The Treatment of Coxofemoral Luxation by Modified Synthetic Capsule Technique in Dogs: 6 Cases

Abstract

In this study, it was aimed to investigate that long-term clinical efficacy of modified synthetic capsule technique in treatment of coxofemoral luxation in dogs. As animal materials, six dogs which different breeds, sex and ages that detected coxofemoral luxation in clinical and radiological examination were subjected. As different from modified synthetic capsule technique, two cortical screws were inserted into the dorsal rim about 5 mm away from the acetabular edge at the 10- and 12-o'clock positions for the left hip and the 12- and 2-o'clock positions for the right hip. Also, the transverse hole was created in greater trochanter. Non-absorbable monofilament suture material was tied to the screw heads previously and then the suture ends were passed as crosswise through the transverse tunnel in the trochanter major. Subsequently, the suture material was tied on the greater trochanter by stretching following that the femoral head was placed into the acetabulum. It was seen that there was no complication related with the reduction or screws in clinical and radiological examinations of the dogs at fourth week. We determined that five dogs recovered "perfect" and one dog "good" end of sixth months.

Full text

Summary
In this study, it was aimed to investigate that long-term clinical efficacy of modified synthetic capsule technique in treatment of
coxofemoral luxation in dogs. As animal materials, six dogs which dierent breeds, sex and ages that detected coxofemoral luxation
in clinical and radiological examination were subjected. As dierent from modified synthetic capsule technique, two cortical screws
were inserted into the dorsal rim about 5 mm away from the acetabular edge at the 10- and 12-o’clock positions for the left hip and the
12- and 2-o’clock positions for the right hip. Also, the transverse hole was created in greater trochanter. Non-absorbable monofilament
suture material was tied to the screw heads previously and then the suture ends were passed as crosswise through the transverse
tunnel in the trochanter major. Subsequently, the suture material was tied on the greater trochanter by stretching following that
the femoral head was placed into the acetabulum. It was seen that there was no complication related with the reduction or screws
in clinical and radiological examinations of the dogs at fourth week. We determined that five dogs recovered “perfect” and one dog
“good” end of sixth months.
Keywords: Coxofemoral luxation, Synthetic capsule technique, Dog
Köpeklerde Kalça Eklemi Çıkığının
Modifiye Sentetik Kapsül Tekniği ile Sağaltımı: 6 Olgu
Özet
Bu çalışmada, köpeklerde coxofemoral lukzasyonun sağaltımında modifiye sentetik kapsül tekniğinin uzun dönem klinik
etkinliğinin araştırılması amaçlandı. Materyali, klinik-radyolojik muayenesinde, kalça çıkığı saptanan değişik yaş ve ırkta 6 köpek
oluşturdu. Tekniğin orijinalinden farklı olarak; sağ kalça için saat 12 ve 2, sol kalça için saat 10 ve 12’ye denk gelecek şekilde, asetabular
kenardan 5 mm kadar uzağa, iki kortikal vida yerleştirildi ve trochanter majore transversal tünel açıldı. Emilmeyen monoament
iplik önce vida başlarına bağlandı, sonra çaprazlaştırılarak trohanter majora açılan tünel içerisinden geçirildi. Daha sonra femur başı
asetabuluma yerleştirildi ve iplikler gergin şekilde trochanter major üzerinde düğümlendi. Dördüncü hafta yapılan klinik ve radyolojik
muayenelerde köpeklerde redüksiyon veya yerleştirilen vidalara ilişkin herhangi bir komplikasyon yaşamadığı görüldü. Altıncı ayın
sonunda 5 köpeğin mükemmel, 1 köpeğin ise iyi düzeyde basış sergilediği saptandı.
Anahtar sözcükler: Koksofemoral çıkık, Sentetik kapsül tekniği, Köpek
The Treatment of Coxofemoral Luxation
by Modified Synthetic Capsule Technique in Dogs: 6 Cases [1]
Ali BELGE 1 Zeynep BOZKAN 1 Murat SARIERLER 1 Rahime YAYGINGÜL 1
[1]
1
Part of this research was presented as an oral presentation at the 11th National Congress of Veterinary Surgery, 26-29 June
2008, Kuşadası, Türkiye
Department of Surgery, Faculty of Veterinary Medicine, University of Adnan Menderes, TR-09016 Aydin - TURKEY
Makale Kodu (Article Code): KVFD-2013-10101
In small animals, luxation of coxofemoral joint is the
most common among all joint [1]. The coxofemoral luxation
constitutes 39-90% of all luxations which occur in dogs
have been reported by some investigators [2,3]. Due to strong
pulling force of gluteal and iliopsoas muscles, direction of
the coxofemoral luxations is often craniodorsal and rarely
caudodorsal, ventral and medial [4-6].
