Pre-gerotal fat patch-A novel alternative to haemostatic agents during partial nephrectomy.

Objective: This study aimed to determine if using a pre-gerotal fat patch at open partial nephrectomy (PN) as a haemostatic bolster is a viable alternative to using synthetic haemostatic agents. Materials and methods: Human Research Ethics Committee approval was obtained for audit of a prospectively kept database from July 2012 to July 2021, which followed outcomes of patients who received a low-tension pre-gerotal fat patch renorrhaphy at open PN. Patient demographics, intraoperative measures, histological outcomes and post-operative complications were analysed. Using a retroperitoneal approach, the peritoneum was mobilised and a vascularised pedicle of pre-gerotal fat was rotated in the direction of the kidney. Routine definition of the hilum, clamping of the hilar vessels and dissection of mass followed. After watertight closure and haemostasis, the harvested pre-gerotal fat patch was placed over the defect and secured using low-tension renorrhaphy. Two-layer closure of the abdominal wall with placement of a drain was routine. Results: A total of 55 patients underwent open PN. Mean age was 60.4 (35-77) years. There were 38 men and 17 women, and 32 right and 23 left PNs. Mean mass size was 31.9 mm (10-95 mm) and collecting system was breached in 36.5% of cases. One patient (1.9%) suffered a Clavien-Dindo IIIb complication requiring return to theatre and transfusion due to a bleed from an intercostal artery. There were no renal bed bleeds, urine leaks or urine fistulas detected. Mean intraoperative blood loss was 355 mL (50-1500 mL) and mean post-operative creatinine increased by 10.7 µmol/L (51-172 µmol/L). Mean follow up was 40.2 (4-109) months. Conclusion: Utilisation of an anatomical pre-gerotal fat patch to provide pressure at the renorrhaphy site during open PN is an effective technique to assist with surgical haemostasis. This simple technique avoids the costs of haemostatic agents, whilst adding minimal operating time to procedures.

Xeroform Gauze Bolster: A Cost-Effective Alternative to Synthetic Skin Grafts.

This case presentation describes and justifies the use of petrolatum gauze that is impregnated with 3% bismuth tribromophenate (Xeroform) as a low-cost and effective alternative for synthetic skin grafts. Herein, we discuss clinical trials that demonstrate the benefits of utilizing Xeroform for second-intention healing as well as photographs of a case in which the authors used this method and followed a patient's wound-healing process over time.

Comparative biofidelity of the Hybrid III and THOR 50th male ATDs under three restraint conditions during frontal sled tests.

OBJECTIVE: The purpose of this study was to provide a whole-body biofidelity assessment of the Hybrid III (HIII) and THOR 50th percentile male anthropomorphic test devices (ATDs) during frontal sled tests, incorporating data from kinematics, chest deflection, and test buck reaction load cells. Additionally, the accuracy of the injury risk prediction capabilities for each ATD was evaluated against injuries observed in matched postmortem human surrogate (PMHS) tests. METHODS: Sled tests, designed to simulate a United States New Car Assessment Program (US-NCAP) frontal test, were conducted using the HIII, THOR, and 8 approximately 50th percentile male PMHS under 3 restraint conditions. The test buck was instrumented with load cells on the steering column, knee bolster supports, and foot supports. ATD and PMHS reaction force-time histories were quantitatively compared using the ISO/TS-18571 objective rating metric. Previously published biofidelity analyses of kinematic and chest deflection data from the same tests were combined with the reaction force analyses to perform an overall assessment of the comparative biofidelity of each ATD. Injury risk predictions from existing HIII and proposed THOR injury risk curves for the US-NCAP were compared to observed injuries. RESULTS: For the reaction forces, the HIII and THOR had similar levels of biofidelity on average, except for 2 locations. The HIII produced more biofidelic knee bolster support forces, and the THOR lap belt forces were more biofidelic. The comparative biofidelity of the ATDs also varied by body region. The THOR head response was more biofidelic, whereas the HIII thorax and lower extremity responses had higher biofidelity. When all body regions were pooled, the HIII was more biofidelic, but differences between ATDs were generally small. Both ATDs were able to predict the observed injuries, except for the HIII chest, HIII neck, and THOR neck, all of which underpredicted PMHS injury outcomes. CONCLUSIONS: This study revealed that biofidelity assessed through response time histories and accuracy of injury risk predictions do not always align. Specifically, the HIII had marginally better time history biofidelity, whereas the THOR had better injury prediction. However, not all THOR responses could be fully assessed, so more work is needed to assess the THOR in complex loading environments.

