Prospective cohort study of 123 total skin grafts]

CONTEXT

Despite the use of total skin grafting in the treatment of loss of skin substances on the palmar surface of the fingers, the palm of the hand and the sole of the foot, the data published in the literature on long-term results in black-skinned patients are non-existent.

METHODS

The present study, filling this gap, used data from a prospective cohort of 123 total skin grafts performed on 93 black African patients who benefited from plantar skin grafts versus skin grafts from hairy areas to cover loss of skin substances. of the palmar surface of the fingers, the palm of the hand and the sole of the foot. This study covers a period of 163 months.

RESULTS

Sixty-four grafts of hairy areas were carried out in 52 patients, 29 of whom were male and 23 female, for a M/F sex ratio of 1.3; and 59 plantar skin grafts in 41 patients including 21 males and 20 females, M/F sex ratio of 1. The digital palmar surface was the most recipient of the plantar graft, i.e. 35.5% of cases. After a post-operative follow-up of at least 12 months, patients or their entourage judged the functional and aesthetic results of plantar skin grafts to be better and acceptable, unlike the results of hairy area grafts. The texture and color are even better if the total skin graft is taken from an identical histological area.

CONCLUSION

In view of these results, we recommend a plantar skin graft for black-skinned patients to cover losses of skin substances on the palmar surface of the fingers, the palm of the hand and the sole of the foot, if indicated.

Investigation of factors affecting pediatric type 1 endoscopic tympanoplasty results and success rates of surgery

OBJECTIVE

There are many factors that affect the results of tympanoplasty in children. Recurrent ear infections, hearing loss, and more serious complications due to cholesteatoma may be observed. This study examined factors affecting the success of type 1 endoscopic tympanoplasty surgery in pediatric patients and investigated recommended procedures to increase the success of the operation.

METHODS

Our study included pediatric patients who underwent type 1 endoscopic tympanoplasty operation for chronic otitis media. Patient files were analyzed retrospectively. Hearing results before and after the operations were recorded.. Patients were divided into groups according to gender, age (<12 age group, ≥12 age group), and perforation type. Hearing results and physical examination findings were compared for each group.

RESULTS

A total of 204 pediatric patients were included in our study: 114 were male and 90 were female. Patients' hearing results were compared according to the size and location of their tympanic membrane perforations. Hearing loss was found to increase as the size of the tympanic membrane perforation increased. In addition, it was observed that perforations in the posterior quadrant caused more severe hearing loss than in the other quadrants. The postoperative results of the two groups <12 years old, and ≥12 years old were evaluated according to age. Postoperative improvement was higher in the ≥12 age group compared to the <12 age group.

CONCLUSION

According to the results of this study, tympanoplasty surgeries performed on patients younger than 12 have a decreased success rate. Among the many factors that affect the success of an operation, age is one of the most important. There are many factors that affect the results of the operation, perforation size and localization is one of them. There are many factors that affect the success of surgery such as pediatric patients and adult patients. It is useful to make a personal evaluation and to plan the surgery by evaluating the obstacles such as eustachian tube maturation and difficulty in postoperative care in pediatric patients.

Advances in Soft Tissue Injuries Associated with Open Fractures

Management of soft tissue injury is a key component in the overall treatment of upper extremity fractures. Hand surgeons must rely on their armamentarium for treating soft tissue deficits for functional outcomes. Understanding the role of fracture fixation and wound adjuncts, including negative pressure wound therapy and dermal regenerative templates, is the keys to success. In addition, detailed knowledge of local and free tissue options is essential for hand reconstruction.

Platelet-rich fibrin in rhinoplasty: A precise and standardized approach

Rhinoplasty is a complex procedure. To achieve the expected aesthetic result, surgeons often use grafts both for structural and camouflage purposes. The perfect camouflage graft should be soft, malleable and precisely tailored to the patient's needs, with as few donor sites as possible. The use of diced cartilage has been widely described, but it cannot be used as a free graft in all cases. Platelet-rich fibrin is an interesting matrix for the creation of soft grafts with great precision and high reproducibility while promoting biocellular regeneration via growth factors. This article describes the use of platelet-rich fibrin in liquid and solid forms for the creation of standardized soft grafts with diced cartilage. We detail the procedure, and present the different grafts created by the author for dorsal camouflage and augmentation, tip management, and revision rhinoplasty.

A rare case of femoral artery saccular aneurysm caused by tuberculosis in a male patient: A case report and review of literature

INTRODUCTION

Tuberculosis (TB) is still a major global health issue. In over 75 % of all cases of mycotic aneurysm, TB spreads directly by eroding through the vascular wall. Aortic and innominate arteries are frequently the sites of tubercular aneurysms, primarily due to contiguous dissemination from pulmonary infection sites. We report a case of a saccular aneurysm at the distal common femoral artery associated with tuberculosis.

CASE PRESENTATION

A 34-year-old man had the chief complaint of a voluminous pulsatile mass in the left thigh. We found a bruit on auscultation examination at the site of the mass. A computed tomography (CT) angiography showed a saccular aneurysm at the distal common femoral artery and stenosis at the proximal femoral profunda artery. A chest CT scan was conducted, and the result showed a ground-glass appearance and multiple enlarged lymph nodes.

CLINICAL DISCUSSION

The patient was treated surgically by resection of the aneurysm and reconstruction with an inter-positional saphenous vein graft. Later, he was treated with a drug regimen for tuberculosis by pulmonologist. The patient was discharged with no post-operative complications.

CONCLUSION

Patients with femoral artery aneurysms are at high risk of rupture and death by exsanguination. It can be a severe complication of tuberculosis, especially in immunocompromised patients. Although this was a very rare case, all surgeons must be aware. A combination of medical and surgical intervention is imperative. Careful clinical care postoperatively is mandatory because of the risk of repetitive anastomotic aneurysms and recurrent aneurysms in another vessel.

Nasal reconstructive techniques following Mohs surgery or excisions: a systematic review

Numerous reconstructive techniques for nasal defects following skin cancer removal have been described; however, the literature lacks a comprehensive systematic review. Our objective was to systematically review nasal reconstruction methods after tumor removal, correlate the use of specific techniques to the nasal subunits involved, assess the quality of the available evidence, and set the stage for future research on this topic. Eight databases were searched for studies published in English from January 2004 to December 2018 containing repair data for nasal defects following Mohs or excision for four or more subjects. Recorded data included author specialties, study design, subject number, demographics, defect characteristics, procedure type, reconstructive methods, outcome measures, and complications. One-hundred and eleven studies were included. Study types included case series (73%), observational cohort studies (25%), and clinical trials (2%). Most authors were dermatologic surgeons (61%). Resection was most commonly performed via Mohs (82%). Flaps (42%), linear closures (28%) and grafts (25%) were most utilized for reconstruction. In Zones I and II, transposition flaps were the most common followed by advancement flaps. In Zone III, full thickness skin grafts were the most common repair. Most studies were case series or small cohort studies, representing low level evidence. Flaps are the most common method described in the literature for nasal reconstruction. The overall quality of the evidence available on this topic is low.

Gingival phenotype changes after different periodontal plastic surgical techniques: a single-masked randomized controlled clinical trial

ABSTRACT: OBJECTIVES: Aim of this clinical study was to evaluate the effects on gingival thickness of three surgical techniques for root coverage: the coronally advanced flap (CAF) alone, with a sub-epithelial connective tissue graft (SCTG) or with leukocyte- and platelet-rich fibrin (L-PRF) membranes.

METHODS

Sixty patients with RT1 single maxillary gingival recession were treated with CAF + L-PRF (20 patients), CAF + SCTG (20 patients) or CAF alone (20 patients). At baseline and 6-month after treatment, gingival thickness (GT), keratinized tissue width (KT), gingival recession (GR), clinical attachment level (CAL), probing depth (PD), PROMs, and the aesthetic outcome were recorded.

RESULTS

CAF + SCTG and CAF + L-PRF groups showed a significantly greater mean GT increase than CAF alone (0.31 ± 0.10 mm) with no significant differences between CAF + SCTG (0.99 ± 0.02 mm) and CAF + L-PRF (0.92 ± 0.52 mm) groups (p = 0.55). CAF + SCTG was associated with a significantly greater KT gain (3.85 ± 1.04 mm), while in CAF + L-PRF (2.03 ± 0.53 mm) and CAF (1.50 ± 0.69 mm) groups, KT was not significantly increased. Both GR and CAL showed a significant within groups' improvement, without among-groups differences. No significant among-groups difference for the aesthetic outcome but greater discomfort and pain-killer consumption in CAF + SCTG group was detected.

