enceDire
INFORMACIÓN DEL Propósito: Evaluar la efectividad y la seguridad de una nueva técnica de doble fijación para
ARTÍCULO fracturas rotativas desplazadas con tornillos de tracción canulados bioabsorbibles y bandas de
tensión de sutura trenzada de poliéster.
Historial del artículo:
Métodos: Quince pacientes (edad media de 46,2 años) con fracturas de retícula desplazadas
Recibido el 22 de julio de 2010
Recibido en forma revisada el 5 de enero de 2011
transversales o conminutas se inscribieron en este estudio prospectivo. Todos los pacientes fueron
Aceptado el 24 de enero de 2011 sometidos a un proceso de fijación interna de reducción abierta (ORIF) utilizando tornillos de
tracción canulados bioabsorbibles y bandas de tensión de sutura trenzada de poliéster. Los
pacientes fueron seguidos después de la cirugía para evaluar (1) el tiempo requerido para la unión
Palabras clave: ósea radiográfica, (2) el rango de movimiento de la articulación de la rodilla en el momento de la
Tornillos de goma canulados bioabsorbibles unión ósea radiográfica, (3) el grado de dolor evaluado usando la escala visual analógica (EVA), (4)
Sutura trenzada de poliéster
la función de la rodilla con el puntaje de Lysholm y (5) la presencia de más cirugía adicional.
Banda de tensión
Resultados: Todos los pacientes fueron seguidos después del tratamiento por más de 1 año (rango,
Fractura de rótula
Fijación doble 12-19 meses, tiempo medio de seguimiento posterior al tratamiento, 14 meses). La unión ósea de
las fracturas, tal como se observaba radiográficamente, se hizo aproximadamente 3 meses
después de la cirugía en todos los casos sin falla del implante o redisplazamiento del sitio
fracturado. El rango medio de movimiento de la articulación de la rodilla fue de 0 a 134.68, y la
puntuación media de EVA fue de 0.7 en el momento de la unión ósea. Las medias de Lysholm en
el momento de la unión y 12 meses después de la cirugía fueron 86,7 y 95,7, respectivamente. No
se observaron complicaciones postoperatorias, como infección, dislocación o rotura de los
implantes. Además, todos los pacientes volvieron a su nivel de actividad anterior.
Conclusión: esta nueva técnica de doble fijación que utilizaba tirafondos canulados bioabsorbibles
y bandas de tensión de sutura trenzada de poliéster resultó en resultados satisfactorios para las
fracturas de rótula sin complicaciones obvias.
Patella fractures are relatively uncommon and only La técnica de banda de tensión se usa con mayor frecuencia para
account for 0.5–1.5% of all bone fractures.3,7 Due to the fracturas de rótula y se ha demostrado que produce resultados
patella’s importance as regards the extensor mechanism, satisfactorios25,30. En general, se han utilizado implantes metálicos,
efforts should to be made to preserve the patella. The como alambres de acero inoxidable, agujas de Kirschner y tornillos
goal of the therapy is the anatomical reduction of both para este método de fijación. Sin embargo, numerosas complicaciones
the fracture and the articular surface in addition to the que incluyen el dolor postoperatorio, la migración de Kirschner y otras
stable fixation of the fracture, which allows early complicaciones relacionadas con el uso de implantes metálicos son
rehabilitation of the knee. Surgical treatment becomes
bastante comunes 14,18,27,28 y es necesaria una cirugía de revisión
necessary when the fracture displacement exceeds 3 mm
para extraer los implantes. Según Hung et al.18, la incidencia de
or the articular incongruity exceeds 2 mm.14
complicaciones relacionadas con el uso de bucles de alambre fue del
47%, y el 15% requirió la remoción del cable. Además, también se han
informado complicaciones mucho más graves, como la migración
§
This research was supported by Department of Orthopaedic intraarticular del cable roto.
Surgery, West China Hospital, Si Chuan University. Research was En los últimos años, los implantes no metálicos están disponibles para
performed at Department of Orthopaedic Surgery, West China su uso en la fijación de fracturas. Algunos autores han evaluado nuevas
Hospital, Si Chuan University. técnicas de fijación para fracturas de rótula u olécranon utilizando
* Corresponding author. Tel.: +86 13908016178; fax: +86 028 diversos materiales, como suturas trenzadas de poliéster y tornillos
85423438.
E-mail addresses: liqimm@163.com (L. Qi),
biodegradables, a través de estudios biomecánicos y ensayos clínicos
hxlijian.china@163.com (L. Jian). 1
aleatorizados10,14,16,17,20,21,27. Han descubierto que
Tel.: +86 13880765013; fax: +86 028 85423438.
Lesión, Int. J. Care Injured 42 (2011) 1116-112
Fig. 3. Radiografías y una fotografía del sitio operado. (a) Radiografía lateral preoperatoria; (b) dos alambres de
Kirschner (2 mm de diámetro) perforados desde una dirección distal a proximal longitudinalmente como alambres
guía; (c) después de perforar por encima las porciones distales de los agujeros de perforación, se enroscó un tornillo
canulado bioabsorbible en los orificios de perforación desde una dirección distal a la proximal; (d) fotografía después
de la fijación mostró que la sutura se colocó debajo de la fascia y en contacto íntimo
Los ejercicios postoperatorios de 2 o 3 días, los postoperatoria, las actividades diarias normales para
ejercicios de levantamiento parcial o total de peso los participantes con ejercicios que incluían el uso de
duraron por un período de 4 semanas. A partir del muletas también comenzaron en este momento y se
cuarto día se comenzó bajo la protección de una permitieron. Aproximadamente 3 meses después de
bisagra, mientras caminaban durante la semana la cirugía,
Lesión, Int. J. Care Injured 42 (2011) 1116-112
Tabla 1
Características clínicas de los 15 pacientes.