The most common causes of the hip joint luxations are
traffic accidents and falling from high. Traumatic luxations
INTRODUCTION
 İleşim (Correspondence)
 +90 536 6381727
 alibelge@hotmail.com
Journal Home-Page: http://vetdergi.kafkas.edu.tr
online SubmiSSion: http://vetdergikafkas.org RESEARCH ARTICLE
Kafkas Univ Vet Fak Derg
20 (3): 337-343, 2014
DOI: 10.9775/kvfd.2013.10101

338
The Treatment of Coxofemoral ...
originate from the shifting of gravity center to outside of
the hip in the cases which suddenly jumped or fell [7,8]. The
joint capsule and also round ligament may completely or
partially tear [3].
The basic principles of hip luxation treatment are to
provide stability without damage to joint surfaces for
regenerate the normal functioning of the joint and to
restrict the animal movements for healing surrounding
soft tissues as soon as possible [3]. Closed reduction is
usually possible in normal joint luxation without any
complication [4-6,8,9]. However, closed reduction can be
ideally made in 48-72 hours after trauma [1,10]. As increase
of elapsed time, closed reduction becomes more difficult,
because of severity and width of inammation, fibrosis
and cartilage damage also increases [2,11]. Some methods
have been used for supporting of closed reduction such
as Ehmer sling stabilization, ischio-ilial pinning or dynamic
transarticular pinning [1,2].
The luxation should be treated surgically; if there are
complications such as hip dysplasia existence prior to
trauma, femoral and/or acetabular avulsion fractures, intra
articular fractures, arthrosis and conditions such as multiple
orthopedic injuries or chronic luxation, closed reduction
failure and extreme instability after reduction [5,8,12,13].
Techniques which are used for the surgical treatment of
coxofemoral luxations can be categorized as extracapsular
such as suture of a joint capsule (capsulorrhaphy) [3,5,12],
synthetic capsule technique [2,3,6,14], transposition of the
greatertrochanter [2,5,6,12], triple pelvic osteotomy [2,8] and
intra capsular techniques such as Modified Knowles Toggle
pin fixation [3,6,8,15,16], Toggle rod stabilization [17,18], trans
acetabular pinning [2,6,19] transposition of the sacrotuberous
ligament [20,21]. Additionally, exible external fixation [8],
total hip replacement [22-24] and femoral head and neck
osteotomy [2,25,26] can be also applied for the treatment of hip
luxation. For surgery, there are dierent surgical exposures
techniques (such as cranio-lateral or dorsal approach)
which can be selected depending on the method of
surgery, luxation direction, accompanying complications
and physician’s habits [8,13,27-29]. Postoperative immobilization
should be provided with most of the surgical technique as
with the closed reduction [3,19,28].
The joint capsule repair and tightening following the
reduction is a technique that can be applied for luxations
which occurred with simple tears [3,5,12]. Synthetic capsule
technique is performed with eight shape suture between
a transverse hole created in femoral neck (or a screw
placed in the trochanteric fossa) and two bone screws
which is inserted into the dorsal rim of the acetabulum
at the 10- and 1-o’clock positions for the left hip and the
11- and 2-o’clock positions for the right hip. Care must
be taken not to damage to the articular surface during
screwing [1,3,8]. In intra articular techniques, mostly, caput
femoris and acetabulum are connected to each other by
various materials that mimic an intra-articular ligament.
The major disadvantages of these methods are that they
cause extra damage to the articular surface and may
create predisposition to degenerative joint disease in
long-term [8,30]. In the pinning techniques, complications
such as pin tract infection or position changing of pin from
where applied are possible [9,31]. The techniques of femoral
head and neck osteotomy and total hip replacement
are proposed for the dogs with hip dysplasia from mild
to severe and for the animals with complications which
restrain closed and open techniques [8].
