Donor Morbidity Research Articles

Adductor magnus muscle transfer to restore knee extension: Anatomical studies and clinical applications

Loss of knee extension causes significant impairment. Though nerve-based reconstruction is preferable in cases of femoral nerve palsy or injury, these surgeries are not always appropriate if the pathology involves the quadriceps muscles or presentation too late for muscle reinnervation. Muscle transfers are another option that has been underutilized in the lower extremity. We describe the successful restoration of knee extension by adductor magnus muscle transfer without functional donor morbidity, along with anatomical considerations. Ten fresh frozen cadaveric lower limbs were dissected at the groin and thigh. In addition, three patients presented with femoral nerve palsy for which nerve-based reconstruction was not appropriate because of late presentation. In these patients, adductor magnus muscle transfers were performed, along with sartorius, gracilis, and tensor fasciae latae transfers if available and healthy. In cadavers, the pedicle for the adductor magnus is at the level of the gracilis and adequate for muscle transfer, with sufficient weavable tendon length. The only major structure at risk is the femoral neurovascular bundle, which is in a reliable anatomic position. Two patients recovered 4/5 active knee extension and ambulation without assistive devices. A third required reoperation for a loosened tendon weave, after which the noted improved stability and strength with ambulation but did not regain strong active knee extension and continued to require a cane. We present a novel reconstructive approach for loss of quadriceps function in patients, which yields good clinical outcomes, with anatomic and technical details to demonstrate the utility of this technique. Ongoing evaluation of optimal technique and rehabilitation to maximize functional outcomes is still needed.

Photobiomodulation: An Effective Approach to Enhance Proliferation and Differentiation of Adipose-Derived Stem Cells into Osteoblasts.

Osteoporosis is regarded as the most common chronic metabolic bone condition in humans. In osteoporosis, bone mesenchymal stem cells (MSCs) have reduced cellular function. Regenerative medicine using adipose-derived stem cell (ADSC) transplantation can promote the growth and strength of new bones, improve bone stability, and reduce the risk of fractures. Various methods have been attempted to differentiate ADSCs to functioning specialized cells for prospective clinical application. However, commonly used therapies have resulted in damage to the donor site and morbidity, immune reactions, carcinogenic generation, and postoperative difficulties. Photobiomodulation (PBM) improves ADSC differentiation and proliferation along with reducing clinical difficulties such as treatment failures to common drug therapies and late initiation of treatment. PBM is a noninvasive, nonthermal treatment that encourages cells to produce more energy and to undergo self-repair by using visible green and red and invisible near-infrared (NIR) radiation. The use of PBM for ADSC proliferation and differentiation has been widely studied with multiple outcomes observed due to laser fluence and wavelength dependence. In this article, the potential for differentiating ADSCs into osteoblasts and the various methods used, including biological induction, chemical induction, and PBM, will be addressed. Likewise, the optimal laser parameters that could improve the proliferation and differentiation of ADSC, translating into clinical success, will be commented on.

A Workhorse Flap for Covering Moderate-sized Defects after Breast-conserving Surgery: Supercharged Lateral Thoracodorsal Flap.

Background:The lateral thoracodorsal (LTD) flap technique is a type of oncoplastic breast surgery that involves transposition of tissue from the lateral aspect of a partial mastectomy defect. It is a relatively simple procedure and shows lower donor morbidity and good aesthetic outcomes. Complications, such as fat necrosis and wound dehiscence due to poor circulation, may occur at the distal part of the flap. We used a supercharged LTD flap to reduce this problem. In this study, the outcomes of the LTD flap over 13 years were reviewed.Methods:We performed a retrospective study of 86 patients who underwent an LTD flap procedure between 2007 and 2019. We analyzed patient information using medical chart review and classified patients into groups according to lateral thoracic artery perforator supercharging. The incidence of complications, such as fat necrosis and wound dehiscence, was also analyzed.Results:The mean tumor weight was 83.67 g, and defects had a moderate size, as they represented 25.02% of the total breast volume. Fat necrosis was noted in 19.4% of cases in the group without lateral thoracic artery perforator supercharging and 4% of cases in the group with supercharging, with a significantly lower rate in the supercharged group.Conclusions:Our findings show that the LTD flap could be used to cover moderate-sized defects after breast-conserving surgery. Careful dissection to preserve the lateral thoracic artery perforator resulted in the reduction of complications, such as fat necrosis, and excellent aesthetic results.

