Evidence of Bacterial Metabolism in Synovial Fluid of Patients With Graft Failure After Anterior Cruciate Ligament Reconstruction: A Microbiological Comparison of Primary Anterior Cruciate Ligament and Hamstring Tendon Autograft Ruptures

PURPOSE

To investigate whether the bacterial presence in a primary ruptured native anterior cruciate ligament (ACL) differs from that in a ruptured hamstrings ACL autograft and whether low-grade infections cumulatively can be detected in the case of graft failure.

METHODS

In a retrospective case-control study with prospectively collected data, synovial fluid aspirates and tissue samples of failed ACL grafts were examined for evidence of bacterial colonization and compared to samples of the native ACL in primary ACL reconstruction (ACLR) using microbiological culture, 16S rRNA-PCR and histopathological examination. Furthermore, synovial fluid aspiration was investigated for possible future biomarkers for a low-grade infection.

RESULTS

A total of 112 consecutive patients undergoing primary ACLR without history of previous surgeries to the affected knee (n = 59) and revision ACLR after reconstruction with a hamstring tendon autograft (n = 53) were recruited from one center. No patient had a history or showed clinical signs of infection. A total of 389 samples were analyzed by culture. Bacteria were detected in 9.4% of patients with a graft rupture (n = 5/53) compared to 3.4% of patients with a primary ACL rupture (n = 2/59) showing no statistical difference (P = .192). One patient with a "true" low-grade infection was found in our study population, resulting in a prevalence of 1.9% (1/53) in the graft group. The percentage of polymorphonuclear leukocytes (PMN%) as a highly sensitive marker for joint infections was significantly higher in aspirated synovial fluid of graft ruptures (27% ± 3% vs 20% ± 4%; P = .032), as well as glucose levels were significantly lower (83 mg/dL ± 2 mg/dL vs 88 mg/dL ± 2 mg/dL; P = .042).

CONCLUSIONS

Synovial fluid obtained before revision ACLR showed a higher percentage of polymorphonuclear leukocytes and lower glucose levels compared with primary ACLR, suggesting bacterial metabolism and demonstrating that the intra-articular milieu changes significantly after ACLR. Tissue samples of ACL grafts revealed a low-grade infection in one case, although overall cultivable bacterial presence did not differ significantly when compared to samples of a native ACL.

LEVEL OF EVIDENCE

Level III, retrospective case-control study.

Rectangular-Tunnel Anterior Cruciate Ligament Reconstruction Using Quadriceps Tendon-Patellar Bone Autograft Can Reduce Early Donor Site Morbidity While Maintaining Comparable Short-term Clinical Outcomes

Background

Rectangular tunnel and graft have been recently designed to closely resemble the native anatomy in anterior cruciate ligament reconstruction (ACLR). This study was performed to compare the short-term clinical outcomes between rectangular and round femoral tunnels in ACLR using quadriceps tendon-patellar bone (QTPB) autografts.

Methods

A total of 78 patients who underwent primary ACLR with QTPB autografts performed by three senior surgeons and had at least 1 year of postoperative follow-up were retrospectively reviewed. Patients who underwent rectangular tunnel ACLR (n = 40) were compared to those treated with the conventional round tunnel ACLR (n = 38). Outcomes including knee stability, clinical scores, quadriceps strength, associated complications, postoperative knee range of motion, and cross-sectional area of the graft were assessed.

Results

Significant improvements in knee stability and clinical scores were observed after surgery in both groups (all p < 0.001). The postoperative measurements of knee stability and clinical scores were not significantly different between the two groups. Knee extension strength deficit at 60°/sec was significantly less in the rectangular tunnel group than in the round tunnel group at postoperative 6 months (41.7% vs. 48.9%, p = 0.032). The cross-sectional area of the partial-thickness QTPB graft was approximately 60% of the full-thickness QTPB graft.

Conclusions

In the short-term, rectangular tunnel ACLR was comparable to round tunnel ACLR with QTPB autograft despite the smaller cross-sectional area. Additionally, the rectangular tunnel ACLR allowed partial-thickness grafting technique, which could subsequently reduce early donor site morbidity.

Strength symmetry after autograft anterior cruciate ligament reconstruction

OBJECTIVE

To compare postoperative isometric quadriceps strength indices (QI%) and hamstring strength limb symmetry indices (HI%) between partial thickness quadriceps tendon (pQT), full thickness quadriceps tendon (fQT), and bone-patellar-tendon bone (BPTB) autograft anterior cruciate ligament reconstruction (ACLR).

METHODS

Patients with primary ACLR with pQT, fQT, or BPTB autograft with the documentation of quantitative postoperative strength assessments between 2016 and 2021 were included. Isometric Biodex data, including QI% and HI% (calculated as the percentage of involved to uninvolved limb strength) were collected between 5 and 8 months and between 9 and 15 months postoperatively.

RESULTS

In total, 124 and 51 patients had 5-8- and 9-15-month follow-up strength data, respectively. No significant difference was detected between groups for sex. However, patients undergoing fQT were found to be older than those undergoing BPTB (24.6±7 vs 20.2±5; ​p = 0.01). There were no significant differences in the number of concomitant meniscus repairs between the groups (pQT vs. fQT vs. BPTB). No significant differences were detected in median (min-max) QI% between pQT, fQT, and BPTB 5-8 months [87 ​% (44%-130 ​%), 84 ​% (44%-110 ​%), 82 ​% (37%-110 ​%) or 9-15 months [89 ​% (50%-110 ​%), 89 ​% (67%-110 ​%), and 90 ​% (74%-140 ​%)] postoperatively. Similarly, no differences were detected in median HI% between the groups 5-8 months or 9-15 months postoperatively.

CONCLUSION

The study was unable to detect differences in the recovery of quadriceps strength between patients undergoing ACLR with pQT, fQT, and BPTB autografts at 5-8 months and 9-15-months postoperatively.

LEVEL OF EVIDENCE

III.

Outcomes of bone-patellar tendon-bone autograft and quadriceps tendon autograft for ACL reconstruction in an all-female soccer player cohort with mean 4.8-year follow up

OBJECTIVE

The purpose is to compare functional outcomes, return to soccer rates, and revision rates in an all-female soccer player cohort undergoing quadriceps tendon (QT) autograft ACLR versus bone-patellar tendon-bone (BPTB) autograft ACLR.

METHODS

Female soccer players who sustained an ACL rupture and underwent primary anatomic, single-bundle ACLR with BPTB autograft or QT autograft were included. Demographic and surgical characteristics were collected. Outcomes of interest included Tegner score, International Knee Documentation Committee (IKDC) score, Marx score, return to soccer rates, and failure rates.

RESULTS

Data on 23 patients undergoing BPTB autograft ACLR and 14 undergoing QT autograft ACLR was available. Average age was 18.7 years, and average follow up was 4.8 years. Overall, 76 ​% (28/37) returned to soccer and 5.4 ​% (2/37) underwent revision ACLR. No major significant differences were found in demographic or surgical characteristics. No differences were found in postoperative IKDC scores, preoperative, postoperative, or change from pre-to postoperative Marx activity scores, or pre-and postoperative Tegner scores between the groups. QT autograft ACLR patients had significantly less change in Tegner scores pre-to postoperatively compared to the BTPB autograft ACLR group (0.6 ​± ​1.2 versus 2.1 ​± ​1.8; p ​= ​0.02). Both groups had similar rates of return to soccer [78 ​% (18/23) BPTB autograft ACLR versus 71 ​% (10/14) QT autograft ACLR; p ​= ​0.64] and rates of revision (8.7 % (2/23) BPTB autograft ACLR; 0 % (0/14) QT autograft ACLR.

CONCLUSION

Results of this study suggest that BPTB autograft ACLR and QT autograft ACLR produce comparable, successful functional and return to soccer outcomes in this all-female soccer player cohort study. Larger, prospective studies are needed to improve the strength of conclusions and provide more information on the optimal graft choice for female soccer players. Surgeons can use the results of this study to counsel female soccer players on expected outcomes after ACLR.

LEVEL OF EVIDENCE

III.

Editorial Commentary: Augmentation With Allograft Patch Results in Similar Outcomes to Anterior Cable Reconstruction With Autograft Biceps Tendon for Chronic, Retracted, Anterior, L-Shaped Supraspinatus Tears

Chronic retracted rotator cuff tears are difficult entities to treat. L-shaped tears are a particular subset of such rotator cuff tears that pose challenges for surgeons attempting to reduce the supraspinatus tendon back to the greater tuberosity. Lack of full coverage of the tuberosity, need for medialization of the tendon, undue tension, and incomplete reconstitution of the rotator cable are some of the reasons L-shaped retracted tears of the supraspinatus can be challenging. Anterior cable reconstruction (ACR) is a technique that has gained increasing recent popularity, as is the use of patch augmentation. The long head of the biceps tendon is often readily available for use in ACR, but when it isn't, patch augmentation is an option for partially repairable rotator cuff tears. These produce similar postoperative improvements in range of motion as well as Constant and American Shoulder and Elbow Surgeons scores, but comparison to partial repair is still unknown.

Ten-year outcomes of anterior cruciate ligament reconstruction with hamstring tendon autograft and femoral fixation with a cortico-cancellous screw suspension device

PURPOSE

To evaluate the clinical and radiographic outcomes of anterior cruciate (ACL) reconstruction at minimum 10-year follow-up.

METHODS

Ninety-three patients who underwent primary unilateral ACL reconstruction with hamstring tendon autograft, transtibial technique and femoral cortico-cancellous screw suspension device (Athrax, Leader Medica s.r.l) between 2010 and 2012 were retrospectively reviewed. Mean follow-up was 136 months. Evaluation was performed using the International Knee Documentation Committee score (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm Knee Score and Tegner Activity Level Scale. Incidence of OA was determined by comparing standard anteroposterior and lateral weightbearing radiographs of the ACL-reconstructed and contralateral knee. Osteoarthritis severity was graded according to the Kellgren-Lawrence (KL) score.

