Graft Length Research Articles

Supercharging DIEP Flaps Using Contralateral Superficial Inferior Epigastric Vein Grafts

Introduction: Venous congestion, even with a patent deep venous anastomosis, can afflict some DIEP (Deep Inferior Epigastric Perforator) flaps and various techniques of superficial venous supercharging have been described, although the indications for its use are not consensual. The main goal of this study is to confirm that superficial venous supercharge of DIEP flaps, utilizing the contralateral Superficial Inferior Epigastric Vein (SIEV) as an interposition vein graft, is feasible and functional. Materials and Methods: We retrospectively reviewed all DIEP flap breast reconstruction patients treated at our institution between June 2016 and December 2017 and that met all the inclusion criteria: Unilateral breast reconstruction with a DIEP flap; flap weighing more than 750 gm; supercharging of the ipsilateral superficial venous system; contralateral SIEV interposition graft; implantable doppler probe in the superficial system for at least 5 days. In the technique described here, the contralateral SIEV graft was harvested and anastomosed to the ipsilateral SIEV, obtaining this way a long vein that easily reaches the recipient vein (distal end of the Internal Mammary Vein - IMV). A Doppler probe was implanted in the superficial system, for at least 5 postoperative days, to monitor the function of this supercharging. We also analyzed the patient’s history, flaps weight, number and perforator rows, recipient vessels, SIEV graft length and diameter and all perioperative complications. Results: Ten patients met all inclusion criteria. They were treated using this technique and analyzed. Two patients had some type of alteration of the Doppler signal and clinical signs of venous congestion. They were surgically revised with success and were analyzed in detail. No total or partial flap failures were found. Clinical fat necrosis was also absent. Conclusion: This technique seems to be feasible, functional and adds an extra length to ipsilateral SIEV to reach a recipient vein. This way, the flap inset is not compromised by a short SIEV. No further significant morbidity is added for SIEV harvest that is in the same operative field, unlike the saphenous or cephalic veins. In selected patients, it could be an alternative supercharging technique.

Exploring morphological variations and clinical significance of interconnections between flexor hallucis longus and flexor digitorum longus tendons

BackgroundThe tendons of the flexor hallucis longus (FHL) and flexor digitorum longus (FDL) are commonly utilized in reconstructive foot surgery to address deformities. These tendons intersect on the plantar surface and exhibit varying interconnections that can significantly impact graft length and complicate the tendon harvesting process. The objective of this study was to comprehensively categorize these interconnections using a modified classification system and precisely determine their positional relationships with surgically significant bony landmarks. MethodsSixty embalmed feet of 30 cadavers were studied to analyze the interconnections between FHL and FDL in the planta pedis, classify them in a modified classification system and measure distances to surgically relevant anatomic landmark. ResultsThe study revealed three primary types of interconnections. Type I, representing a proximal-to-distal connection from the FHL to the FDL, was observed in 85% of the feet. Type II, signifying a proximal-to-distal connection from the FDL to the FHL, was found in 11.66% of the feet. Type III, characterized by a crossed connection, was identified in 3.33% of the feet. The average point of branching for the FHL and FDL tendons was situated 4.5 cm and 3.5 cm distal to the navicular tuberosity, respectively. ConclusionThe presence of atypical proximal-to-distal interconnections from the FHL to the FDL may play a role in preserving residual function in the lesser toes following FDL transfer procedures. Awareness of anatomical variations in the location of these interconnections is crucial for preserving them during surgical interventions, ultimately mitigating the risk of functional impairment in the lateral toes post-tendon grafting.

Reliability of Long Vein Grafts for Reconstruction of Massive Wounds.

When handling large wounds, zone of injury is a key concept in reconstructive microsurgery, as it pertains to the selection of recipient vessels. Historically, surgeons have avoided placing microvascular anastomosis within widely traumatized, inflamed, or radiated fields. The harvest of vein grafts facilitates reconstruction in complex cases by extending arterial and/or venous pedicle length. To illustrate the utility and fidelity of these techniques, this paper reviews the indications and outcomes for vein grafting in ten consecutive patients at a single tertiary referral center hospital. The case series presented is unique in three aspects. First, there are two cases of successful coaptation of the flap artery to the side of the arterial limb of an arteriovenous loop. Second, there is a large proportion of cases where vein grafts were used to elongate the venous pedicle. In these 10 cases, the mean vein graft length was 37 cm. We observed zero flap failures and zero amputations. Although limited in sample size, these case data support the efficacy and reliability of long segment vein grafting in complex cases in referral centers.