Use of absorbable hemostat bolster for prevention of donor renal artery kinking in kidney transplant.

Transplant renal artery stenosis due to mechanical kinking is a rare but significant complication in kidney transplantation that can lead to graft dysfunction due to graft hypoperfusion, delayed graft function, or even global kidney infarction. When detected during surgery, re-anastomosis is usually performed after re-clamping, which inevitably prolongs the warm ischemia time, and increases the possibility of primary graft non-function. In this report, we describe a novel, noninvasive surgical technique whereby the donor renal artery is padded with absorbable hemostatic material (i.e., Surgicel) bolster, placed below the middle third of the renal artery in recipients who were found to have mechanical kinking during the implantation procedure. The bolster technique was used in 12 kidney transplant recipients who were found to have kinking of the donor artery during the primary surgery. After pillowing the renal artery with absorbable hemostatic bolster, no residual kinking was observed intra-operatively, and good allograft perfusion was confirmed with no Doppler ultrasound evidence of renal artery stenosis confirmed at 1 week, 1 month, and 1 year after transplantation.

Are tie-over bolster dressings necessary for healing or success of full thickness skin graft reconstruction following facial skin cancer excision?

Skin grafts are commonly used for reconstruction of defects following excision of facial skin cancers. Tie-over bolster dressings are routinely placed to secure these grafts, but are they necessary for healing or graft success?A total of 96 patients was treated from 2013-2019 who underwent full thickness skin graft (FTSG) reconstruction following facial skin cancer excision were retrospectively analysed. All patients were treated by one consultant with non-fenestrated FTSG's placed on defects varying from 10 to 55mm in maximum diameter. Grafts were sutured circumferentially with a continuous resorbable suture. Tie-over bolster dressings were not used, and the recipient site was dressed with MepitelTMand SteristripsTM. Primary defect sites where we used this technique included the pinna, the nose and face, and less commonly, the scalp. Graft harvest sites included the neck, pre-auricular, and submental regions.Complete graft take was noted in 94/96 patients. Partial graft failure was observed in two patients, one who healed and had successful late scar revision surgery and one who was managed conservatively and healed well. Two further patients with complete graft healing later underwent minimal revisional contour surgery with satisfactory results.This retrospective study has shown FTSG success in cutaneous defects of the head and neck to be excellent without the use of tie-over bolsters. This has significant benefits of saving operative time, reducing cost, and sparing the patient both unnecessary intraoperative steps, and the inconvenience of a bolster with its often-painful removal. We recommend that the use of tie-over bolsters in the management of most FTSG reconstructed head and neck cutaneous defects be considered an unnecessary step. We believe there are no adverse effects of our described simple technique, and that there are significant benefits to the patient.

Effects of horizontal versus vertical bolster alignment on anatomical orientation of kidney as applied to prone percutaneous nephrolithotomy.