In the present study, it was aimed to investigate and
present that long-term clinical efficacy of the modification
of synthetic capsule technique which is often preferred
in case with wide joint capsule defect and considered to
cause relatively fewer complications compared to other
techniques for the treatment of coxofemoral luxation.
MATERIAL and METHODS
As materials, six dogs from various breeds and at
dierent ages which were presented to Adnan Menderes
University Veterinary Faculty Animal Hospital with
complaints of severe lameness or inability to stand up and
detected coxofemoral luxation at clinical and radiological
examination were subjected (Table 1).
Table 1. The distribution of breed, age, gender, body weight, and clinical findings of cases
Tablo 1. Olguların ırk, yaş, cinsiyet, vücut ağırlığı ve klinik bulgularının dağılımı
No Breed Age (month) Gender Weight PTP (day) Presentation Diagnosis
1 Mix Breed 24 M 28 kg 4 Severe Lameness (Unilateral) Unilateral Luxation (Right)
2 Pointer 72 M 22 kg 3 Constant Recumbency Unilateral Luxation (Right),
Femoral Fracture (Left)
3 German Shepherd 120 M 26 kg 4 Constant Recumbency Bilateral Luxation, Greater
Trochanter Fracture (Right)
4 Husky 48 M 25 kg 5 Severe Lameness (Unilateral) Unilateral Luxation (Left)
5 Kangal 18 F 37 kg 3 Severe Lameness (Unilateral) Unilateral Luxation (Left)
6 Mix Breed 72 M 18 kg 4 Severe Lameness (Unilateral) Unilateral Luxation (Left)
M: Male, F: Female; PTP, Posttraumatic Period

339
BELGE, BOZKAN,
SARIERLER, YAYGINGÜL
According to the history; each of hip luxation resulted
from traffic accident, 2 of dogs were not able to stand up
and 4 of dogs could not use related legs. Posttraumatic
periods were 3 days for 2 dogs, 4 days for 3 dogs and 5 days
were 1 dog.
During clinical and radiological examination; coxo-
femoral luxations were determined as unilateral of 5 dogs,
3 at the left side and 2 at the right side, and bilateral of 1
dog. There was also femoral fracture in one dog with right
sided hip luxation (case no. 2) and one dog with bilateral hip
luxation (case no. 3) had also greater trochanter fracture.
All of luxation was cranio-lateral direction, with one
ventral direction exception (case no. 3, bilateral luxation).
Treatment of the luxation in ventral direction of the dog
which had bilateral luxation was not included the study.
Furthermore, in study animals, it was determined that
there were no other complications accompanying luxation
and any stage of the hip dysplasia which exist prior to
trauma by radiological examinations (Table 1).
Dogs underwent surgery following 24 h starving
period. Induction of anesthesia was performed with
combination of atropine sulfate 0.04 mg/kg body weight,
subcutaneously (Atropin®, Teknovet, Turkey), xylazine HCl
0.5 mg/kg body weight (Alfazyne®, Egevet, Turkey) and
ketamine HCl 10 mg/kg body weight (Alfamine®, Egevet,
Turkey), intramuscularly. Anesthesia was maintained with
inhalation of Isourane (Forane®, Abbott, Latina, Italy) at a
concentration of 2%.
The dog was placed in the lateral recumbence upon
operating table. After disinfection of the region, the
operation was started with skin incision extended up and
down from front of the greater trochanter by using dorsal
approach technique. After dissection of the subcutaneous
tissues, the area where is in the triangle consisting of m.
tensor fasciae latae and underlying rectus femoris at
cranial, m. gluteus at dorsal and vastus lateralis at caudal
was reached as a blunt. The joint capsule and the joint
were exposed by external rotation. The remains of the
round ligament and fibrous tissues were removed from
the joint. Dierently from original technique, two cortical
bone screws (3.5Ø, 22-26 mm) were inserted into the dorsal
acetabular rim about 5 mm away from the acetabular edge
at the 10- and 12-o’clock positions for the left hip and the
12- and 2-o’clock positions for the right hip with a slope
that provide not to enter into the joint (Fig. 1/A, Fig. 2/A,B).
Also, the transverse hole was created in greater trochanter
instead of femoral neck (or a screw placed in the trochanteric
fossa) (Fig. 1/B). Non-absorbable monofilament suture
material (USP:1, Ethilon, Ethicon, UK) was tied to the screw
heads previously (Fig. 2/C), then the suture ends were
passed as crosswise through the transverse tunnel in the
trochanter (Fig. 1/C). Subsequently, the suture material was
tied on the greater trochanter by stretching following that
the femoral head was placed into the acetabulum (Fig. 1/D
and Fig. 2/D). During above mentioned tying procedure,
the femoral head was compressed into the acetabulum.