Characterizing the risk of human leukocyte antigen-incompatible living donor kidney transplantation in older recipients

Older compatible living donor kidney transplant (CLDKT) recipients have higher mortality and death-censored graft failure (DCGF) compared to younger recipients. These risks may be amplified in older incompatible living donor kidney transplant (ILDKT) recipients who undergo desensitization and intense immunosuppression. In a 25-center cohort of ILDKT recipients transplanted between September 24, 1997, and December 15, 2016, we compared mortality, DCGF, delayed graft function (DGF), acute rejection (AR), and length of stay (LOS) between 234 older (age ≥60 years) and 1172 younger (age 18-59 years) recipients. To investigate whether the impact of age was different for ILDKT recipients compared to 17 542 CLDKT recipients, we used an interaction term to determine whether the relationship between posttransplant outcomes and transplant type (ILDKT vs CLDKT) was modified by age. Overall, older recipients had higher mortality (hazard ratio: 1.632.072.65, P < .001), lower DCGF (hazard ratio: 0.360.530.77, P = .001), and AR (odds ratio: 0.390.540.74, P < .001), and similar DGF (odds ratio: 0.461.032.33, P = .9) and LOS (incidence rate ratio: 0.880.981.10, P = 0.8) compared to younger recipients. The impact of age on mortality (interaction P = .052), DCGF (interaction P = .7), AR interaction P = .2), DGF (interaction P = .9), and LOS (interaction P = .5) were similar in ILDKT and CLDKT recipients. Age alone should not preclude eligibility for ILDKT.

Anterior Cruciate Ligament Tears in the Adolescent Population: Injury Demographics and Risk of Reinjury Among High School Athletes.

The incidence of anterior cruciate ligament (ACL) injuries is increasing among the adolescent population with a peak occurring in the high school age range. To characterize recent epidemiologic trends of ACL injuries, ACL reconstruction (ACLR), and retear rates in high school adolescents based on age, participating sport, and mechanism of injury. Retrospective case series. A prospectively maintained institutional database was retrospectively reviewed for all patients 18 or younger who underwent primary ACLR between 2015 and 2020. Odds ratios were calculated for baseline patient characteristics and their association with risk of retear. Multivariate regression analysis was also performed to identify the relationship between retear and specific categorical variables. A total of 482 patients were included, with a mean follow-up time of 13.0 ± 11.8 months. Patients were an average age of 16.1 ± 1.3 years old (range: 13 to 18 y). Initial presentation of ACL injuries in high school athletes often occurred at 16 years old regardless of the sport played. Based on age, high school freshmen and seniors are found to have an increased risk of ACL retear. One hundred three patients (21.6%) completed at least 2 or more years of follow-up after ACLR. Of these patients, 38.8% received a bone-tendon-bone (BTB) autograft, 36.9% hamstring autograft, 14.6% quadriceps tendon autograft, and 3.9% received hamstring allograft or other graft (eg, tibialis anterior and BTB allograft), respectively. There were 25 ipsilateral ACL retears that occurred in the patient cohort (5.2%). Thirteen (52%) of retears were females. Football and soccer were the most common sports played by patients with a retear of the ipsilateral knee (31.8% and 27.3%, respectively). Patients who were 13 to 14 or 18 years old ( P = 0.009 and 0.035, respectively) or who received a tibialis anterior/BTB allograft ( P = 0.002) were found to have increased risk of ACL retear compared with other age groups. When evaluating by sex, female soccer players had a greater risk of retear compared with male soccer players ( P = 0.007). When adjusting for multiple variables, (including age, sex, body mass index, primary reconstruction graft choice, sport, and length of follow-up), the odds of ipsilateral retear in patients who received hamstring autograft ( P = 0.02), sustained a contralateral ACL tear ( P = 0 .04), or a contact injury ( P = 0.01) were increased. Initial presentation of ACL injuries in high school athletes often occurs at 16 years old regardless of the sport played. Based on age, high school freshmen and seniors are found to have an increased risk of ACL retear. However, the overall rate of ACL retear in high school athletes of all ages is low. Patients who underwent ACLR with hamstring tendon autograft had a greater risk of retear compared with other graft types. Female soccer players also had a greater risk of ACL retear. High school athletes must take caution when in the early high school years (underclassman) and more senior years (upperclassman), as susceptibility for ACL retears is elevated. Level IV.

Augmentation with a non-vascularized autologous fibular graft for the management of Cierny-Mader type IV chronic femoral osteomyelitis: a salvage procedure.