Combination of BMP2 and EZH2 Inhibition to Stimulate Osteogenesis in a 3D Bone Reconstruction Model.

High concentrations of bone morphogenetic protein 2 (BMP2) in bone regeneration cause adverse events (e.g, heterotopic bone formation and acute inflammation). This study examines novel epigenetic strategies (i.e., EZH2 inhibition) for augmenting osteogenesis, thereby aiming to reduce the required BMP2 dose in vivo for bone regeneration and minimize these adverse effects. Human bone marrow-derived mesenchymal stem cells (BMSCs) were grown on three-dimensional (3D)-printed medical-grade polycaprolactone scaffolds and incubated in osteogenic media containing 50 ng/mL BMP2 and/or 5 μM GSK126 (EZH2 inhibitor) for 6 days (n = 3 per group and timepoint). Constructs were harvested for realtime quantitative polymerase chain reaction analysis at Day 10 and immunofluorescence (IF) microscopy at Day 21. After pretreating for 6 days and maintaining in osteogenic media for 4 days, BMSC-seeded scaffolds were also implanted in an immunocompromised subcutaneous murine model (n = 39; 3/group/donor and 3 control scaffolds) for histological analysis at 8 weeks. Pretreatment of BMSCs with BMP2 and BMP2/GSK126 costimulated expression of osteoblast-related genes (e.g., IBSP, SP7, RUNX2, and DLX5), as well as protein accumulation (e.g., collagen type 1/COL1A1 and osteocalcin/BGLAP) based on IF staining. While in vivo implantation for 8 weeks did not result in bone formation, increased angiogenesis was observed in BMP2 and BMP2/GSK126 groups. This study finds that BMP2 and GSK126 costimulate osteogenic differentiation of MSCs on 3D scaffolds in vitro and may contribute to enhanced vascularization when implanted in vivo to support bone formation. Thus, epigenetic priming with EZH2 inhibitors may have translational potential in bone healing by permitting a reduction of BMP2 dosing in vivo to mitigate its side effects. Impact statement While autografts are still the gold standard for bone reconstruction, tissue availability and donor morbidity are significant limitations. Previous attempts to use high concentrations of bone morphogenetic protein 2 (BMP2) have been shown to cause adverse events such as excessive bone formation and acute inflammation. Overall, the utilization of EZH2 inhibitors to modulate gene expression in favor of bone healing has been demonstrated in vitro in a tissue engineering strategy. Our study will pave the way to developing tissue engineering strategies involving GSK126 as an adjuvant to increase the effects of BMP2 for stimulating cells of interest on a three-dimensional scaffold for bone regeneration.

Endoscopic treatment of biliary complications in donors after living donor liver transplantation in a high volume transplant center.

Although living donor liver transplantation (LDLT) has been accepted as a primary treatment for adults with end-stage liver disease, concerns about donor health have been emerged. As LDLT is technically complex, it creates perioperative morbidity and mortality risk in donors. Biliary complications such as stricture and leakage are seen most frequently in donors after liver transplantation. While some of these complications get treated with conservative approach, endoscopic, surgical, and percutaneous interventions may be required in some others. We aimed to present endoscopic retrograde cholangiography (ERC) results in donors who developed biliary complications after LDLT. Between June 2010 and January 2018, a total of 1521 donors (1291 right lobe grafts, 230 left lobe grafts) of patients who underwent LDLT, were retrospectively reviewed. 63 donors who underwent ERC due to biliary complication, were included in the study. Biliary stricture was found in 1.6% (25/1521), biliary leakage in 2.1% (33/1521), and stricture and leakage together in 0.3% (5/1521) donors. Our endoscopic success rates in patients with biliary leakage, biliary stricture, and stricture and leakage were 85% (28/33), 92% (23/25), and 80% (4/5), respectively. Surgical treatment was performed on 12.6% (8/63) donors who failed ERC. We found that ERC is a successful treatment for post-LDLT donors who have biliary complications.