Caso Edad / Tipo de Periodo de Tiempo ROM en la Puntuación VAS Puntuación de Complicaciones
sexo fractura seguimiento para la unión ósea (unión ósea / 12 Lysholm (unión (12 meses
(años) (meses) unión ósea (extensión / meses después ósea / 12 meses después de
(meses) flexión) de la cirugía) después de la cirugía)
cirugía)
1 26/F Transverso 15 2.5 0/135 0/0 90/100 Ninguna
2 67/F Conminuto 13 3 0/130 1/1 82/91 Ninguna
3 34/M Transverso 16 3.5 0/140 1/0 89/99 Ninguna
4 33/M Transverso 15 3.5 0/135 0/0 95/100 Ninguna
5 55/M Transverso 13 3 0/135 0/0 89/99 Ninguna
6 40/F Conminuto 15 3 0/120 3/1 80/90 Ninguna
7 35/M Transverso 14 2.5 0/140 0/0 85/99 Ninguna
8 47/M Transverso 12 2.5 0/135 1/0 85/94 Ninguna
9 52/F Transverso 17 3 0/140 0/0 90/94 Ninguna
10 58/M Conminuto 13 3 0/130 2/1 85/95 Ninguna
11 38/M Transverso 14 3 0/140 0/0 90/100 Ninguna
12 62/F Transverso 16 3.5 0/130 1/1 85/91 Ninguna
13 43/F Transverso 15 2.5 0/140 0/0 89/99 Ninguna
14 48/M Transverso 19 3 0/135 1/0 86/94 Ninguna
15 55/M Transverso 17 3 0/135 0/0 83/91 Ninguna
promedio 46.2 14 2.96 0/134.6 0.7/0.3 86.7/95.7
se permitieron actividades deportivas de confrontación, siempre especialmente durante la flexión de la rodilla. Sin embargo, este
que los indicadores clínicos del paciente fueran satisfactorios y que sistema de cables de tensión probablemente no ofrece una
hubiera evidencia radiográfica de curación ósea. compresión suficiente y puede provocar un desplazamiento de la
Resultados fractura durante la extensión total de la rodilla o debido a la atrofia
de los tejidos blandos unas semanas después de la cirugía. 7,8,12,18,23
Todos los pacientes fueron seguidos durante más de 1 año después Generalmente, 25-42 % de los pacientes que se sometieron a la
del tratamiento (rango, 12-19 meses, tiempo medio de técnica del cable de la banda de tensión modificada tienen
seguimiento postratamiento de 14 meses), y las características resultados subóptimos debido a la migración del cable, la falla de
clínicas de todos los pacientes se mostraron en la Tabla 1. la fijación y el dolor postoperatorio debido a la implantación
Tiempo de unión ósea radiográfica irritación2,3,8,14,18,22
La unión de la fractura se produjo aproximadamente 3 meses Alternativamente, en algunos casos se han introducido tornillos de
después de la cirugía en todos los casos que no implicó la falla de presión canulados metálicos con o sin un cable de banda de
los implantes o el redesplazamiento del sitio fracturado. tensión colocado a través de los tornillos. 1,7 Según informes
Rango de movimiento anteriores, la combinación de tirafondos canulados metálicos con
En el momento de la unión ósea, el rango medio de la articulación un cable de banda de tensión podría proporcionar una fuerza de
de la rodilla era 0-134,68. Sin embargo, un paciente obeso con una fijación superior y una mayor estabilidad junto con un menor
fractura conminuta de la retícula tenía un rango de movimiento de riesgo de luxación de fracturas que cada método individual. Los
rodilla de 0-1208 en el momento de la unión durante la tirafondos y las bandas de tensión pueden ofrecer compresión del
recuperación. Sin embargo, este paciente tenía un rango normal sitio de la fractura tanto durante la extensión de la rodilla como en
de movimiento de la rodilla y una función satisfactoria de la rodilla la flexión, así como durante tiempos de mayor capacidad de carga.
4,7,30 Esta técnica es aplicable principalmente a fracturas de rótula
a los 6 meses después de la cirugía.
Puntaje VAS transversales y conminutas con adecuada composición ósea para
tornillos, mientras que los pacientes con fracturas rotas
La puntuación media de VAS de todos los pacientes fue de 0.7 en
conminutas severas no fueron elegibles, como en nuestro estudio.
el momento de la unión ósea. Con mayor frecuencia, se informó
Estudios previos 9,20 han demostrado que los síntomas
que el dolor se localizó en la parte delantera de la rodilla y fue
postoperatorios relacionados con los implantes de fractura de
causado por una actividad excesiva. En particular, ningún paciente
rótula disminuyen en severidad con el uso de implantes no
se quejó de dolor debido a la irritación de los implantes.
metálicos. En los últimos años, se ha llevado a cabo una importante
Función de la rodilla (puntaje de Lysholm)
cantidad de investigaciones sobre el uso de suturas trenzadas de
Los puntajes medios de Lysholm en el momento de la unión ósea y
poliéster con alta resistencia a la tracción en los procedimientos de
12 meses después de la cirugía fueron 86.7 y 95.7,
fijación de la fractura de la rótula, lo que sugiere su uso como
respectivamente. Todos los pacientes finalmente regresaron a su
alternativa a los alambres de metal.14,16,17,24,27 Estos trenzados las
nivel de actividad preoperatoria.
suturas de poliéster tienen varias ventajas tanto in vitro como in
Complicaciones vivo. En primer lugar, los estudios in vitro han demostrado que las
No se observaron complicaciones postoperatorias, como infección, suturas de poliéster trenzadas tienen mayor rigidez y resistencia a
dislocación o rotura de los implantes hasta el examen de la tracción que otras suturas no absorbibles o absorbibles.13 En
seguimiento final. segundo lugar, las suturas trenzadas de poliéster demuestran una
Discusión reacción tisular mínima y se ha demostrado que son seguras para
uso clínico. Además, las suturas trenzadas de poliéster pueden
La técnica de alambre de la banda de tensión modificada sugerida mantener sus características mecánicas in vivo 5,15. El examen de
por el Abreitsgemeinshaft für Osteosynthese (AO) parece ser el varias configuraciones de sutura realizadas por Patel et al. 27
abordaje más aceptado para prácticamente todos los tipos de determinó que el tamaño medio de la brecha de fractura de la
fracturas de rótula 2,18,30. Para esta técnica, se obtiene la técnica de sutura de Lotke con dos bucles del N°5 Ethibond era
compresión del sitio de la fractura solo por la presencia de un cable comparable a la técnica de Lotke de alambre en que no ocurrieron
de tensión de ocho en forma de figura situado delante de la rótula,
Lesión, Int. J. Care Injured 42 (2011) 1116-112
Injury
journal homepage: www.elsevier.com/locate/injury
A R T I C L E I N F O S U M M A R Y
Article history: Purpose: To evaluate the effectiveness and safety of a new double fixation technique for displaced
Received 22 July 2010 patellar fractures using bioabsorbable cannulated lag screws and braided polyester suture tension
Received in revised form 5 January 2011 bands.
Accepted 24 January 2011
Methods: Fifteen patients (mean age of 46.2 years) with displaced transverse or comminuted patella
fractures were enrolled in this prospective study. All of the patients were treated via the open reduction
Keywords: internal fixation (ORIF) procedure using bioabsorbable cannulated lag screws and braided polyester
Bioabsorbable cannulated lag screws
suture tension bands. The patients were followed post-surgery to evaluate (1) the time required for
Braided polyester suture
Tension band
radiographic bone union, (2) the knee joint range of motion at the time of radiographic bone union, (3)
Patella fracture the degree of pain assessed using the visual analogue scale (VAS), (4) the function of the knee using the
Double fixation Lysholm score and (5) the presence of any additional complications from the surgery.
Results: All of the patients were followed post-treatment for more than 1 year (range, 12–19 months;
mean post-treatment follow up time, 14 months). The bone union of the fractures as seen
radiographically occurred approximately 3 months from surgery in all cases without implant failure
or redisplacement of the fractured site. The mean knee joint range of motion was from 0 to 134.68, and
the mean VAS score was 0.7 at the time of bone union. The mean Lysholm scores at the time of bone
union and 12 months post-surgery were 86.7 and 95.7, respectively. No postoperative complications,
such as infection, dislocation or breakage of the implants, were observed. Moreover, all of the patients
returned to their previous activity level.
