Tissucol

The surgeries were carried out by the same surgeon (MIC). After pterygium excision, different grafts were applied to each patient. (a) Conjunctiva autograft: the superior conjunctiva was used as a donor site for the graft. The graft was placed with the epithelial side up, and the limbal edge was positioned toward the limbus. Finally, fibrin glue (Tissucol^®, Baxter AG, Vienna, Austria) was applied to fix the graft. (b) PRGF membrane: the membrane was placed over the bare scleral bed. Tissucol^® was applied at the scleral-PRGF membrane interface and held until complete gluing (see Figure 1). The patient received additional treatment with instilled ePRGF four times a day during the first month after the surgery. (c) Amniotic membrane graft: the AM was obtained from nonpreserved, lyophilized and cryopreserved samples on a cellulose nitrate filter. The epithelial/basement membrane side was positioned on the up side. Tissucol^® was applied at the scleral-AM interface, and the AM was held until complete gluing was achieved. The postoperative treatment in all groups was the same: Chloramphenicol and Dexamethasone eye ointment for 24-hour with eye bandage and then Dexamethasone/Tobramycin eye drops with a decreasing dosage for twelve weeks.

Collagen sponges (Gelfoam, Pfizer, São Paulo, SP, Brazil), derived from purified skin pig, were cut to produce samples with 5 mm in diameter and 2 mm height. This preparation was carried out in a laminar flow cabinet to keep the material sterile. Fibrin glue (Tissucol, Baxter, São Paulo, SP, Brazil), a combination of human fibrinogen, aprotinin and thrombin, was prepared immediately before using according to the manufacturer’s instructions. Solutions of fibrinogen and aprotinin were heated for 10 min at 37°C, mixed and kept for 1 min at 37°C. In another flask, a solution of thrombin was combined with calcium chloride and kept at 37°C. Mixtures of aprotinin with fibrinogen and thrombin with calcium chloride were placed in separate syringes connected by a Y-piece that allowed them to blend immediately before implantation in bone defect.

The skin incision and the preparation of the inguinal region in the fibrin-sealant group did not differ from that applied in the SUT group. The preliminary shaping of the mesh was identical to that described for the suture group. A single absorbable suture was used in the fibrin-sealant group to narrow the internal inguinal ring and fixate the two tails of the mesh lateral to the internal ring (32 (link)). However, the mesh was then exclusively fixated with 2 ml of Fibrin glue (500 IU Tissucol^® Baxter Healthcare). The fibrin glue was prepared according to the manufacture’s instruction, and applied using the Duploject syringe and a spray head (32 (link)). After the preparation of the inguinal region and correct positioning of the mesh the complete prepared Tissucol was placed over the entire surface of the mesh, using the spray-effect. Subsequent, the mesh was pressed onto the tissue for 2 min until the polymerization of the glue was completed (32 (link)). Closure of the external oblique aponeurosis and the skin was identically to that applied in the suture group.

First, arthroscopy was performed to confirm the location and size of the defect as well as the feasibility of the AMIC procedure. This first step was followed by lower limb osteotomy when indicated.
Then, an open procedure that consisted of debridement and excision of the loosened cartilage fragment followed by Pridie drilling of the sclerotic bone and coverage of the defect with a collagen I/III membrane (Chondro-Gide^®, Geistlich Pharma AG, Switzerland) was performed under a tourniquet. In the first six patients, the membrane was sutured to the surrounding healthy cartilage only. For the subsequent patients, the membrane was sutured and glued with Tissucol^® (Baxter, Unterschleissheim, Germany). For the chondral defects close to the cartilage margins, the membrane has been sutured to the adjacent periosteum. At the end of the procedure, the tourniquet was released, and the correct filling of the defect by blood clotting was confirmed (Fig. 2).Fig. 2

a–c Intraoperative images of an AMIC procedure for a retropatellar chondral defect. a Initial defect; b Pridie drilled surface; c defect covered with a sutured collagen I/III membrane

Nerve stumps coaptation was performed by using either a commercially available fibrin sealant-Tissucol (Baxter®, Vienna, Austria) or a patented fibrin sealant derived from snake venom, kindly supplied by the Center for the Study of Venoms and Venomous Animals (CEVAP) of UNESP (patent registration numbers BR1020140114327 and BR1020140114360). At the time of use, the components were previously thawed, reconstituted, mixed, and applied [24 (link)–27 (link), 31 (link)].