Comparison between long and lower medial head triceps branches in dual neurotization for shoulder function restoration in upper brachial plexus palsy.

In upper brachial plexus injury (UBPI), restoring shoulder function is crucial. This study compares the transfer of long and lower medial heads of triceps branches to the axillary nerve to achieve proper restoration of function. A retrospective comparative study was conducted between two groups of patients with (UBPI). Group I patients (10) [mean age: 19 ± 10.6 years] were managed by transferring triceps long head branch to axillary nerve while group II patients (8) [mean age: 26 ± 9.6 years] were managed by triceps lower medial head branch transfer. The mean time from injury to surgery was 6 ± 1.3 and 5 ± 1.7 months respectively. All patients were followed up for a minimum of 12 months with the assessment of VAS, DASH score, active range of motion (AROM) and strength of shoulder abduction and external rotation; in addition to shoulder endurance and strengths of donors. Postoperative, three-monthly, electrodiagnostic assessments were performed. Postoperatively, the mean VAS and DASH scores; in addition to endurance time, showed significant enhancement in both groups. Patients in both groups have accomplished a mean abduction (AROM) of 98° ± 27.9 and 97° ± 11.9 respectively. The mean external rotation (AROM) was 48° ± 18.4 and 47° ± 9.2 respectively. Furthermore, group II patients had less triceps morbidity in addition to earlier and enhanced electrophysiological recovery. Dual neurotization for shoulder function restoration in (UBPI) is capable of providing proper functional results with minimal donor morbidity. The triceps lower medial branch provides an excelling donor due to less triceps morbidity, extra length; yet, earlier and enhanced electrophysiological recovery.

The Effect of Medial Sural Artery Perforator Flap on Reconstruction of Soft Tissue Defects: A Meta-Analysis With Multiple Free Soft Flaps.

With the gradual popularity of relatively novel medial sural artery perforator flap (MSAPF), robust studies are needed to compare the surgical outcomes of MSAPF versus multiple free soft flaps (MFSFs) to verify the advantages and disadvantages of MSAPF. The authors searched PubMed, Web of Science, EMBASE, Cochrane Library, Chinese BioMedical Literature Database (CBM), and China National Knowledge Infrastructure (CNKI) until September, 2020, to identify studies that compared surgical outcomes of MSAPF and MFSFs. Two authors followed the PRISMA guidelines, individually extracted the data and performed the quality assessments. Survival rate of flaps, satisfaction degree of patients in recipient and donor site, skin grafting, and morbidity of recipient and donor site were evaluated. A total of 441 cases from 7 studies were included in our analysis. No significant differences were found regarding survival rate of flaps, recipient morbidity, and recipient satisfaction degree between the 2 groups. However, MSAPF group was significantly superior to MFSFs group in terms of skin grafting, morbidity, and satisfaction degree of donor site. Our meta-analysis showed that the MSPAF and MFSFs groups were similar in terms of survival rate of flaps, recipient morbidity, and recipient satisfaction degree. Medial sural artery perforator flap group was superior to MFSFs group in terms of morbidity and satisfaction degree of donor site. The results may prove that MSAPF is gaining popularity for a reason and is a good choice for repairing soft tissue defects.

Reliability of CT volumetry as a tool to calculate the preoperative donor liver volume: Correlation with the intraoperative graft weight in living donor liver transplantation (LDLT)