The study aimed to evaluate preliminary clinical and radiographic results of patients with Cierny-Mader type IV chronic femoral osteomyelitis and augmented with a non-vascularized fibular autograft as a salvage procedure because of the poorly regenerated new bone after bone transport over an intramedullary nail (BTON). Patients diagnosed with CM type IV chronic femoral bone infection and treated with BTON procedure between 2003 and 2020 were retrospectively reviewed. Seven patients were included in the study whose distraction gap was poorly regenerated and then augmented with a non-vascularized fibular autograft. A three-stage treatment was administered. First, the infection was eradicated. Second, BTON was performed. Third, the poorly regenerated distraction gap was augmented with a fibular autograft before removing the external fixator (EF). Clinical and radiological results were evaluated based on the criteria described by Paley-Maar and Li classification. The mean patient age was 52 years. The mean treatment time was 24.8 months, with a mean femoral lengthening of 12.6 cm. The mean EF and bone healing indexes were 0.57 months/cm and 0.8 months/cm, respectively. The mean length of the fibular graft was 13 cm. The bone healing of new bones was achieved in all patients with good quality after grafting. Functional scores were excellent in four patients. No patients experienced any sequelae. Non-vascularized fibular autograft augmentation may be an effective salvage procedure for poorly regenerated new bone after BTON to manage chronic femoral bone infection.

Similar return to sport between double cortical button and docking techniques for ulnar collateral ligament reconstruction in baseball players

A double cortical button technique for ulnar collateral ligament reconstruction (UCLR) has advantages including significant control over graft tensioning, less concern about graft length and minimized risk of bone tunnel fracture compared to traditional UCLR techniques. This double cortical button technique was recently found to be non-inferior in mechanical performance compared to the traditional docking technique regarding joint strength, joint stiffness, and graft strain. However, clinical outcomes have not been compared between these UCLR techniques. Therefore, the purpose of this study was to determine whether baseball players who underwent UCLR with a double cortical button (double button) technique have similar return to sport (RTS) outcomes compared to baseball players who underwent UCLR with the traditional docking (docking) technique. Baseball players that underwent primary UCLR from 2011-2020 across two institutions were identified. Included patients were contacted to complete a follow-up survey evaluating reoperations, RTS, and functional outcome scores. Functional outcome surveys include the Kerlan-Jobe Orthopaedic Clinic (KJOC) score, Conway-Jobe score, Andrews-Timmerman (AT) elbow score, and the Single Assessment Numeric Evaluation (SANE) score. Overall, 78 male baseball players (age: 18.9±2.4 years) with an average follow-up of 3.1±2.4 years were evaluated, with 73 of the players being baseball pitchers. Players in the double button group more frequently received palmaris longus autografts (78% vs. 30%) and less frequently received gracilis autografts (22% vs. 58%) compared to players in the docking group (p=0.001); however, all other demographic factors were similar between groups. All players in the double button group were able to RTS in 11.1±2.6 months, while 96% of players in the docking group were able to RTS in 13.5±3.4 months (p>0.05). All post-operative outcomes and patient-reported outcomes were statistically similar between groups, and remained similar after isolating pitchers only and after separating partial-thickness from full-thickness UCL tears (all p>0.05). Return to sport and other post-operative outcomes may be similar between baseball players who underwent UCLR with the double button technique and the docking technique. While future research may be necessary to strengthen clinical recommendations, these findings provide the first clinical outcomes in light of a recent cadaveric study finding similar elbow strength, joint stiffness, and graft strain compared to the docking technique.

Mini-Invasive Harvesting of Quadriceps Tendon Graft With Patellar Bone Block for ACL Reconstruction Using a Dedicated Harvester

Background: The selection of the type of graft used to reconstruct the anterior cruciate ligament (ACL) remains a matter of debate. In the past, the quadriceps tendon (QT) was associated with considerable morbidity and less favorable outcomes than other grafts. Improvements in harvesting methods have decreased morbidity of the surgical procedure and led to an increase in the use of QT in recent years. Indications: The QT graft with patellar bone block is a viable option for all patients with closed physis undergoing ACL reconstruction. It is especially suitable for young and active patients who practice activities that require kneeling or athletes in which hamstrings preservation is advisable. Technique Description: A vertical mini-invasive longitudinal incision starts 1 cm proximal to the middle of the patellar pole. After dissection, the bone block is marked and detached with an oscillating saw. A drill hole is performed in the bone block to serve for the passage of a traction suture. The bone block is lifted with the help of the traction suture, and the graft is trimmed to the desired diameter. The layer between tendon and capsule is separated by blunt dissection to spare the capsule of the suprapatellar pouch. Harvesting is achieved using a dedicated QT harvester. Usually, a graft length of 8 cm is harvested. The defect in the QT is closed using a suture passer at the proximal end. Finally, the graft is prepared and calibrated according to the planned technique for ACL reconstruction. Results: There was no major intraoperative complication in the senior author's series (more than 50 patients) using the dedicated QT harvester. On rare occasions (&lt;10% of the cases), the device opened the suprapatellar joint capsule, creating the additional need for capsular repair during defect closure. On two occasions, the graft was shorter than expected, which may have been caused by insufficient dissection or improper use of the harvester. Discussion/Conclusion: ACL reconstruction with minimally invasive QT graft harvesting methods has shown very good clinical outcomes with few complications. It can be recommended for primary and revision ACL reconstruction. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Parallel Reconstruction of Vascularized Fibula Autograft for Treatment of Complications after Resection of Malignant Tumor from the Thigh.