CONCLUSION

All investigated surgical techniques produced significant GR reduction and CAL gain. GT was similarly augmented by CAF + L-PRF and CAF + SCTG techniques; however, the CAF + SCTG technique produced a more predictable KT and GT increase.

CLINICAL RELEVANCE

The results of our study suggest that the CAF + SCTG technique represents the most predictable method for the clinician to improve the gingival phenotype, an important factor for long term gingival margin stability.

Dorsal Augmentation: A Review of Current Graft Options

Background

Dorsal augmentation is one of the more complication-prone procedures in rhinoplasty, demanding ample skill and experience to produce an aesthetic and functional result. Numerous autologous grafts, allografts, xenografts, and alloplastic materials have been attempted for augmentation with varying success. Each graft material has its own unique properties that require varying surgical intricacies. The relative risks and benefits of these strategies and materials are also variable and must be weighed. Alloplastic implants are commonly used in eastern countries, but, due to different patient populations and complication profiles, have found less acceptance among western surgeons.

Methods

A PubMed search was done using the terms "dorsal augmentation rhinoplasty," "liquid rhinoplasty," and "grafts used for rhinoplasty." Publication dates ranging from 1957-2022 were included. Abstracts were screened for relevance, and references from each article were reviewed to identify further articles. Chapters on dorsal augmentation from two key rhinoplasty textbooks were also reviewed.

Results

A total of 79 articles and 2 textbooks were formally screened; of these, 65 resources were included. Findings were grouped under the headings "facial analysis," "ethnic factors in graft selection," "graft characteristics," "septal cartilage," "auricular cartilage," "costal cartilage," "diced cartilage grafts," "bone grafts," "soft tissue grafts," "nonsurgical/liquid rhinoplasty," and "alloplastic implants."

Conclusions

Current dorsal augmentation literature focuses on retrospective studies and expert experiences. There are limited quantitative and prospective studies present to delineate an ideal graft. With consistently advancing technology and knowledge of facial aesthetics, a surgeon must maintain a thorough understanding of the current graft and implant options to offer a specialized treatment plan for each deformity and patient.

FEMORAL HEAD DECOMPRESSION AND GRAFT: TECHNIQUE WITH NEW INSTRUMENTS

INTRODUCTION

Osteonecrosis of the femoral head (ONFH) is a pathology that can be treated with many approaches by the hip surgeon. Advanced decompression is a technique that aims to prevent the collapse of the femoral head and the arthrosis process of the joint, a technique already widespread and used by hip surgeons. In this study, we performed the technique with a new retractable blade and a new bone substitute as graft for the femoral head.

OBJECTIVE

To evaluate the technique with new instruments (EasyCore Hip^®) and a calcium phosphate bone substitute (Graftys^® HBS).

METHODS

Patients with osteonecrosis of the femoral head without major degenerative changes, such as femoral head collapse, were selected. Femoral head decompression was performed using the EasyCore Hip^® retractable blade along with the calcium phosphate bone substitute as graft (Graftys^® HBS).

RESULTS

The instruments proved to be reliable and reproducible, and the bone substitute presented good mechanical resistance, maintaining its temperature during the surgery. The disposable retractable blade presents variation in size and angle, which is an advantage in the removal of necrotic bone. However, we must take some precautions in order to achieve a better result.

CONCLUSION

using EasyCore Hip^® instruments and a calcium phosphate bone substitute (Graftys^® HBS) is safe; however, some precautions must be taken during the use of the technique. Level of Evidence IV, Case Series.

Unusual complications at the recipient site following periodontal plastic surgery procedures: a systematic review

OBJECTIVE

To identify and describe unusual soft tissue complications of periodontal plastic surgery procedures at the recipient site after periodontal grafts.

MATERIALS AND METHODS

Two independent reviewers performed a comprehensive search in MEDLINE, Cochrane, periodontics journals, reference lists, and grey literature for articles dated up to July 2021. Publications related to surgical interventions only around the teeth with an unusual complication at the recipient site were selected. No restrictions were made in the number of cases, follow-up period, or language. The Cochrane Collaboration's tool for assessing risk of bias, the Newcastle-Ottawa Scale (NOS), and two validated case report/series checklists were used to critically appraise the studies.

RESULTS

A total of 1434 articles were examined, of which 28 met the inclusion criteria: one RCT, two cohort studies, and twenty-five case reports/series. The periodontal plastic surgery procedures described in these articles were conducted to treat lack of attached gingiva and gingival recessions. The following unusual complications were found: bone exostosis, epithelial inclusion, root resorption, abscess, overgrowth, "liver clot" formation, and oroantral communication.

CONCLUSION

Bone exostosis and epithelial inclusions were the most prevalent unusual complications following treatment with subepithelial connective tissue graft, free gingival graft, and acellular dermal matrix allograft. Due to the nature of the reports, the clinical recommendations for diagnosis and treatment cannot be homogenized. Clinical studies reporting complications are required to develop management protocols (PROSPERO CRD42021230875).

CLINICAL RELEVANCE

Clinicians need to know the main complications that can occur in mucogingival surgeries as well as their clinical management to provide a successful and predictable treatment.

Nasal skin reconstruction: Time to rethink the reconstructive ladder?

BACKGROUND

Nasal scarring can compromise aesthetics and function given its complex three-dimensional structure and central location. This study aimed to measure patients' satisfaction after reconstruction for nasal defects following Mohs micrographic surgery.

METHODS

Patients presenting with nasal nonmelanoma skin cancer at Memorial Sloan Kettering Cancer Center New York, USA and Catharina Hospital Eindhoven, Netherlands from April 2017 to November 2019 were asked to participate. Reconstruction type, complications, and patients satisfaction were assessed. Patients completed the FACE-Q Skin Cancer - Satisfaction with Facial Appearance scale (preoperative and 1-year postoperative) and the Appraisal of Scars scale (1-year postoperative).

RESULTS

A total of 128 patients completed the preand postoperative scales. There were 35 (27%) surgical defects repaired with primary closures, 71 (55.5%) with flaps, and 22 (17.2%) with full-thickness skin grafts (FTSG). Patients that underwent a flap or FTSG reconstruction had higher scar satisfaction scores than primary closures (p = 0.03). A trend was seen with patients following flap reconstructions scoring 7.8 points higher than primary closures and patients with upper nose defects scoring 6.4 points higher than lower nose defects. Males were significantly more satisfied than females. No significant difference was observed in the preoperative and postoperative facial appearance scores between the three groups (p = 0.39).

CONCLUSION

Patients are more satisfied in the long term with their scars after flap reconstructions compared to primary closures. Therefore, nasal skin reconstruction may not follow the traditional reconstructive ladder and more complex approaches may lead to higher long-term scar satisfaction.

The added benefit of L-PRF to autogenous bone grafts in the treatment of degree II furcation involvement in mandibular molars

BACKGROUND

Tissue regeneration within the periodontally involved furcation area is one of the most challenging aspects of periodontal surgery. The aim of this study was to evaluate the additional benefit of leukocyte and platelet-rich fibrin (L-PRF) to autogenous bone grafts (ABGs) in the treatment of mandibular molar degree II furcation involvement, comparing the clinical outcomes with those from open flap debridement (OFD)+ABG and OFD alone treatments.

METHODS

Fifty-four patients, exhibiting one buccal or lingual mandibular molar furcation defect, were randomly assigned to three treatment groups: OFD+ABG+L-PRF(n = 18); OFD+ABG (n = 18); and OFD (n = 18). Clinical [probing pocket depth (PPD), horizontal clinical attachment level (HCAL), vertical clinical attachment level (VCAL), gingival recession (GR)] and radiographic [vertical bone level (VBL)] parameters were evaluated at baseline and 6 months after treatment. HCAL change was the primary outcome.

RESULTS

No significant differences within each group were reported for GR changes, but statistically significant improvements in HCAL, VCAL, PPD and VBL were observed in all groups, except for VBL in the OFD group. At 6 months, the mean HCAL gain was 2.29±0.18 mm in the OFD+ABG+L-PRF group, which was significantly greater than that in the OFD+ABG (1.61±0.18 mm) and OFD (0.86±0.18 mm) groups. Both OFD+ABG+L-PRF and OFD+ABG therapies produced a significantly greater clinical and radiographic improvement than OFD.

CONCLUSION

The addition of L-PRF to ABG produces a significantly greater HCAL gain and PPD reduction as compared to OFD+ABG treatment in mandibular degree II furcation involvements. This article is protected by copyright. All rights reserved.