Conclusion: This new double fixation technique using bioabsorbable cannulated lag screws and braided
polyester suture tension bands resulted in satisfactory outcomes for patella fractures without any
obvious complications.
ß 2011 Elsevier Ltd. All rights reserved.
Introduction The tension band technique is most often used for patella
fractures, and has been shown to produce satisfactory out-
Patella fractures are relatively uncommon and only account for comes.25,30 Metal implants, such as stainless steel wires, K-wires
0.5–1.5% of all bone fractures.3,7 Due to the patella’s importance as and screws have generally been used for this method of fixation.
regards the extensor mechanism, efforts should to be made to However, numerous complications including postoperative pain,
preserve the patella. The goal of the therapy is the anatomical K-wire migration and other complications related to the use of
reduction of both the fracture and the articular surface in addition metal implants are fairly common,14,18,27,28 and revision surgery to
to the stable fixation of the fracture, which allows early remove the implants becomes necessary. According to Hung et
rehabilitation of the knee. Surgical treatment becomes necessary al.18 the incidence of complications related to the use of wire loops
when the fracture displacement exceeds 3 mm or the articular was 47%, and 15% had required wire removal. Moreover, far more
incongruity exceeds 2 mm.14 serious complications, such as intra-articular migration of the
broken wire, have also been reported.11
In recent years, non-metallic implants have become available
§
This research was supported by Department of Orthopaedic Surgery, West for use in fracture fixation. Some authors have evaluated new
China Hospital, Si Chuan University. Research was performed at Department of
fixation techniques for fractures of the patella or olecranon using
Orthopaedic Surgery, West China Hospital, Si Chuan University.
* Corresponding author. Tel.: +86 13908016178; fax: +86 028 85423438.
various materials, such as braided polyester sutures and biode-
E-mail addresses: liqimm@163.com (L. Qi), hxlijian.china@163.com (L. Jian). gradable screws, via biomechanical studies and randomised
1
Tel.: +86 13880765013; fax: +86 028 85423438. clinical trials.10,14,16,17,20,21,27 Such studies have discovered that
0020–1383/$ – see front matter ß 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.injury.2011.01.025
[()TD$FIG]
L. Qi et al. / Injury, Int. J. Care Injured 42 (2011) 1116–1120 1117
Patients
Fig. 3. Radiographs and a photograph of the operated site. (a) Preoperative lateral radiograph; (b) two Kirschner wires (2 mm in diameter) drilled from a distal to proximal
direction longitudinally as guide wires; (c) after the distal portions of the drill holes were overdrilled, bioabsorbable cannulated screw was screwed into the drill holes from a
distal to proximal direction; (d) photograph after fixation showed that the suture was placed beneath the fascia and in intimate contact with the bone surface; (e) C-arm
lateral radiograph immediately after fixation; (f) radiograph 12 months after surgery.
postoperative day 2 or 3, partial or full weight-bearing exercises lasted for a period of 4 weeks. Beginning in the fourth
were started under the protection of a hinge brace, while walking postoperative week, normal daily activities for the participants
exercises involving the use of crutches also began at this time and were permitted. Approximately 3 months after the surgery, non-
L. Qi et al. / Injury, Int. J. Care Injured 42 (2011) 1116–1120 1119
Table 1
Clinical features of the 15 patients.
Case Age/sex Fracture Follow-up Time to bone ROM at VAS score Lysholm score Complications
(years) type period union bone union (bone union/12 (bone union/12 (12 months
(months) (months) (extension/flexion) months after surgery) months after surgery) after surgery)
loops of No. 5 Ethibond was comparable to the wire Lotke patients with patella fractures without obvious complications. The
technique in that no failures of fixation occurred. Thus, we used applications include procedures involving transverse patella
two loops of No. 5 Ethibond in our study. fractures and comminuted patella fractures with adequate bone
Metal cannulated lag screws with a tension band wire and the composition to accommodate screws.
Lotke technique with suture were both proved to be stable fixation
techniques for patella fractures.23,27 The technique reported herein References
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Reacción comparativa entre suturas Mersilene y de seda
Implantadas en el Corazón *
CLARENCE I. BRITT, MD, EDWARD M. MILLER, JR., MD,
MARTIN E. FELDER, MD, HOWARD D. ŠIRÁK, MD
FIG. E, F. Aspecto
microscópico crónico. E.
A las 4 semanas,
fragmentación de la
sutura de seda por
crecimiento interno
celular (Fecha). F.
Mismo animal,
encapsulación y
fragmentación mínima
de Mersilene.
No se encontraron bacterias en ninguno de los El colágeno comenzó a aparecer a los siete días, se
abscesos de sutura. Los abscesos de sutura volvió prominente por 14 días y formó una cicatriz
implicaron el miocardio del tabique auricular y el organizada por cuatro semanas. El colágeno y el
extremo libre del material de sutura. Los cinco tejido cicatricial tendieron a formar una cápsula que
abscesos de sutura cerca de la sutura de seda en algunos casos cortó completamente la sutura.
estaban presentes en animales en los que se había
encontrado un coágulo groseramente.
HIGO. 4 E, F.
Hallazgos tardíos
inusuales. E. A las 18
semanas, calcificación
ectópica cerca de una
sutura de Mersilene. F. A
las 18 semanas,
osificación de cartílago y
calcificación ectópica en
el cierre de la pared
auricular con seda.
Resistencia a tracción de
MERSILENE * y seda SUTURAS
el observado adyacente a cualquier sutura en
el tabique auricular. La incidencia de
formación de cartílago en la pared auricular
fue significativamente mayor.
Resistencia a la tracción
La r e s i s t e n c i a a l a t r a c c i ón y e l d i á me t r o
d e c a d a su t ur a d e M er s i l e n e y s e d a
c o l o c a d a e n e l mú s c u l o d e l a p a r e d t o r á c i c a
s e d e t e r mi n a r o n e n e l mo me n t o d e l
s a c r i fi c i o . O c h o a 24 s e ma n a s d e s pu é s d e
l a i mp l a n t a c i ó n, e l d i á me t r o d e l M e r s i l e n e
va r i a b a d e 9. 1 a 1 0 mi l s , mi e n t r a s q u e e l
d i á me t r o d e l a s s u tu r a s d e s e d a va r i a b a d e
9 . 5 a 11 .8 5 mi l s ( U . S.P . 8 a 10 mi l s ) . E l
d i á me t r o d e l a s e d a fu e c o n s i s t en t e me n t e
FIG. 5. Resistencia a la tracción de Mersilene má s gr a n d e qu e e l d e l M e rs i l e n e e n va l o r e s
en comparación con la seda. La seda sufre una q u e va n d e l 2 p o r c i e n to al 27 .4 p o r c i e n to .
pérdida gradual de resistencia a la tracción con el E n d o s mu e s t r a s , e l di á m e t r o d e l a s u tu r a
aumento del tiempo. La resistencia a la tracción de
Mersilene es constante y se aproxima a U.S.P. d e s e d a e xc e d i ó e l U . S .P . e s t á n d a r e s ( 8 a
estándares. El rango de resistencia a la tracción de 1 0 mi l s ) p a r a s u tu r a d e s e da 3 - 0.
cada sutura de seda varió ampliamente y el de
Mersilene fue más uniforme.