Liver transplantation has become an ideal management for end stage liver diseases. The preoperative volumetric assessment of donor liver is an important factor in determining the surgical strategy and in predicting post operative donor and recipient mortality and morbidity. CT has high spatial and contrast resolution and provides comprehensive parenchymal vascular and volumetric preoperative evaluation of donor undergoing live donor liver transplant and its accuracy can be established by comparing it with the intraoperative actual graft volume.52 patients who underwent donor right hepatectomy were included in the study and underwent CT scanning during the period from July 2017 to June 2019. Manual tracing of CT volumetry was done for calculating liver volume. The actual liver volume is obtained by weighing the graft immediately after resection. The difference between preoperative CT volume and intraoperative graft weight was defined as a percentage error ratio, which was classified as overestimation (+) and underestimation (-).In 28 (53.8%) cases, right lobe liver grafts obtained including MHV, whereas in 24(46.2%) cases right liver lobe grafts obtained excluding MHV. The mean preoperative liver volume calculated was 816.5+ 142.5g, while the mean volume measured intraoperatively was 812.6 g + 136.8g. The mean volume difference between preoperative and actual graft volume was 51.96+33.65cm(range 4-131cm). The mean error ratio was 6.59+4.623%. 30(57.7%) cases had underestimation, whereas 22(42.3%) cases had overestimation of liver volume. The mean preoperative volume had a good correlation with actual graft volume.The present study concludes that CT volumetry accurately predicted preoperative graft volume and showed excellent correlation with actual graft volume.

Comparison of transverse upper gracilis and profunda femoris artery perforator flaps for breast reconstruction: A systematic review.

Thigh-based flaps are generally considered a secondary option for breast reconstruction, with inner thigh-based transverse upper gracilis (TUG) flaps being the preferred choice for many surgeons; however, its well-established drawbacks include short pedicle length, lack of volume, and donor morbidity. The posterior thigh-based profunda femoris artery perforator (PAP) flap was introduced as an alternative approach, but these flaps were not comparatively analyzed with TUG flaps on a large scale. We aimed to systematically review TUG- and PAP-flap breast reconstruction to determine the better secondary option. We performed a systematic review of the literature using the PubMed database. Our selected series for systematic analyses included 613 TUG flaps in 432 patients and 475 PAP flaps in 329 patients. Elementary data on the flaps and complications were collected and analyzed. Pooled estimates of proportions of flaps with recipient complications and donor site morbidity were compared using random effect single arm meta-analysis. The basic patient demographics were comparable between the flap types. The mean operation time was comparable. The PAP flap had longer pedicle length and higher flap weight. The total loss (p = .6579), partial loss rate (p = .3247), and fat necrosis rate (p = .0771) were comparable between flap types. Regarding donor morbidity, the PAP flap group had less wound dehiscence (p < .0001) and lower rate of sensory disturbance (p < .0001). The study findings indicate that the PAP flap, when compared with the TUG flap, could be a better secondary option for breast reconstructions.

Extracellular matrix derived from allogenic decellularized bone marrow mesenchymal stem cell sheets for the reconstruction of osteochondral defects in rabbits

Bioactive scaffolds from synthetical polymers or decellularized cartilage matrices have been widely used in osteochondral regeneration. However, the risks of potential immunological reactions and the inevitable donor morbidity of these scaffolds have limited their practical applications. To address these issues, a biological extracellular matrix (ECM) scaffold derived from allogenic decellularized bone marrow mesenchymal stem cell (BMSC) sheets was established for osteochondral reconstruction. BMSCs were induced to form cell sheets. Three different concentrations of sodium dodecyl sulfate (SDS), namely, 0.5%, 1%, and 3%, were used to decellularize these BMSC sheets to prepare the ECM. Histological and microstructural observations were performed in vitro and then the ECM scaffolds were implanted into osteochondral defects in rabbits to evaluate the repair effect in vivo. Treatment with 0.5% SDS not only efficiently removed BMSCs but also successfully preserved the original structure and bioactive components of the ECM When compared with the 1% and 3% SDS groups, histological observations substantiated the superior repair effect of osteochondral defects, including the simultaneous regeneration of well-vascularized subchondral bone and avascular articular cartilage integrated with native tissues in the 0.5% SDS group. Moreover, RT-PCR indicated that ECM scaffolds could promote the osteogenic differentiation potential of BMSCs under osteogenic conditions while increasing the chondrogenic differentiation potential of BMSCs under chondrogenic conditions. Allogenic BMSC sheets decellularized with 0.5% SDS treatment increased the recruitment of BMSCs and significantly improved the regeneration of osteochondral defects in rabbits, thus providing a prospective approach for both articular cartilage and subchondral bone reconstruction with cell-free transplantation.