Approach for Rhinoplasty in African Descendants

The main objectives of rhinoplasty in African descendants are to improve the definition and projection of the nasal tip, augment the dorsum, and reduce the alar base. Open rhinoplasty using costal cartilage graft, with lateral crural tensioning and septal extension graft associated with en bloc dorsal augmentation is the workhorse. Cartilage resections should be minimal. Oral isotretinoin and triamcinolone injection may improve tip definition. Surgical success ultimately depends on the ability of the surgeon to accurately identify the anatomic variables and reconcile these anatomic realities with the patient's aesthetic expectations and his or her sense of ethnic identity.

Empty nose syndrome pathogenesis and cell-based biotechnology products as a new option for treatment

Empty nose syndrome (ENS) is a rare complication that develops after partial or complete turbinectomy. The main feature of ENS is paradoxical nasal obstruction feeling despite objectively wide nasal airway. ENS pathogenesis is multifactorial and includes changes in laminar physiological airflow, disruption of mucosa functions and deficient neural sensation. This leads to the development of ENS symptomatology such as dyspnea, nasal dryness, nasal burning, nasal obstruction, feeling of suffocation and even comorbid psychiatric disorders that significantly impairs life quality. Specific effective treatment of ENS does not exist up to date. In this review we outline existing biomaterial for surgical reconstitution of nasal anatomy and discuss the perspective of stem cell-based technologies in ENS management. The main focus is directed to justification of rationality application of adult mesenchymal stem cells (MSCs) from different tissues origin and neural crest-derived stem cells (NCSCs) based on their intrinsic biological properties. MSCs transplantation may stimulate mucosa tissue regeneration via trophic factors secretion, direct transdifferentiation into epithelial cells and pronounced immunosuppressive effect. From the other hand, NCSCs based on their high neuroprotective properties may reconstitute nerve structure and functioning leading to normal sensation in ENS patients. We postulate that application of cell-based and tissue-engineered products can help to significantly improve ENS symptomatology only as complex approach aimed at reconstitution of nasal anatomy, recovery the nasal mucosa functionality and neural tissue sensation.

[Predictors of complex urethral surgery in anterior urethral stricture disease.]

OBJECTIVE

To determine the clinical-surgical factors associated with Complex Urethral Surgery (CUC) in anterior urethral stenosis.

MATERIAL AND METHOD

This is a cross-sectional study with retrospective data recording, including all male patients who under went anterior urethroplasty between 2011 and 2018. CUC included two or more grafts urethroplasty, excisional augmented anastomotic urethroplasty, combined flaps and grafts urethroplasty and stages surgery. The data were collected from the electronic medical record, recording the demographic data, background of previous treatments as well as the characteristics of the stenosis (etiology, anatomical location, length, number of strictures, among others). A univariate and multivariate analysis were conducted using the chi-squared test and logistic regression to identify the variables related to CUC.

RESULTS

The data of 665 patients met the inclusion criteria were analyzed. The mean age was 56.1 years, 27.5% were smokers, 32.5% had received some previous treatment, and dilatations were the most common procedure. The most prevalent etiology was iatrogenic, followed by idiopathic in a 61.1 and 20.3% respectively. Bulbar urethral stricture were the most common location (56.2%) while the mean length of the stenosis was 4.8 cm. After univariate and multivariate analysis, previous dilations (HR 2.6), multifocality (2.51), lengthof stenosis (>4 cm) (HR 1.49) and the hypospadias etiology (HR 11.9) were independent predictors for CUC (p<0.05)CONCLUSIONS: Hypospadias was the only etiology factor that predicts the need for CUC. Regarding radiological findings, extensive and multifocal stenosis, were predictors of complex surgery. History of previous dilations were also predictors of CUC.

Use of quantitative cardiovascular magnetic resonance myocardial perfusion mapping for characterization of ischemia in patients with left internal mammary coronary artery bypass grafts

BACKGROUND

Quantitative myocardial perfusion mapping using cardiovascular magnetic resonance (CMR) is validated for myocardial blood flow (MBF) estimation in native vessel coronary artery disease (CAD). Following coronary artery bypass graft (CABG) surgery, perfusion defects are often detected in territories supplied by the left internal mammary artery (LIMA) graft, but their interpretation and subsequent clinical management is variable.

METHODS

We assessed myocardial perfusion using quantitative CMR perfusion mapping in 38 patients with prior CABG surgery, all with angiographically-proven patent LIMA grafts to the left anterior descending coronary artery (LAD) and no prior infarction in the LAD territory. Factors potentially determining MBF in the LIMA-LAD myocardial territory, including the impact of delayed contrast arrival through the LIMA graft were evaluated.

RESULTS

Perfusion defects were reported on blinded visual analysis in the LIMA-LAD territory in 27 (71%) cases, despite LIMA graft patency and no LAD infarction. Native LAD chronic total occlusion (CTO) was a strong independent predictor of stress MBF (B = - 0.41, p = 0.014) and myocardial perfusion reserve (MPR) (B = - 0.56, p = 0.005), and was associated with reduced stress MBF in the basal (1.47 vs 2.07 ml/g/min; p = 0.002) but not the apical myocardial segments (1.52 vs 1.87 ml/g/min; p = 0.057). Extending the maximum arterial time delay incorporated in the quantitative perfusion algorithm, resulted only in a small increase (3.4%) of estimated stress MBF.

CONCLUSIONS

Perfusion defects are frequently detected in LIMA-LAD subtended territories post CABG despite LIMA patency. Although delayed contrast arrival through LIMA grafts causes a small underestimation of MBF, perfusion defects are likely to reflect true reductions in myocardial blood flow, largely due to proximal native LAD disease.

Double-face Augmentation Urethroplasty for Bulbar Urethral Strictures: Technical Implications and Short-term Outcomes for a Dorsal Versus Ventral Approach

This study describes technical implications and compares short-term outcomes after a dorsal versus ventral approach for double-face augmentation urethroplasty (DFAU) for treating a near-obliterated bulbar urethral stricture (BUS). This was a retrospective evaluation of a prospectively collected database of patients with BUS (<2 cm) who underwent DFAU. The choice between the approaches depended on (1) landmark identification (the relation between the bulbospongiosus muscle and the distal end of the stricture) and (2) corpus spongiosum width. In DFAU, inlay augmentation was at the level of the narrowed urethral plate (<6 Fr). Patient follow-up data (symptom score and uroflowmetry) were assessed every 3 mo for the first year, and every 6 mo thereafter. A successful outcome was defined as a normal urinary flow rate without obstructive voiding symptoms. Fifty-two patients underwent DFAU for BUS (dorsal approach, n = 30; ventral approach, n = 22). The maximum flow rate and symptom scores significantly improved in both groups. The overall success rates (86%) were similar. In conclusion, a dorsal approach for DFAU is versatile and can be considered in all circumstances. A ventral approach should be performed in patients with proximal BUS. The short-term outcomes were similar for both approaches.

Patient summary

We assessed whether double-face augmentation urethroplasty is a suitable option for treating near-obliterated bulbar urethral strictures using two free grafts for augmentation to improve the urinary flow. This operation can be performed using two methods and both techniques were safe with similar short-term outcomes.

In reply to the letter to the editor regarding "Palisade cartilage tympanoplasty compared to one-piece composite cartilage-perichondrium grafts for transcanal endoscopic treatment of subtotal tympanic membrane perforations: a retrospective study"

This is a reply letter to the manuscript "The size and diameter of pieces of cartilage are not fixed for the palisade technique and one-piece technique", regarding the elevation of a tympanomeatal flap and keratin pearl formation in "Palisade cartilage tympanoplasty compared to one-piece composite cartilage-perichondrium grafts for transcanal endoscopic treatment of subtotal tympanic membrane perforations: a retrospective study" ( https://doi.org/10.1007/s00405-020-05947-3 ).

The long-term outcomes of different grafts in anterior cruciate ligament reconstruction: a network meta-analysis

OBJECTIVES

To compare the long-term prognosis of patients with different types of grafts used in anterior cruciate ligament reconstruction (ACLR).

METHODS

PubMed, Ovid (MEDLINE and Embase) and the Cochrane library were searched up to Feb 2020. Eligible studies about different grafts in ACLR were searched for identifying the evidence comparing the long-term (mean or median follow-up time or the general description of the follow-up time≥2 years) knee outcomes of different grafts for ACLR. The final included articles and evaluation criteria were confirmed by the authors and senior clinicians to ensure the validity of the included articles. Lysholm score, the results of pivot shift test, Lachman test and International Knee Documentation Committee (IKDC) evaluation were selected as prognostic indicators. A Bayesian network meta-analysis was conducted.