The authors herein introduce a modification of parallel reconstruction with a vascularized fibula autograft (VFA) for cases of femur allograft complications. Conventional parallel reconstruction, in which the fibula with its vascular pedicle is placed on the medial side of the femur and allogeneic bone, may be an effective means to solve the allograft complications. However, the limited contact area between the fibula and femur/allogeneic bone can affect the bone healing ability. Furthermore, the rigid internal fixation method for the VFA may cause stress shielding and result in bone resorption. The authors propose the use of modified parallel reconstruction of the VFA with fibula expansion and titanium cable fixation for patients with allograft-host junction nonunion, allogeneic bone fracture, and femoral shaft fracture after surgical removal of a malignant tumor from the thigh. The modified parallel reconstruction has been performed on 5 patients (2 patients underwent fibular expansion). All 5 patients with 7 nonunions of the allograft-host junction or fracture were followed up for 33.2 months. The length of fibular graft was 10 to 20 cm, with an average of 15.0 cm. The union rate of allograft-host junction and fracture was 100% (7 of 7), and the union time was 15.9 months. This modified parallel reconstruction technique can achieve satisfactory union in treatment of the above complications.

Clinical and Kinematic Outcomes Based on Bone Graft Utilization for Salvage First Metatarsophalangeal Arthrodesis: A Systematic Review

Motion-preserving options for the treatment of first metatarsophalangeal (MTP) osteoarthritis are appealing, but the conversion to arthrodesis in failed cases comes with additional challenges. Loss of first ray length may not only lower arthrodesis success rates but can also cause aberrancies in the biomechanics of the foot and ankle. Selection of the proper graft for the restoration of length is crucial in order to minimize the chance of post-operative complications. The primary objective of this systematic review was to determine the optimal graft type for MTP salvage arthrodesis in terms of clinical outcomes, kinematic outcomes, and bony integration to improve patient care. A systematic review was performed using PubMed, SPORTDiscus, Cumulated Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, and Web of Science from database inception until 20 June 2023. Inclusion criteria were articles that examined clinical outcomes, examined different types of bone grafts, discussed impact of bone graft on lengthening, and articles related to first MTP arthrodesis salvage procedures. Data extraction relating to clinical metrics and kinematic metrics was performed and analyzed. Subgroup analysis was performed to compare graft types, such as (1) foot and ankle autograft, (2) non-foot and ankle autograft, and (3) allograft. A total of ten articles met eligibility criteria from 180 articles initially retrieved. Included patients (n = 164) had a frequency-weighted mean age of 55.2 ± 4.6 years with a frequency-weighted mean time from primary to salvage procedure of 36.6 ± 21.9 months and a frequency-weighted mean follow-up time of 42.7 ± 17.4 months. The non-foot and ankle autograft group had a mean length restoration of 4.4 ± 0.1 mm (n = 33, 73.3% reported) whereas the allograft group had a mean length restoration of 7.6 ± 3.5 mm (n = 49, 100% reported). The foot and ankle autograft group (n = 12 procedures) had an overall complication rate of 25.0%, the non-foot and ankle autograft group (n = 45 procedures) had an overall complication rate of 53.3%, and the allograft group (n = 49 procedures) had an overall complication rate of 10.2%. Preoperative AOFAS scores were lower but improved postoperatively, with the allograft group showing the highest postoperative scores, shorter time to union, and varying graft lengths among different autograft subgroups. The allograft group for salvage MTP arthrodesis has promise, as this group had the greatest mean length restoration and the lowest complication rate. This is the first systematic review examining different bone graft utilization for salvage MTP arthrodesis. More high-quality research is needed before solid recommendations can be made on this topic.

Bilateral Lumbar Artery Perforator Flaps for Breast Reconstruction: A Perforator Classification System.