PURPOSE: To evaluate the anatomical changes in kidney orientation in prone position with use of horizontal or vertical bolster alignment. METHODS: Patients having renal stone(s) on ultrasonogram or X-ray underwent split bolus computed-tomo-urography (CTU) in prone position with horizontal and vertical bolster positions. CTUs were read by a single radiologist to quantify the cranio-caudal, antero-posterior, side to side and rotational movements of kidneys as relevant to prone percutaneous nephrolithotomy. RESULTS: 19 adult patients with 38 renal units and mean basal metabolic index of 25.6 kg/m2 underwent CTU. Greater inferior displacement of both kidneys was seen with horizontal bolsters as compared to vertical bolsters. The right upper calyceal-diaphragm distance was 2.1 ± 1.5 cm and the lower calyceal-diaphragm distance was 2.0 ± 1.6 cm greater with the horizontal bolsters (p < 0.01). Similarly, the displacement on the left side was 1.5 ± 0.8 cm and 1.4 ± 0.8 cm, respectively (p < 0.01). Horizontal bolsters also result in significantly longer calyceal-skin distance at both poles of both kidneys [right upper: 0.4 ± 0.5 cm (p < 0.01), right lower: 0.8 ± 0.7 cm (p < 0.01), left upper: 0.4 ± 0.6 cm (p = 0.02), left lower: 0.8 ± 1.1 cm (p < 0.01)] and wider erector spinae-mid posterior calyceal-colon angle (124.8 v/s 110.0 on the right and 96.2 v/s 85.7 on the left) (p < 0.01). CONCLUSION: Horizontal bolsters provide significantly more caudal displacement of the kidneys; the right kidney being displaced more as compared to the left. However, there is also an increase in the skin-calyceal distance with horizontal as compared to the vertical bolsters. These assessments may help the surgeons decide optimal bolster position individualized to the patient.

Congenital Symmastia: A Four-Step, Minimally Invasive Approach.

Symmastia is a rare condition in which breasts are unified medially due to aberrant development of mammary tissue in the intermammary region, resulting in the appearance of an intermammary web. There are limited reports on this rare anomaly and hence, no standard protocols on its management. Additionally, creating a normal cleavage in these young patients without scars over or around the breast is a challenge from an esthetic standpoint. In this article, we present a case of congenital symmastia corrected by four steps: liposuction of the intermammary region, use of suction drains along medial breast border, transdermal bolster sutures, and customized compression garment. Esthetic creation of the medial breast footprint and good preservation of breast contours was achieved with considerably less scars. Thus, we propose our four-step approach as an effective, minimally invasive method for treating congenital symmastia.

Risk factors for auricular hematoma and recurrence after drainage.

OBJECTIVES/HYPOTHESIS: To review an institutional experience with auricular hematoma across all clinical settings including the emergency department (ED) and outpatient clinics at an urban tertiary care academic hospital, characterize practice patterns across setting and specialty, and assess for factors predictive of treatment success. METHODS: Patients presenting to the ED, admitted to an inpatient ward, or seen in the outpatient setting between 2000 and 2017 with a diagnosis of auricular hematoma were reviewed. A number of relevant patient features including demographic factors, medications, and social risk factors were analyzed, as were several factors related to the presentation and management of the hematoma to identify variables of clinical significance. RESULTS: A total of 87 individual cases were identified. Auricular hematomas most commonly occurred in males after sports-related trauma (e.g., martial arts, wrestling, boxing). Factors associated with lower rates of recurrence included initial treatment by or in consultation with an otolaryngologist and application of a bolster dressing. CONCLUSIONS: In our cohort, initial management of auricular hematoma by an otolaryngologist or with an otolaryngology consultation and placement of a bolster dressing was associated with lower rates of hematoma recurrence. LEVEL OF EVIDENCE: 2b Laryngoscope, 130:628-631, 2020.

Submarining sensitivity across varied anthropometry in an autonomous driving system environment.

