Initial Experience with the PONTiS Tendon Repair System in Traumatic Upper Extremity Injuries.

BACKGROUND: Tendon injuries of the upper extremity remain a common surgical condition requiring prompt intervention. The authors review their initial experience with the PONTiS flexor tendon repair system, a knotless, multifilament, stainless steel crimp system. METHODS: Consecutive patients undergoing repair by plastic and orthopedic surgeons with the PONTiS system were reviewed for the period from 2015 to 2017. Multivariate risk and Kaplan-Meier survival analyses were performed to assess risk factors associated with complications. RESULTS: Eighty-one patients, with a mean follow-up of 75 days (range, 0 to 33 months), were identified. The most common demographics showed patients were right-handed (82.9 percent), male (71.4 percent), and laborers (35.7 percent) and sustained laceration injuries (77.1 percent) at zone 2 (27.2 percent). There were, on average, 3.7 tendon injuries per patient. Associated injuries included fractures (21.4 percent), arterial injuries (24.3 percent), and nerve injuries (61.4 percent). Thirteen patients (16.0 percent) developed complications, including adhesions/contracture ( n = 4), rupture ( n = 2), flap ischemia ( n = 2), arterial thrombosis ( n = 1), wound dehiscence ( n = 1), tendon lag ( n = 1), and erosion of the PONTiS system through soft-tissue grafts ( n = 2). Multivariate analysis identified poor soft-tissue coverage (OR, 9.990; p = 0.043) and zone 2 involvement (OR, 7.936; p = 0.016) as risk factors, while epitendinous repairs (OR, 0.096; p = 0.010) were protective against complications. CONCLUSIONS: The PONTiS flexor tendon repair system is rapid, simple to deploy, and advantageous, especially in multiple traumatic tendon injuries. In comparison to traditional suture repair, it has a comparable overall complication profile but superior rupture and tenolysis rates. The authors advise using it with caution in cases with poor soft-tissue coverage to minimize risks of extrusion, and they strongly recommend the use of epitendinous sutures concurrently to limit complications.

The Impact of Mesh Reinforcement with Components Separation for Abdominal Wall Reconstruction.

The goal in abdominal wall reconstruction (AWR) is to minimize morbidity and prevent hernia recurrence. Components separation and mesh reconstruction are two options, however, with advantages and disadvantages. The purpose of this review was to investigate outcomes in patients with abdominal wall hernia undergoing primary closure with component separation (CS) versus CS with acellular dermal matrix (ADM) reinforcement (CS + mesh). Medical records of consecutive patients who underwent abdominal wall reconstruction using CS with or without ADM reinforcement were retrospectively reviewed. Primary fascial closure was achieved in all patients. ADM reinforcement when used was performed using the underlay technique. Reconstructive technique and postoperative complications including delayed healing, skin necrosis, fistula, seroma, hematoma and surgical site infection, recurrence, and reoperation were recorded. Comparisons between the two groups were assessed. One hundred and seven patients were included (mean age, 55.7; 51.4% male; median follow-up 297 days). Twenty-six patients (24%) underwent CS alone; whereas 81 patients (76%) CS + mesh placement. Patient comorbidities, including smoking (26%), diabetes (20%), and hypertension (46%); body mass index (mean 32.3 ± 7.6); and albumin level on the day of surgery (mean 3.4 ± 0.5 mg/dL) were not significantly different between groups. Surgical site infection was significantly higher among CS + mesh patients (22.2%) versus CS only patients (3.9%) (P = 0.02). The recurrence rate of abdominal hernia was significantly lower in CS + mesh patients compared with CS only (14.8% vs 34.6%; P = 0.02). No significant differences in other postoperative complications were identified between the two groups. ADM reinforcement at the time of components separation is often selected in more complex, higher risk patients. Although the incidence of infection was higher in these patients, it was usually treated without mesh removal and recurrence rate was significantly lower when compared to CS alone.

The Effect of BMI on Outcomes Following Complex Abdominal Wall Reconstructions.