Autologous breast reconstruction is continually evolving, with focus on the ideal donor site. This study presents 108 consecutive simultaneous lumbar artery perforator (LAP) flaps and a perforator classification system. A retrospective review of all LAP flaps was completed, and appropriate data were recorded. All simultaneous bilateral LAP flaps were included, and perforator patterns were assessed using CT angiography (CTA). Fifty-four patients (108 flaps) were included in the final review. The mean patient age was 50.7 years, and the mean body mass index was 26.6. Mean ischemia times for all flaps and grafts were 130 ± 64.5 and 300.6 ± 97.3 minutes, respectively. The average pedicle length was 4.6 ± 1.5 cm, and the average composite graft length was 6.2 ± 1.7 cm. Donor-site complications consisted of seromas (10 patients [19%]), hematomas (6 patients [11%]), procedural wounds (4 patients [8%]), and infections (2 patients [4%]). The total flap loss rate was 2.8%. Perforators were classified into categories based on pedicle pattern, lumbar spine level, and clusters, all in relation to posterior iliac bone as seen per CTA. Vascular pedicle patterns were categorized as type 1 (43.9%), 2 (45.6%), 3 (8.8%), or 4 (1.8%). Perforators were dissected at lumbar spine level L3 in 51.8% of patients, L4 in 46.5%, and L5 in 1.8%. The authors present a CTA-directed anatomic perforator classification system to assist in preoperative planning, dissection, and choice of the composite graft best suited for particular perforator patterns or calibers. Simultaneous LAP flaps can be performed successfully with excellent outcomes in cases unsuitable for other flaps. Therapeutic, IV.

Fascicular shifting in the reconstruction of brachial plexus injuries: an anatomical and clinical evaluation.

Until recently, autologous sensory nerve grafting has remained the gold-standard technique in peripheral nerve reconstruction. However, there are several disadvantages to these grafts, such as donor site morbidity, limited availability, and a qualitative mismatch. Building on this shortage, a new concept, the fascicular shift procedure, was proposed and successfully demonstrated nerve regeneration in a rat nerve injury model. This approach involves harvesting a fascicular group distal to a peripheral nerve injury and shifting it to bridge the defect. The present study aimed to evaluate the clinical applicability of this technique in brachial plexus reconstruction. The supra- and infraclavicular nerves of the brachial plexus were bilaterally explored in 18 formalin-fixed cadaveric specimens. Following dissection, their fascicular shifting potential was evaluated. The medial antebrachial cutaneous and sural nerves were investigated and used as references for the required cross-sectional area of potential nerve grafts. Furthermore, 29 brachial plexus injuries, which qualified for surgical repair, were subjected to retrospective analysis. The intraoperatively measured lengths of the harvested and ultimately transplanted nerve grafts served as a basis to assess graft requirements in brachial plexus lesions. The transplanted nerve grafts measured a total length of 51.9 ± 28.1 cm in brachial plexus injuries. The individual inserted nerve grafts averaged 10.3 ± 5.1 cm. In the anatomical exploration, the ulnar and median nerves qualified for fascicular shifting. Their fascicular graft lengths measured 26.6 ± 2.5 cm and 24.8 ± 5.2 cm, respectively. The long thoracic, suprascapular, musculocutaneous, thoracodorsal, and axillary nerves were not suitable for fascicular shifting. The sensory graft length of the medial antebrachial cutaneous nerve measured 20.6 ± 3.4 cm. In the surgical reconstruction of brachial plexus injuries, fascicular shifting of the ulnar and median nerves provides sufficient donor material. Even though potential donor length is limited in the radial nerve, it may still help to expand the surgical armamentarium in selected clinical scenarios. Overall, the fascicular shift procedure presents a novel alternative to allow modality-matched grafting in the reconstruction of large proximal nerve defects and was found to be an attractive option in brachial plexus reconstruction.

Preliminary results of a new surgical technique: bladder mucosal graft harvested with holmium:YAG (HO:YAG) laser. A new option in bulbar replacement urethroplasty?

To describe the technique of transurethral harvesting of bladder mucosal graft using the Holmium:YAG (Ho-YAG) laser and describe the preliminary results from 7 cases where this graft was used for urethroplasty. We performed a single-stage dorsal onlay urethroplasty using bladder mucosal graft in 7 patients with anterior urethral stricture. Transurethral harvesting was performed with the Ho-YAG laser. We performed a prospective and descriptive analysis with uroflowmetry performed at 30, 90 and 180 days after surgery and applied the PROM translated into Portuguese before and 6 months after urethroplasty. Seven patients were included, 2 (28.5%) with penile urethral stricture, and 5 (71.5%) with bulbar urethral stricture. Mean stricture length was 50mm (range 35-60mm). Stricture etiology was trauma in 3 (42.9%) patients, iatrogenic in 1 (14.3%) patient, and idiopathic in 3 (42.9%) patients. Two patients (28.6%) had previously undergone ventral buccal mucosa urethroplasty. Mean bladder mucosal graft length was 52.86mm (± 13.801), and mean harvest time was 46.43min (± 14.639). Dorsal onlay urethroplasty using bladder mucosa was successfully completed in 5 patients (71.4%). Two patients (28.6%) couldn't have the procedure completed using bladder mucosa, one due to thermal damage of the graft during harvesting, and one due to insufficient graft length. In both cases the procedure was completed using buccal mucosa. Two patients (28.6%) experienced minor hematuria between the twelfth and eighteenth postoperative day, but neither required hospitalization and/or additional procedures. All patients achieved normalization of peak flow, and this was maintained throughout the follow-up period. Mean peak flow was 17.8 ml/s (± 3.271) at 30 days, 20.6 ml/s (± 5.413) at 90 days, and 19.6 ml/s (± 8.019) 180 days. Mean IPSS score decreased from 19.3 to 5.4. Similar improvements were also seen in the ICIQ-MLUTS Score (a mean drop from 3.8 to 2.0) and Peeling's Voiding Picture Score (a mean drop from 4.0 to 2.2). Quality of Life improved post urethroplasty, with increases in EQ-5D (from 0.6371 to 0.7285) and EQ-VAS (from 58.0 to 84.0). Transurethral harvesting of bladder mucosa using the Holmium laser (Ho-YAG) is feasible and reproducible. Our preliminary experience suggests that bladder mucosa grafts achieve comparable results to other grafts when used for dorsal onlay urethroplasty. Further research is needed to confirm these results.