RESULTS

A total of 30 articles were included in our network meta-analysis. Finally, we found that artificial graft or augmentation can provide the not bad Lysholm score but the worse result of IKDC evaluation for patients with ACLR compared with other types of grafts. Double-bundle hamstring autograft can provide a good Lysholm score as well as lower positive rate of pivot shift test and Lachman test. Patellar tendon autograft can provide the better result of IKDC evaluation. The patients with allogeneic tendon graft may get the higher positive rate of pivot shift test and Lachman test. Patients with single-bundle hamstring autograft may get the ordinary result of IKDC evaluation and Lysholm score.

CONCLUSIONS

Double-bundle hamstring autograft may be a better choice because of more items of good prognosis for the patients with ACLR. Patellar tendon autograft is a right choice which only shows the disadvantage on the Lysholm score. The prognosis of patients with single-bundle hamstring autograft is ordinary. The effect of artificial graft or augmentation needs more evidence to prove. Allogeneic tendon graft is not a better choice when compared with other grafts referred in our network meta-analysis.

TRANSLATIONAL POTENTIAL STATEMENT

In this study, we made a comprehensive comparison of the grafts commonly used in anterior cruciate ligament reconstruction. The evidence presented in this study provides a reference for clinicians to select a suitable anterior cruciate ligament graft.

Increasing kidney grafts for transplantation

INTRODUCTION

The current pool of organs available for transplantation does not cover requirements, for this reason non-standard risk donors need to be incorporated into the pool. In this way, donors with small renal tumour are considered for transplantation after bench tumour excision. The aim of our study was to analyse our experience in using these grafts for transplantation.

MATERIALS AND METHODS

Retrospective analysis from our prospective accrued database of donors with incidental renal mass used for kidney transplantation between January 2007 and August 2018.

RESULTS

Twenty kidney transplantations were performed, thirteen cases received the affected kidney (after tumour removal) and seven the contralateral kidney; from six living and eleven deceased donors. Donor and recipient median age was 58 years (range 22-82) and 56.5 years (range 38-74), respectively. Mean tumour diameter was 12.7 mm (SD 9.5). Tumours resulted in two benign lesions and fifteen renal cell carcinoma. Surgical margins were negative. Two cases presented with bleeding after reperfusion was solved without repercussion. One case presented with immediate vein thrombosis. None of them present delayed graft function. After a 69 month follow-up none of the donors or the recipients presented tumour recurrence.

CONCLUSIONS

Kidneys with small incidental tumours seem to be a good option for kidney transplantation in selected patients after bench surgery excision with good functional and oncologic results. More studies and longer follow-up are needed to confirm these results.

Upper lip graft (ULG) for redo urethroplasties in children. A step by step video

PURPOSE

Lower lip and cheek are commonly used sources of buccal mucosa grafts for urethroplasty. In recent years, aiming to improve the donor site morbidity, our preference changed to the use (ULG). The aim of this video is to illustrate the technical details of the ULG harvesting for children.

MATERIAL AND METHODS

The inner surface of the upper lip is exposed by two stay sutures. The frenulum is spared, the mucosa to be harvested is marked and local submucosal infiltration is done with a solution of bupivacaine plus epinephrine. The edges are incised ant the submucosa plane created with a scissor. The graft is detached, defatted, and applied with quilting stitches over the recipient site with the standard technique. Hemostasis is secured and the donor site is left open.

RESULTS

From 2015 to 2018, 25 ULG harvests were done in 24 patients. Only one (5%) presented local pain associated to the procedure in the first 24 h. After minimum 2 months after surgery, none of the patients presented perioral nubmness, difficulty with mouth opening, contraction of the donor site or changes in salivation.

CONCLUSIONS

ULG harvest is easy and a suitable alternative source of oral mucosa for urethroplasty in children.

Current challenges and future trends in manufacturing small diameter artificial vascular grafts in bioreactors

Cardiovascular diseases are a leading cause of death. Vascular surgery is mainly used to solve this problem. However, the generation of a functional and suitable substitute for small diameter (< 6 mm) displacement is challengeable. Moreover, synthetic prostheses, made of polyethylene terephthalate and extended polytetrafluoroethylene show have shown insufficient performance. Therefore, the challenges dominating the use of autografts have prevented their efficient use. Tissue engineering is highlighted in regenerative medicine perhaps in aiming to address the issue of end-stage organ failure. While organs and complex tissues require the vascular supply to support the graft survival and render the bioartificial organ role, vascular tissue engineering has shown to be a hopeful method for cell implantation by the production of tissues in vitro. Bioreactors are a salient point in vascular tissue engineering due to the capability for reproducible and controlled variations showing a new horizon in blood vessel substitution. This review strives to display the overview of current concepts in the development of small-diameter by using bioreactors. In this work, we show a critical look at different factors for developing small-diameter and give suggestions for future studies.

Recent Advances in Arteriovenous Access Creation for Hemodialysis: New Horizons in Dialysis Vascular Access

Recent advances in technology show promise in providing greater vascular access options for hemodialysis patients. This review discusses novel methods for creating an anastomosis for arteriovenous (AV) fistulas and new materials for prosthetic AV grafts. Two technologies for endovascular arteriovenous fistula creation, the Ellipsys and WavelinQ endovascular systems, are discussed. When an AV fistula is not possible, an AV graft or devices to augment the AV fistula may be appropriate. New materials that have been developed that show promise as an alternative to the expanded polytetrafluoroethylene graft are discussed. Such potential conduits include bioengineered vessels and both allogenic or xenogenic biologic grafts. Devices designed to optimize blood flow to reduce maturation failure and improve AV fistula outcomes are explored.

Palisade cartilage tympanoplasty compared to one-piece composite cartilage-perichondrium grafts for transcanal endoscopic treatment of subtotal tympanic membrane perforations: a retrospective study

PURPOSE

The endoscopic approach to tympanoplasty is gaining popularity, but its adoption for the palisade tympanoplasty technique is unstudied. The aim of the present study was to evaluate the effectiveness of endoscopic cartilage palisade tympanoplasty compared to one-piece composite cartilage-perichondrium grafts for tympanic membrane closure in adult patients with subtotal perforations.

METHODS

Retrospective study of 42 adult patients who underwent endoscopic tympanoplasty for a subtotal perforation in a university tertiary referral center from January 2018 to June 2019. Patients underwent transcanal tympanoplasty either with cartilage palisade grafts or with one-piece composite cartilage-perichondrium grafts. Both techniques were compared for graft take rate and audiometric results.

RESULTS

Twenty palisade and 22 single-piece tympanoplasties were analyzed. No statistically significant differences between groups were found in terms of tympanic membrane closure (85% vs. 86.3%, p = 0.5) or hearing improvement.

CONCLUSION

The results of the present study suggest that similar results can be obtained with palisade cartilage grafts compared to the one-piece composite cartilage-perichondrium technique for endoscopic tympanic membrane closure. Further studies with long-term results will be needed to confirm these findings.

Surgical Management of Peyronie's Disease With Co-Existent Erectile Dysfunction

INTRODUCTION

Surgical intervention in Peyronie's disease (PD) should ideally be delayed until the resolution of acute inflammatory phase.

AIM

The objective of this review was to highlight the results of penile prosthesis to correct refractory erectile dysfunction (ED) in patients with PD, and the secondary procedures that may be required to correct the penile curvature.

METHODS

A systematic search on PubMed online database using Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations was done using the MeSH terms "Peyronie's disease" and "erectile dysfunction."

MAIN OUTCOME MEASURE

Success and satisfaction rates of various procedures.

RESULTS

The search yielded 324 language-specific (English and Spanish language) articles and 58 articles were retained for final review. The following variables were assessed in different studies: number of patients, types of secondary procedure to correct the curvature, satisfaction rates, and follow-up period.

CONCLUSION

The aim of the surgery in PD should be to achieve a functionally straight penis (<20 degree curvature) with good erection. Patients with refractory ED in PD are candidates for penile prosthesis. Secondary procedures, like manual modeling, plication, plaque incision, or excision grafting, may be required depending on the degree of penile curvature and penile length. In quest for the best graft, TachoSil graft seems to have gained popularity in Europe. Krishnappa P, Fernandez-Pascual E, Carballido J, et al. Surgical Management of Peyronie's Disease With Co-Existent Erectile Dysfunction. Sex Med 2019;7:361-370.