BACKGROUND: The management of complex abdominal wall defects continues to be a challenging process secondary to the high potential for wound healing issues and ventral hernia recurrences. Body mass index (BMI) is a well-known risk factor when it comes to complications. We hypothesize that higher BMIs result in higher rates of postoperative complications in complex abdominal wall reconstructions (CAWRs). METHODS: We retrospectively reviewed all patients who underwent CAWR at Emory University Hospital over a 12-year period. Patients were divided into 4 cohorts based on BMI (15-24.9, 25-29.9, 30-34.9, and ≥35 kg/m). Complication rates among the 4 groups were evaluated as the primary outcome using Pearson χ analysis. Further analysis was done on specific complications including mesh exposure, skin necrosis, delayed healing, rate of fistula formation, seroma, hematoma, infection, rate of recurrence, and rate of reoperation. RESULTS: We included 313 patients with a mean follow-up of 15.6 months. The rate of overall complications demonstrated a nonsignificant increase with BMI of 15 to 24.9, 25 to 29.9, 30 to 34.9, and 35 kg/m or greater (31.7%, 35.0%, 47.6%, and 48.3%; P = 0.079, respectively). The rate of skin necrosis was significantly increased in the higher BMI groups (1.7%, 1.3%, 9.5%, and 13.5%; P = 0.004). The rate of ventral hernia recurrence was significantly increased in the higher BMI groups (8.3%, 12.5%, 29.8%, and 27.0%; P = 0.002). Rates of reoperation were also statistically increased in the higher BMI groups (25.0%, 22.5%, 41.7%, and 34.8%; P = 0.035). Rates of mesh exposure, delayed healing, fistula formation, seroma, hematoma, and infection were not statistically significant among the 4 BMI groups. CONCLUSIONS: Patients undergoing CAWR with BMIs greater than 30 kg/m have significantly higher rates of skin necrosis, hernia recurrence, and reoperation compared with subgroups of lower BMI. Rates of overall complications among all BMI groups are similar, although trended up with BMI. Surgeons should weight the risks and benefits of CAWR in patients with higher BMIs to reduce specific postoperative complications.

Time to completion of nipple reconstruction: what factors are involved?

BACKGROUND: Nipple reconstruction is often used as a marker for completion of the breast reconstructive process. The purpose of this study was to determine the average time to nipple reconstruction and the factors that influence this process. METHODS: All patients who underwent postmastectomy breast reconstruction at Emory University between 2005 and 2011 were reviewed. Only those who had completed nipple reconstruction were included. Variables recorded were body mass index, age, smoking history, surgeon, presence of preoperative or postoperative chemotherapy or radiation therapy, type of reconstruction, timing of reconstruction, unilateral or bilateral reconstruction, and complication history. Time to completion of nipple reconstruction was calculated and comparisons were made. RESULTS: A total of 451 patients completed nipple reconstruction (128 implant reconstructions, 120 latissimus plus implant reconstructions, 23 latissimus only reconstructions, and 180 transverse rectus abdominus myocutaneous flap [TRAM] or deep inferior epigastric perforator flap [DIEP] reconstructions). Average time to nipple reconstruction was 12.25 months. Patients who underwent TRAM or DIEP flaps completed reconstruction on average earlier than implant-based reconstruction and latissimus-only reconstruction (8.67 vs 11.2 and 11.3 months, respectively, P = 0.0016). Patients who underwent postoperative chemotherapy or radiation therapy were delayed compared to those that did not (11.3 vs 9.33 and 13.87 vs 9.87 months, P = 0.0315 and P = 0.0052). Timing of completion was also dependent on attending surgeon (9.8 and 11.43 months for the 2 senior surgeons, P = 0.0135) and presence of complications (10.3 compared to 9.77 months for patients without complications, P = 0.0334). Body mass index, smoking history, preoperative chemotherapy or radiation therapy, timing of reconstruction, and unilateral versus bilateral reconstruction did not affect time to nipple reconstruction. CONCLUSIONS: Type of reconstruction, surgeon, presence of complications, and need for postoperative chemotherapy or radiation therapy all affect timing to completion of breast reconstruction. Patients should be counseled as to these factors at the initial consultation to set appropriate expectations.