Feasibility and Accuracy of Holographic Graft Length Measurement, a Sub-study of the FAST TRACK CABG Trial

Feasibility and Accuracy of Holographic Graft Length Measurement, a Sub-study of the FAST TRACK CABG Trial

Mucomucosal anastomotic non-transecting augmentation (MANTA) urethroplasty: a ventral modification for obliterative strictures.

To present a surgical modification for the repair of bulbar urethral strictures containing short, highly obliterative segments and report on long-term objective and patient-reported outcomes. We considered patients undergoing bulbar buccal mucosal graft urethroplasty (BMGU) between July 2016 and December 2019. Eligibility criteria for mucomucosal anastomotic non-transecting augmentation (MANTA) urethroplasty were strictures of ≥2 cm with an obliterative segment of ≤1.5 cm. The stricture is approached ventrally to avoid extensive dissection and mobilisation. Dorsally, the scar is superficially excised and the spongiosum is left intact. Dorsal mucomucosal anastomosis is complemented by ventral onlay graft. Perioperative characteristics were prospectively collected including uroflowmetry data and validated patient-reported outcome measures on voiding, erectile, and continence function. We evaluated functional follow-up, incorporating patient-reported (lower urinary tract symptoms [LUTS] score) and functional success. Recurrence was defined as need of re-treatment. Of 641 men treated with anterior BMGU, 54 (8.4%) underwent MANTA urethroplasty. Overall, 26 (48%) and 45 (83%) had a history of dilatation and urethrotomy, respectively, and 14 (26%) were redo cases. Location was bulbar in 38 (70%) and penobulbar in 16 patients (30%), and the mean (SD) graft length was 4.5 (1.4) cm. At a median (interquartile range) follow-up of 41 (27-53) months, the functional success rate was 93%. Whereas the median LUTS score significantly improved from baseline to postoperatively (13 vs 3.5; P < 0.001), there was no change in erectile function (median International Index of Erectile Function - erectile function domain score 27 vs 24) or urinary continence (median International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form sum score 0 vs 0; all P ≥ 0.4). All patients were 'satisfied' (27%) or 'very satisfied' (73%) with the outcome of their operation. With excellent long-term objective and patient-reported outcomes, MANTA urethroplasty adds to the armamentarium for long bulbar strictures with a short obliterative segment.

Long-Term Outcomes and Growth Analysis of Costochondral Grafts for Hemifacial Microsomia: 24-Year Experience of a Single Surgeon.

Costochondral grafts (CCGs) can be used in mandibular reconstruction of Kaban-Pruzansky IIB/III hemifacial microsomia (HFM). Their growth is variable, occasionally necessitating secondary surgery. This study examined one surgeon's 24-year experience to better quantify long-term outcomes and surgical care required in CCG reconstruction of HFM mandibles. Serial 3-dimensional computed tomography scans, from preoperative to most recent, were analyzed in patients with a minimum of 4 years of clinical follow-up after CCG reconstruction. Graft/ramus height, length, volume, bilateral mandibular body length, and chin deviation were measured. Changes in measurements were analyzed preoperatively, immediately postoperatively, at the most recent imaging before secondary surgery, and at the most recent imaging overall. Growth rates per measure were calculated using scans after CCG but before secondary surgery. Thirteen patients were analyzed. Median (SD) clinical follow-up was 10.0 (5.1) years. One patient developed temporomandibular joint ankylosis secondary to stacked-graft malposition, which was repaired without further complications. CCG reconstruction led to immediate improvement in graft/ramus height ( P = 0.03), length ( P = 0.002), and volumetric symmetry ( P = 0.02). No difference was found between graft and native ramus height ( P = 0.4) or length measures ( P = 0.5), whereas graft volume and the affected mandibular body grew significantly more slowly. According to the latest imaging, 63% of patients required secondary surgery, including distraction osteogenesis or orthognathic surgery, due to differential graft or hemimandible growth behavior. Based on the most recent clinical follow-up, this proportion increased to 93%. CCGs provide significant short-term mandibular and facial symmetry improvement in HFM IIB/III. Long-term analysis reveals frequent undergrowth requiring secondary intervention to promote and maintain symmetry. Therapeutic, IV.