Simultaneous two-layer harvesting of scalp split-thickness skin and dermal grafts for acute burns and postburn scar deformities

BACKGROUND

The scalp, an excellent donor site for thin skin grafts, presents a limited surface but is rich in stem cells. The purpose of this study was to test a double harvesting procedure from the scalp and to evaluate the capacity of the dermal layer.

METHODS

Two layers corresponding to a split-thickness skin graft (SSG) and a split-thickness dermal graft (SDG) were harvested from the scalp using a Zimmer dermatome during the same procedure. Healing of the scalp donor site, reason for recipient site grafting, and the percentage of graft loss were evaluated.

RESULTS

Fourteen patients, comprising six men and eight women with a mean age of 34.2 years, were treated according to our protocol. The most common reason for a recipient site graft was a postburn scar deformity (10/14 patients). The mean area of scalp SSGs was 151.8 cm2. The mean area of scalp SDGs was 88.2 cm2. The mean healing time of scalp donors was 9.9 days. The only donor complication was a tufted scar deformity.

CONCLUSIONS

Skin defects in the scalp of donors healed faster and led to less scarring than defects at other donor sites. Scalp SDGs needed 10 days for adequate epithelization. The scalp was the best donor site for SSGs and SDGs for burn reconstructive patients.

Mandibular reconstruction with autogenous non-vascularised bone graft

Background

Reconstruction of mandibular defects can be challenging because an acceptable aesthetic and functional outcome must be achieved simultaneously.

Aim

To evaluate the pattern of mandibulectomy and reconstruction materials used in the reconstruction of mandibular defects.

Materials and methods

This was a retrospective study of mandibulectomies with reconstruction in Sokoto, Nigeria between 2012 and 2016. Data such as demographics, type of tumour, type of resection and type of reconstruction materials used were extracted and stored.

Results

Fifty-two cases of mandibulectomies were done comprising 24 males and 28 females (ratio 1:1.2). Age ranged 5–80 years with mean±SD (37.8±15). Most of the cases 30 (57.7%) were on the right. There are 35 (67.3%) benign and 17 (32.7%) malignant cases. Thirty (57.7%) lateral, 16 (30.8%) condylar, 1 (1.9%) central and 5 (9.6%) combined mandibular defects were seen. Reconstruction plate alone was used in 11 (21.2%) cases, reconstruction plate with rib and tibia grafts in 16 (30.8%) cases, reconstruction plate with Iliac crest and tibia grafts in 15 (28.8%) cases. Graft length ranged from 0–20cm. There was satisfactory outcome altogether in 32 (80.0%).

Conclusion

This study has shown the types of mandibulectomies and reconstruction materials used in our centre.

Systemic signalling through translationally controlled tumour protein controls lateral root formation in Arabidopsis

The plant body plan and primary organs are established during embryogenesis. However, in contrast to animals, plants have the ability to generate new organs throughout their whole life. These give them an extraordinary developmental plasticity to modulate their size and architecture according to environmental constraints and opportunities. How this plasticity is regulated at the whole-organism level is elusive. Here we provide evidence for a role for translationally controlled tumour protein (TCTP) in regulating the iterative formation of lateral roots in Arabidopsis. AtTCTP1 modulates root system architecture through a dual function: as a general constitutive growth promoter enhancing root elongation and as a systemic signalling agent via mobility in the vasculature. AtTCTP1 encodes mRNAs with long-distance mobility between the shoot and roots. Mobile shoot-derived TCTP1 gene products act specifically to enhance the frequency of lateral root initiation and emergence sites along the primary root pericycle, while root elongation is controlled by local constitutive TCTP1 expression and scion size. These findings uncover a novel type for an integrative signal in the control of lateral root initiation and the compromise for roots between branching more profusely or elongating further. They also provide the first evidence in plants of an extracellular function of the vital, highly expressed ubiquitous TCTP1.

Reconstruction of the pulmonary artery by a novel biodegradable conduit engineered with perinatal stem cell-derived vascular smooth muscle cells enables physiological vascular growth in a large animal model of congenital heart disease

Lack of growth potential of available grafts represents a bottleneck in the correction of congenital heart defects. Here we used a swine small intestinal submucosa (SIS) graft functionalized with mesenchymal stem cell (MSC)-derived vascular smooth muscle cells (VSMCs), for replacement of the pulmonary artery in piglets.

MSCs were expanded from human umbilical cord blood or new-born swine peripheral blood, seeded onto decellularized SIS grafts and conditioned in a bioreactor to differentiate into VSMCs. Results indicate the equivalence of generating grafts engineered with human or swine MSC-derived VSMCs. Next, we conducted a randomized, controlled study in piglets (12–15 kg), which had the left pulmonary artery reconstructed with swine VSMC-engineered or acellular conduit grafts. Piglets recovered well from surgery, with no casualty and similar growth rate in either group. After 6 months, grafted arteries had larger circumference in the cellular group (28.3 ± 2.3 vs 18.3 ± 2.1 mm, P < 0.001), but without evidence of aneurism formation. Immunohistochemistry showed engineered grafts were composed of homogeneous endothelium covered by multi-layered muscular media, whereas the acellular grafts exhibited a patchy endothelial cell layer and a thinner muscular layer.

Results

show the feasibility and efficacy of pulmonary artery reconstruction using clinically available grafts engineered with allogeneic VSMCs in growing swine.

Placental membrane grafts for urethral replacement in a rabbit model: a pilot study

PURPOSE

Several graft materials are available for use in the treatment of urethral stricture disease. Placental membrane is being used in a variety of settings as a graft in wound healing and tissue repair. We aim to evaluate the effect of implanting decellularized human placental membrane into rabbit urethras.

METHODS

Dorsal onlay graft urethroplasty using prepared human placental membrane was performed in 10 New Zealand White rabbits (Oryctolagus cuniculus). After 3 months, the rabbits underwent cystourethroscopy to evaluate urethral patency. The rabbits were then euthanized and the urethras examined for pathological findings.

RESULTS

All urethroplasties were performed without complication. There were no observed episodes of urinary retention, infection, or renal failure. Urethral patency was achieved in all rabbits 3 months postoperatively. Urothelial replacement of the placental membrane graft was observed in all rabbits without malignant transformation.

CONCLUSION

Dorsal onlay urethroplasty using decellularized human placental membrane can safely be performed in a rabbit model. This pilot study demonstrated urothelial replacement of human placental membrane in the rabbit urethra without stricture formation. Placental membrane is a promising biomaterial for urethral reconstruction.

Liquid buccal mucosa graft endoscopic urethroplasty: a validation animal study

PURPOSE

To validate a novel method of urethral stricture treatment using liquid buccal mucosal grafts (LBMG) to augment direct vision internal urethrotomy (DVIU) in an animal model.

MATERIALS AND METHODS

A rabbit stricture model was used to test this method. Strictures were induced in 26 rabbits using electroresection of urethral epithelium. The animals were randomized into two groups: Group-1, treated with DVIU and LBMG in fibrin glue, and Group-2, DVIU with fibrin glue only. LBMG was prepared by suspension of mechanically minced buccal mucosa micrografts in fibrin glue. This LBMG-fibrin glue mixture was later injected into the urethrotomies of Group-1 animals. All animals were killed at 24 weeks after repeat retrograde urethrogram (RUG) and urethroscopy by surgeon blinded to the treatment arm. Radiographic images and histological specimens were reviewed by a radiologist and a pathologist, respectively, blinded to the treatment arm. Stricture treatment was considered a success if a diameter measured on RUG increased by ≥ 50% compared to pre-treatment RUG diameter. Histological specimens were assessed for the presence of BMG engraftment.

RESULTS

In Group-1, 8/12(67%) animals demonstrated engraftment of LBMG, compared to none in Group-2 (p = 0.0005). 7/12(58%) in Group-1 showed radiographic resolution/improvement of strictures compared to 5/13 Group-2 rabbits (38%, p = 0.145). The median percent change for the Group-1 was 59%, compared to 41.6% for Group-2 (p = 0.29).

CONCLUSION

This proof-of-concept study demonstrates feasibility of LBMG for endoscopic urethral stricture repairs. Further studies are needed to establish the role of this novel concept in treatment of urethral strictures.

[Primary revision with replasty of the anterior cruciate ligament]

OBJECTIVE

Restoration of knee stability after rerupture of an anterior cruciate ligament (ACL) graft.