The joint capsule was sutured within the possibilities. Skin
and subcutaneous tissues were closed routinely.
Ehmer sling was applied to all dogs for one week after
the surgery. Postoperative antibiotic, cefazolin sodium (20
mg/kg body weight, IM, Iespor®, I. E. Ulagay, Istanbul) and
anti-inammatory drug, carprofen (2 mg/kg body weight,
PO, Rimadyl®, Pfizer, Zavantem, Belgium), were prescribed
to the all of cases for 5 days. After a week, weight bearing
of the related leg was allowed.
Fig 1. The modified synthetic capsule
technique; A- insertion of the screws into the
dorsal rim; B- the transverse tunnel drilled in
the greater trochanter; C- tying of the suture
material to the head of screws and passing
of the suture as crosswise through the
transverse tunnel in the greater trochanter;
D- tying and stretching of the suture material
on the greater trochanter
Şekil 1. Modifiye sentetik kapsül tekniği;
A- dorsal kenara vidaların yerleştirilmesi;
B- trochanter major’e açılan transversal kanal;
C- vida başlarına dikiş materyalinin bağlan-
ması ve ipin trochanter major’deki transver-
sal tünelden çapraz şekilde geçirilmesi;
D- dikiş materyalinin trochanter major üze-
rinde bağlanması ve gerilmesi

340
The Treatment of Coxofemoral ...
RESULTS
Clinical and radiological examinations were performed
for all cases at weeks 1, 2 and 4 (Fig. 3). For lameness
evaluation, each of the dogs was observed by investigator
while an assistant made the dog walk at least 10 m and
lameness status was scored as; not exist, mild, moderate
and severe (Table 2).
At first week radiological examination, there was no
problem in terms of the reduction in all of cases and then
Ehmer slings were removed. None of the dogs were able
to use the related legs. However, it was learned that one
dog started to use the related leg on the day after, two
dogs on 2 days after and one dog 3 days after removal
of the Ehmer sling, with limping at dierent stages from
the owners. Also, it was expressed that the dog with
bilateral hip luxation were not able to stand up without
support and the dog with right sided hip luxation plus
left sided femoral fracture stood up with aid of the right
leg but received support from bandage on left side while
standing up.
Skin sutures were removed at second week controls. No
infection-related complications were determined within
this time period in all of cases. During clinical examination,
3 of dogs could use the related legs with frequently and
one dog occasionally. The bandage on the dog’s left sided
femoral fracture, which applied after fracture repair, was
removed and the dog started to use the right leg more.
Besides, the dog with bilateral luxation was reluctant to
stand up and showed rotational weight bearing between
two rear legs, but more used the leg which performed
synthetic capsule technique.
Clinical and radiological examination findings at fourth
week were as follows; there was no complication related
with reduction or screws in all of dogs, 3 of dogs were
able to walk without limping and one dog with slightly
limping, the dog with right sided hip luxation plus left
sided femoral fracture could walk with the right side as
completely healthy and with the left side as slightly limping
and the dog with bilateral luxation (for treatment of right
hip luxation with greater trochanter fracture, femoral head
and neck osteotomy was performed) was not able to use
Fig 2. Implementation of the modified
synthetic capsule technique during the
operation; A, B- insertion of the screws into
the dorsal acetabular rim; C- tying of the
suture material to the head of screws; D-
tying and stretching of the suture material
between the screws and greater trochanter
Şekil 2. Operasyon sırasında modifiye
sentetik kapsül tekniğinin uygulanışı; A,B-
dorsal asetabular kenara vidaların yerleş-
tirilmesi; C- vida başlarına dikiş materyalinin
bağlanması; D- dikiş materyalinin vida baş-
ları ile trochanter major arasında bağlan-
ması ve gerilmesi
Table 2. At postoperative periods, start of weight bearing (post-operative day) and lameness scoring (at week 1, 2, 4) of dogs
Tablo 2. Köpeklerin operasyon sonrası dönemde ağırlık taşımaya başladıkları süre (postoperatif gün) ve topallık skorları (1, 2 ve 4. haftada)
Case
No
Start of Weight Bearing
(post-op. day)
Lameness Scoring (Postoperative)
Week 1 Week 2 Week 4
1 9 Severe Mild Not Exist
2 12 Severe Moderate Not Exist
3 14 Severe Moderate Mild
4 10 Severe Moderate Not Exist
5 8 Severe Mild Not Exist
6 9 Severe Mild Not Exist

341
both leg fully, but weight bearing mostly was performed
with the leg which performed synthetic capsule technique.