Objective: Self-driving technology will bring novelty in occupant seating choices and vehicle interior design. Thus, vehicle safety systems may be challenged to protect occupants over a wider range of potential postures and seating choices. This study aims to investigate the effects of occupant size, seat recline, and knee bolster position on submarining risk and injury prediction metrics for reclined occupants in frontal crashes.Methods: Frontal crash finite element (FE) simulations were performed with the 3 simplified Global Human Body Model Consortium (GHBMC) occupant models: small female, midsize male, and large male. Additionally, a detailed GHBMC midsize male model was used to compare with selected simplified cases. For each simulation, parameters including seatback recline angle (0.9°, 10.9°, 20.9°, 30.9°) and knee bolster position relative to the occupant (baseline, close, far, and no knee bolster) were varied. Impacts were simulated with the U.S. New Car Assessment Program 56 km/h frontal crash pulse. Occupant kinematics data were extracted from each simulation in a full-factorial sensitivity study to investigate how changes in anthropometry, seating position, and knee bolster position would affect submarining across all simulated cases.Results: Overall, increasing the occupant-to-knee bolster distance resulted in more submarining cases. The threshold for submarining was also affected by the seat recline angle. The lowest threshold observed occurred with 10.9° of recline with the small female model. Submarining was observed at recline angles at and above 20.9° for the midsize male model and 30° for the large male model. The initial lap belt position, pelvis orientation, and their relationship were good predictors of submarining. Increased lumbar flexion moment was observed with increased seat recline angle as well as occupant-to-knee bolster distance. The detailed GHBMC model was more prone to submarining than the simplified model.Conclusions: Submarining may be a major challenge to overcome for reclined occupants, which may become more prevalent with autonomous driving systems. This study shows that the angle of recline, anthropometric variation, and position of the knee bolster affect the risk of submarining. To our knowledge, this is the first study to computationally evaluate the occupant protection implications of seatback recline for multiple body sizes, postures, and positions relative to the vehicle interior.

Evaluation of Hybrid III and THOR-M neck kinetics and injury risk under various restraint conditions during full-scale frontal sled tests.

OBJECTIVE: The objective of this research was to compare the kinetics and predicted injury risks of the Hybrid III (HIII) and Test device for Human Occupant Restraint (THOR)-M necks during full-scale frontal sled tests under 3 safety restraint conditions: knee bolster (KB), knee bolster and steering wheel airbag (KB/SWAB), and knee bolster airbag and steering wheel airbag (KBAB/SWAB). METHODS: Twelve sled tests were performed for the HIII and THOR-M, and 8 matched sled tests were performed using postmortem human surrogates (PMHSs). The tests were designed to match the 2012 Toyota Camry New Car Assessment Program (NCAP) full-scale crash test. Upper and lower neck forces and moments were collected from the HIII and THOR-M load cells. Inverse dynamics was used to calculate PMHS upper neck forces and moments from acceleration data until the time of head contact. The PMHSs experienced head contact with the SWAB before appreciable neck loading occurred. Therefore, PMHS neck forces and moments were only compared to the HIII and THOR-M for the KB condition. Neck injury risks were calculated for the HIII and THOR-M and were compared to the injuries observed for the PMHSs. RESULTS: The HIII had greater upper and lower neck shear forces than the THOR-M, whereas both surrogates had similar upper and lower neck axial forces. The HIII also experienced greater peak upper neck bending moments than the THOR-M, which experienced negligible upper neck bending moments. Before head contact, the PMHSs experienced upper neck flexion, and the HIII experienced extension. The HIII and THOR-M injury risk curves predicted less than a 50% risk of an Abbreviated Injury Scale (AIS) 3+ injury. No AIS 3+ neck injuries were observed for the PMHS tests, but at least one AIS 2 injury was observed per condition. CONCLUSIONS: The results of this study showed that the HIII and THOR-M had different neck kinetics for these restraint conditions. In particular, the THOR-M experienced lower upper neck shear forces and bending moments. These differences are likely due to the very different neck designs of the anthropomorphic test dummies (ATDs), particularly the increased compliance of the THOR-M neck. Despite these differences, both ATDs still predicted a similar risk of AIS 3+ neck injury.

Maintenance of the Anatomic Contours in Auricular Reconstruction: The Button Technique.