RESULTS

Median Tegner activity level was 6 (5-7). Lysholm and IKDC scores were 100 (95-100) and 90 (86-95), respectively, KOOS was 98 (95-100). Of ACL-reconstructed knees, 41 (50%) had radiographic OA, of which 6 (7.3%) had severe OA (KL III). Of the contralateral healthy knees, 28 (34.1%) had radiographic evidence of OA. Of these 22 (26.8%) and 6 (7.3%) patients had, respectively, KL-I and KL-II. 11 patients (11.8%) underwent subsequent knee surgery: 5 (5.4%) revisions, 3 (3.2%) meniscal surgeries, 2 (2.2%) other surgeries, 1 (1.1%) contralateral ACL reconstruction.

CONCLUSIONS

The study demonstrates that ACL reconstruction with HT autograft and cortico-cancellous screw suspension device determines satisfying clinical results after 10 years of follow-up. From our cohort, a low rate of graft failure has been reported, even though almost 50% of patients present a knee OA greater or equal to grade II KL.

No Superior Bone Union Outcomes with Allografts Compared to No Grafts and Autografts Following Medial Opening Wedge High Tibial Osteotomy: A Retrospective Cohort Study

OBJECTIVE

There has been long-standing debate about whether a medial opening wedge high tibial osteotomy (MOWHTO) gap should be filled with autologous bone graft or any other filler to expedite the healing process. The main purpose of this study was to compare the clinical and radiological outcomes of MOWHTO with an opening gap ≥10 mm, utilizing autograft, allograft, or no graft at 1 year postoperatively.

METHODS

A total of 68 patients were included in this retrospective study and divided into three treatment groups: Group A (no bone graft), Group B (autologous iliac crest graft), and Group C (allogenous tibia plateau graft). At postoperative 1-year follow-up, the area of callus filling in the most medial side of the knee was measured using anteroposterior radiographs, and a modified van Hemert scoring system was used to evaluate bone union outcomes in five mediolaterally divided zones. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores and relevant complications were assessed. The correlations between the gap width and bone union scores were evaluated.

RESULTS

Patients in the autograft group demonstrated better bone union progression (p = 0.031) and higher bone union scores (p < 0.01) compared to patients in the allograft or no graft groups. There were no significant differences in terms of postoperative WOMAC scores and incidence of complications among the three groups. No discernible linear relationships between the width of the opening gap and the bone union score were found.

CONCLUSION

For MOWHTOs with an average gap opening width of 12.1 mm, autografts resulted in superior bone union outcomes compared to allografts and no graft at 1 year postoperatively. However, no bone graft achieved similar outcomes to allografts, suggesting that routine use of allografts should not be recommended.

Volume retention rate after breast autogenous fat grafting and related influencing factors: A systematic review and meta-analysis

The volume retention of breast autologous fat grafting is unpredictable, and the volume retention rate and related influencing factors have not been systematically reviewed. Therefore, this systematic review and meta-analysis aimed at evaluating the volume retention rate and related influencing factors of breast autologous fat grafting, which is for reconstructive or esthetic purposes. Literature search was conducted using the PubMed, Embase, Cochrane Library, and Web of Science databases from inception of study to December 2022. Sensitivity analysis was performed for all outcomes. Begg's test was performed to test publication bias. Subgroup analysis was performed based on population, method of fat preparation, method of volume measurement, number of fat grafting, and injected fat grafting volume. A total of 25 studies were included in this systematic review and meta-analysis. The follow-up time ranged from 3 to 36 months. Results showed that the pooled volume retention rate at the latest follow-up point was 54% [95% confidence interval (CI): 48.5%-59.5%]. Based on the fat preparation methods, the pooled rate was 51.5% (95%CI: 41.5%-61.5%) for centrifugation, which was higher than that for sedimentation [38.7% (95%CI: 30.9%-46.5%)]. In addition, the enrichment of stromal vascular fraction obtained after centrifugation was found to be associated with higher volume retention rate (weighted mean difference: 17.36, 95%CI: 8.84-25.87). Our findings may provide guidance for evaluating the volume retention rate of breast autologous fat grafting in clinical settings. Further studies are needed to verify our findings.

Editorial Commentary: Irreparable, Symptomatic, Hip Labral Tears Should Be Reconstructed in Patients without Osteoarthritis. However, Comparison of the Two, as Well as Allograft versus Autograft Reconstruction, Is Challenging

Hip acetabular labrum plays a chondroprotective role by maintaining stability, providing a suction seal, and contributing to load distribution. In symptomatic patients without osteoarthritis, arthroscopic labral repair has strong clinical and biomechanical data to support its use. For irreparable tears, the labrum should be reconstructed. Biomechanically, labral reconstruction does not demonstrate superiority when compared to labral repair or the intact native labrum state. However, it is superior to labral excision. One challenge in making these comparisons is the heterogeneity in surgical technique. Labral reconstruction techniques can vary significantly. In terms of reconstruction, allograft offers the advantage of no donor site morbidity, but availability, costs, and risks must be considered. Autograft use is limited by donor site morbidity and increased operative time. Direct comparisons again show no clear evidence to suggest superiority of one over the other.

Effect of graft types for outcomes in revision anterior cruciate ligament reconstruction: A meta-analysis

PURPOSE

This meta-analysis was performed to compare outcomes among different types of graft for revision anterior cruciate ligament reconstruction (ACLR).

METHODS

A comprehensive search from Embase, PubMed, and Cochrane Library was performed to identify relevant articles. Studies that conducted a comparative analysis on outcomes among different types of grafts were included. A meta-analysis was performed using Review Manager 5.4 software.

RESULTS

In total, 7 non-randomized studies with a minimum 1-year follow-up were included in analysis, and all studies compared outcomes between autograft and allograft. International Knee Documentation Committee subjective knee (IKDC) scores and side-to-side anterior laxity were not significantly different between autograft and allograft. Revision ACLR with allograft had a higher risk of failure than autograft at the final follow-up (OR=2.22, 95% CI=1.55-3.18). The rates of return to pre-injury type of sport and return to same and higher level of pre-injury sport were not significantly different between autograft and allograft.

CONCLUSION

The outcomes of IKDC score, side-to-side anterior laxity, and rates of return to sport were not significantly different between autograft and allograft. Autografts provide a significantly lower risk of failure than allografts in revision ACLR.

LEVEL OF EVIDENCE

IV; meta-analysis.

Distinct Cell-Intrinsic Functional Differences Between Iliac Crest and Distal Radius Autografts

PURPOSE

Autologous bone grafts demonstrate osteoconductive, osteoinductive, and osteogenic properties. Hand surgeons commonly augment surgical fixation with autografts to promote fracture healing. This study compared the intrinsic stem cell-like properties of 2 commonly used autograft sources in hand surgery: the iliac crest and distal radius.

METHODS

A total of 9 subjects who received an iliac crest bone graft and distal radius bone graft harvest as a part of the standard care of distal radius malunion or nonunion correction or scaphoid nonunion open reduction and internal fixation were enrolled in the study. Cells were isolated by serial collagenase digestion and subjected to fibroblast colony-forming units, osteogenesis, and adipogenesis assays. The expression levels of genes involved in osteogenesis and adipogenesis were confirmed using quantitative polymerase chain reaction.

RESULTS

The cells isolated from the iliac crest bone graft compared with those isolated from the distal radius bone graft demonstrated significantly higher mean fibroblast colony-forming unit efficiency; increased osteogenesis, as measured using alizarin red quantification; increased adipogenesis, as measured using oil red O quantification; and higher expression levels of genes involved in osteogenesis and adipogenesis under the respective differentiation conditions.

CONCLUSIONS

The cells isolated from the iliac crest bone graft demonstrated a higher fibroblast colony-forming unit capacity and an increased capability to undergo both osteogenesis and adipogenesis.

CLINICAL RELEVANCE

Limited evidence exists comparing the intrinsic stem cell-like properties of the iliac crest and distal radius despite the widespread use of each source in hand and wrist surgery. The information from this investigation may assist hand and wrist surgeons with the selection of a source of autograft.

No Difference In Clinical Outcomes Following Repair of Large Retracted Anterior Rotator Cuff Tears Using Patch Augmentation With Human Dermal Allograft Versus Anterior Cable Reconstruction With Biceps Tendon Autograft

PURPOSE

To compare the clinical outcomes and tendon integrity after rotator cuff repair combined with anterior cable reconstruction (ACR) using the proximal biceps tendon and patch augmentation (PA) using a human dermal allograft (HDA) in a large retracted anterior rotator cuff tear.

METHODS

Patients who underwent arthroscopic rotator cuff repair with 2 different augmentation procedures between January 2017 and December 2020 were enrolled. The inclusion criteria were patients who were treated by arthroscopic rotator cuff repair with ACR using the proximal biceps tendon (ACR group) or patch augmentation using a an HDA (PA group) and follow-up for at least 2 years. Clinical outcomes were assessed using American Shoulder and Elbow Surgeons (ASES) score, Constant score, and the number of patients who achieved minimal clinically important differences (MCID). Magnetic resonance imaging was performed to evaluate tendon integrity after surgery.

RESULTS

A total of 92 patients were enrolled (ACR group = 55 patients and PA group = 37 patients). The mean ASES and Constant scores significantly improved in the ACR group (68.8 ± 15.3 and 58.4 ± 16.9 before surgery vs 91.4 ± 6.3 and 87.8 ± 6.0 after surgery, P < .001) and in the PA group (63.7 ± 16.7 and 57.9 ± 15.4 before surgery vs 93.1 ± 6.3 and 88.3 ± 6.2 after surgery, P < .001). Overall, 78 patients (84.8%) achieved the MCID with 81.8% in the ACR group and 89.2% in the PA group, with no significant differences between the 2 groups (P = .638). Ten patients (18.2%) had retear in the ACR group, and three patients (8.1%) had retear in the PA group (P = .174).

CONCLUSIONS

In large retracted anterior rotator cuff tears, both augmentation techniques using biceps tendon autograft and HDA provided satisfactory clinical outcomes that achieved the MCID in 84.8%, range of motion restoration, and lower retear rates with no significant differences between the two groups.

LEVEL OF EVIDENCE

Level III, retrospective case-control study.

