Partial Graft Research Articles

P9.05: Biliary Complications Following Liver Transplantation: A 13-Years Single-Center Experience

Introduction: Orthotopic liver transplantation (LT) is the chosen treatment for end-stage liver disease. Despite the advances in the surgical techniques, biliary tract complications are the most common problems seen after transplantation with an incidence range of 10-25%. We aim to describe the incidence of biliary complications at our center. Patients and Methods: Retrospective study of patients who suffered from biliary complications after LT between September 2009 and February 2022 in a single center. Demographic characteristics: cause of liver failure, MELD score, time on waiting list (WL), DRI, national, regional or local procurement; preservation solution, warm ischemia time (WIT), cold ischemia time (CIT), chosen treatment and success rate (SR), patient and graft survival. Biliary complications were divided into 2 groups, according to the moment of appearance: early complication (EC) when they happened within the first 30 post-operative days and delayed complication (DC) when they ocurred afterwards. All analyses were performed using IBM SPSS v25.0. Results: From a total of 549 LT that were performed during the period of study, 90 (16%) had biliary tract complications. Among them, 78 were adult recipients, with a mean age of 48 years old (DS 21). Sixty-four transplants (71%) were performed due to cirrhosis, caused mainly due to viral disease (25, 39%) and alcohol (18, 28%). Sixty-nine (90%) were performed with whole liver and 8 (10%) with partial grafts (7 right and 1 left lobe). The most frequent biliary complication in the EC and DC group was the biliary anastomotic stenosis, with 21 (60%) and 33 cases (78%), respectively. Eighteen patients (23%) lost their graft (7 EC and 11 DC). Table 1 shows biliary complications according to time of appearance and initial treatment chosen.Among the pediatric patients, the mean age was 3 years old (range 1-10) and the main cause for transplant was biliary atresia (5, 42%). Nine patients suffered of biliary leak (8 within the EC groups and 1 DC) and 3 of biliary anastomotic stenosis (2 EC and 1 DC). Three patients (25%) lost their grafts (all from EC). Table 2 shows biliary complications according to time of appearance and initial treatment chosen.Discussion: Biliary complications remain a major cause of morbidity, dysfunction, and mortality in liver transplant recipients and continue to be a challenging aspect in the management of such patients. With appropriate management, however, there impact on graft and overall survival could be minimized.

Meta-analysis of total versus partial graft excision: Which is the better choice to manage arteriovenous dialysis graft infection?

Arteriovenous graft infection (AVGI) is a major cause of hemodialysis access failure. Delayed diagnosis and inappropriate treatment may lead to increased morbidity (3-35%) and mortality up to 12%. Compare the postoperative outcomes of total graft excision (TGE) and partial graft excision (PGE) in the treatment of AVGI. Systematic review and meta-analysis METHODS: The dataset was defined by searching PubMed, EMBASE, Google Scholar, and the Cochrane database for articles outlining the terms arteriovenous graft infection, infected dialysis graft, TGE and PGE published between 1995-2020. The data analysis evaluated the outcomes of TGE and PGE in the management of AVGI. The meta-analysis was performed using Review Manager Software version 5.4.1. 30-day mortality, recurrent infection, and reoperation rate. Eight studies, including 555 AVGI, and 528 patients. PGE showed a significant increase in recurrent graft infection rate (OR=0.23,95% CI=0.13-0.41, P<.00001) and re-operation rate for control of infection (OR=0.14,95% CI=0.03-0.58, P<.007). However, the 30-day mortality rate did not differ significantly between the groups (OR=0.92,95% CI=0.39-2.17, P=.85). TGE remains a safe and effective surgical method for the management of AVGI. PGE is associated with a higher risk of graft infection and need for re-operation. As a result, PGE should only be considered in carefully selected patients. Risk of bias due to the differences in patient characteristics. None.

234.12: Long-term Pancreas Graft Function – What Can We Expect in the Future?