BACKGROUND AND OBJECTIVE: Reconstructing the contours of the auricle is a unique challenge. Various bolster techniques have been tried to help prevent complications such as hematoma, seroma, and morbidity. Here, we describe a simple technique using a button to maintain the natural ear contour when it is at risk of a poor aesthetic outcome. MATERIALS AND METHODS: A 77-year-old man underwent resection of a squamous cell carcinoma of the postauricular skin on the right ear, which involved the helical margin. A skin graft was chosen to close the defect. However, on initial inspection of the repair, buckling of the scaphoid fossa, collapse of the antihelical fold, and notching of the helix were observed. When these buckling changes persisted even after the anesthesia-related swelling resolved the following day, a button bolster was placed for 2.5 weeks to provide support for the cartilage. RESULTS: Standardized digital imaging revealed maintenance of the original contours and sulci of the ear with an excellent cosmetic result. CONCLUSION: Recreation of the auricular contours is critical for an excellent cosmetic outcome. Using a button bolster is worth considering as it is of low cost, can easily fit into the natural ear contours, and can provide a rigid structure to ensure maintenance of the ear shape.

Tie-Over Bolster Dressings vs Basting Sutures for the Closure of Full-Thickness Skin Grafts: A Review of the Literature.

BACKGROUND: Full-thickness skin grafting is a well-established technique in the reconstruction of various tissue defects and wounds. However, lack of uniformity in the procedure of closing and securing the grafts has led to a wide range of different techniques. OBJECTIVE: This article reviews the use of tie-over bolster dressings compared to basting sutures for the fixation and postsurgical immobilization of full-thickness skin grafts (FTSGs), discusses details of each method, and proposes a practice guideline for the closure of FTSGs. METHODS: A traditional review of the literature was performed through a search of PubMed using the following keywords: full-thickness skin graft, FTSG, closure, suture, tie-over bolster, quilting, and bolster. RESULTS: The current literature regarding tie-over bolster dressings does not demonstrate improved outcomes compared to quilting sutures. The 2 techniques appear equivalent in terms of utility and outcome, both possessing distinct advantages and disadvantages. CONCLUSION: Despite minimal head-to-head studies between tie-over bolsters and quilting, the best evidence from the literature appears to show comparable results regarding graft take, cosmetic outcomes, and postoperative complications. Ultimately, the choice of using a tie-over bolster technique or quilting sutures relies on surgeon preference and anatomic location.

Occupant kinematics of the Hybrid III, THOR-M, and postmortem human surrogates under various restraint conditions in full-scale frontal sled tests.

OBJECTIVE: The objective of this research was to compare the occupant kinematics of the Hybrid III (HIII), THOR-M, and postmortem human surrogates (PMHS) during full-scale frontal sled tests under 3 safety restraint conditions: knee bolster (KB), knee bolster and steering wheel airbag (KB/SWAB), and knee bolster airbag and steering wheel airbag (KBAB/SWAB). METHODS: A total of 20 frontal sled tests were performed with at least 2 tests performed per restraint condition per surrogate. The tests were designed to match the 2012 Toyota Camry New Car Assessment Program (NCAP) full-scale crash test. Rigid polyurethane foam surrogates with compressive strength ratings of 65 and 19 psi were used to simulate the KB and KBAB, respectively. The excursions of the head, shoulders, hips, knees, and ankles were collected using motion capture. Linear acceleration and angular velocity data were also collected from the head, thorax, and pelvis of each surrogate. Time histories were compared between surrogates and restraint conditions using ISO/TS 18571. RESULTS: All surrogates showed some degree of sensitivity to changes in restraint condition. For example, the use of a KBAB decreased the pelvis accelerations and the forward excursions of the knees and hips for all surrogates. However, these trends were not observed for the thorax, shoulders, and head, which showed more sensitivity to the presence of a SWAB. The average scores computed using ISO/TS 18571 for the HIII/PMHS and THOR-M/PMHS comparisons were 0.527 and 0.518, respectively. The HIII had slightly higher scores than the THOR-M for the excursions (HIII average = 0.574; THOR average = 0.520). However, the THOR-M had slightly higher scores for the accelerations and angular rates (HIII average = 0.471; THOR average = 0.516). CONCLUSIONS: The data from the current study showed that both KBABs and SWABs affected the kinematics of all surrogates during frontal sled tests. The results of the objective rating analysis indicated that the HIII and THOR-M had comparable overall biofidelity scores. The THOR-M slightly outperformed the HIII for the acceleration and angular velocity data. However, the HIII scored slightly better than the THOR-M for the excursion data. The most notable difference in biofidelity was for the knee excursions, where the HIII had a much higher average ISO score. Only the biofidelity of the HIII and THOR-M with regard to occupant kinematics was evaluated in this study; therefore, future work will evaluate the biofidelity of the ATDs in terms of lower extremity loading, thoracic response, and neck loading.