Guiding Lineage Specific Differentiation of SHED for Target Tissue/Organ Regeneration.

Stem cells from Human Exfoliated Deciduous teeth (SHED) are considered one of the most attractive cell sources for tissue engineering due to their easy acquisition with no donor morbidity, ready availability, ability to self-renew with high proliferation, capacity for multilineage differentiation and immunomodulatory functions. To date, SHED are able to differentiate into odonto-/ osteoblasts, neuronal cells, endothelial cells, hepatocyte-like cells, chondrocytes, epidermal cells among many other cell types. Accordingly, SHED possess a promising potential to be used in the cell-based therapy for various diseases, including reversible pulpitis, orofacial bone defects, neurodevelopmental disease and ischemic injury. Despite this potential, it has been a concern that tissue specific stem cells do not differentiate with the same efficacy into all the different lineages as they may have an inherent tendency to differentiate toward the tissues from which they were originally derived. Furthermore, stem cell niche comprises of a complex microenvironment where various cells, soluble signals, extracellular matrix and physical cues interplay to maintain the stemness of SHED and modulate their differentiation. Therefore, it is of significant importance to identify the specific microenvironmental cues that regulate lineage specific differentiation of SHED, which could inspire to develop functional approaches in target tissue regeneration. In this review, we highlight the recent studies that demonstrated multilineage differentiation capacity of SHED, focusing on how the microenvironment could be modified using different cues in order to achieve tissue specific regeneration.

12. Health care costs and characteristics of spinal fusion patients receiving concentrated bone marrow aspirate (BMAC), iliac crest autograft or bone morphogenic protein (BMP) therapy: a retrospective cohort study utilizing administrative claims

BACKGROUND CONTEXT To aid in fusion, surgeons may choose to use a biologic or other grafting agent in posterior lumbar spinal fusion procedures. This study explored the differences in cost and a variety of outcomes of bone marrow aspirate concentrate (BMAC), iliac crest autogenous bone grafting (autograft) and recombinant human bone morphogenetic proteins (rhBMP) -2 and -7. Autograft complications include pain, risk of infection and donor morbidity. BMP drawbacks are high cost and at risk of stimulating too much bone growth. While BMAC has been shown to promote bone and soft tissue healing, possible risks include bleeding and infection or nerve damage. PURPOSE A market assessment was conducted to explore the clinical value of each product. The study also looked at patient demographics, outcomes, and cost across the grafting products. STUDY DESIGN/SETTING Retrospective administrative claims data from the Optum Commercial and Medicare Advantage affiliated claims dataset between January 1, 2016 and December 31, 2017. PATIENT SAMPLE The final study cohort consisted of 14,668 patients (BMAC: n=3,181; autograft: n=11,085; BMP: n=402) in the US. 84.5% (n=12,683) of patients had only 1 index procedure product and 97.2% (n=14,251) had a successful fusion. The majority of patients were aged 65+ (n=7,581 /52%), female (n=8,122 /55%), and received Medicare coverage (n=8,639 /59%). OUTCOME MEASURES Data on select patient demographic and clinical characteristic measures were collected, including Charlson Comorbidity Index (CCI) score and top AHRQ comorbidities. Inpatient and outpatient hospital costs, length of stay (LOS) and mean standardized cost per patient by procedure were among the data collected to drive the cost analysis. METHODS Patients with >= 1 a CPT code for a procedure of interest for autograft or BMAC or an ICD-10-PCS code for BMP of interest were identified during the study time period. Patients were indexed at admission date of MS-DRG involving first observed instance of a procedure of interest and required to have 6 months pre-and 12 months post-index continuous medical and pharmacy coverage. Data were analyzed using descriptive statistics. The mean differences in costs were assessed using Student's t-test for statistical significance. RESULTS The average length of stay (BMAC=3.6 days; autograft=3.8 days; BMP=4.3 days [p-value: BMAC vs autograft= CONCLUSIONS Data from this study showcases the cost savings and potential impact on health outcomes which can be incurred through the implementation of BMAC as a biologic in treating spine fusion patients. Given the rising cost of spinal fusion procedures performed annually in the US, further research should focus on evaluating the cost-effectiveness of the various procedures. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