Background and Study Purpose: Outcome of recent pancreas transplants has improved significantly. Most advances are noted in the first year post-transplant. It is unknown if these improvements in short-term-outcome translate to improved long-term outcome. Assessment of long-term outcome depends on length of follow-up time. For transplants performed between 2008 and 2017 the actual follow-up time is not long enough to estimate long-term outcome. A mathematical model is needed to predict and verify long-term graft function. Methods: Between 1998 and 2017, 21,418 primary deceased donor pancreas transplants (77% SPK, 15% PAK, 8% PTA) in diabetic patients were reported to UNOS/IPTR with follow-up times depending on the year of transplant. Pancreas graft function was defined as insulin-independence and kidney graft function as being dialysis free. Dying with a functioning graft or partial graft function were defined as graft failures. Multivariate Cox regression models for pancreas and kidney graft function adjusted for donor, recipient and transplant factors were developed to functionally describe graft survival during different time periods. The model is based on the first 5 years post-transplant for the years 1998-2012 and the first 3 years for 2013-17 (due to shorter follow-up). Additional models were assessed for transplants which were functioning at 1-year post-transplant. Depending on the time period, half-lives then were estimated. The models were verified for the time periods 1998-02 and 2003-07, for which actual long-term results were available. Results: Table 1 shows the observed (1998-2007) or estimated (2008-2017) half-lives for the analyzed time period. The differences between observed and estimated half-life for transplants performed between 1998 and 2007 were actually small (2-5 months) so that we can assume that the estimates for the years 2008 to 2017 are reliable estimates. The models show that increased long-term graft function can be expected. Half-life for SPK performed in 2013-17 reached now 17 years for both organs and increases to more than 18 years for transplants that were functioning at 1 year post-transplant. The improved outcomes in PAK showed a doubling in half-life between 1998-02 and 2013-17. This improvement was greatest for grafts that had reached the 1-year time mark as functioning graft. The half-life of PTA also improved over time but did not reach the results of SPK. When a PTA graft is functioning at the 1-year mark, 50% of patients will still have graft function at 8 years post-transplant. Conclusions: These statistical models not only confirm improvements in long-term pancreas and pancreas/kidney transplantation but also show the expected duration of average graft function in the most recent eras. The models underline the importance of function throughout the first year post-transplant and its impact on long-term graft function.

A Novel Microsurgical Robot: Preliminary Feasibility Test in Ophthalmic Field.

PurposeThis study investigated the feasibility and potential advantage of using a new microsurgical teleoperated robot, Symani Surgical System, in the ophthalmology field. In particular, considering the extreme precision of the system and the dexterity of the instrument, possible use of the Symani Surgical System has been explored for suturing in corneal graft surgery.MethodsManual and robot-assisted suturing of partial corneal transplants was performed on the porcine eye model by an ophthalmologist with experience with the porcine model. Suturing execution time, suture placement, and tomographic parameters were analyzed to assess the regularity and distribution of corneal sutures for both manual and robotic treatment.ResultsThe two robot-assisted procedures were properly completed on the porcine model, confirming the ease of use of the system and its capabilities, as well as the dexterity of the microinstruments. Manual and robotic treatments were found to be equivalent in terms of distance and angular precision of suture placement and corneal surface regularity (Gaussian anterior curvature). The robotic procedure required longer suturing execution times compared with the manual procedure.ConclusionsThe technical and clinical feasibility of robot-assisted suturing of partial corneal graft using the Symani Surgical System has been confirmed for the first time, to our knowledge, using an ex vivo porcine model. Robotic suturing required longer time to complete but was equivalent to the manual procedure with regard to the imaging data collected.Translational RelevanceThis study evaluated the use of the Symani Surgical System in the ophthalmology field. Future investigations could further identify the advantages offered by the stability, dexterity, and motion precision of the system for corneal surgeries, paving the way for clinical use in both adult and even more challenging pediatric therapy.

Arthroscopic Superior Capsule Reconstruction With Fascia Lata Autograft And In-Situ Biceps Tendon Augmentation: Feasible Outcomes After Minimum Two-Year Follow-Up