Peri-Transplant Inflammation and Long-Term Diabetes Outcomes Were Not Impacted by Either Etanercept or Alpha-1-Antitrypsin Treatment in Islet Autotransplant Recipients

The instant blood-mediated inflammatory response (IBMIR) causes islet loss and compromises diabetes outcomes after total pancreatectomy with islet autotransplant (TPIAT). We previously reported a possible benefit of etanercept in maintaining insulin secretion 3 months post-TPIAT. Here, we report 2-year diabetes outcomes and peri-operative inflammatory profiles from a randomized trial of etanercept and alpha-1 antitrypsin (A1AT) in TPIAT. We randomized 43 TPIAT recipients to A1AT (90 mg/kg IV x6 doses, n = 13), etanercept (50 mg then 25 mg SQ x 5 doses, n = 14), or standard care (n = 16). Inflammatory cytokines, serum A1AT and unmethylated insulin DNA were drawn multiple times in the perioperative period. Islet function was assessed 2 years after TPIAT with mixed meal tolerance test, intravenous glucose tolerance test and glucose-potentiated arginine induced insulin secretion. Cytokines, especially IL-6, IL-8, IL-10, and MCP-1, were elevated during and after TPIAT. However, only TNFα differed significantly between groups, with highest levels in the etanercept group (p = 0.027). A1AT increased after IAT in all groups (p < 0.001), suggesting endogenous upregulation. Unmethylated insulin DNA ratios (a marker of islet loss) and 2 years islet function testing were similar in the three groups. To conclude, we found no sustained benefit from administering etanercept or A1AT in the perioperative period.

Late Pulmonary Autograft Dilation: Can We Make a Good Operation Great? The Supported Ross

The Ross procedure is an excellent option for aortic valve replacement resulting in outstanding hemodynamic performance and the ability to avoid systemic anticoagulation. The long-term durability of the autograft is generally good but concerns for later aortic root dilation with ensuing neoaortic insufficiency have prompted efforts to stabilize the autograft, root, sinuses and Sino-tubular junction in order to delay or entirely avoid late reinterventions on the neoaortic root. We have employed an inclusion technique, supporting the Auto-graft in a Terumo Gelweave™ Valsalva graft. We performed a retrospective study of all 129 patients undergoing the Ross procedure from 1992 to 2019 at Children's Wisconsin. Fifty-one underwent the supported Ross (SR) and 78 underwent unsupported Ross (UR). Structured clinical data was collected and echocardiograms were reviewed. Median follow-up was 4.9 years (up to 22.6 years) for UR patients and 3.6 years (up to 11.4 years) for SR patients. In order to provide a fair comparison, we sub -analyzed patients aged 10 to 18 years who underwent the Ross procedure, 16 who underwent the UR and 18 patients who underwent the SR. Change in aortic annulus diameter (P = 0.002), aortic sinus diameter (P = 0.001) change in left ventricular function (P = 0.039) and change in aortic insufficiency (P = 0.008) were all worse in UR. The SR is simple, reproducible, and predictable. It seems to prevent change in annulus diameter, sinus diameter and to reduce late neoaortic insufficiency. Longer follow-up with a larger group of patients is required to draw definitive conclusions.

Late Pulmonary Autograft Dilation: Can We Make a Good Operation Great? The Tailored Approach

While it is the main viable option in the growing child and young adult, the Ross procedure has expanded its applicability to older patients, for whom long-term results are equivalent, if not superior, to prosthetic aortic valve replacement. Strategies aiming at mitigating long-term autograft failure from root enlargement and valve regurgitation have led some to advocate for root reinforcement with prosthetic graft material. On the contrary, we will discuss herein the rationale for a tailored approach to the Ross procedure; this strategy is aimed at maintaining the natural physiology and interplay between the various autograft components. Several technical maneuvers, including careful matching of aortic and autograft annuli and sino-tubular junction as well as external support by autologous aortic tissue maintain these physiologic relationships and the viability of the autograft, and could translate in a lower need for late reintervention because of dilation and/or valve regurgitation.

Modified osteochondral autograft transplantation for steroid-induced osteonecrosis of femoral head in idiopathic thrombocytopenic purpura: a case report and literature

Osteochondral autograft transplantation (OAT) has been commonly applied in the knee and ankle while the technique has not yet been a popularity in the femoral head. In this article, we present a 28-year-old female patient, who has a history of 1-year-use of glucocorticoid in the treatment of idiopathic thrombocytopenic purpura, with steroid-induced osteonecrosis of the femoral head (SONFH). She underwent surgical hip dislocation, osteochondroplasty, OAT, and internal fixation. Her Harris Hip Score improved from 64 to 82 in 36 months to follow-up. The case is valuable considering that a single, instead of several, 1.5 cm autograft was harvested from the non-bearing part of the same femoral head. This modification dispensed with the need of surgery for harvesting autograft from knee or ankle and reduced the structural vulnerability brought by the multihole donor part of the femoral head.

Anterior Cruciate Ligament Reconstruction with Semitendinosus Tendon Autograft among Paramilitary Patients Undergoing Arthroscopic Surgery in a Tertiary Care Centre

Introduction

In orthopaedic practice, injuries to the anterior cruciate ligaments occur almost on an epidemic scale, yet it continues to be of interest in orthopaedic surgery whether semitendinosus or gracilis hamstring autografts can be used for better anterior cruciate ligament reconstruction. This study aimed to determine the prevalence of anterior cruciate ligament reconstruction using semitendinosus tendon autografts among paramilitary patients undergoing arthroscopic surgery in a tertiary care centre.

Methods

This descriptive cross-sectional study was conducted among paramilitary individuals who had knee injuries and were admitted between 6 february 2020 and 26 January 2022 for arthroscopic surgery after obtaining ethical approval from the Institutional Review Committee. Demographic details and the mode of injury were obtained from the patients. The treating orthopaedic surgeons evaluated the pre- and post-analysis Lysholm Knee Score and Lysholm Knee Scale based on the patient's response. A convenience sampling method was used. The point estimate was calculated at a 95% Confidence Interval.

Results

Among 166 patients, anterior cruciate ligament reconstruction using a semitendinosus tendon autograft was done in 58 (34.94%) (27.69-42.19, 95% Confidence Interval). Most of the patients in the pre-analysis had mild/periodic limp issues 52 (89.66%), followed by instability during athletics or other severe exertion 43 (74.14%).

Conclusions

The prevalence of anterior cruciate ligament injuries in our study is higher than other studies done in similar settings.

Keywords

anterior cruciate ligament; grafts; semitendinosus tendon.

Metal interference screw fixation combinations show high revision rates in primary hamstring tendon ACL reconstruction

BACKGROUND

Different fixation methods in anterior cruciate ligament reconstruction (ACLR) have been associated with different revision rates, specifically in the early postoperative period. However, most previous research has either grouped together different fixation types or evaluated femoral-sided fixation or tibial-sided fixation separately. Therefore, the purpose of this study was to determine ACL revision rates for specific combinations of femoral and tibial fixation methods within 2 years of primary hamstring tendon autograft ACLR based on data from the Swedish National Knee Ligament Registry (SNKLR).

METHODS

Patients that underwent primary hamstring tendon autograft ACLR between 2005 and 2018 in the SNKLR were included. The collected data included patient characteristics (age, sex, body mass index [BMI]), activity at time of injury, surgical information (concomitant injuries, time from injury to surgery, fixation types at the femur and tibia), and subsequent revision ACLR. Revision rate within 2 years of the index procedure was chosen, as ACLR fixation is most likely to contribute to ACLR revision within the first 2 years, during graft maturation.

RESULTS

Of the 23,238 included patients undergoing primary hamstring ACLR, 581 (2.5%) underwent revision ACLR within 2 years of the index procedure. Among the combinations used for > 300 patients, the femoral metal interference screw/tibial metal interference screw fixation combination had the highest revision rate followed by metal interference screw/resorbable screw and Endobutton/AO screw fixation combinations, with respective revision rates of 4.0, 3.0, and 3.0%. The lowest revision rate within 2 years of ACLR was found in the Endobutton/metal interference screw with backup Osteosuture fixation combination, used in 433 cases, with a failure rate of 0.9%.

CONCLUSION

Different early ACL revision rates were found across different combinations of femoral and tibial fixation devices within 2 years of primary hamstring tendon autograft ACLR. Metal interference screw fixation, particularly when performed on both the femoral and tibial sides, most frequently resulted in revision ACLR. These findings may be helpful for surgeons in selecting appropriate fixation devices for hamstring ACLR.

LEVEL OF EVIDENCE

IV.

Tape-Reinforced Graft Suturing and Retensioning of Adjustable-Loop Cortical Buttons Improve Quadriceps Tendon Autograft Biomechanics in Anterior Cruciate Ligament Reconstruction: A Cadaveric Study

PURPOSE

To investigate the biomechanical effects of tape-reinforced graft suturing and graft retensioning for all-soft tissue quadriceps tendon (ASTQT) anterior cruciate ligament reconstruction (ACLR) in a full-construct human cadaveric model.

METHODS

Harvested cadaveric ASTQT grafts were assigned to either (1) double-suspensory adjustable-loop cortical button device (ALD) fixation in which both graft ends were fixed with a suspensory fixation device with (n = 5) or without (n = 5) tape-reinforced suturing or (2) single-suspensory distal tendon fixation in which only the patellar end was fixed with an ALD (n = 5) or fixed-loop cortical button device (FLD) (n = 5). All specimens were prepared using a No. 2 whipstitch technique, and tape-reinforced specimens had an integrated braided tape implant. Graft preparation time was recorded for double-suspensory constructs. Samples were tested on an electromechanical testing machine using a previously published protocol simulating rehabilitative kinematics and loading.

RESULTS

Tape-reinforced graft suturing resulted in greater graft load retention after cycling (11.9% difference, P = .021), less total elongation (mean [95% confidence interval (CI)], 5.57 mm [3.50-7.65 mm] vs 32.14 mm [25.38-38.90 mm]; P < .001), greater ultimate failure stiffness (mean [95% CI], 171.9 N/mm [158.8-185.0 N/mm] vs 119.4 N/mm [108.7-130.0 N/mm]; P < .001), and less graft preparation time (36.4% difference, P < .001) when compared with unreinforced specimens. Retensioned ALD constructs had less cyclic elongation compared with FLD constructs (mean total elongation [95% CI], 7.04 mm [5.47-8.61 mm] vs 12.96 mm [8.67-17.26 mm]; P = .004).

CONCLUSIONS

Tape-reinforced graft suturing improves time-zero ASTQT ACLR construct biomechanics in a cadaveric model with 83% less total elongation, 44% greater stiffness, and reduced preparation time compared with a whipstitched graft without tape reinforcement. ALD fixation improves construct mechanics when compared with FLD fixation as evidenced by 46% less total elongation.