The subsequent follow-up of the dogs were continued
until 6th postoperative month for 3 of dogs and 12th
postoperative month for others by phone call. At the end
of these periods, it was learned that the 5 dogs which had
“Not Exist” lameness score at week 4 were completely
healthy and the one dog (case no. 3) could use both leg
similarly but uncoordinatedly.
DISCUSSION
The mechanism of trauma-related hip dislocations;
when the dog began to fall in the direction of impact
force, the aected leg becomes adducted and the hip
moves in ventrolaterally toward the ground. The adducted
femoral head directs outward from the acetabulum to the
extent permitted by the joint capsule and round ligament.
When greater trochanter hits the ground, kinetic energy
is transmitted to the caput femoris through the collum
femoris. Caput femoris moves upward from acetabular
rim, round ligament and joint capsule tear. Usually, caput
femoris remains in craniodorsal position because of gluteal
muscles contraction [7].
Based on this mechanism, it is understood that the
restriction of the adduction of the leg is very important for
prevention of reluxation in the postoperative period when
joint capsule has not recovered yet. In our technique,
distal screw was placed slightly cranially then the original
synthetic capsule technique. Femoral connection was
established by the transverse hole in the greater trochanter
which is relatively more proximal instead of femoral neck
(or a screw placed in the trochanteric fossa). Thus, it was
hypothesized that the possibility of reluxation would
reduce because of suture material tightening in this way
would lead to more adduction and internal rotation of
the leg. The original synthetic capsule technique has also
restrictive eect on adduction and external rotation of the
leg similar to Ehmer sling [8]. In our study, to improve of
those eects of original technique was intended.
Closed reduction is possible for normal hip joint
within 48-72 h after luxation. If the luxated hip joint waits
longer time, the probability of pathological changes of
femoral head and acetabulum will increase [1,2,8,10]. Small
osteochondral fragments or hemorrhage may cause to
closed reduction failure by joint movement restriction. The
round ligament and inward folding of the joint capsule
may prevent reduction of the femoral head [6].
According to history, posttraumatic period of the dogs
included in the study was range 3-5 days. For this reason,
it was thought that open reduction is a healthier option.
Study was carried out on a series of 6 cases. The dogs which
successful closed reduction could be performed and the
dogs which the modified synthetic capsule technique
was found unenforceable because of any stage of hip
dysplasia or accompanying complications were not
included in this study. For this reason, the number of cases
remained limited.
There are numerous methods which perform successfully
for open reduction of hip joint. For hip luxation treatment,
the options which have minimal intraoperative and post-
operative complications possibilities should be considered.
The joint capsule repair and tightening following the
reduction is a technique that can be applied for luxations
which occurred with simple tears [3,5,12], that’s why indication
of this method is a relatively limited. The reduction with
Toggle pin can be disrupted by suture breaking between
femoral head and acetabulum [29,32]. In a study, traumatic
craniodorsal coxofemoralluxations in cats and small
dogs were treated successfully by using using a modified
Knowles technique, but mean weight of included dogs in
this study was 15 kg [16]. In another study which compared
toggle rod and suture anchor, it was reported that toggle
rod constructs failed primarily by breakage of the suture at
the rod eyelet and suture anchor constructs failed when the
anchors pulled through the medial acetabular wall [17]. In
two dierent studies which used toggle rod with 62 dogs
and 13 dogs, reluxation rates were declared as 11% [18] and
23% [33], respectively. Besides, intraarticular stabilization
methods may cause articular damage and subsequent
arthrosis [30]. The complications related with transarticular
pinning or De Vita pinning such as pin migration, pin
loosening, septic arthritis, sciatic nerve injury, subluxation,
femoral head and neck osteonecrosis, penetration to
colon and rectum has been reported [4,8]. There is limited
information about exible external fixator because of
it has not been widely used. Possible complications of
this technique are hemorrhage, sciatic nerve damage,
pin loosening, pin track drainage and disruption of the
exible band [9,31]. Additionally, total hip replacement [22-24]
and femoral head and neck osteotomy [2,25,26] can be also
BELGE, BOZKAN,
SARIERLER, YAYGINGÜL
Fig 3. Preoperative (A) and postoperative 1st week (B) radiographs of
the Case 6 (72 months old male mix breed dog)
Şekil 3. Altı numaralı vakanın (72 aylık, erkek melez köpek) preoperatif
(A) ve postoperatif 1. hafta (B) radyografileri

342
The Treatment of Coxofemoral ...