La r e s i s t e n c i a a l a t r a c c ió n d e lo s d o s
ma t e r i a l e s d e s u t u r a s e d et e r mi n ó c o mo un
e s t i r a mi e n t o recto después de la
Había pequeñas áreas de calcificación h u me c t a c i ó n y s e c o mp a r ó c o n lo s
intracelular ectópica (Fig. 4 D, E, F) cerca e s t á n d a r e s e s p e r a do s p a r a l a s e d a t r en z a d a
de la sutura de Mersilene en cuatro perros, n e gr a 3 -0 ( U .S .P . 5 .0 l i bra s ) ( fi gu r a 5 ) . E l
cerca de la seda en un perro y en el cierre de M e r s yl e n e i mp l a n t a do c o mp a r ó b a s t a nt e
seda de la pared auricular en un perro. fa vo r a b l e me n t e con el estándar, la
r e s i s t e n c i a a l a t r a c c ió n d e l o s e sp e c í me n e s
Se hizo una comparación entre la reacción q u e o s c i l a e n t r e 4 , 35 y 5 , 83 li b r a s . La
tisular de la seda en el cierre de la pared d u r a c ió n d e l a i mp l a n ta c i ó n n o a fe c t ó
auricular y la de los dos tipos de bucles de a p r e c i a b l e me n t e a M e r s i l e n e du r a n t e l a s 24
sutura en el tabiqu e auricular. El método de s e ma n a s d e l e s t ud i o. La r e s i s t e n c i a a l a
colocar las suturas septales fue diseñado t r a c c i ó n d e l a s u tu r a de M e r s i l e n e fu e
para minimizar el trauma. Se usaron agujas c o n s i s t en t e me n t e mu c h o m a yo r q u e l a d e l a
atraumáticas y se insertaron cuidadosamente s e d a , qu e va r i ó d e 4, 65 a u n a b a j a d e 1 ,3
en el tabique auricular y las suturas se l i b r a s a l a s 1 4 s e ma n a s . Lo s va l o r e s d e
unieron sin apretar. Se usó una sutura de resistencia a la tracción para la seda
seda atraumática 3 -0 continua en el cierre de mo s t r a r o n u n a d i s mi n u c ión c on s t a nt e c on
la pared auricular que tuvo que estirarse lo r e s p e c t o a l e s t á nd a r U . S .P . o ri gi n a l
suficiente para obtener hemostasia. La d e s p u é s d e s e i s s e ma n a s . H u bo un a gr a n
incidencia de formación de coágulos en el va r i a c i ó n e n l a r e s i s t e n c i a a l a t r a c c i ó n d e
cierre de la pared auricular fue la misma que l a s s u t u r a s d e s e d a c o n e l mi s mo i n t e r va l o
la observada para las suturas de seda en el d e i mp l a n t a c ió n .
tabique auri cular. El tamaño de los coágulos Discusión
en la pared auricular fue uniformemente más
grande que los de las suturas septales. Los
S e s a b e q u e M e r s i l en e , un p r odu c t o d e
hallazgos microscópicos en el cierre de la
c o nd e n s a c i ón d e fi b r a d e p ol i é s t e r d e
pared auricular fueron mucho más intensos.
e t i l e n gl i c ol y t e r e ft a l a t o d e d i me t i l o , e s
El grado de inflamación aguda y crónica b i e n t ol e r a do e n l a p i e l y o t r o s t ej i do s
fue mucho mayor en la pared auricular que b l a nd o s. 3 , 5 S e p u ed e e s t er i l i z a r e n
Volumen Suturas de seda implantada dentro del corazón
153 número 61
1
a u t o c l a ve s i n p é rd id a d e r e s i s t e n c i a a l a en forma de edema y cambios inflamatorios
t r a c c i ó n o c a mb i o e n s u s p ro p i ed a d e s son esencialmente los mismos. Sin embargo,
q u í mi c a s . S e c o n s i d e r a no c a r c i n o gé n i co Mersilene tiene varias ventajas distintas
p o rq u e n o e s u n d e r i va do d e a l qu i t r án d e (Tabla 1) sobre la seda cuando se implanta
h u ll a . dentro de las cámaras cardíacas: 1) La
formación de trombos ocurre con menos
E s d e s e a b l e qu e e l ma t e r i a l d e s u tu r a no frecuencia en el Mersilene que en la sutura
a b s o rb i bl e u t i li z a d o d e n tr o d e l c o r a z ón de seda. Cuando se desarrolló un coágulo en
p r od u z c a u n a r e a c c i ó n t is u l a r mí n i ma y ambas suturas, el trombo en el Mersilene era
ma c r o s c ó p i c a mí n i ma d u ra n t e e l p e rí od o más pequeño. 2) La cantidad y duración de la
i n me d i a t a me n t e p o s t e ri o r a la reacción inflamatoria crónica persistió más
i mp l a n t a c i ó n. Ta mb i é n e s i mp o r t a n t e qu e tiempo y fue más severa alrededor de la seda
p r o voqu e c a mb i o s i n fl a ma t o r io s c r ó ni c o s que alrededor de la Mersilene. 3) Se
mí n i mo s . 2 , 4 E s t o s fa c t o r e s p u e d e n t en e r encontraron abscesos estériles, asociados con
ma yo r i mp o r t a n c i a en lo s p r o c e di mi e n t o s un trombo, en las suturas de seda de tres a
d e c o r a z ón a b i e r to p o rque s o n c u e rp o s seis meses después de la implantación,
e xt r a ñ o s c u yo s e xt r e mo s l i b r e s s o n enfatizando la alta incidencia de formación
p o s ib l e s s i ti o s d e fo r ma c i ó n d e t ro mb o s . de granuloma con seda. No se vieron
Ad e má s , c o n fr e c u e n c i a s e c o l o c a n c e r c a abscesos alrededor del Mersilene. 4) El
d e ví a s d e c o nd u c c ió n i mp o rt a n t e s do nd e tamaño y la resistencia a la tracción de
u n a r e a c c i ó n e xa ge r a d a d e l t e j id o po d rí a Mersilene es más uniforme y constante que la
p r od u c ir s e e n e l b lo qu e o c a r d í a c o. seda después de períodos variables de
D e b i do a q u e l o s ma t e r i a l e s p r o t é s i c o s s e implantación.
c o l o c a n c on fr e c u e n c i a c e r c a d e ví a s d e
c o nd u c c ió n i mp o rt a n t e s d on d e una
r e a c c i ó n e xa ge r a d a d e l t e j i d o p od r í a
p r od u c ir s e e n e l b lo qu e o c a r d í a c o. Resumen
D e b i do a q u e l o s ma t e r i a l e s p r o t é s i c o s
s o n fr e c u e n t e me n t e n e c e s a r i o s p a r a c e r r a r
1. Suturas de Mersilene y seda fueron
l o s d e fe c t o s , y d e b i do a q u e l a c u r a c ió n
colocados en el tabique auricular por
d e lo s ma t e r i a l e s p r o t é s ic o s o cu r r e má s
oclusión de flujo proximal en 46 perros.
l e n t a me n t e , p u ed e s e r imp o r t a n t e t e n e r
Los animales fueron sacrificados a
u n a su tu r a c on ma yo r d u r ab i l id a d.
intervalos variables de 24 horas a 24
semanas para estudiar las reacciones
TABLA 1.Ventajas relativas de Mersilene
macroscópicas y microscópicas al
más de sutura de seda
material de sutura implantado.