CLINICAL RELEVANCE

Tape-reinforced implants and graft retensioning using ALDs improve time-zero ACLR graft construct biomechanics in a time-zero biomechanical model. Clinical studies will be necessary to determine whether these implants improve clinical outcomes including knee laxity and the incidence of graft rupture.

Editorial Commentary: Quadriceps Tendon Anterior Cruciate Ligament Graft Shows Advantages and Disadvantages

A quadriceps tendon autograft is becoming an increasingly popular graft option for both primary and revision ACL reconstruction. The biomechanical properties of a QT autograft are favorable compared to a bone-patellar tendon-bone (BPTB) or a doubled hamstring (HS) autograft. A QT autograft is associated with less donor site morbidity, such as anterior knee pain and difficulty with kneeling, than a BPTB autograft, and short-term studies have shown comparable clinical results when compared to a BPTB or a HS autograft. However, if harvested with a bone block, a QT autograft carries a higher risk of patellar fracture than a BPTB autograft. Other potential disadvantages include persistent quadriceps weakness, and registry data have shown a higher revision rate compared to a BPTB or HS ACL reconstruction, which is thought to be due to a high learning curve, leading to higher revision rates in low volume centers. Finally, a graft-fixation construct with good time 0 biomechanical characteristics may only be successful in the long term if the graft heals effectively. Time will tell.

Long-Term Patient Outcomes for Treatment of Difficult Osteochondral Lesions of the Talus with Particulated Juvenile Allograft Cartilage Implantation ± Calcaneal Autograft: A Cohort Study

BACKGROUND

Osteochondral lesions of the talus (OCLT) are common injuries that can be difficult to treat. To date, long-term patient reported outcome measures (PROMs) of patients with particulated juvenile allograft cartilage implantation with or without calcaneal autograft have not been compared.

METHODS

Thirteen patients with difficult to treat OCLTs underwent arthroscopic-assisted implantation of particulated juvenile allograft cartilage (DeNovo NT®) with or without autogenous calcaneal bone grafting by a single surgeon. Calcaneal bone graft use was determined by lesion size > 150 mm2 and/or deeper than 5 mm. Patients were evaluated using physical examination, patient interviews, and PROMs.

RESULTS

When comparing patients in regards to calcaneal bone graft implantation, no difference in age, BMI, pre-operative PROMs, or follow-up was noted, however, calcaneal bone graft patients did have a significantly larger lesion size (188.5 ± 50.9 vs. 118.7 ± 29.4 mm2 respectively; p value = 0.027). VAS and FAAM ADL scores during final follow-up improvement did not significantly differ between cohorts. The FAAM Sports score improved significantly more for the DeNovo alone group compared to the bone graft cohort (p value = 0.032). The AOFAS score improvement did not differ between cohorts (p value = 0.944), however, the SF-36 PCS improved significantly more for the DeNovo alone group compared to the bone graft cohort (p value = 0.038). No intraoperative/perioperative complications were observed with calcaneal bone grafting.

CONCLUSION

While patients followed over the course of ~ 8 years after implantation of particulated juvenile allograft cartilage (DeNovo NT®) with/without autogenous calcaneal bone graft had positive post-operative PROMs, patients without calcaneal bone graft had significantly greater improvement in functional outcome scores. Whether these differences are due to graft incorporation or larger lesion size is unclear.

LEVEL OF EVIDENCE

III, retrospective cohort study.

[Femoral nerve repair with autografts for proximal retroperitoneal damage (case report and literature review)]

Femoral nerve damage, especially in proximal retroperitoneal space, is rare. Therefore, surgical strategy is still unclear for these patients. Various specialists discuss repair with autografts or neurotization by the obturator nerve or its muscular branch.

OBJECTIVE

To demonstrate the diagnostic algorithm for proximal femoral nerve injury and favorable outcomes after repair with long autografts.

MATERIAL AND METHODS

We assessed movements and sensitivity using a five-point scale, as well as ultrasound, magnetic resonance imaging and electroneuromyography data in a patient with extended iatrogenic femoral nerve damage before and after repair with long autografts (10.5 cm).

RESULTS AND DISCUSSION

The patient had complete femoral nerve interruption in proximal retroperitoneal space with 10-cm defect that required repair with five autografts from two sural nerves. Postoperative ultrasound and magnetic resonance imaging revealed signs of graft survival and no neuroma within the nerve suture lines. The first signs of motor recovery occurred after 10 months. After 14 months, strength of quadriceps femoris muscle comprised 4 points, and electroneuromyography confirmed re-innervation.

CONCLUSION

Femoral nerve repair with autografts for complete proximal anatomical interruption can provide sufficient restoration of movements and sensitivity. Therefore, this surgical option should be preferred instead of neurotization. Ultrasound, MRI and ENMG are valuable to clarify the diagnosis and state of the autografts.

Monitoring angiogenesis in skin autografts using photoacoustic microscopy

BACKGROUND

Skin autografts have been broadly used to manage the skin and soft tissue defects. It is important for surgeons to assess the vitality of skin autografts via observing the angiogenesis. However, there is lack of reliable approach for giving the quantitative angiogenesis information on the skin autografts. Recently, photoacoustic microscopy imaging has attracted much attention based on its good performance in angiography.

METHODS

In this study, we aim to monitor angiogenesis in skin autografts via PAM, and further verify its clinical potential for the early prediction of skin autografts clinical outcome.

RESULTS AND CONCLUSIONS

The results indicate that PAM is a feasible, precise, high-resolution, noninvasive technique for the early prediction of necrosis of skin autografts via monitoring the angiogenesis, providing a promising tool for surgeons to use this surgical technology.

The impact of bone graft type used to fill bone defects in patients undergoing ACL reconstruction with bone-patellar tendon-bone (BPTB) autograft on kneeling, anterior knee pain and knee functional outcomes

PURPOSE

Multiple different materials are used for filling bone defects following bone-patellar tendon-bone (BPTB) graft ACL reconstruction surgery. The theoretical objective being to minimize kneeling pain, improve clinical outcomes and reduce anterior knee pain following surgery. The impact of these materials is assessed in this study.

METHODS

A prospective monocentric cohort study was conducted from January 2018 to March 2020. There were 128 skeletally mature athletic patients who underwent ACL reconstruction using the same arthroscopic-assisted BPTB technique, with a minimum follow-up of two years identified in our database. After obtaining approval from the local ethics committee, 102 patients were included in the study. Patients were divided into three groups based on type of bone substitute. The Bioactive glass 45S5 ceramic Glassbone™ (GB), collagen and hydroxyapatite bone void filler in sponge form Collapat® II (CP), and treated human bone graft Osteopure®(OP) bone substitutes were used according to availability. Clinical evaluation of patients at follow-up was performed using the WebSurvey software. A questionnaire completed in the 2nd post-operative year included three items: The ability to kneel, the presence of donor site pain, and the palpation of a defect. Another assessment tool included the IKDC subjective score and Lysholm score. These two tools were completed by patients preoperatively, and postoperatively on three occasions (6 months, 1 year, and 2 years).

RESULTS

A total of 102 patients were included in this study. In terms of Kneeling pain, the percentage of GB and CP patients' who kneel with ease were much higher than that of OP patients (77.78%, 76.5% vs 65.6%, respectively). All three groups experienced an important increase in IKDC and Lysholm scores. There was no difference in anterior knee pain between the groups.

CONCLUSION

The use of Glassbone® and Collapat II® bone substitutes reduced the incidence of kneeling pain compared to Osteopure®. There was no influence of the bone substitute type on the functional outcome of the knee or on the anterior knee pain at two years of follow.

A prospective randomized controlled study of hamstring and bone-free quadriceps tendons autografts in arthroscopic ACL reconstruction

INTRODUCTION

Anterior cruciate ligament (ACL) reconstruction is one of the most common surgical procedures worldwide. However, the ideal graft source is still debatable. This study compared hamstring (HT) and bone-free quadriceps (QT) tendon autografts in terms of muscle strength and patient-reported outcomes.

METHODS

Between June 2018 and December 2019, 46 patients were enrolled in the study and randomly assigned to one of two groups for the ACL reconstruction surgery-the HT autograft group or the QT autograft group. An experienced examiner performed preoperative and postoperative examinations. The HUMAC NORM isokinetic machine (Computer Sports Medicine International-CSMI, 2004) was used to assess flexor and extensor thigh muscle strength. Both groups received the same surgical technique and fixation method. All patients were examined after three, six, nine, and 12 months. The final evaluations were performed at the 24-month follow-up. Patients' scores on the International Knee Documentation Committee (IKDC) evaluation form and the Lysholm Knee Scoring Scale were used to evaluate patient-reported outcomes. The two groups were also compared in terms of postoperative complications and activity levels.

RESULTS

The difference between preoperative and postoperative knee flexor peak torques (FPT) was lower in the QT group than in the HT group. The average difference between preoperative and postoperative knee extensor peak torque (EPT) was higher in the QT group than in the HT group. As a result, the HT group had a lower postoperative H/Q ratio (flexor strength normalized to body mass divided by extensor strength normalized to body mass) than the QT group (p < 0.001). The mean IKDC scores for the HT and QT groups were 90.13 ± 6.99 and 87.12 ± 6.61, respectively. The scores of the two groups postoperatively were close, and both groups showed significant improvement. The average graft size in the QT group was significantly greater than that in the HT group. Saphenous nerve palsy was the most common complication in the HT group (22%). Thigh hematomas were observed in two patients in the QT group and required urgent intervention (12%).

CONCLUSION

After ACL reconstruction, we found a significant decrease in strength at the donor sites in both techniques, with similar patient-reported measures and stability outcomes. The H/Q strength ratio was higher in the QT group postoperatively, which may have a protective effect on the reconstructed ligament. Level of Evidence I It is a randomized controlled trial.

All-Arthroscopic Glenoid Bone Augmentation Using Iliac Crest Autograft Procedure for Recurrent Anterior Shoulder Instability: Button Fixation Is a Feasible and Satisfactory Alternative to Screw Fixation

PURPOSE

To investigate the efficacy of all-arthroscopic glenoid bone augmentation surgery using the iliac crest autograft procedure. Furthermore, we sought to compare the clinical and radiographic outcomes of using screw versus button fixation, in patients with recurrent anterior shoulder instability.

