic dislocations. We present two cases of closed medial subtalar dislocation and a systematic literature review of the last 25 years. METHODS: We performed an Embase, Medline, Pubmed and Cochrane search of the literature written in English between January 1988 and December 2012. Keywords used were subtalar, peritalar, subastragalar, luxatio pedis sub talo, dislocation and dislocations. All articles presenting original patient data were included. All available data regarding gender, age, direction, affected side, open or closed injury, accompanying fractures, reduction, time of immobilization and outcomes were collected in a database. RESULTS: Seventy-six articles were included with a total of 528 reported cases. Males (318/419 = 76%) and the right foot (122/200 = 61%) were affected more often than females and the left foot. Average age was 33.8 years (range 19 months-86 years). Cause of injury was a traffic accident in 43.7% (157/359), a fall in 32.9% (118/359), sports injuries in 13.9% (50/359), sprain injuries in 5.3% (19/359) and other causes in 4.2% (15/359). The direction of the dislocation was medial in 71.5 % (352/492), lateral in 26.0% (128/492), posterior in 1.6% (8/492) and anterior in 0.8% (4/492). Open dislocation was reported in 22.5% (67/298). In 61.4% (216/352) an additional osseous injury was diagnosed. Closed reduction was unsuccessful in 14.0% (51/364) requiring immediate open reduction. Overall outcomes in the literature were good in 52.3% (172/329), fair in 25.2% (83/329) and poor in 22.5% (74/329). LEVEL OF CLINICAL EVIDENCE: 4.

Robot-assisted ramicotomy: evaluation in a swine model.

BACKGROUND: To evaluate the feasibility of robot-assisted thoracoscopic T2-T5 ramicotomy. METHODS: In 5 pigs, a robot-assisted thoracoscopic T2-T5 ramicotomy was performed, followed by T2-T5 sympathectomy 10 min later. Ramicotomy and sympathectomy times, and core (esophageal) and surface (left front foot) temperatures, were monitored and recorded. RESULTS: The procedure was successfully completed in all 5 animals. In all cases, the sympathetic chain remained intact. No major hemorrhage occurred. The mean operating time for T2-T5 ramicotomy from incision until transsection of the last efferent ramus was 34 min (32-40). After completion of the ramicotomy, a total T2-T5 sympathectomy was performed, with a mean duration of 7 min (4-12). Mean core temperature before the operation was 37.6°C (36.7-38.0). Mean surface temperature before the operation was 34.2°C (33.3-35.5). Ten minutes after completion of the ramicotomy, temperatures stabilized. Mean postramicotomy core temperature was 37.4°C (36.3-38) and mean postramicotomy surface temperature was 35.4°C (33.9-37). Mean postsympathectomy temperatures were: core 37.3°C (36.1-38) and surface 35.8°C (33.8-37.1). CONCLUSION: Robot-assisted thoracoscopic T2-T5 ramicotomy is feasible and effective in a porcine model.