INDICATION

Acute and chronic functional instability with rerupture of an ACL graft with subjective instability with anatomical or non-anatomical bone tunnel without tunnel widening.

CONTRAINDICATIONS

Partial anatomical bone tunnels of the previous operation, significant tunnel widening of anatomical bone tunnels, local infection of the knee joint, local soft tissue damage.

SURGICAL TECHNIQUE

Graft choices are hamstring tendons (semitendinosus muscle, gracilis muscle), the quadriceps tendon, patellar tendon and a peroneus tendon split graft. In cases with anatomical tunnels, careful debridement is performed down to the tunnel wall. In non-anatomical tunnels, a new femoral tunnel is drilled over a deep anteromedial portal with the knee flexed more than 110° in the insertion area of the ACL. Using drills and dilators, a tunnel is prepared. At the tibia, the anterior horn of the lateral meniscus serves as a landmark in the absence of an ACL stump. The cortical tibial tunnel aperture is probed with a guide wire and the tunnel is drilled stepwise until the tunnel wall is reached, which is debrided with a spoon or synovial resector to remove graft residues and implants from the tunnel. The femoral fixation can either be done with a flip button, an interference screw or in the case of a bone block graft implant-free. At the tibial side, the graft is fixed with a resorbable interference screw and fixation button.

POSTOPERATIVE MANAGEMENT

The rehabilitation program comprises 4-5 phases. Inflammatory phase (weeks 1-2): control of pain and swelling (cooling, isometric tension exercises, 20 kg partial load). Phase 2 (weeks 2-6): increasing load and range of motion with closed chain exercises (target: extension/flexion 0-0-120°). Phase 3 (from week 6): strength and coordination exercises. Phase 4: balance, strength and jump exercises. Return to competitive sport not before postoperative month 6-10.

RESULTS

Included were 51 patients with recurrent instability after ACL surgery where primary ACL replacement was performed with ipsilateral bone quadriceps tendon graft or contralateral semitendinosus-gracilis graft. All patients had anatomical or non-anatomical tunnel locations without significant widening (>11 mm). After 2 years, the side-to-side difference for anterior tibial translation measured with the KT 1000 arthrometer was 2.0 ± 1.2 mm for the quadriceps group and 3.0 ± 2.9 mm for the semitendinosus-gracilis group (P = 0.461). No difference in the rate of positive pivot shift tests (P = 0.661); no significant difference in the individual Knee Injury and Osteoarthritis Outcome Score (KOOS) subscores or in the frequency of anterior knee pain.

Decision-making in closure of oroantral communication and fistula

After removal of a dental implant or extraction of a tooth in the upper jaw, the closure of an oroantral fistula (OAF) or oroantral communication (OAC) can be a difficult problem confronting the dentist and surgeon working in the oral and maxillofacial region. Oroantral communication (OAC) acts as a pathological pathway for bacteria and can cause infection of the antrum, which further obstructs the healing process as it is an unnatural communication between the oral cavity and the maxillary sinus. There are different ways to perform the surgical closure of the OAC. The decision-making in closure of oroantral communication and fistula is influenced by many factors. Consequently, it requires a combination of knowledge, experience, and information gathering. Previous narrative research has focused on assessments and comparisons of various surgical techniques for the closure of OAC/OAF. Thus, the decision-making process has not yet been described comprehensively.

The present study aims to illustrate all the factors that have to be considered in the management of OACs and OAFs that determine optimal treatment.

Histological evaluation of subepithelial connective tissue grafts harvested by two different techniques: Preliminary study in humans

Subepithelial connective tissue graft (SCTG) is an essential therapeutic tool in periodontal plastic surgery and implantology. The aim of this preliminary study was to observe and make a histological and histomorphometric comparison of the composition of subepithelial connective tissue grafts (SCTGs) harvested from the palatal mucosa by two different harvesting techniques: mucoperiosteal (lamina propria and complete submucosa including periosteum) and mucosal (lamina propria and a portion of the submucosa). The main hypothesis proposes that SCTG harvested with the mucosal technique contains a greater proportion of connective tissue proper (CTP) and a lower proportion of adipose tissue (AT) than the mucoperiosteal technique. Twenty healthy patients who required SCTG for different purposes were selected and assigned to one of the two following groups: group A (n=10; mucoperiosteal harvesting technique) and group B (n=10, mucosal harvesting technique). The histological sample was obtained by removing a 2 mm thick slice from the most distal portion of the graft. The proportions of adipose tissue (AT), connective tissue proper (CTP) and vascular tissue (VT) were evaluated. In group A, histomorphometric analysis showed that CTP accounted for 58.2% of the graft while AT accounted for 32.64%. In group B, the proportions of CTP and AT were 79.86% and 11.93%, respectively. The differences between groups were statistically significant for both tissues (p< .05). In contrast, no statistically significant difference was observed in the proportion of VT. Within the limitations of this study, the results show that the SCTGs harvested by the mucosal technique contain a greater proportion of CTP and a lower proportion of AT than those obtained by the mucoperiosteal technique, whereas the proportion of VT does not differ. Further long-term clinical and histological studies with more samples are needed to evaluate the clinical implications of SCTG composition.

The Cotton High-Affinity K+ Transporter, GhHAK5a, Is Essential for Shoot Regulation of K+ Uptake in Root under Potassium Deficiency

Potassium (K) deficiency is a key limiting factor in cotton (Gossypium hirsutum) production. By grafting two contrasting cotton cultivars, CCRI41 (more susceptible to K+ deficiency) and SCRC22 (more tolerant of K+ deficiency), we established that cotton shoot plays a vital role in the regulation of root K+ uptake. To identify the genetic basis of this finding, we performed RNA sequencing (RNA-seq) of roots of CCRI41 self-grafts (CCRI41/CCRI41, scion/rootstock) and SCRC22/CCRI41 reciprocal-grafts exposed to K+ deficiency. We found that GhHAK5a, an orthologous of Arabidopsis thaliana high-affinity K+ transporter, AtHAK5, was significantly induced in the CCRI41 rootstock by the SCRC22 scion. This gene was mainly expressed in roots and was more highly induced by K+ deficiency in roots of SCRC22 than those of CCRI41. Agrobacterium-mediated virus-induced gene silencing and yeast complementary assay showed that GhHAK5a is a high-affinity K+ uptake transporter. Importantly, silencing of GhHAK5a in the CCRI41 rootstock almost completely inhibited the K+ uptake induced by SCRC22 scion in CCRI41 rootstock. We identified a key high-affinity K+ transporter, GhHAK5a in cotton, which is the essential target for shoot regulation of root K+ uptake under K+ deficiency.

Natural bioceramics: our experience with changing perspectives in the reconstruction of maxillofacial skeleton

Objectives

Various bone graft substitute materials are used to enhance bone regeneration in the maxillofacial skeleton. In the recent past, synthetic graft materials have been produced using various synthetic and natural calcium precursors. Very recently, eggshell-derived hydroxyapatite (EHA) has been evaluated as a synthetic bone graft substitute. To assess bone regeneration using EHA in cystic and/or apicectomy defects of the jaws through clinical and radiographic evaluations.

Materials and Methods

A total of 20 patients were enrolled in the study protocol (CTRI/2014/12/005340) and were followed up at 4, 8, 12, and 24 weeks to assess the amount of osseous fill through digital radiographs/cone-beam computed tomography along with clinical parameters and complications. Wilcoxon matched pairs test, means, percentages and standard deviations were used for the statistical analysis.

Results

The sizes of the lesions in the study ranged from 1 to 4 cm and involved one to four teeth. The study showed significant changes in the formation of bone, the merging of material and the surgical site margins from the first week to the first month in all patients (age range, 15-50 years) irrespective of the size of the lesions and the number of teeth involved. Bone formation was statistically significant from the fourth to the eighth week, and the trabecular pattern was observed by the end of 12 weeks with uneventful wound healing.

Conclusion

EHA showed enhancement of bone regeneration, and healing was complete by the end of 12 weeks with a trabecular pattern in all patients irrespective of the size of the lesion involved. The study showed enhancement of bone regeneration in the early bone formative stage within 12 weeks after grafting. EHA is cost effective and production is environment friendly with no disease transfer risks. Thus, natural bioceramics will play an important role in the reduction of costs involved in grafting and reconstruction.