UPPER MIDLINE INCISION COULD BE STANDARD PROCEDURE FOR LIVING DONOR RIGHT HEPATECTOMY

Introduction: Laparoscopic donor hepatectomy has become more popular because of the donor’s demand for cosmetic and functional concern. However, laparoscopic approach has not been performed in almost living right donor hepatectomy (LDRH) because this is more technically demanding and is associated with increased donor morbidity. Instead, several studies have described LDRH using upper midline incision (UMI) to reduce donor morbidity. Herein, we describe our experience with small UMI as a standard procedure for LDRH. Material and Methods: We retrospectively reviewed the outcomes of 444 living donor right hepatectomy (LDRH) at our institution from January 2010 to June 2019; 124 donors received LDRH using UMI (UMI group), whereas 320 donors underwent LDRH using J shaped incision. (J shaped group) We began to use small UMI during LDRH since 2016 and now, this incision has been standard procedure for LDRH regardless of graft type, body mass index, graft weight or vascular variations. Patient demographics, intraoperative parameters, laboratory data and postoperative complications were compared between the 2 groups. Results: The mean size of the UMIs is 12.9cm (ranged from 11 to 16cm) and the overall complication rates did not differ significantly between the 2 groups. Most postoperative parameters were not different between the 2 groups, but postoperative hospital stay and operation time in UMI group were significantly lower than those in J shaped group. In multivariate logistic regression analyses, only large graft (≥900g) and severe hepatic steatosis (≥15%) were significant risk factors for difficult operation but not related to UMI incision. Moreover, in high-risk group for hepatectomy (donors with large graft or severe graft steatosis), neither the operation time nor intraoperative blood loss in UMI group were higher than those in J shaped group. Conclusion: LDRH could be safely performed under small UMI with better cosmesis and could be considered as standard procedure during LDRH regardless of donor’s variations.

Total and near‐total lower eyelid reconstruction with prefabricated orbicularis oculi musculocutaneous island flap

Full thickness lower lid defects are frequently encountered during daily practice. The unique anatomy of the eyelids hinders reconstructive efforts. The aim of the study is to develop an effective and easy procedure for the reconstruction of full thickness defects of the lower eyelid. Here we present six cases, which we treated with an orbicularis oculi musculocutaneous island flap prefabricated with a chondrocutaneous graft. Five of the six cases suffered from tumors, while one had congenital coloboma of the lower lid. A chondrocutaneous graft harvested from the ear was placed under the orbicularis oculi musculocutaneous flap. Three weeks later, the defect was created and the prefabricated flap was transposed to the defect. Two cases had superficial distal skin loss and one had prolonged oedema. No major complication or tumor recurrence was seen. Using this method, the principle "replace with like" is fulfilled. Orbicularis oculi musculocutaneous island flap prefabricated with postauricular chondrocutaneous composite graft seems to be a feasible method for the reconstruction of full thickness defects of the lower eyelid with its low donor morbidity and good outcomes.

Pronator Quadratus to Extensor Carpi Radialis Brevis Nerve Transfer in C5-C7 or C5-C8 Brachial Plexus Injuries for Independent Wrist Extension.