La formación de trombos ++
cambios inflamatorios crónicos ++
absceso de sutura ++ 2. Mersilene parecía ser superior a la seda
Resistencia a la tracción ++ cuando se implantaba en el corazón
tamaño de sutura ++ porque la formación de trombos era
cambios inflamatorios agudos + considerablemente menor, la inflamación
La encapsulación +
crónica era menos intensa y remitía antes
la formación de cartílago + y no se producía la formac ión de abscesos
La osificación en el miocardio + de sutura.
OPEN-HEART procedures require perma- placed in the atrial septum of dogs (Fig.
nent implantation of suture material within 1 A). These two sutures were placed in
the heart for closure of atrial and ventric- the same dog, far enough apart in the
ular septal defects and the repair of atrial septum to prevent overlapping of the
cardiotomy incisions. These sutures, acting cellular reaction so that each could be
as foreign bodies, may induce thrombus studied separately. In this way, each dog
formation or provoke excessive edema served as his own control for the two ma-
which, if near the ventricular conduction terials. To avoid crushing tissue, each su-
system, may predispose to heart block. In- ture was tied loosely. The atrium was
flammatory changes following suture im- closed with a continuous atraumatic 3-0
plantation may result in endocarditis, myo- silk suture.
carditis, pericarditis or abscess formation.' The remainder of each Mersilene and
Mersilene "* suture has been shown to silk suture was implanted in the chest wall
be less reactive than silk when implanted muscle during closure. This provided a
in the skin, subcutaneous tissues and fas- means of comparing the tensile strength of
cia.'-3' 5Also, it provides greater tensile each suture after varying intervals of
strength with a smaller caliber.2' There- implantation.
fore, it seemed worthwhile to compare ex- Forty-six dogs were prepared as de-
perimentally the reactions of Mersilene and scribed. The findings at the time of sac-
silk sutures in heart tissue. Early and late, rifice were classified into early, inter-
gross and microscopic changes were mediate and late groups. In the early
studied. The tensile strength of the two group, four dogs were sacrificed at 24, 48,
materials was determined after varying 72 and 96 hours, and one week after
intervals of implantation. operation. In the intermediate group, four
Experimental Method
dogs were sacrificed at two weeks and at
one, one and one-half, and two months. In
Using proximal inflow occlusion and the late group, two dogs were sacrificed at
right atriotomy, interrupted sutures of three, three and one-half, four, four and
atraumatic 3-0 silk and 3-0 Mersilene were one-half and six months.
*
Submitted for publication May 20, 1960. Gross Observations. At the time of sac-
"
Mersilene sutures are Dupont's dacron rifice, the atrial septum was inspected for
polyester fibre. Supplied by Mr. C. W. Norman, the presence of thrombi on the suture
Ethicon, Inc., Somerville, New Jersey. (Fig. 1 B, C, D). Subendocardial hemor-
Supported by grants from the Bremer Founda-
tion of Youngstown, Ohio, and Ethicon, Inc., of rhage near the suture was assigned a 1-to-
somerville, New Jersey. 4-plus according to the number of quad-
52
Volume 153 SILK SUTURES IMPLANTED WITHIN THE HEART
Number 1 53
FIG. 1. Gross appearance of Mersilene (M) and Silk (S). A. No abnormal reaction after
12 weeks. B. At 6 weeks, fresh clot present on septal and wall (W) sutures. C. At 14 weeks,
organized thrombus on both septal sutures. D. Organized clot on silk only. E. At 4 weeks,
2+ (2 quadrants involved) endocardial sclerosis around silk. F. at 48 hours, 3+ 3 quadrants
involved) endocardial hemorrhage around Mersilene. G. At 16 weeks, endothelioid coating of
silk, but not of Mersilene.
rants involved (Fig. 1 F). The white zone tissue containing each suture was obtained
of endocardial sclerosis noted in the myo- for microscopic examination. The amount
cardium near the suture was similarly of edema was estimated according to the
quantitated (Fig. 1 E). The thickness of amount of separation of the myocardial
the endothelioid coating (fibrin, platelets b)tlndles near the sutulre mater-ial (Fig. 2 A,
and leukocytes) on the exposed suture sur- B, C, D). Microscopic hemorrhage or red
face was noted (Fig. 1 G). cell infiltration of the tissue adjacent to the
Microscopic Observations. A block of suture was quantitated according to its
I3RITT, MILLER, FELDER AND SIRAK Annals of Surgery
54 January 1961
s jt 2t + tt % t eSj Z e
depth and the number of quadrants in- from its depth, concentration and the de-
volved (Fig. 2 E, F). gree of lymphocyte, macrophage, fibroblast
The degree of acute inflammation was and plasma cell infiltration (Fig. 3 A, B, C,
estimated by determining its depth, con- D). The amount of collagen and granula-
centration and the number of quadrants of tion tissue present influenced this estimate.
polymorphonuclear infiltration (Fig. 2 A, The presence of scar formation, the tend-
B, D). The presence of early granulation ency toward encapsulation (Fig. 3 F) of
tissue an(ld the presence or al)sence of the suttire mviaterial, and the degree of
clironic inflanimnatory cells was also taken fraiginenitattioni (Fig. 3 E) of the suture
into consideration. were studied. Incidental findings, such as
Chronic inflammation was estimated the formation of suture abscesses (Fig.
Volume 153 SILK SUTURES IMPLANTED WITHIN THE HEART
Number 1 55
4 A), myxomatous degeneration (Fig. 4 B,
C), cartilage formation (Fig. 4 C, D),
calcification (Fig. 4 D, E, F) and os-
sification (Fig. 4 F) were noted.
Results
Gross Findings. In this series of 46 dogs,
the sutures and atrial wall closure were
free of thrombus formation in 28 dogs
(60%-Fig. 1 A). An organized thrombus
was found twice as frequently on the black
silk suture in the atrial septum (12 dogs)
when compared to the Mersilene (6 dogs).
There was an equal incidence of clot for-
mation on silk placed in the atrial septum
(12 dogs) and on the silk in the atrial wall
closure (11 dogs), but thromnbi on the
atrial wall were consistently larger (Fig.
1 B). In three dogs, a clot was present on
all three suture sites (Fig. 1 B) (atrial
septum Mersilene, atrial septum silk, and
atrial wall silk), but the thrombus was
smaller on the Mersilene in two of the
three animals. In two animals, :a thrombus
was present on the atrial septal silk and
the Mersilene and the clot was smaller
on the Mersilene in one (Fig. 1 C). In
the atrial septum, clot formation was most
commonly found on the silk onlv (4 dogs-
Fig. 1 D). One preparation had a clot on
the Mersilene only. The remainder of the
dogs had clots on the atrial wall only (5
dogs). Three dogs had a clot on both the
septal silk and the atrial wall closure.