Paper 02: Distal Radius Allograft for Glenohumeral Instability: A Novel Osteochondral Allograft Reconstruction Option in the Setting of Glenoid Bone Loss

Objectives: Glenoid bone loss in the setting of recurrent shoulder instability remains a challenging surgical problem. The coracoid process and iliac crest currently serve as primary autograft options for glenoid reconstruction. With regards to allograft alternatives, the distal tibia, first described in 2007, has good midterm outcomes when used during an index surgery and in cases of failed prior Latarjet reconstruction. While the distal tibia performs well in reconstructing the glenoid bony defect, it is a nonanatomic reconstruction and does not match the glenoid radius of curvature (ROC) in the anterior to posterior (AP) plane. No prior work has evaluated and described the utilization of the dorsal articular portion of the distal radius as an allograft reconstruction option for recurrent instability with glenoid bony deficiency. The purpose of this study was to evaluate distal radius fresh frozen allograft as a potential match for glenoid reconstruction through assessment of graft ROC and bone mineral density (BMD). Distal tibia allograft was utilized as the primary comparison group with both cadaveric and Computerized Tomography (CT) analysis. Methods: Eighteen fresh-frozen human cadaveric specimens (6 shoulder, 6 wrist, and 6 tibia) were utilized for this study. Specimens without osteoarthritis or prior surgical procedures were included. CT scans were obtained of all specimens to confirm the absence of osteoarthritis, significant joint deformity, or evidence of prior surgical procedure. Specimens were dissected free of all soft tissues except for the glenoid labrum of the shoulder and dorsal wrist ligaments of the distal radius. The ROC for each specimen were independently measured by two fellowship trained shoulder surgeons in both the superior to inferior (SI) and AP planes. Graft length in the SI plane was also assessed. A thirty percent defect was then created in all glenoid specimens and both distal tibia and distal radius grafts were harvested to assess graft fit post-fixation [Figure 1]. CTs were also analyzed to assess bony ROC and BMD for each specimen. Results: On cadaveric analysis, the mean SI graft length of the glenoid was 39.7 mm compared to 36.8 mm for the distal radius and 30.0 mm for the distal tibia [Table 1A]. Average ROC in the SI plane was 29.0 +/- 5.3 for the glenoid, 37.8 +/- 4.9 for the distal radius and 24.0 +/- 3.7 for the distal tibia; in the AP plan average ROC was 39.6 +/- 6.6 for the glenoid, 30.4 +/- 18.6 for the distal radius and 126.3 +/- 9.5 for the distal tibia [Table 1B]. On CT analysis, average ROC in the SI plane was 30.4 +/- 1.5 for the glenoid, 30.3 +/- 5.6 for the distal radius and 24.5 +/- 9.4 for the distal tibia; in the AP plane average ROC was 30.8 +/- 2.0 for the glenoid, 19.1 +/- 2.3 for the distal radius and 46.7 +/- 21.7 for the distal tibia [Table 2A]. Mean BMD was 226.3 +/- 79.0 for the glenoid, 228.5 +/-94.7 for the distal radius, 235.0 +/- 96.2 for the coracoid process, and 235.1 +/- 84.6 for the distal tibia [Table 2B]. Conclusions: Given fresh frozen allograft supply and cost constraints, exploration of additional graft options is necessitated. This study presents distal radius allograft as a novel reconstruction option for patients with anterior glenoid bone loss in the setting of recurrent glenohumeral instability. Compared with the distal tibia allograft, the distal radius had greater graft length in the SI plane providing possible utilization in cases of larger bony defects. The distal radius also has a more acute ROC in the AP plane (closer to that of the glenoid) compared with the distal tibia allograft providing a greater potential buttress to anterior humeral translation. Furthermore, the distal radius also has potential to employ the dorsal radio-carpal ligaments to perform an anterior capsular repair following allograft fixation. Finally, compared to currently utilized grafts (coracoid process and distal tibia), the distal radius BMD was not significantly diminished on CT analysis. This study presents the distal radius as a novel allograft reconstruction option in the setting of glenoid bone loss; further biomechanical and clinical investigation is indicated. [Table: see text][Table: see text]

Drop-off in axonal regeneration along the length of a cross-face nerve graft: An experimental study in rats.