A modified free gingival graft technique for gaining vertical and horizontal soft tissue augmentation

The aim of this case report was to describe a modified free gingival graft technique for gaining vertical and horizontal soft-tissue growth in the posterior region of the mandible before installation of dental implants. Patient A.A., a 38-year-old female, received a modified free gingival graft in the posterior region of the mandible. After 90 days, an increase, both horizontally and vertically, of the gingival tissue was observed, and the patient was satisfied with the result. The dental implant was installed, and a 3-mm of the vertical gain of keratinized gingiva was observed. Further research is needed to evaluate the effectiveness of this technique before prosthetic dental implantation.

In Vivo and In Vitro Quantitative Analysis of Neural Crest Cell Migration

The neural crest is an embryonic cell population induced at the border of the neural plate from where it delaminates and migrates long distances across the embryo. Due to its extraordinary migratory capabilities, the neural crest has become a powerful system to study cellular and molecular aspects of collective and single cell migration both in vivo and in vitro. Here we provide detailed protocols used to perform quantitative analysis of molecular and cellular aspects of Xenopus laevis neural crest cell migration, both in vivo and in vitro.

Surgical options in oroantral fistula management: a narrative review

An oroantral fistula (OAF) is a pathological abnormal communication between the oral cavity and the maxillary sinus which may arise as a result of failure of primary healing of an OAF, dental infections, osteomyelitis, radiation therapy, trauma, or iatrogenic complications. With the presence of a fistula, the maxillary sinus is permanently open. Microbial flora passes from the oral cavity into the maxillary sinus, and the inflammation of the sinus occurs with all potential consequences. In literature, various techniques have been proposed for closure of OAFs. Due to the heterogeneity of the data and techniques found, we opted for a narrative review to highlight the variety of techniques discussed in the literature. Techniques of particular interest include the bone sandwich with resorbable guided tissue regeneration (GTR) membrane and platelet-rich fibrin (PRF) used alone as both a clot and a membrane. The great advantage of these techniques is that no donor site surgery is necessary, making the outcome valuable in terms of time savings, cost and, more importantly, less discomfort to the patient. Additionally, both bony and soft tissue closure is performed for OAF, in contrast to flaps, which are typically used for procedures in the sinus area. The reconstructed bony tissue regenerated from these techniques will also be appropriate for endosseous dental implantation.

Trends and Costs of External Electrical Bone Stimulators and Grafting Materials in Anterior Lumbar Interbody Fusion

Study Design

Retrospective review.

Purpose

To identify the trends in stimulator use, pair those trends with various grafting materials, and determine the influence of stimulators on the risk of revision surgery.

Overview of Literature

A large number of studies has reported beneficial effects of electromagnetic energy in healing long bone fractures. However, there are few clinical studies regarding the use of electrical stimulators in spinal fusion.

Methods

We used insurance billing codes to identify patients with lumbar disc degeneration who underwent anterior lumbar interbody fusion (ALIF). Comparisons between patients who did and did not receive electrical stimulators following surgery were performed using logistic regression analysis, chi-square test, and odds ratio (OR) analysis.

Results

Approximately 19% of the patients (495/2,613) received external stimulators following ALIF surgery. There was a slight increase in stimulator use from 2008 to 2014 (multi-level R²=0.08, single-level R²=0.05). Patients who underwent multi-level procedures were more likely to receive stimulators than patients who underwent single-level procedures (p<0.05; OR, 3.72; 95% confidence interval, 3.02–4.57). Grafting options associated with most frequent stimulator use were bone marrow aspirates (BMA) plus autograft or allograft for single-level and allograft alone for multi-level procedures. In both cohorts, patients treated with bone morphogenetic proteins were least likely to receive electrical stimulators (p<0.05). Patients who received stimulation generally had higher reimbursements. Concurrent posterior lumbar fusion (PLF) (ALIF+PLF) increased the likelihood of receiving stimulators (p<0.05). Patients who received electrical stimulators had similar revision rates as those who did not receive stimulation (p>0.05), except those in the multilevel ALIF+PLF cohort, wherein the patients who underwent stimulation had higher rates of revision surgery.

Conclusions

Concurrent PLF or multi-level procedures increased patients’ likelihood of receiving stimulators, however, the presence of comorbidities did not. Patients who received BMA plus autograft or allograft were more likely to receive stimulation. Patients with and without bone stimulators had similar rates of revision surgery.

[Rejuvenate, it's as old as the hills…]

Legends and myths regarding eternal youth exist since Antiquity. Prior to the 19th century those wishing to rejuvenate used baths or blood injections, searching to the Fountain of Youth or calling for an alchemist claiming to have found the Elixir of Youth. In the 19th century, Charles Edouard Brown Séquard (1819-1894), after the discovery of the function of the endocrinal glands and testicular secretions, inject himself with an extract from guinea pigs and dogs. He found himself rejuvenated! In the beginning of the 20th century, several surgeons transplanted human testicles coming from death row prisoners inmates or voluntary donors. The transplantation of monkey testicles by Serge Voronoff (1866-1951) had a important aftermath and more than 300 similar interventions took place. The simple ligation of the vas deferens (vasectomy) was recommended by Eugen Steinach (1866-1944). Sigmund Freud was one of the "beneficiaries". Steinach also advised the irradiation of the ovaries for female rejuvenation. In 1935, Alexis Carrel (1873-1944) and Charles Lindbergh (1902-1974) built a pump to feed and regenerate targeted organs. The discovery of pluripotent stem cells and senolytic molecules are building up new hopes on the matter.

Acellular dermal matrix allograft versus free gingival graft: a histological evaluation and split-mouth randomized clinical trial

OBJECTIVES

This split-mouth controlled randomized clinical trial evaluated clinical and histological results of acellular dermal matrix allograft (ADM) compared to autogenous free gingival graft (FGG) for keratinized tissue augmentation.

MATERIAL AND METHODS

Twenty-five patients with the absence or deficiency of keratinized tissue (50 sites) were treated with FGG (control group) and ADM (test group). Clinical parameters included keratinized tissue width (KTW) (primary outcome), soft tissue thickness (TT), recession depth (RD), probing depth (PD), and clinical attachment level (CAL). Esthetic perception was evaluated by patients and by a calibrated periodontist using visual analog scale (VAS). Histological analysis included biopsies of five different patients from both test and control sites for each evaluation period (n = 25). The analysis included percentage of connective tissue components, epithelial luminal to basal surface ratio, tissue maturation, and presence of elastic fibers. Data were evaluated by ANOVA complemented by Tukey's tests (p < 0.05).

RESULTS

After 6 months, PD and CAL demonstrated no differences between groups. ADM presented higher RD compared to FGG in all periods. Mean tissue shrinkage for control and test groups was 12.41 versus 55.7%. TT was inferior for ADM group compared to FGG. Esthetics perception by professional evaluation showed superior results for ADM. Histomorphometric analysis demonstrated higher percentage of cellularity, blood vessels, and epithelial luminal to basal surface ratio for FGG group. ADM group presented higher percentage of collagen fibers and inflammatory infiltrate.

CONCLUSIONS

Both treatments resulted in improvement of clinical parameters, except for RD. ADM group presented more tissue shrinkage and delayed healing, confirmed histologically, but superior professional esthetic perception.

CLINICAL RELEVANCE

This study added important clinical and histological data to contribute in the decision-making process between indication of FGG or ADM.

Delivery of Allogeneic Adipose Stem Cells in Polyethylene Glycol-Fibrin Hydrogels as an Adjunct to Meshed Autografts After Sharp Debridement of Deep Partial Thickness Burns

Harvesting of autografts results in donor site morbidities and is limited in scenarios such as large total body surface area burns. In these instances, coverage is increased by meshing grafts at the expense of delayed biologic closure. Moreover, graft meshing increases the likelihood of contraction and hypertrophic scarring, limits range of motion, and worsens cosmesis. Many tissue engineering technologies have touted the promise of adipose‐derived stem cells (ASCs) for burn wounds. The primary objective of the current study was to determine feasibility and efficacy of in situ ASC delivery via PEGylated fibrin (FPEG) hydrogels as adjuncts to meshed split thickness skin grafts in a porcine model. Deep partial thickness burns were created on the dorsum of anesthetized Yorkshire pigs, and subsequently debrided on post‐burn day 4. After debridement, wounds were treated with: split thickness skin grafts (STSG); meshed STSG (mSTSG); and mSTSG + FPEG with increasing doses of ASCs. We show that FPEG hydrogels can be delivered in situ to prevent the contraction seen after meshing of STSG. Moreover, ASCs delivered in FPEG dose‐dependently increase blood vessel size which significantly correlates with CD31 protein levels. The current study reports a dual‐action adjunct therapy to autografting administered in situ, wherein FPEG acts as both scaffolding to prevent contraction, and as a delivery vehicle for ASCs to accelerate angiogenesis. This strategy may be used to incorporate other biologics for generating tissue engineered products aimed at improving wound healing and minimizing donor sites or scarring. stemcellstranslationalmedicine2018;7:360–372

The Formation of Extragraft Bone Bridging after Anterior Cervical Discectomy and Fusion: A Finite Element Analysis

Objective

In addition to bone bridging inside a cage or graft (intragraft bone bridging, InGBB), extragraft bone bridging (ExGBB) is commonly observed after anterior cervical discectomy and fusion (ACDF) with a stand-alone cage. However, solid bony fusion without the formation of ExGBB might be a desirable condition. We hypothesized that an insufficient contact area for InGBB might be a causative factor for ExGBB. The objective was to determine the minimal area of InGBB by finite element analysis.