Organizing clots were found on silk and
Mersilene more commonly during the early
period of the study, but were found as
long as six months after implantation.
There was little difference between silk
and Mersilene in the frequency and amount FIC. 2 E, F. Acute microscopic appearance. E.
of gross hemorrhage near the sutures (Fig. At 24 hours, 1+ hemorrhage (H) around the
1 F), of endothelioid coating of the free silk. F. At 48 houirs, 3+ hemorrhage near the
Mersilene.
surfaces of the sutuire material (Fig. 1 G),
and of endocardial sclerosis a(ljacent to materials. In the early group (24 houirs to
the site of implantation (Fig. 1 E). 1 week), edenma of slightly greater in-
M i c r o s c o p i c Observations-Acute tensity appeared earlier around the Mersi-
Changes. Edema was greatest on the sec- lene than around the silk (Fig. 2 A, B, C,
ond and third days around both suture D), but subsided sooner around the Mer-
56 I3RITT, MILLER, FELDER AND SIRAK January 1961
S'- :."_ b .1 -f - ".--
..- '- .-%
silene. An equal amount of edema was still subsided in two weeks. It seemed slighUy
present around both sutures one month greater around the Mersilene than the silk
after operation. No edema was noted in in the early group.
later specimens. Actute polymorplhonuiclear leuikocytic in-
Microscopic hemnorrlhage (Fig. 2 E, F) filtration was greatest on the first and
was greater on the second postoperative second days and completely subsided in
day around both sutures and completely four weeks. Consideration of all dogs in
Veiume 153 SILK SUTURES IMPLANTED WITHIN THE HEART
Number 1 57
FIG. 3 E, F. Chronic
microscopic appearance.
E. At 4 weeks, fragmen-
tation of silk suture by
cellular ingrowth (Ar-
row). F. Same animal,
encapsulation and min-
imal fragmentation of
Mersilene.
FIG. 4 E, F. Unusual
late findings. E. At 18
weeks, ectopic calcifica-
tion near a Mersilene su-
ture. F. At 18 weeks, os-
sification of cartilage and
ectopic calcification in
the atrial wall silk
closure.
the silk sutures in the intermediate and end of the suture material. The five suture
late groups. abscesses near the silk suture were present
Microscopic suture abscesses with cen- in animals in which a clot had been found
tral suppuration (Fig. 4 A) were found in grossly.
three dogs about the silk septal suture and Collagen began to appear at seven days,
in two dogs near the atrial wall silk closure. became prominent by 14 days and formed
None were found with the Mersilene. No organized scar by four weeks. The collagen
b)acteria were present in any of the suture anid scatr tisstue tended to formn a capsule
abscesses. The suture abscesses involved completely walling off the suture in some
the atrial septal myocardium and the free cases. Complete encapsulation (Fig. 3 F)
BRITT, MILLER, FELDER AND SIRAK Annals of Surgery
60 January 1961
TENSILE STRENGTH OF MERSILENE AND
SILK SUTURES
A comparison was made between the
tissue reaction of the silk in the atrial wall
closure and that of the two kinds of suture
--, loops in the atrial septum. The method of
-_
(I' placing the septal sutures was designed to
minimize trauma. Atraumatic needles were
C0~
used and inserted carefully in the atrial
:. septum and the sutures tied loosely. A con-
K5 tinuous 3-0 atraumatic silk suture was
co~ used in the atrial wall closure which had
to be pulled tight enough to obtain he-
2 4 5 8 ib i. 14 i6 mostasis. The incidence of clot formation
DAYS WEEKS on the atrial wall closure was the same as
FIG. Tensile strength of Mersilene compared
5. that observed for the silk sutures in the
to silk. Silk undergoes a gradual loss of tensile atrial septum. The size of the clots on the
strength with increasing time. The tensile strength
of Mersilene is constant and approximates U.S.P. atrial wall was uniformly larger than those
standards. The range of tensile strength of each on the septal sutures. The microscopic
silk suture varied widely and that of Mersilene was
more uniform. findings in the atrial wall closure were
much more intense. The degree of acute
occurred more often about the Mersilene. and chronic inflammation was much greater
Fragmentation of the suture material by in the atrial wall than that observed ad-
ingrowth of macrophages, fibroblasts and jacent to either suture in the atrial septum.
chronic inflammatory cells appeared at The incidence of cartilage formation in the
four weeks (Fig. 3 E). The incidence and atrial wall was significantly higher.
degree was equal for the two suture
materials. Tensile Strength
Unexpected pathologic findings were The tensile strength and diameter of
noted in the surrounding soft tissue in each Mersilene and silk suture placed in
several instances. Myxomatous degenera- the chest wall muscle was determined at
tion was found in the late group of animals the time of sacrifice. Eight to 24 weeks
adjacent to the Mersilene suture in two after implantation, the diameter of the
dogs (Fig. 4 B, C) and in the atrial wall Mersilene varied from 9.1 to 10 mils, while
silk closure in two dogs. None was found the diameter of the silk sutures varied
in the septum near the silk suture. Cartilage from 9.5 to 11.85 mils (U.S.P. 8 to 10 mils).
formation was found in large quantities The diameter of the silk was consistently
around the silk suture in one dog and larger than that of the Mersilene by values
around the atrial wall silk closure in seven ranging from 2 per cent to 27.4 per cent.
dogs (Fig. 4 D). One dog showed ossifica- In two specimens the diameter of the silk
tion of the cartilage (Fig. 4 F) that had suture exceeded U.S.P. standards (8 to 10
developed in the atrial wall closure. No mils) for 3-0 silk suture.
cartilage formation or ossification was seen Tensile strength of the two suture ma-
near the Mersilene suture. There were terials was determined as straight pull after
small areas of ectopic intracellular calcifica- wetting and was compared to the expected
tion (Fig. 4 D, E, F) near the Mersilene stanidards for black braided .3-0 silk (U.S.P.
suture in four dogs, near the silk in one dog 5.0 lbs.) (Fig. 5). The implanted Mersi-
and in the atrial wall silk closure in one lene compared quite favorablv with the
dog. standard, the tensile strength of the speci-
Volume 153 SILK SUTURES IMPLANTED WITHIN THE HEART
Number 1 61
mens ranging from 4.35 to 5.83 pounds. TABLE 1. Relative Advantages of Mersilente
I'le (Itdirationi of imiplantation (lid not ap- over Silk Suture
pieciably afiect the Mcrsilcne dutring the TI hroiiibus foritiatioin tt
24 wccks of the stut(ly. The tensile strcngtlh Chroniic inflanmimiatory chainges tt
of the Mersilenie suture was consistently Suture abscess tt
Tensile strength tt
much greater than that of the silk which Suture size tt
varied from 4.65 to a low of 1.3 pounds at Acute inflammatory changes t
14 weeks. The tensile strength values for Encapsulation t
Cartilage formation t
the silk showed a consistent decline from Ossification in myocardium t
the original U.S.P. standard after six weeks.