Background Patients with lesions affecting C7 and C8 roots (in addition to C56) demonstrate loss of independent wrist dorsiflexion in addition to loss of shoulder abduction and elbow flexion. Traditionally, this deficit has been addressed using tendon transfers after useful function at the shoulder and elbow has been restored by primary nerve surgery. Confidence with nerve transfer techniques has prompted attempts to replace this method by incorporating procedures for wrist dorsiflexion in the primary operation itself. Aim The objective of this study was to report the results of pronator quadratus motor branch transfers to the extensor carpi radialis brevis motor branch to reconstruct wrist extension in C5–C8 root lesions of the brachial plexus. Patients and Methods Twenty-three patients, average age 30 years, with C5–8 root injuries underwent operations an average of 4.7 months after their accident. Extrinsic extension of the fingers and thumb was weak or absent in two cases while the remaining 18 patients could open their hand actively. The patients lacked independent wrist extension when they were examined with the fingers flexed as the compensatory action of the extrinsic finger extensors was removed. The average follow-up was 21 months postoperative with the minimal follow-up period was at least 12 months. Results Successful reinnervations of the extensor carpi radialis brevis (ECRB) were demonstrated in all patients. In 17 patients, wrist extension scored M4, and in 3 patients it scored M3. Conclusions The pronator quadratus (PQ) to ECRB nerve transfer in C5–C7 or C5–C8 brachial plexus injuries for independent wrist extension reconstruction gives consistently good results with minimal donor morbidity.

The medial sural artery perforator (MSAP) flap: A versatile flap for lower extremity reconstruction

BackgroundThe medial sural artery perforator (MSAP) flap provides a thin, pliable and durable soft tissue reconstruction with adequate pedicle length and low donor morbidity. It is an ideal choice for small-to-moderate defects of the lower extremity, although it does have limitations. We report our experience of the flap in a three-pronged anatomical, clinical and patient reported outcome-based study. MethodsCadaveric fresh frozen lower limbs (n = 10) were used for anatomical dissections to assess pertinent and clinically relevant findings. Data relating to MSAP flaps was collected from a prospectively maintained database over a 2-year period. Both clinical data and modified Enneking scores were analysed. ResultsAnatomical study: A mean of 2.1 ± 0.99 perforators arose from the medial sural artery, located 11.9 cm ± 2.07 along the line between the popliteal fossa and medial malleolus. The largest perforator was located 13.58 cm ± 2.01 from the popliteal artery. The distance from the dominant perforator to the first branching point within the gastrocnemius was 7.39 ± 1.50 (range 5–9.2 cm). The short saphenous vein was located on average 3.08 cm ± 0.77 from the dominant perforator. Clinical study: Twenty free and nine pedicled MSAPs were included (n = 29). Open lower limb fractures (n = 18, 62%) and infection (n = 10, 35%) were the most common aetiologies. Defects sites included: foot-and-ankle (n = 12, 55%), knee (n = 9, 31%) and anterior leg (n = 4, 14%). Four patients (14%) required SSG to for donor site coverage. Venous congestion was responsible for partial flap necrosis in 6.9%(n = 2) of patients. All wounds were healed at discharge. At 14 months, the mean Enneking score was 72.5%. All patients were ambulant, 96% returned to work and 87% were using pre-operative footwear. ConclusionsThe MSAP provides robust foot-and-ankle reconstruction, whilst permitting glide when over the knee. Patient satisfaction and functional outcomes are excellent with careful patient selection. Care should be taken to avoid compression or kinking of the large, thin walled veins as the most commonly observed complication was venous congestion. We advocate MSAP as a first choice flap for small-to-moderate foot, ankle or knee defects.

Increase in interventricular septum thickness may be the first sign of cardiovascular change in kidney donors.

Because of the inadequate number of deceased kidney donors, living kidney donation remains an important issue for kidney transplantation. Previous studies have shown that living donation does not differ life expectancy and progression to end-stage renal disease compared with the normal population. In this study, we investigated short-term cardiovascular changes after donor nephrectomy. Thirty-four patients who underwent donor nephrectomy between January 2015 and July 2015 at Ege University Renal Transplantation Unit were included in the study. Arterial stiffness, multifrequency bioimpedance analysis, renal ARFI elastography, and echocardiography performed prior to the donor nephrectomy and 6months after nephrectomy. A total of 34 kidney donors were enrolled in this study. Twenty donors were female (59%) and 14 donors were male (41%). The pathological evaluation of donor kidneys using implantation renal biopsy sample revealed mean Karpinski Renal Score of 1.5 and the mean glomerulosclerosis ratio was 5% for all donated kidneys. Arterial stiffness, systolic and diastolic blood pressure measures, body fluid composition, and left atrial size did not change significantly during the follow-up. However, interventricular septum thickness of donors increased by 1mm during a 6-month period (9.6mm vs 10.6mm, P=.002). We observed an increase in interventricular septum thickness in kidney donors during a 6-month follow-up. In order to evaluate the net effect of this change on donor morbidity, prospective studies investigating an increased number of donors with long-term follow-up should be needed.