Methods

A validated 3-dimensional, nonlinear ligamentous cervical segment (C3-7) finite element model was used. This study simulated a single-level ACDF at C5-6 with a cylindroid interbody graft. The variables were the properties of the incorporated interbody graft (cancellous bone [Young's modulus of 100 or 300 MPa] to cortical bone [10000 MPa]) and the contact area between the vertebra and interbody graft (Graft-area, from 10 to 200 mm²). Interspinous motion between the flexion and extension models of less than 2 mm was considered solid fusion.

Results

The minimal Graft-areas for solid fusion were 190 mm², 140 mm², and 100 mm² with graft properties of 100, 300, and 10000 MPa, respectively. The minimal Graft-areas were generally unobtainable with only the formation of InGBB after the use of a commercial stand-alone cage.

Conclusion

ExGBB may be formed to compensate for insufficient InGBB. Although various factors may be involved, solid fusion with less formation of ExGBB may be achieved with refinements in biomaterials, such as the use of osteoinductive cage materials; changes in cage design, such as increasing the area of polyetheretherketone or the inside cage area for bone grafts; or surgical techniques, such as the use of plate/screw systems.

Part two: Tendon grafts used for knee ligament reconstruction

OBJECTIVES

The aim of this study was to provide information about the mechanical properties of grafts used for knee ligament reconstructions and to compare those results with the mechanical properties of native knee ligaments.

METHODS

Eleven cadaveric knees were dissected for the semitendinosus, gracilis, iliotibial band (ITB), quadriceps and patellar tendon. Uniaxial testing to failure was performed using a standardized method and mechanical properties (elastic modulus, ultimate stress, ultimate strain, strain energy density) were determined.

RESULTS

The elastic modulus of the gracilis tendon (1458±476MPa) (P<0.001) and the semitendinosus tendon (1036±312MPa) (P<0.05) was significantly higher than the ITB (610±171MPa), quadriceps tendon (568±194MPa), and patellar tendon (417±107MPa). In addition, the ultimate stress of the hamstring tendons (gracilis 155.0±30.7MPa and semitendinosus 120.1±30.0MPa) was significantly higher (P<0.001, respectively P<0.05), relative to the ITB (75.0±11.8MPa), quadriceps tendon (81.0±27.6MPa), and patellar tendon (76.2±25.1MPa). A significant difference (P<0.05) could be noticed between the ultimate strain of the patellar tendon (24.6±5.9%) and the hamstrings (gracilis 14.5±3.1% and semitendinosus 17.0±4.0%). No significant difference in strain energy density between the grafts was observed.

CONCLUSIONS

Material properties of common grafts used for knee ligament reconstructions often differ significantly from the original knee ligament which the graft is supposed to emulate.

The immunological function of CD52 and its targeting in organ transplantation

INTRODUCTION

CD52 (Campath-1 antigen), a glycoprotein of 12 amino acids anchored to glycosylphosphatidylinositol, is widely expressed on the cell surface of immune cells, such as mature lymphocytes, natural killer cells (NK), eosinophils, neutrophils, monocytes/macrophages, and dendritic cells (DCs). The anti-CD52 mAb, alemtuzumab, was used widely in clinics for the treatment of patients such as organ transplantation. In the present manuscript, we will briefly summarize the immunological function of CD52 and discuss the application of anti-CD52 mAb in transplantation settings.

FINDINGS

We reviewed studies published until July 2016 to explore the role of CD52 in immune cell function and its implication in organ transplantation. We showed that ligation of cell surface CD52 molecules may offer costimulatory signals for T-cell activation and proliferation. However, soluble CD52 molecules will interact with the inhibitory sialic acid-binding immunoglobulin-like lectin 10 (Siglec10) to significantly inhibit T cell proliferation and activation. Although the physiological and pathological significances of CD52 molecules are still poorly understood, the anti-CD52 mAb, alemtuzumab, was used widely for the treatment of patients with chronic lymphocytic leukemia, autoimmune diseases as well as cell and organ transplantation in clinics.

CONCLUSION

Studies clearly showed that CD52 can modulate T-cell activation either by its intracellular signal pathways or by the interaction of soluble CD52 and Siglec-10 expressing on T cells. However, the regulatory functions of CD52 on other immune cell subpopulations in organ transplantation require to be studied in the near future.

[Patch augmentation of the rotator cuff. A reasonable choice or a waste of money?]

BACKGROUND

Although reconstruction methods have improved, tendon retears remain a major complication associated with rotator cuff repair. With the application of patches, either by interposition or by augmentation, surgeons can attempt to close an irreparable cuff defect or improve the mechanical and biological properties of tendons respectively.

OBJECTIVES

Which factors need to be considered when using a patch and what outcome can be expected?

MATERIALS AND METHODS

Based on the current literature, an overview of the techniques and materials in use and biomechanical and clinical experience is provided.

RESULTS

The literature shows clear improvements in the biomechanical properties of a repair with patch augmentation; in particular, weakened tendons of the anterior supraspinatus and superior infraspinatus benefit most. It is important to keep in mind that each patch material has its own individual properties, which makes comparison of the various patch types difficult. The current scientific evidence is promising, although larger level 1 studies are still required.

CONCLUSIONS

The general use of patches cannot be recommended at this time. Nevertheless, the use of a patch should be considered in patients who are at a high risk of recurrent retears. In future, patches will probably be applied mainly as part of a combined effort, together with biological measures to further reduce retear rates.

Demineralized Freeze Dried Bone Allograft With Amniotic Membrane in the Treatment of Periodontal Intrabony Defects - 12 Month Randomized Controlled Clinical Trial

AIM

The goal of randomized controlled clinical study was to compare the clinical and radiological outcomes of the combination of Open flap debridement, Amniotic membrane and Demineralized Freeze Dried bone Allograft with Open flap debridement and Demineralized Freeze Dried bone Allograft alone in the management of periodontal intrabony defects.

METHOD

10 patients with bilaterally similar intrabony defects were selected. Each of the intrabony defects were randomly allocated for control and test groups. Control group (n= 10) received open flap debridement (OFD) and Demineralized Freeze Dried bone Allograft (DFDBA) while the test group (n=10) received OFD, DFDBA and Amniotic membrane. Pocket Probing Depth reduction (PPD), Clinical Attachment Level (CAL) gain and radiographic bone gain were assessed.

RESULTS

Both the groups demonstrated statistically significant PPD reduction, CAL gain and radiographic bone gain. The Intrabony defect (IBD) reduction of 1.78 ± 0.04 mm in radiovisiography (RVG) and 2.02 ± 0.83 mm in cone beam computed tomography (CBCT) with defect resolution of 58.28 % (RVG) and 58.24 % (CBCT) was noted in test group when compared to control group.

CONCLUSION

All the parameters measured showed similar improvement such as PPD reduction, CAL gain, IBD reduction and defect resolution with OFD + DFDBA + AM and OFD + DFDBA, no statistical significant difference was observed between the two groups .

Differential regenerative ability of sensory and motor neurons

After injury, the adult mammalian central nervous system (CNS) lacks long-distance axon regeneration. This review discusses the similarities and differences of sensory and motor neurons, seeking to understand how to achieve functional sensory and motor regeneration. As these two types of neurons respond differently to axotomy, growth environment and treatment, the future challenge will be on how to achieve full recovery in a way that allows regeneration of both types of fibres simultaneously.

[Prevention of aortic erosion by a bone cement skid : Thoracic endovascular aortic repair following kyphoplasty]

The underlying case report describes the successful endovascular prevention of an aortic injury by a bone cement skid after kyphoplasty. The intervention was performed in order to prohibit fatal aortic rupture or embolisation and underlines the role of vascular surgery techniques in interdisciplinary clinical networks.