METHODS

Between 2015 and 2019, 134 shoulders with persistent instability were surgically treated with an arthroscopically placed autologous iliac crest bone graft transfer procedure. Preoperative and postoperative clinical follow-up data were evaluated using the range of motion, and the Walch-Duplay, American Shoulder and Elbow Society, and Rowe scores. Radiologic assessment on 3-dimensional computed tomography scans was performed preoperatively, immediately after surgery, as well as postoperatively, at 3 months, 6 months, 1 year, and at the final follow-up stage. Graft positions, healing, and resorption were evaluated from postoperative images.

RESULTS

This study included 102 patients who underwent arthroscopic iliac crest bone grafting procedure with 2 screws fixation (n = 37; group 1) and 2 button fixation (n = 65; group 2). The mean follow-up period was 37 months. There were no significant differences between groups in terms of clinical scores, shoulder motion range, graft healing, or graft positions on computed tomography scans (P>.05). In group 1, 1 patient showed mechanical irritation and persistent pain around the screw insertion site, being treated through the arthroscopic removal of the screws. The average postoperative bony resorption percentages were 20.3% and 11.2% at 6 months, and 32.4% and 19.3% at 12 months, in group 1 and group 2, respectively. A statistically significant difference was detected between the two groups (P<.05).

CONCLUSIONS

In the arthroscopic iliac crest bone grafting procedure for the treatment of chronic osseous anterior shoulder instability, excellent functional results were obtained after both button fixation and screw fixation techniques. In addition, less graft resorption and no hardware-related complications were detected with suture button fixation technique.

LEVEL OF EVIDENCE

Level III, retrospective comparative therapeutic trial.

Osteoperiosteal Iliac Autograft Transplantation for Unreconstructable Tibial Plafond After Malunions of Pilon Fractures in Young Patients

BACKGROUND

Malunion of tibial pilon fracture, especially with a large cartilage loss of the tibial plafond, is a tough clinical conundrum. This study describes a joint-preserving technique that mainly involves corrective intraarticular osteotomy and osteoperiosteal iliac autograft transplantation for treating these generally considered unreconstructable tibial plafond.

METHODS

Sixteen patients with an average age of 33.6 years who were treated with this joint-preserving method between 2013 and 2020 were retrospectively analyzed. Ankle distraction was applied in all patients. Additional osteochondral autograft transplantation for talus was performed in 4 patients and supramalleolar osteotomy in 2 patients. The visual analog scale (VAS) score, the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, the 36-Item Short Form Health Survey (SF-36) score, and the ankle range of motion (ROM) were used for outcome analysis. Radiographic assessment was conducted, and the complications were recorded.

RESULTS

At a mean follow-up of 41.1 months, the mean VAS, AOFAS, and SF-36 scores improved from 6.3, 47.6, and 38.0 to 1.7, 84.4, and 70.8, respectively (P < .001 for each). The ankle ROM improved from 27.5 to 32.2 degrees (P = .023). The mean area of ilium blocks was 3.5 cm2, and the mean external fixation time was 94.1 days. Radiographs showed that good osteointegration was found in all patients and no significant progression of osteoarthritis in 15 patients. The major complications included poor incision healing in 2 patients and severe ankle stiffness in 2 patients, with one of them developing considerable varus-type osteoarthritis but reporting no pain. No deep infection, nonunion, or malunion occurred, and no secondary arthrodesis was performed during the final follow-up.

CONCLUSION

Osteoperiosteal iliac autograft transplantation might be an alternative surgical option for reconstructing unreconstructable malunited pilon fractures with a large cartilage loss of the tibial plafond in young patients.

LEVEL OF EVIDENCE

Level IV, case series.

The Effect of Autografts from the Inferior and Superior Bulbar Conjunctiva on the Ocular Surface in Primary Pterygium Surgery: A Cytology Study

Objectives

This study aimed to evaluate the effect of using an inferior or superior conjunctival autograft in primary pterygium surgery on the postoperative ocular surface.

Materials and Methods

Forty eyes of 40 patients who underwent pterygium surgery with autograft were included in the study. Cytological cell counts were performed on samples taken from the bulbar conjunctiva by impression cytology before and 1 year after the operation. Schirmer 1 test score, lissamine green conjunctival staining score, tear film break-up time (TBUT), and fluorescein corneal staining scores were evaluated. The pain levels of the patients were evaluated with visual analog scale at postoperative 1 day and 1 week.

Results

Corneal and conjunctival staining, TBUT, and Schirmer test results demonstrated significant improvement in all patient groups after surgery, but there was no difference between groups (p>0.05). In both preoperative and postoperative impression cytology, the number of goblet cells in the inferior bulbar conjunctiva was higher than in the superior bulbar conjunctiva (p<0.001), while there was no such difference in epithelial cell or mucin staining. There were no significant cytological changes postoperatively in either group (p>0.05).

Conclusion

Pterygium surgery with autografting improved tear function tests regardless of graft location. Goblet cell count was higher in the inferior bulbar conjunctiva than in the superior bulbar conjunctiva in both postoperative and preoperative impression cytology. However, there was no significant difference in postoperative epithelial and goblet cell counts or mucin staining between the groups before and after surgery. We think that using the inferior bulbar conjunctiva is an appropriate choice in cases where the superior conjunctiva cannot be used as a graft or when future glaucoma surgery is possible.

A comparative analysis of suture-augmented and standard hamstring autograft single-bundle ACL reconstruction outcomes: short-term functional benefits without long-term impact

BACKGROUND

Augmentation of the biologic graft with nonabsorbable suture material during anterior cruciate ligament reconstruction (ACLR) is a relatively new technique to enhance its biomechanical properties and add additional support to the critical process of healing. We aimed to compare the short-term functional patient-reported outcome measures (PROMs) and complication rates of patients treated with either standard single-bundle four-strand hamstring ACLR or added suture augmentation (SA).

METHODS

Patients undergoing arthroscopic ACLR between February 2015-January 2017 and in the standard ACLR group, and between February 2017-September 2019 in the SA-ACLR group operated by adding a no.5 FiberWire® (Arthrex, Naples, FL, USA) braided suture to the hamstring autograft, were retrospectively reviewed and the PROMs were compared. Patients were followed up for a 24-month period and PROMs were assessed by the International Knee Documentation Committee (IKDC) Subjective Knee Form and Tegner-Lysholm knee score. Patients' demographic and clinical characteristics, and postoperative complications including graft retear requiring revision surgery, deep vein thrombois, and surgical site infection were recorded and analyzed.

RESULTS

We included 79 patients with mean age of 31.6 ± 8.3 years in the standard ACLR group, and 90 patients with mean oge of 30.5 ± 7.6 in the SA-ACLR group. There was no statistically significant difference between the two groups in terms of age, sex, body mass index, and medical comorbidities. The values of the IKDC scores increased to 75.8 ± 18.9 in the standard ACLR group, and 85.6 ± 12.6 in the SA-ACLR group, 24 months after the operation (P < 0.05). The 24-month postoperative Tegner-Lysholm scores escalated to 79.3 ± 21.0 in the standard ACLR group and 91.0 ± 13.7 in the SA-ACLR group (P < 0.05). Four (5.1%) patients in the standard ACLR group and 4 (4.4%) in the SA-ACLR group experienced graft retear requiring revision surgery (P > 0.05). Incidence of surgical site infection and deep vein thrombosis showed no significant differences between the two groups, 24 months after ACLR.

CONCLUSION

SA-ACLR is associated with improved short-term functional PROMs compared to the standard hamstring ACLR. Although SA did not reduce the retear rate, and infection and DVT rates did not differ between study groups, superior improvement of PROMs in SA approach, leverages this method for ACLR.

[Is there still role for the Ross procedure?]

The ideal aortic valve substitute for young and middle-aged adults with aortic valve disease is still debated. The Ross procedure (pulmonary autograft replacement) is the only operation that allows replacement of the diseased aortic valve with a living substitute. During the years, the use of this procedure has declined significantly due to concerns over increased intraoperative risk and especially potential long-term failure of the operation. However, several recent publications have shown that, after appropriate learning curve and in specialized centers, the Ross procedure can be performed safely in appropriately selected patients. Moreover, comparative studies suggest that the Ross procedure is associated with better long-term outcomes compared to conventional aortic valve replacement in young and middle-aged adults.

A novel skin grafting modality: prefabricated large sheet of postage-stamp autografts and allografts to repair extensive burn wounds; a prospective matched-control study

BACKGROUND

The excessively long operative time has been the greatest barrier to the success of transplanting postage-stamp auto- and allografts directly and piece-by-piece onto extensive burn wounds. To solve this challenge, the authors present a novel grafting modality, that is, the prefabricated-large-sheet grafting that moves the labor-intensive and time-consuming process of grafts-positioning before grafting and thereby markedly shortens the operative time.

METHODS

Twenty-one operations using the novel modality were performed on 11 patients with extensive deep burns. The grafting time using the novel modality was recorded and compared with that of the conventional piece-by-piece grafting. Eventually, the take rates of the two modalities were compared.

RESULTS

All patients were healed and discharged. The average grafting time per unit area (100 cm2) of prefabricated-large-sheet grafting and piece-by-piece grafting were (0.41±0.09) min and (7.46±1.07) min, respectively, and the difference is statistically significant(P<0.001). The average take rate of the prefabricated sheets was (85.43±6.14)% and that of the piece-by-piece transplanted grafts was (87.29±5.23)% and there is no significant difference(P>0.05).

CONCLUSIONS

The prefabricated-large-sheet grafting significantly reduces the intraoperative grafting time while ensures uniformity of the skin grafts and secures good outcomes, thereby making the intermingled transplantation of postage-stamp auto- and allografts, which has been an excellent modality per se but limited to repair small residual wounds, now feasible to repair extensive deep burn wounds. It is worth wider understanding and application in the treatment of extensive deep burns.

Pterygium surgery using inferior rotational conjunctival autograft versus conventional conjunctival autograft with sutures - A comparative study

PURPOSE

To compare the outcomes of pterygium surgery by using an inferior rotational autograft and a conventional superior conjunctival autograft.