applied for the treatment of hip luxation, however these
techniques are usually preferred, if there is degenerative
joint disease. In a multicenter internet based study on
assessment of canine total hip replacement in 170 dogs,
there were only 6 dogs which applied total hip replacement
with coxofemoral luxation treatment indication [24].
Lower complication rate, higher clinical healing
rate [8,13,30,34-36] and also 0 to 6% reluxation rate based on small
number case series [14,34] has been reported on synthetic
capsule technique. In our study, 4 dogs of 6 had (case no.
1, 4, 5, 6) only unilateral coxofemoral luxation without
complications and Dog 2 had femoral fracture and Dog
3 had right hip luxation with greater trochanter fracture
together with the opposite side hip luxation. Four dogs
which have only coxofemoral luxation began to use their
related leg within 7-9 days. The other two dogs needed
more time (12 days for Dog 2 and 14 days for Dog 3) to start
using their leg which applied modified synthetic capsule
technique. The dog with bilateral luxation (for treatment
of right hip luxation with greater trochanter fracture,
femoral head and neck osteotomy was performed) was
not able to use both leg fully, but weight bearing mostly
was performed with the leg which performed synthetic
capsule technique.
No sign of infection was observed in postoperative
period. 5 of all dogs healed with almost excellent degree.
According to information from Owner, one dog (case no.
3) could use both leg similarly but uncoordinatedly. No
reluxation occurred in all of cases.
In a study on femoral head and neck osteotomy, it was
indicated that weight is not as much eective as age on
the outcome, when the dogs were grouped as under and
above 10 kg body weight [26]. However, according to some
sources, femoral head and neck osteotomy require the
dog below 17 kg [1] or 22 kg [37] body weight. Acar et al.[33]
reported that toggle pin technique is appropriate for the
dog below 10 kg body weight based on the observation
of reluxation in 3 of 4 dogs which weighing over 10 kg
in their study. In our study, all of the dogs were weighed
over 17 kg and only one dog was weighed below 22 kg,
however 5 dogs healed completely, including even the
dog which weighed 37 kg. Besides, it was thought that
the uncoordinated walking of the one dog (case no. 3)
might be resulted from spinal nerve injury which occurred
during trauma. These results have led us to consider
that the technique is eective regardless of the weight of
the dog.
Smith et al.[7] has been indicated the hip luxation does
not arise from individually rupture of the round ligament,
joint capsule or dorsal acetabular rim. The hip luxations in
small animals mostly result from simultaneous rupture of
the round ligament and the joint capsule [10]. Based on this
information, it was thought that the strong joint capsule
can support position of femoral head within acetabulum.
The expectation of the synthetic capsule technique
is the formation of organized scar tissue and remodeling
of the joint capsule provide stabilization of reduction [3,38].
Some studies on hip luxation and subsequent joint capsule
and ligament healing showed that fibrous reaction of
the joint capsule and round ligament healing occurred at
14th day [39]. Also, using of Ehmer sling or other temporary
stabilization materials for 2 weeks has been shown to be
eective enough in ensuring the long term stability of the
joint [6,13]. In our study, although Ehmer sling removed from
all of dogs 1 week after surgery, no reluxation occurred.
This results were attributed to modification of the original
technique more limits the joint movement by providing
more adduction and internal rotation.
As a result, postoperatively, infection signs, the hip joint
laxity or reluxation were not determined in clinical and
radiological examinations. Although a precise comment
could not be made about contribution of the modification
to the prevention of reluxation because of 7 days Ehmer
sling application, the lower reluxation rate (0%) compared
with reported reluxation rate of original technique (%6)
seem to be advantage.
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BELGE, BOZKAN,
SARIERLER, YAYGINGÜL