The average nerve graft length utilized in cross-face nerve grafting for reconstruction of facial nerve palsy is 20-22 cm. While the graft length is thought to be one of the greatest determinants of muscle strength, the mechanism through which this happens remains unknown. We studied changes in axonal regeneration along the length of a 2 cm cross-face nerve graft in a rat model. The hypothesis was that axon count would decrease along the length of the graft. A 2 cm nerve graft (sciatic nerve) was used as a cross-face nerve graft in 16 adult female, 210-250 g, Sprague Dawley rats. Thirteen weeks later, 5 mm nerve biopsies were taken at four sites: the facial nerve trunk (control), proximal graft, midpoint of graft (1 cm distal to coaptation) and distal graft (2 cm distal to coaptation). Retrograde nerve labeling with FluoroGold was performed at the biopsied nerve site and the facial motor nucleus was taken 1 week later. Microscopic imaging and manual counting of axons and labeled motor nuclei was performed. Retrograde-labeled motor neuron counts were decreased at the midway point of the graft compared to the facial trunk (1517 ± 335 axons, Δ% = 92.5, p = .01) and even further decreased at the distal end of the graft (269 ± 293 axons, Δ% = 175.5, p = .006). Analysis of the nerve biopsies demonstrated no significant differences in myelinated axon count between the nerve trunk and over the length of the nerve graft (range 6207-7179 axons, Δ% = 14.5, p = .07). In a rat model, the number of regenerating motor neurons drops off along the length of the graft and axon count is preserved due to axon sprouting. How this pattern correlates to ultimate muscle strength remains unknown, but this study provides insight into why shorter grafts may afford better outcomes.

Labral Pull-Through Technique for Arthroscopic Labral Reconstruction of the Hip

Background: The goal of hip labral reconstruction is to restore the suction seal, requiring the labral graft to be precisely secured along the acetabular rim. When performed arthroscopically, controlling the graft as it is suspended in the hip joint between 2 cannulas can be challenging, making fixation in the optimal position to restore the suction seal difficult to achieve. Indications: Labral reconstruction/augmentation is indicated for patients with a deficient/dysfunctional labrum when repair alone cannot restore/maintain the suction seal. Technique Description: Following diagnostic arthroscopy, debridement, and measurement of the labral deficiency (30 mm), 70 mm tibialis anterior allograft was tubularized with a whipstitch and prepared with long suture tails at both ends and a single mattress stitch placed through the graft at the medial end. Holes for the anchors were pre-drilled. Viewing from the anterolateral portal, the graft was introduced down a sled through the modified anterior portal, pulled through the joint, and guided into the posterolateral portal cannula via instrumentation through the distal anterolateral accessory portal. With initial fixation achieved medially with the mattress stitch, directing the graft into position while achieving optimal coverage of the deficient area was facilitated by the excess graft length pulled into the posterolateral portal cannula. Results: Labral reconstruction can restore the suction seal of the hip joint when repair alone is not sufficient. Comparative studies with matched repair cohorts have demonstrated comparable survivorship and patient-reported outcomes between groups, with similar rates of patient acceptable symptomatic state and minimal clinically important difference between groups, and similar rates of return to sport in high-level athletes. Recent systematic reviews have largely corroborated these findings. Discussion/Conclusions: Arthroscopic labral reconstruction is an effective treatment option when repair alone cannot restore the suction seal when the graft is secured in an optimal position, but controlling the graft during passage and fixation while achieving a final length spanning the segmental deficiency in continuity with native tissue at both ends can present technical challenges. The labral pull-through technique greatly facilitates this process. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Determinism of some phytohormones and potassium nitrate on the vegetative growth of Tangelo (Citrus x tangelo) in the Sudano-Sahelian area of Mali

In Mali, citrus fruits contribute significantly to the nutritional balance of the population due to their high content of vitamin C, carotenoids and polyphenols. The citrus sector in Mali is rich in several species, but the current trend in citrus production is towards the production of Tangelo (or Citrus×tangelo). The objective of this study was to determine the effects of phytohormones 2,4,5-T, AG3 and potassium nitrate (KNO3) on vegetative growth of Tangelo. The trial was conducted in Koulikoro district, especially on the experimental plot of the IPR/IFRA of Katibougou. The plant material used is Tangelo orlando with white pulp. The experimental design was a Fisher block with three replications. The three products and water (check) were applied by spraying the leaves of the young plants at 110 days after planting. Observations were made on the following growth parameters: graft diameter, graft length and number of vegetative branches at 90th, 180th and 270th days after the application. The results of the analysis of variance of the different treatments revealed significant (p&lt;1% and p&lt;5%) and non-significant differences. The phytohormone 2,4,5-T followed by AG3, showed the best growth in height, diameter and number of vegetative branches at all measurement periods. Weak to very weak effects of KNO3, and water were found on all studied parameters. The application of 2,4,5-T on Tangelo at the plant’s seedling stage improved vegetative growth which may result in early flowering and could improve yield and fruit quality in Sudano-Sahelian area of Mali.