METHODS

This was a prospective interventional comparative study of 85 eyes of patients who were divided into two groups of 45 and 40. Standard techniques of both procedures were performed by a single surgeon. Astigmatism, recurrence rates, time taken, and other complications were compared.

RESULTS

All the subjects were in the age group 53 ± 7.56 (40-74) years. Demographic data and type of pterygium were comparable in the two groups. In the rotational group, the preoperative astigmatism was - 2.14 ± 1.36 D, which decreased in 1 week to 1.42 ± 1.11 D, in 1 month to - 1.13 ± 0.99 D, in 3 months to 0.91 ± 0.72 D, and in 6 months to 0.81 ± 0.85 D (P < 0.05 each). Preoperative astigmatism in the conventional group was - 2.63 ± 1.47 D, which decreased to - 1.43 ± 1.04 D in 1 week, -1.18 ± 0.85 D in 1 month, -1.07 ± 0.81 D in 3 months, and - 1.01 ± 0.78 D in 6 months (P < 0.05 each). There was no significant difference between the groups in terms of astigmatism at any follow-up visit (P < 0.05). Complications like dellen, graft edema, and superficial vascularization were seen in both groups. The rotational group had one recurrence (2.86%). No recurrence was noted in the conventional group. None of the complication rates was significantly different between the two groups (P < 0.05).

CONCLUSION

Inferior rotational conjunctival autografting is a good technique for management of pterygium. It has a profile similar to that of conventional conjunctival autograft.

Drivers of vascular growth and remodeling: A computational framework to promote benign adaptation in the Ross procedure

In the sixties, Dr Donald Ross designed a surgical solution for young patients with aortic valve disease by using the patients' own pulmonary valve. The Ross procedure is the only aortic valve replacement technique that can restore long-term survival and preserve quality of life. The main failure mode of the Ross procedure is wall dilatation, potentially leading to valve regurgitation and leakage. Dilatation occurs due to the inability of the pulmonary autograft to adapt to the sudden increase in loading when exposing to aortic pressures. Previous experimental data has shown that a permanent external support wrapped around the artery can prevent the acute dilatation of the arterial wall. However, the textile support leads to stress-shielding phenomena due to the loss of mechanical wall compliance. We present a pragmatic and modular computational framework of arterial growth and remodeling predicting the long-term outcomes of cardiovascular tissue adaptation, with and without textile wrapping. The model integrates mean, systolic and diastolic pressures and assumes the resulting wall stresses to drive the biological remodeling rules. Rather than a single mean pressure or stress deviation from the homeostatic state, we demonstrate that only pulsatile stresses can predict available experimental results. Therefore, we suggest that a biodegradable external support could induce benign remodeling in the Ross procedure. Indeed, a biodegradable textile wrapped around the autograft fulfills the trade-off between prevention of acute dilatation on the one hand and recovery of arterial wall compliance on the other hand. After further validation, the computational framework can set the basis for the development of an actual biodegradable external support for the Ross procedure with optimized polymer mechanical properties and degradation behavior.

Management of Retinal Detachment With a Coexistent Macular Hole: Submacular Placement of Retinal Autograft Through a Macular Hole

PURPOSE

In this article, a submacular autologous neurosensory retinal transplantation technique is presented in patients with large macular hole (MH) accompanying retinal detachment.

METHODS

In the surgical procedure, 23-G pars plana vitrectomy and peripheral vitrectomy were performed. An autologous neurosensory retinal patch, which should be larger than the diameter of the MH, was released from a suitable quadrant. The retinal patch was grasped using a 23 gauge microforceps and then passed through the MH and placed under the macula. Liquid perfluorocarbon (PFCL) was injected, and the retina was reattached. A subfoveal autologous neurosensory retinal patch was repositioned in the center of the MH with gentle manipulation under fluid perfluorocarbon, if necessary. Laser retinopexy was applied to peripheral tears under PFCL Subsequently, a 5,000-cSt silicone oil-PFCL exchange was also performed.

RESULTS

Four eyes of four patients were operated on using the technique described earlier. Silicone oil was removed from two patients, and the macular holes were closed in all patients at the last follow-up.

CONCLUSION

This technique has been beneficial in refractory MHs and can improve the visual potential in eyes with MHs.

A randomized controlled trial evaluating the effect of epithelial removal on free soft tissue autograft healing

BACKGROUND

The purpose of this study is to determine if there is a difference in dimensional change of a free soft tissue autograft (FSTA) with epithelium compared to without epithelium. The secondary aim is to determine the patient and professional evaluation of color match and graft texture between the two groups.

METHODS

Patients with ≤2 mm keratinized tissue indicated for a FSTA were randomly assigned to control group (FSTA with epithelium) or test group (de-epithelialized FSTA). The vertical and horizontal measurements of the grafts were taken at surgery, and 1, 3, and 6 months postoperatively. Patients were asked to evaluate the color match at each postoperative time point on a 21-step Numeric Rating Scale (NRS-21). Professional assessment of color match and graft texture were evaluated on images at the same time points.

RESULTS

Forty-six patients and 55 grafts were included in the study. For change in graft height, width, and area, there were no significant differences between the treatment groups at any time point. Graft height and area in both groups decreased significantly from baseline to month 1 (p < .001), but no other difference was significant over time. When patients and professionals used the NRS-21 for evaluation of color match between the graft site and the surrounding soft tissue, there was no significant difference between the treatment groups. Similarly, evaluation of texture match on color images and black-and-white images revealed no significant differences between or within groups.

CONCLUSION

De-epithelialized FSTA showed no difference in dimensional change or color and texture match compared to FSTA with epithelium.

No difference in return to play rates between different elite sports after primary autograft ACL reconstruction

PURPOSE

To demonstrate return to play (RTP) rates, the level of RTP and time taken to RTP in different sports after anterior cruciate ligament reconstruction (ACL-R) and compare the differences between football and rugby. The secondary aims were to compare the differences in intra articular injuries and their treatments and reoperation rates between these sports.

METHODS

A retrospective review of a consecutive series of all primary ACL-R undertaken by the senior author between 2005 and 2019 was undertaken. Patients were included if they were elite athletes and were a minimum of 2 year post-primary autograft ACL-R. The outcomes measured were RTP (defined as participation in a professional match or in national/international-level competition in amateur sports), time to RTP after surgery and RTP level (Tegner score).

RESULTS

Three hundred and ninety-four elite athletes, with 420 ACL-Rs were included. 235 (55.9%) were in footballers and 125 (29.8%) were in rugby players. 399 (95.0%) of all elite athletes returned to competition at an average of 10.3 months after ACL-R. 386 (90.2% played at the same or higher level post-surgery. Although there was no difference in RTP rates between different sports, rugby players RTP significantly faster than footballers (9.6 vs 10.6 months, (p = 0.027). Footballers were more likely to rupture their ACL during jumping/landing manoeuvres and to receive a PT graft than rugby players. There were no other significant differences between football and rugby players regarding patient characteristics, intraoperative findings, re-rupture and re-operation rates.

CONCLUSIONS

Over 95% of all elite athletes RTP after primary ACL-R with 90% able to play at the same level. Rugby players RTP significantly faster than footballers.

LEVEL OF EVIENCE

Level IV.

Fusion rate of Escherichia coli-derived recombinant human bone morphogenetic protein-2 compared with local bone autograft in posterior lumbar interbody fusion for degenerative lumbar disorders

BACKGROUND CONTEXT

The use of recombinant human bone morphogenetic proteins-2 (rhBMP-2) for spinal fusion has been reported to be effective. However, most studies have focused on posterolateral and anterior lumbar interbody fusion, and few have investigated posterior lumbar interbody fusion (PLIF).

PURPOSE

This study aimed to determine the effectiveness and safety of the delivery of Escherichia coli-derived rhBMP-2 (E.BMP-2) with hydroxyapatite (HA) and β-tricalcium phosphate (β-TCP) poloxamer hydrogel composite carriers for PLIF.

STUDY DESIGN

A retrospective study.

PATIENT SAMPLE

Patients who underwent 1 to 3 levels of PLIF for lumbar degenerative disc disorders between 2015 and 2020 with a follow-up of ≥1 year were enrolled. In total, 254 patients (357 levels) were included in the analysis. The evaluation was performed at each segment level. In the E.BMP-2 group, 160 patients (221 levels) received autologous local bone with E.BMP-2 (maximum 0.5 mg/level), and in the control group, 94 patients (136 levels) received only local bone graft.

OUTCOME MEASURES

The primary outcome of this study was to compare the X-ray and CT fusion rates between the two groups. Secondary outcomes included analysis of the patients' clinical outcomes and postoperative complications on CT scans.

METHODS

Clinical evaluations were performed using a visual analog scale for back pain, the Oswestry Disability Index for disability, and physical and mental component summaries of the Short Form 36-Item Form Health Survey to assess functional effects and quality of life. The fusion was evaluated using radiography and CT. On radiography, solid fusion was defined when the difference between extension and flexion was less than 5°. On CT, solid fusion was defined when the upper and lower vertebral bodies were connected by the trabecular bone (bone bridge formation). In addition, complications such as osteolysis, cage subsidence, and screw loosening were investigated using CT.

RESULTS

All clinical results for low back pain, disability, and quality of life in both groups were excellent and showed statistically significant improvements compared with baseline (p<.0001). According to the X-ray evaluations, fusion was achieved in 92.31% (204/221) of the patients in the E.BMP-2 group and 82.35% (112/136) of the patients in the control group (p=.0041). According to the CT evaluations, the fusion rates were 93.21% (206/221) and 88.24% (120/136) in the E.BMP-2 and control groups (p=.1048), respectively. Except for screw loosening, which had a significantly higher incidence in the control group (p=.0014), the rates of most postoperative complications were not significantly different between the groups.

CONCLUSIONS

This study demonstrated that the adjunctive use of a low dose of E.BMP-2 with HA and β-TCP hydrogel can effectively promote bone fusion, making it a promising option for patients with limited autograft availability or compromised bone quality in PLIF.