There was a wide variation in tensile t Slightly superior.
strength of silk sutures with the same in- tt Markedly superior.
terval of implantation.
This experimental study indicates that
Discussion the early gross and microscopic changes
appear to be primarily related to the
Mersilene, a polyester fibre condensa- trauma of placing the suture rather than
tion product of ethylene glycol and di- to a specific response to the suture ma-
methyl terephthalate, is known to be well terial. During the first seven days after im-
tolerated in skin and other soft tissues.3 5 plantation, the tissue response to silk and
It can be sterilized by autoclaving without Mersilene in the form of edema and in-
loss of tensile strength or change in its flammatory changes are essentially the
chemical properties. It is considlered to be same. However, Mersilene has several dis-
noncarcinogenic because it is not a coal tinct advantages (Table 1) over silk when
tar derivative. implanted within the cardiac chambers: 1)
It is desirable that the nonabsorbable Thrombus formation occurs less frequently
suture material used within the heart pro- on the Mersilene than on the silk suture.
duce minimal gross and microscopic tis- When a clot developed on both sutures the
sue reaction during the immediate post thrombus on the Mersilene was smaller.
implantation period. It is also important 2) The amount and duration of chronic
that it evoke minimal chronic inflammatory inflammatory reaction persisted longer and
changes.' 4 These factors may have greater was more severe around the silk than
significance in open-heart procedures be- around the Mersilene. 3) Sterile abscesses,
cause they are foreign bodies whose free associated with a thrombus, were found on
ends are possible sites of thrombus forma- the silk sutures three to six months after
tion. Also, they are frequently placed near implantation, emphasizing the high in-
important conduction pathways where an cidence of granuloma formation with silk.
exaggerated tissue reaction could eventuate Abscesses were not seen around the Mersi-
in heart block. Because prosthetic ma- lene. 4) The size and tensile strength of
terials are frequently placed near important Mersilene is more uniform and constant
conduction pathways where an exagger- than silk after varying periods of im-
ated tissue reaction could eventuate in plantation.
heart block. Because prosthetic materials
are frequently necessary to close defects,
Summary
and because healing to prosthetic ma- 1. Loops of Mersilene and silk suture
terials occurs more slowly, it may be im- were placed in the atrial septum by proxi-
portant to have a suture with greater mal inflow occlusion in 46 dogs. The ani-
durablity. mals were sacrificed at varying intervals
62 BRITT, MILLER, FELDER AND SIRAK January 1961
fromn 24 hlours to 24 wvecks to sttudy the 3. Dcttingcr, G. B. and W. F. Bowers: Tissuec
gross anid mnicroscopic r-cactionls to tlle ifn- Recspon.se to Orloio aiid D)acroi Soittur.cs; A
Comparison Vitlh Nyloni, Cottont and Silk.
plante(d suitur-e milaterial. Suirgery, 42:325, 1957.
2. Mersilene appeared to be superior to) 4. Madsenl, E. T.: An Expcriiuiiictal . iil Clinical
silk when implanted within the lheart be- Evaluattion of Surgical Suture Materials III.
cause thrombus formation was consider- Surg. Gynec. & Obst., 106:216, 1958.
ably less, chronic inflammation was less 5. Narat, J. K., J. P. Cangelosi and J. V. Bel-
monte: Evaluation of Dacron. Suture Ma-
intense and subsided earlier and suture terial for General Surgery. Surgical Forum,
abscess formation did not occur. 7:176, 1959.
3. The tensile strength of Mersilene, un- 6. Phelan, J. T., W. P. Young and J. W. Gale:
like silk, was unaffected by implantation. The Effect of Suture Material on Small
Artery Anastomoses. Surg. Gynec. & Obst.,
Bibliography 107:79, 1958.
7. Postlethwait, R. W., J. F. Schauble, M. L.
1. Bahnson, H. T., F. C. Spencer and I. L. Dillon, and J. Morgan: Wound Healing II;
Bennett: Staphylococcal Infections of the An Evaluation of Surgical Suture Material.
Heart and Great Vessels Due -to Silk Sutures. Surg. Gynec. & Obst., 5:555, 1959.
Ann. Surg., 146:399, 1957. 8. Wolstenholme, J. T., H. Lotman and M.
2. Deterling, Jr., R. A. and S. B. Bhonslay: An Malament: The Reaction of Human Sometic
Evaluation of Synthetic Materials and Fab- Tissue to Implanted Dacron Fabric: Report
rics Suitable for Blood Vessel Replacement. of Five Cases. Plastic and Reconstructive
Surg., 38:71, 1955. Surg., 19:156, 1957.
Trastornos musculoesqueléticos BMC BioMed Central
Address: Department of Trauma and Orthopaedics, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW, UK
Email: Crawford R Deane - crdeane@gmail.com; Nicholas A Ferran* - nferran@uku.co.uk; Adel Ghandour - member@oghandour.fsnet.co.uk;
Rhidian L Morgan-Jones - lorraine.timmons@cardiffandvale.wales.nhs.uk
* Corresponding author
Resumen
Antecedentes: La osteotomía de la tibia tibial ha demostrado ser muy prometedora en la revisión del
reemplazo total de rodilla. Los métodos de reparación descritos anteriormente incluyen fijación por
tornillo y alambre. Ambos métodos tienen complicaciones significativas.
Metodos: Este artículo describe la fijación de la sutura de la osteotomía utilizando suturas Ethibond
ubicadas medialmente con una bisagra periosteal lateral.
Resultados: Este método de fijación se basa en un segmento de osteotomía adecuado que incluye la
inserción completa del tendón de la rótula. La bisagra periosteal lateral se mantiene y se agrega a la
estabilidad de la construcción. Se pasan un mínimo de dos suturas Ethibond número 5 medialmente a
través de orificios para asegurar el segmento de la osteotomía. No se requiere inmovilización
postoperatoria.
Conclusion: Las suturas Ethibond proporcionan una fijación adecuada del segmento de osteotomía de la
tuberosidad tibial en la artroplastia de rodilla de revisión con un riesgo reducido de complicaciones en
comparación con los métodos de fijación convencionales.
Resultados
Todos los pacientes se someten a un proceso de
consentimiento informado antes de la cirugía. Bajo
anestesia general o espinal, el paciente se coloca en
decúbito prono y se aplica un torniquete en la mitad del
muslo inflado a 300-350 mmHg. Se usa un soporte
lateral y una almohada para mantener la rodilla en una
flexión de aproximadamente 90 °. Se usa una
preparación aséptica estándar y cortina.
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Figura 2
Osteotomía creada con el uso de osteótomos.
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Figura 4
Exposición ganada por el uso de osteotomía.
Figura 5
Colocación de agujeros de perforación y suturas.