Olecranon bone grafting for the treatment of nonunion after distal finger replantation

Aim: Although not very popular, the olecranon bone graft is a useful option for this type of operation due to the minimal donor morbidity and its ease of use in small bone defect reconstruction and non-union therapy. To our best knowledge, few studies have evaluated the use of the olecranon bone graft as a treatment for non-union after distal finger replantation. Our aim in this report was to present our experience of using olecranon grafts in our nonunion patients undergoing distal replantations. Methods: Between 2013 and 2019, a total of 14 patients who developed nonunion or had segmental bone defects due to the injury were included in the study. Retrospectively the results were analyzed in terms of complication and union rates. Results: The mean follow-up period was 37 months (range 8-72 months). No major complications were seen in the donor region or recipient regions. One patient developed necrosis in the nail bed and one patient had a hematoma in the donor site. The minor complications were solved without any problem. Conclusion: In conclusion, we found the olecranon bone grafting for the treatment of nonunion after distal finger replantation is a safe and convenient method. It can be preferred as the first choice for nonunions of distal finger replantations.

SkinDot: A modified full-skin transplantation technique

Existing epidermal transplantation procedures applied in burn surgery or wound treatment, such as mesh grafting or the Meek method, do not lead to a restoration of all the skin layers. Dermal skin layers are indispensable in ensuring the quality and function of the transplanted skin as a frictional surface and a carrier of skin appendages such as hair, sweat glands, and sebaceous glands, as well as nerve receptors for detecting pressure, vibration, and temperature. Because of the restricted skin surface area that can be provided by the donor, full-skin transplants cannot be transplanted over a large area. Cultured skin procedures, based on skin cells cultivated in a laboratory, have not yet reached a stage of development where a complex full epidermal transplantation is possible. In particular, the introduction of skin appendages with a functional cell-to-cell communication has not been observed thus far in cultivated skin. Based on the Reverdin transplantation method, in which concave skin islands with epidermal and dermal parts are transplanted, Davis in 1910 described the transplantation of multiple 2−5 mm sized full-skin islands as a new method for the treatment of skin lesions. Further modifying this 100-year-old procedure, we developed a miniaturization and automation of the Davis transplantation method that started in 2011 and called it “SkinDot”. In the following article we describe the effectiveness of the full-skin island transplant procedure in two patients. The transplantation of single 2−3 mm full-skin islands results in a full-skin equivalent without any limits on donor area and with a reduced donor morbidity.

Utility of magnetic resonance proton density fat fraction technique in quantification of liver fat in living donors for liver transplantation

BackgroundHepatic steatosis in living donors for liver transplantation causes morbidity of both donor and recipient. This study aims at evaluating magnetic resonance proton density fat fraction technique (MR PDFF) in quantitative evaluation of living donor’s hepatic steatosis compared to histopathology.ResultsThe examined potential living liver donors’ liver biopsies revealed hepatic steatosis < 5% (grade 0) in 40 donors and 5–10% (grade 1) in 7 donors. MR PDFF technique with IDEAL sequence showed excellent results for prediction and quantitative evaluation of liver fat with sensitivity, specificity, and accuracy of 85.7%, 97.5%, and 95.7%, respectively, compared to histopathology (95% confidence interval 0.98–1.01). There was an excellent inter-reader agreement between both readers in estimation of MR liver fat fraction (r = 0.969 at 95% confidence interval 0.946–0.983).ConclusionNoninvasive hepatic MR PDFF technique with IDEAL sequence is a precise reliable technique for pre-operative quantitative assessment of hepatic steatosis in potential living liver donors.