Immunohistochemical dynamics of cell wall matrix polymers during tomato autograft healing

A large part of the production of tomato plants is grafted. Although it has recently been described that cell walls play an important role in tomato graft healing, the spatiotemporal dynamics of cell wall changes in this critical process remains largely unknown. The aim of this work was to immunolocalize changes in the major cell wall matrix components of autograft union tissues throughout the course of healing, from 1 to 20 days after grafting (DAG). Homogalacturonan was de novo synthetized and deposited in the cut edges, displaying the low methyl-esterified homogalacturonan a stronger labelling. Labelling of galactan side chains of rhamnogalacturonan increased until 8 DAG, although remarkably a set of cells at the graft union did not show labelling for this epitope. Changes in xylan immunolocalization were associated to the xylem vasculature development throughout, while those of xyloglucan revealed early synthesis at the cut edges. Arabinogalactan proteins increased up to 8 DAG and showed scion-rootstock asymmetry, with a higher extent in the scion. The combination of these changes appears to be related with the success of the autograft, specifically facilitating the adhesion phase between scion-rootstock tissues. This knowledge paves the way for improved grafting using methods that facilitate appropriate changes in the time and space dynamics of these cell wall compounds.

Considerations for Optimal Grafting in Rhinoplasty

A wide variety of grafting materials and techniques can be used to create functional and aesthetic changes in rhinoplasty. Choosing the optimal grafting approach is critical to achieving an optimal patient outcome. We present a review of autografts, allografts, and alloplasts used in primary and revision rhinoplasty and discuss factors that impact graft choice. Autologous grafts serve as the pillar for grafting material in rhinoplasty given their reliable long-term outcomes, low rates of infection, resorption, and extrusion, and ability to provide structural scaffolding as well as contour. Cadaveric allografts can be utilized as a source of grafting material in certain clinical scenarios including revision rhinoplasty and have been shown to be equally safe and effective as autologous grafts while avoiding donor-site morbidity. Alloplasts can prove useful in rhinoplasty in cases of iatrogenic nasal deformities or revision cases. Careful consideration of clinical scenario, patient factors, and outcome goals is necessary to choose the appropriate grafting approach to address functional and cosmetic outcomes.

A comparative study of reconstruction modalities after knee joint-preserving tumor resection: reconstruction with a custom-made endoprosthesis versus reconstruction with a liquid nitrogen-inactivated autologous bone graft

BACKGROUND

This study evaluated the feasibility, complications, graft survival rate, and clinical outcomes of joint-preserving resection using a custom-made endoprosthesis and liquid nitrogen-inactivated autologous bone graft reconstruction in patients with malignant bone tumors around the knee joint.

METHODS

We retrospectively analyzed 23 consecutive patients who underwent joint preservation surgery between 2008 and 2018 at our center. The study cohort included 13 patients who underwent custom-made endoprosthesis reconstruction and 10 who underwent liquid nitrogen-inactivated autologous bone graft reconstruction. The resected bone length, distance between the resection line and the joint, intraoperative blood loss, operation time, complications, and MSTS were compared between the two groups.

RESULTS

The median follow-up time was 68.5 months in the endoprosthesis group and 65.3 months in the inactivated autograft group. There were no significant differences in baseline characteristics, resected bone length, distance between the resection line and the joint, or intraoperative blood loss between the two groups. The operative time was longer in the inactivated bone graft group than in the endoprosthesis group (p < 0.001). The endoprosthesis group had more complications (six patients) and reoperations due to complications (five) than the inactivated autograft group (one), but there was no significant difference in the incidence of complications between the two groups (p = 0.158). The inactivated autograft group had one patient with type 1b complications, while the endoprosthesis group had one with type 1b complications, one with type 2b complications, and one with type 4a complications. One patient in the endoprosthesis group with type 5a complications experienced two soft tissue recurrences. The overall 5-year survival rate was 86.5% and the graft survival and final limb salvage rates were 100% in both groups. After the follow-up period, the mean MSTS scores were 91% ± 7% in the endoprosthesis group and 94% ± 6% in the inactivated autograft group, with no significant difference (p = 0.280).

CONCLUSION

Joint-preserving resection is a reliable and effective tumor resection method that can achieve good postoperative function. There were no significant differences in the incidence of complications, overall survival rate, or graft survival rate between the two groups.

Comparison of mini-simple limbal epithelial transplantation and conjunctival-limbal autograft for the treatment of primary pterygium: a randomised controlled trial

PURPOSE

The purpose of this double-masked, parallel randomised controlled trial was to compare the recurrence rate and other outcomes between conjunctival-limbal autograft (CLAu) and mini-simple limbal epithelial transplantation (mini-SLET) after excision of pterygium.

METHODS

Eligibility criteria for participants was the presence of a primary nasal pterygium extending equally to or greater than two millimetres on the cornea on its horizontal axis from the nasal limbus. The participants were allocated into two groups (CLAu and mini-SLET) using simple randomisation with a table of random numbers. Participants and the outcome assessor were masked to the intervention. The study protocol is listed and available on https://clinicaltrials.gov (Identifier: NCT03363282).

RESULTS

A total of 61 eyes were enrolled in the study, 33 underwent CLAu (group 1) and 28 mini-SLET (group 2), all eyes were analysed in each group. At 2, 3, 6 and 12 months the CLAu group exhibited a recurrence of 0%, 6.1%, 8.1% and 8.1%, while the mini-SLET exhibited a recurrence of 0%, 17.9%, 50% and 53.5% (p<0.05). There were no intraoperative or postoperative complications in either of the two groups.

CONCLUSION

The findings of this study suggest that mini-SLET has a higher recurrence rate and provides no advantage over CLAu in the treatment of primary pterygium.

Recurrent multinodular goitre and primary hyperparathyroidism due to adenoma arising in a parathyroid autotransplant more than 20 years after near-total thyroidectomy

The patient is a female in her 60s with a remote history of a near-total thyroidectomy in 1997 for multinodular goitre. At the initial operation, she sustained a left recurrent laryngeal nerve injury. A devascularised parathyroid gland was autotransplanted into the right sternocleidomastoid muscle. She had been off of thyroid hormone for long periods, and her most recent levothyroxine requirement had fallen to only 25 mcg daily. The patient presented more than 20 years after her thyroidectomy with hoarseness, fatigue and dyspnoea. Laboratory studies suggested primary hyperparathyroidism. Imaging demonstrated bilateral pulmonary emboli and bulky thyroid tissue extending into her mediastinum. She underwent a completion thyroidectomy with the removal of a parathyroid adenoma arising in the autotransplanted parathyroid. This case illustrates the possibility of regrowth of benign thyroid tissue after thyroidectomy. In addition, to our knowledge, this is the first case report of a parathyroid adenoma arising from autotransplantation of a normal parathyroid.

Use of a hybrid soft tissue autograft for gingival phenotype modification lingual to mandibular incisors

Presence of adequate dimensions of keratinized/attached gingiva (KT/AG) and gingival thickness (GT) is considered necessary to maintain optimal periodontal health and long-term stability of gingival margin. Gingival phenotype modification therapies to increase these two dimensions (GT and KT/AG) on the buccal aspect of teeth have been widely reported, but the literature on lingual gingival augmentation is scarce. The purpose of this paper is to report the outcomes of a case treated with an envelope flap combined with a hybrid soft tissue autograft (subepithelial connective tissue graft with an epithelial collar) for phenotype modification of gingiva lingual to mandibular incisors presenting with thin gingiva (<1 mm) and lack of AG in tooth # 31 and 42. At 12 months follow-up, a substantial gain in KT, AG and GT along with partial root coverage was achieved.

Survivin Dendritic Cell Vaccine Safely Induces Immune Responses and Is Associated with Durable Disease Control after Autologous Transplant in Patients with Myeloma

PURPOSE

We investigated whether a dendritic cell (DC) vaccine transduced with an adenoviral vector encoded with full-length survivin (Ad-S), with mutations neutralizing its antiapoptotic function, could safely generate an immune response and deepen clinical responses when administered before and after autologous stem cell transplant (ASCT) for multiple myeloma.

PATIENTS AND METHODS

This phase I first-in-human trial (NCT02851056) evaluated the safety of DC:Ad-S in newly diagnosed multiple myeloma not having achieved complete response with induction, given 7 to 30 days prior to stem cell collection and 20 to 34 days after ASCT. Anti-survivin antibodies and CD4+ and CD8+ specific T cells were quantified.

RESULTS

A total of 14 patients were treated and 13 included in the primary efficacy analysis. No serious adverse events were attributed to DC:Ad-S vaccine. Detectable anti-survivin antibodies increased from baseline in 9 of 13 (69%) patients, and 11 of 13 (85%) mounted either a cellular or humoral immune response to survivin. Seven patients had an improved clinical response at day +90, all of whom had mounted an immune response, and 6 of 7 patients remain event-free at a median follow-up of 4.2 years. Estimated progression-free survival at 4 years is 71% (95% confidence interval, 41-88).

CONCLUSIONS

Two doses of DC:Ad-S, one given immediately before and another after ASCT, were feasible and safe. A high frequency of vaccine-specific immune responses was seen in combination with durable clinical outcomes, supporting ongoing investigation into the potential of this approach. See related commentary by Dhodapkar, p. 4524.

A novel technique to harvest bone autografts with mild local hyperthermia and enhanced osteogenic bone quality: a preclinical study in dogs

BACKGROUND

Guided bone regeneration (GBR) involves collecting bone autografts with high bio-quality and efficiency. The current non-irrigated low-speed drilling has been limited for broader application in bone autograft harvest due to its low efficiency, inability to conduct buccal cortical perforation, and dependence on simultaneous implant placement. Increasing the drilling speed helps improve the efficiency but may incur thermal-mechanical bone damage. Most studies have addressed thermal reactions during bone drilling on non-vital models, which is irrelevant to clinical scenarios. Little has been known about bone's in vivo thermal profiles under non-irrigated higher-speed drilling and its influences on the resulting bone chips.

AIM

A novel technique for bone harvest and cortical perforation via in-situ non-irrigated higher-speed drilling was proposed and investigated for the first time.

METHODS

The third mandible premolars of eight beagles were extracted and healed for three months. Sixteen partial edentulous sites (left and right) were randomized into four groups for bone autograft harvest without irrigation: chisel, 50 rpm drilling, 500 rpm drilling, and 1000 rpm drilling. Bone chips were harvested on the buccal plates of the missing tooth. An infrared camera and an implantable thermocouple collaboratively monitored in vivo real-time bone temperature at the drilling sites. In vitro performances of cells from bone chips, including cell number, viability, proliferation, migration, ALP activity, in vitro mineralization, mRNA transcriptional level of osteogenic genes and heat shock protein 70 (HSP-70), and HSP-70 expression at the protein level were also studied.