Discusión
La osteotomía de la tuberosidad tibial tiene una
incidencia menor de retraso de los extensores en Mendes et al. informaron sobre 67 artroplastias de
comparación con las exposiciones que utilizan los rodilla de revisión tratadas con TTO fijadas con
cuádriceps, como la disminución del cuádriceps [1]. Si alambres de cerclaje. Hubo 2 fracturas de estrés tibial
bien la osteotomía de la tuberosidad tibial proporciona no desplazadas y 1 unión fibrosa. Dos pacientes
un excelente acceso en la artroplastia de rodilla de requirieron la extracción de cables debido al dolor [6].
revisión, los métodos tradicionales de fijación del
segmento de osteotomía no están exentos de La fijación de la sutura de la osteotomía tiene varias
complicaciones. ventajas sobre otros métodos de fijación. La colocación de
suturas es menos difícil que navegar tornillos para evitar el
Van den Broek y col. informaron sus resultados de 37 componente de revisión tibial. Ethibond ofrece un manejo
pacientes de artroplastia de rodilla de revisión manejados más fácil que el cable y tiene una excelente resistencia a la
con un corte de paso TTO fijado con tornillos; 5 pacientes tracción. Con una manga perióstica lateral intacta,
tuvieron reoperación: 1 para la refijación del fragmento proporciona una fijación adecuada en el contexto de la
migrado, 1 para la reconstrucción del tendón rotuliano artroplastia de rodilla de revisión. En nuestra experiencia,
después de una avulsión y 3 para la extracción de nunca hemos tenido que revisar la fijación del segmento de
tornillos dolorosos [4]. osteotomía con suturas.
Hocking et al. Informó sobre 49 casos de TTO con fijación Las suturas Ethibond ofrecen menos prominencia anterior
de alambre de cerclaje. Un paciente requirió revisión de que los dos tornillos y alambres para reducir la incidencia
un segmento de osteotomía migrado y uno tuvo una del dolor anterior en la rodilla y no hemos tenido que volver
fractura intraoperatoria del segmento de osteotomía [5]. a operar para eliminar las suturas problemáticas o
prominentes.
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Conclusión
Las suturas Ethibond proporcionan un método
alternativo de reparación de la osteotomía de la
tuberosidad tibial cuando se usan para el acceso en la
artroplastia de rodilla de revisión. Esta técnica es más
fácil de realizar con un riesgo reducido de reoperación y
fractura en comparación con la fijación con tornillos y
cerclaje.
Métodos
El segmento de osteotomía de la tuberosidad tibial se
crea utilizando un osteótomo medialmente para
proporcionar un grosor máximo de aproximadamente
1 cm. Se tiene cuidado de incluir toda la inserción del
tendón rotuliano (Figura 1). El osteótomo se pasa a
través del hueso cortical medial, el hueso esponjoso y
parcialmente a través del hueso cortical lateral (Figura
2). El periostio lateral se deja intacto para actuar
como una bisagra para el segmento de osteotomía. No
se realizan pasos proximales o distales. El osteótomo
se usa para levantar el segmento de la tibia (Figura 3),
lo que proporciona acceso al canal medular de la tibia
(Figura 4).
El segmento de osteotomía se realinea bajo visión
directa. La restauración a la posición inicial se usa en
la mayoría de los casos; sin embargo, en casos de
trastorno grueso de la alineación rotuliana, como la
Figura 6 rótula baja, la osteotomía se reubica deliberadamente
Diagrama esquemático de la osteotomía reparada. para corregir la mala alineación. La reubicación de la
rótula requiere que la bisagra periosteal lateral se
libere parcialmente y depende de la elasticidad de los
tejidos para la movilización.
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Figura 7
Radiografía de la reparación de la sutura de la osteotomía de la tuberosidad tibial inmediatamente después de la operación (A) y en el
seguimiento que demuestra trabéculas que cruzan el sitio de la osteotomía (B).
Address: Department of Trauma and Orthopaedics, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW, UK
Email: Crawford R Deane - crdeane@gmail.com; Nicholas A Ferran* - nferran@uku.co.uk; Adel Ghandour - member@oghandour.fsnet.co.uk;
Rhidian L Morgan-Jones - lorraine.timmons@cardiffandvale.wales.nhs.uk
* Corresponding author
Abstract
Background: Tibial Tubercle Osteotomy has shown much promise in revision total knee
replacement. Methods of repair previously described include screw and wire fixation. Both
methods have significant complications.
Methods: This article describes suture fixation of the osteotomy using Ethibond sutures placed
medially with a lateral periosteal hinge.
Results: This method of fixation relies upon an adequate osteotomy segment including the entire
insertion of the patella tendon. The lateral periosteal hinge is maintained and adds to the stability
of the construct. A minimum of two number 5 Ethibond sutures are passed medially through drill
holes to secure the osteotomy segment. No post-operative immobilisation is required.
Conclusion: Ethibond sutures provide adequate fixation of the tibial tubercle osteotomy segment
in revision knee arthroplasty with reduced risk of complication as compared to conventional
fixation methods.
Two methods of fixation of the osteotomy segment have Suture fixation of the TTO has been developed by the sen-
been described: screw fixation and cerclage wire fixation. ior author to reduce the complications associated with tra-
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Results
All patients undergo a process of informed consent prior
to surgery. Under general or spinal anaesthetic, the patient
is placed in the prone position, and a mid-thigh tourni-
quet is applied and inflated to 300–350 mmHg. A lateral
support and bolster are used to maintain the knee in
approximately 90° flexion. A standard aseptic preparation
and drape is used.
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Figure 3reflection
Schematic
allowing diagram of
demonstrating
osteotomy segment
lateral periosteal hinge
are required for adequate fixation however three sutures Schematic diagram demonstrating lateral periosteal hinge
are ideal. allowing reflection of osteotomy segment.
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Hocking et al. reported on 49 cases of TTO with cerclage Ethibond sutures offer less anterior prominence than both
wire fixation. One patient required revision of a migrated screws and wires in order to reduce the incidence of ante-
osteotomy segment and one had an intra-operative frac- rior knee pain and we have not had to re-operate to
ture of the osteotomy segment [5]. Mendes et al. reported remove troublesome or prominent sutures. Stresses on the
on 67 revision knee arthroplastys treated with TTO fixed osteotomy segment are also more widely distributed with
with cerclage wires. There were 2 undisplaced tibial stress sutures than with screws reducing the likelihood of frac-
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Conclusion
Ethibond sutures provide an alternative method of repair
of tibial tubercle osteotomy when used for access in revi-
sion knee arthroplasty. This technique is easier to perform
with reduced risk of re-operation and fracture as com-
pared with screw and cerclage wire fixation.
Methods
The tibial tubercle osteotomy segment is created using an
osteotome medially to provide a maximum thickness of
approximately 1 cm. Care is taken to include all of the
insertion of the patellar tendon (Figure 1). The osteotome
is passed through the medial cortical bone, the cancellous
bone and partially through the lateral cortical bone (Fig-
ure 2). The lateral periosteum is left intact to act as a hinge
for the osteotomy segment. No proximal or distal steps
are made. The osteotome is then used to lever the segment
from the tibia (Figure 3), providing access to the medul-
lary canal of the tibia (Figure 4).
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Radiograph
crossing7theofosteotomy
Figure suture repair
site of
(B)tibial tubercle osteotomy immediately post op (A) and at follow-up demonstrating trabeculae
Radiograph of suture repair of tibial tubercle osteotomy immediately post op (A) and at follow-up demonstrating trabeculae
crossing the osteotomy site (B).
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