Bolstering Skin Grafts With a Surgical Scrub Brush: A Cost-effective Solution.

Objective: The objective of this article is to review the methods currently used for the bolstering of skin grafts and compare their advantages and disadvantages with those of the dry, sterile surgical scrub brush. We report a series of cases performed at a single institution and compare the cost-effectiveness, application, and limitations of this method with other options for skin graft bolstering. Methods: A PubMed search using the parameters "(bolster) AND skin graft" was conducted, yielding 85 results. A total of 40 publications met the criteria for our literature review. The costs of the foam bolsters utilized as stents for skin grafts were obtained from the Central Supply and Resource Division of the University of Louisville Hospital for a cost analysis. The cost per square centimeter of each bolster material was calculated. Results: At $0.003/cm2, the 3M Reston foam is the most inexpensive of the 3 bolster materials analyzed. The dry, sterile surgical scrub brush has a similar cost at $0.006/cm2 but carries the advantage of sterility. The material cost of negative pressure wound therapy is $0.47/cm2, and the cost of the system as a whole makes it a much more expensive alternative. In 6 patients with defects of varying size and location, the scrub brush bolster showed a near 100% graft take and no complications. Conclusions: The dry, sterile surgical scrub brush presents a readily available and low-cost option for the stenting of small skin grafts and should be considered a viable method in the armamentarium of available skin graft bolsters.

Intra-pelvic pressure changes after pelvic fracture: A cadaveric study quantifying the effect of a pelvic binder and limb bandaging over a bolster.

INTRODUCTION: Unstable pelvic fractures can be life-threatening due to catastrophic haemorrhage. Non-invasive methods of reducing and stabilising these injuries include pelvic binder application and also lower limb bandaging over a knee-flexion bolster. Both of these methods help close the pelvic ring and should tamponade bleeding. This study aimed to quantify the intra-pelvic pressure changes that occurred with 3 different manoeuvres: lower limb bandaging over a bolster; a Trauma Pelvic Orthotic Device (T-POD) pelvic binder, and a combination of both. METHODS: Following a pilot study with 2 soft embalmed cadavers, a formal study with 6 unembalmed cadavers was performed. For each specimen an unstable pelvic injury was created (OA/OTA 61-C1) by dividing the pelvic ring anteriorly and posteriorly. A 3-4cm manometric water-filled balloon was placed in the retropubic space and connected to a 50ml syringe and water manometer via a 3-way tap. A baseline pressure of 8cmH2O (equating to the average central venous pressure) was used for each cadaver. Steady intra-pelvic pressures (more reliably reflecting the pressures achieved following an intervention) were used in the subsequent statistical analysis, using R statistical language and Rstudio. Paired t-test or Wilcoxon's rank sum test were used (depending on the normality of the dataset) to determine the impact of each intervention on the intra-pelvic pressure. RESULTS: The mean steady intra-pelvic pressures were significantly greater than the baseline pressure for each intervention. The binder and limb bandaging over a bolster alone increased the mean steady pelvic pressures significantly to 24 (SE=5) (p<0.036) and 15.5 (SE=2) (p<0.02)cmH2O respectively. Combining these interventions further increased the mean steady pressure to 31 (SE=7)cmH2O. However, this was not significantly greater than pressures for each of the individual interventions. DISCUSSION: Both lower limb bandaging over a bolster and pelvic binder application significantly increased intra-pelvic pressure above the baseline pressure. This was further increased through combining these interventions, which could be useful clinically to augment haemorrhage control in these fractures. CONCLUSION: Lower-limb bandaging over a bolster, and pelvic binder application, both significantly increased intra-pelvic pressures, and were greatest in combination. These findings support the use of these techniques to facilitate non-surgical haemorrhage control.