RESULTS

500 rpm produced mild local hyperthermia with a 2-6 °C temperature rise both on the cortical surface and inside the cortical bone. It also held comparable or enhanced cell performances such as cell number, viability, proliferation, migration, ALP activity, in vitro mineralization, and osteogenic genes expression.

CONCLUSIONS

In-situ non-irrigated higher-speed drilling at 500 rpm using a screw drill is versatile, efficient, and thermal friendly and improves the bio-quality of bone chips. Our novel technique holds clinical translational potential in GBR application.

Alternate Graft Options for Staged Flexor Tendon Reconstruction: A Cadaveric Study of Hamstring Autografts Compared to Conventional Autografts

PURPOSE

To compare the semitendinosus and gracilis tendon lengths and diameters to the palmaris longus, plantaris, flexor digitorum profundus, and flexor pollicis longus (FPL) tendons in a cadaveric model to evaluate the feasibility of hamstring autograft use for staged flexor tendon reconstruction.

METHODS

Fifteen fresh cadavers were evaluated for surgical incisions about the knee, forearm, and hand. All flexor digitorum profundus (FDP), FPL, palmaris longus, plantaris, semitendinosus, and gracilis tendons were harvested from each specimen. Diameter and length were recorded and means with SDs were calculated. The mean diameters of the gracilis and semitendinosus were compared to the mean diameters of the FDP and FPL tendons. The hamstring tendon lengths were then compared in terms of percentage of the palmaris longus and plantaris tendon lengths.

RESULTS

The gracilis (18.0 cm) and semitendinosus (19.9 cm) means were notably longer than the palmaris longus (16.0 cm) and shorter than the plantaris (30.0 cm). The average gracilis tendon diameter (3.8 mm) was smaller than the flexor tendon diameters except for the little finger FDP (3.8 mm). The semitendinosus tendon diameter (4.8 mm) was larger than all flexor tendons with the exception of the middle finger FDP (4.6 mm). Average gracilis and semitendinosus tendon diameters were 3.7 mm and 4.5 mm in males, and 3.8 mm and 4.8 mm in females.

CONCLUSIONS

This study showed the gracilis tendon to have adequate length and diameter for potential autograft use in staged flexor tendon reconstruction in all digits but the little finger. The semitendinosus is larger in diameter than the native flexor tendons, making it a poor autograft option in cases with an intact pulley system.

CLINICAL RELEVANCE

Common tendon autograft options for flexor tendon reconstruction are variably present, and the use of gracilis and semitendinosus autograft present potential graft options.

Return to Sport and Clinical Outcomes Following Osteochondral Autograft Transplantation in Baseball Players and Gymnasts With Unstable Osteochondritis Dissecans: A Critically Appraised Topic

CLINICAL SCENARIO

Osteochondritis dissecans (OCD) of the capitellum is a condition occurring at the elbow and often seen in both baseball players and gymnasts due to the repetitive loading of the radiocapitellar joint. Treatment options for OCD vary and are dependent on lesion presentation, elbow motion, and growth plate maturity. OCD lesions categorized as unstable can be treated with an osteochondral autograft transplantation surgery (OATS).

FOCUSED CLINICAL QUESTION

In an adolescent population, what are the return to sport rates and clinical outcomes following OATS in baseball players and gymnasts with unstable OCD lesions?

SUMMARY OF KEY FINDINGS

Three articles met the inclusion criteria for this appraisal, and all indicate an OATS procedure should be considered in the management of unstable OCD lesions. Return to play outcomes were favorable for both baseball players and gymnasts. Self-reported patient function and elbow extension all improved following an OATS.

CLINICAL BOTTOM LINE

An OATS procedure is a favorable option for the management of OCD lesions of the elbow in baseball players and gymnasts.

STRENGTH OF RECOMMENDATION

There is level B evidence to support return to sport and clinical outcomes in baseball players and gymnasts following an OATS procedure. This score is directly related to the quality of evidence that currently exists on the topic.

What Are the Complications, Function, and Survival of Tumor-devitalized Autografts Used in Patients With Limb-sparing Surgery for Bone and Soft Tissue Tumors? A Japanese Musculoskeletal Oncology Group Multi-institutional Study

BACKGROUND

Tumor-devitalized autografts treated with deep freezing, pasteurization, and irradiation are biological reconstruction methods after tumor excision for aggressive or malignant bone or soft tissue tumors that involve a major long bone. Tumor-devitalized autografts do not require a bone bank, they carry no risk of viral or bacterial disease transmission, they are associated with a smaller immunologic response, and they have a better shape and size match to the site in which they are implanted. However, they are associated with disadvantages as well; it is not possible to assess margins and tumor necrosis, the devitalized bone is not normal and has limited healing potential, and the biomechanical strength is decreased owing to processing and tumor-related bone loss. Because this technique is not used in many countries, there are few reports on the results of this procedure such as complications, graft survival, and limb function.

QUESTIONS/PURPOSES

(1) What was the rate of complications such as fracture, nonunion, infection, or recurrence in a tumor-devitalized autograft treated with deep freezing, pasteurization, and irradiation, and what factors were associated with the complication? (2) What were the 5-year and 10-year grafted bone survival (free from graft bone removal) of the three methods used to devitalize a tumor-containing autograft, and what factors were associated with grafted bone survival? (3) What was the proportion of patients with union of the tumor-devitalized autograft and what factors were associated with union of the graft-host bone junction? (4) What was the limb function after the tumor-devitalized autograft, and what factors were related to favorable limb function?

METHODS

This was a retrospective, multicenter, observational study that included data from 26 tertiary sarcoma centers affiliated with the Japanese Musculoskeletal Oncology Group. From January 1993 to December 2018, 494 patients with benign or malignant tumors of the long bones were treated with tumor-devitalized autografts (using deep freezing, pasteurization, or irradiation techniques). Patients who were treated with intercalary or composite (an osteoarticular autograft with a total joint arthroplasty) tumor-devitalized autografts and followed for at least 2 years were considered eligible for inclusion. Accordingly, 7% (37 of 494) of the patients were excluded because they died within 2 years; in 19% (96), an osteoarticular graft was used, and another 10% (51) were lost to follow-up or had incomplete datasets. We did not collect information on those who died or were lost to follow-up. Considering this, 63% of the patients (310 of 494) were included in the analysis. The median follow-up was 92 months (range 24 to 348 months), the median age was 27 years (range 4 to 84), and 48% (148 of 310) were female; freezing was performed for 47% (147) of patients, pasteurization for 29% (89), and irradiation for 24% (74). The primary endpoints of this study were the cumulative incidence rate of complications and the cumulative survival of grafted bone, assessed by the Kaplan-Meier method. We used the classification of complications and graft failures proposed by the International Society of Limb Salvage. Factors relating to complications and grafted autograft removal were analyzed. The secondary endpoints were the proportion of bony union and better limb function, evaluated by the Musculoskeletal Tumor Society score. Factors relating to bony union and limb function were also analyzed. Data were investigated in each center by a record review and transferred to Kanazawa University.

RESULTS

The cumulative incidence rate of any complication was 42% at 5 years and 51% at 10 years. The most frequent complications were nonunion in 36 patients and infection in 34 patients. Long resection (≥ 15 cm) was associated with an increased risk of any complication based on the multivariate analyses (RR 1.8 [95% CI 1.3 to 2.5]; p < 0.01). There was no difference in the rate of complications among the three devitalizing methods. The cumulative graft survival rates were 87% at 5 years and 81% at 10 years. After controlling for potential confounding variables including sex, resection length, reconstruction type, procedure type, and chemotherapy, we found that long resection (≥ 15 cm) and composite reconstruction were associated with an increased risk of grafted autograft removal (RR 2.5 [95% CI 1.4 to 4.5]; p < 0.01 and RR 2.3 [95% CI 1.3 to 4.1]; p < 0.01). The pedicle freezing procedure showed better graft survival than the extracorporeal devitalizing procedures (94% versus 85% in 5 years; RR 3.1 [95% CI 1.1 to 9.0]; p = 0.03). No difference was observed in graft survival among the three devitalizing methods. Further, 78% (156 of 200 patients) of patients in the intercalary group and 87% (39 of 45 patients) of those in the composite group achieved primary union within 2 years. Male sex and the use of nonvascularized grafts were associated with an increased risk of nonunion (RR 2.8 [95% CI 1.3 to 6.1]; p < 0.01 and 0.28 [95% CI 0.1 to 1.0]; p = 0.04, respectively) in the intercalary group after controlling for confounding variables, including sex, site, chemotherapy, resection length, graft type, operation time, and fixation type. The median Musculoskeletal Tumor Society score was 83% (range 12% to 100%). After controlling for confounding variables including age, site, resection length, event occurrence, and graft removal, age younger than 40 years (RR 2.0 [95% CI 1.1 to 3.7]; p = 0.03), tibia (RR 6.9 [95% CI 2.7 to 17.5]; p < 0.01), femur (RR 4.8 [95% CI 1.9 to 11.7]; p < 0.01), no event (RR 2.2 [95% CI 1.1 to 4.5]; p = 0.03), and no graft removal (RR 2.9 [95% CI 1.2 to 7.3]; p = 0.03) were associated with an increased limb function. The composite graft was associated with decreased limb function (RR 0.4 [95% CI 0.2 to 0.7]; p < 0.01).

CONCLUSION

This multicenter study revealed that frozen, irradiated, and pasteurized tumor-bearing autografts had similar rates of complications and graft survival and all resulted in similar limb function. The recurrence rate was 10%; however, no tumor recurred with the devitalized autograft. The pedicle freezing procedure reduces the osteotomy site, which may contribute to better graft survival. Furthermore, tumor-devitalized autografts had reasonable survival and favorable limb function, which are comparable to findings reported for bone allografts. Overall, tumor-devitalized autografts are a useful option for biological reconstruction and are suitable for osteoblastic tumors or osteolytic tumors without severe loss of mechanical bone strength. Tumor-devitalized autografts could be considered when obtaining allografts is difficult and when a patient is unwilling to have a tumor prosthesis and allograft for various reasons such as cost or socioreligious reasons.

LEVEL OF EVIDENCE

Level III, therapeutic study.