PurposeTo investigate the preliminary functional and radiographic outcomes after arthroscopic superior capsule reconstruction (SCR) with long head of biceps tendon (LHBT) augmentation for irreparable rotator cuff tears (RCTs).MethodsRetrospective review of medical records was conducted in patients receiving unilateral SCR with fascia lata autograft and LHBT augmentation for irreparable RCTs between January 2016 and March 2019. LHBT was adopted when the integrity was intact or partial tear was less than 50% in width. We used all-suture anchors for folded graft patch fixation with 2 in supraglenoid fossa and another 2 plus two knotless anchors via compression suture-bridging technique in greater tuberosity. Reinforced fixation with side-to-side suture was added between infraspinatus tendon and graft patch, and between proximal LHBT and graft to improve force coupling. Clinical and radiographic outcomes including magnetic resonance imaging analysis at 2-year follow-up were investigated and compared with preoperative status.ResultsConsecutive 18 patients (mean age, 66.1 years) were included. Mean active forward elevation significantly improved from 75.6⁰ to 157.2⁰ (P < .0001), and external rotation from 33.3⁰ to 53.3⁰ (P < .01). Mean acromiohumeral distance increased from 6.1 ± 2.5 mm to 8.5 ± 2.1 mm (P < .001). The American Shoulder and Elbow Surgeons score improved from 33.8 ± 5.6 to 93.4 ± 5.92 points (P < .00001). Comparable outcomes were found in patients with intact LHBT and those with partial tear. Nine patients had partial tear of graft patch (5, tuberosity side; 4 posterior glenoid); 2 patients had complete tear (tuberosity side) showing inferior outcomes.ConclusionsThe index surgery restored superior glenohumeral stability and function of the shoulder with irreparable RCTs. Despite high incidence of partial graft tear, favorable outcomes suggest SCR with biceps tendon augmentation is a feasible treatment for irreparable RCTs.Level of EvidenceLevel IV, therapeutic case series.

An Innovation in the Technique of Recipient Hepatectomy in Living Donor Liver Transplantation.

Recipient hepatectomy is a challenging surgical procedure. Coagulopathy, multiple collaterals, and dense adhesions secondary to previous spontaneous bacterial peritonitis in cirrhotics are the major contributing factors. However, the appropriate recipient hepatectomy technique can limit the massive blood loss and minimize the operative time. The hepatoduodenal dissection has a key role in recipient hepatectomy. The hilar structures of partial graft in live donor liver transplantation (LDLT) usually have a short length and a small caliber. The concerning task in LDLT recipient hepatectomy is to preserve the integrity, quality, and adequacy of hilar structures for successful implantation. The high hilar dissection technique is usually practiced for getting the adequate length of hilar structures. However, the problems with high hilar dissection inducted the authors to tailor the technique over time. In this report, a modified technique of recipient hepatectomy characterised by the artery-first approach is described. This technique is good in terms of preventing arterial dissection and minimising the anhepatic phase. Key Words: Recipient hepatectomy, Hepatoduodenal dissection, Liver transplantation, Technique.

Increasing Living Liver Donor Pools: Liver Paired Exchange Versus ABO-incompatible Living Donor Liver Transplantation.

Increasing Living Liver Donor Pools: Liver Paired Exchange Versus ABO-incompatible Living Donor Liver Transplantation.

77. Reducing Partial Nipple Graft Necrosis Following Masculinizing Chest Reconstruction with Negative Pressure Wound Therapy

Introduction: Despite a greater recognition of transgender care and advancements in gender-affirmation surgery, chest masculinization is still associated with an elevated rate of postoperative complications, such as nipple graft necrosis. Incidence of partial nipple graft necrosis following chest masculinization has been reported as high as 18.5% of cases. Benefits of negative pressure wound therapy (NPWT) include improved wound healing and graft take through an enhanced inflammatory response and reduction in shear forces, withdrawal of edematous fluid from the affected area, and promotion of wound bed contraction. In cases of breast reconstruction, NPWT use has been demonstrated to lower overall complication rates compared to use of standard wound care (SWC) dressings. Currently there is a paucity of literature regarding the role of NPWT application following chest masculinization surgery. Our study aims to evaluate the outcomes of NPWT use following chest masculinization with free nipple grafting (FNG) in reducing nipple graft necrosis. Methods: From January 2018 to November 2020, all transgender and non-binary patients who underwent chest masculinizing reconstruction with FNG by the senior author (GDC) were retrospectively reviewed. Patients were divided into two cohorts: those treated with (1) NPWT or (2) standard wound care (SWC). Data regarding demographics, comorbidities, operative details, and postoperative partial nipple graft necrosis were collected from the electronic medical record. Each complication was considered a separate event and counted once per breast. Results: A total of 131 patients were included in the study, of which 27.5% (n=36) received NPWT and 72.5% received SWC (n=95). Median age and BMI at time of surgery was 24 years (IQR 20,29) and 28.2 kg/m2 (IQR 24.2, 35) with no difference between cohorts (p=0.145, p=0.753, respectively). In the overall chest masculinization cohort, the median weight of resected breast tissue was 562 grams (IQR 430, 828) and was not significantly different between NPWT and SWC cohorts (562g vs. 576g; p=0.939). Only 12.5% of those receiving NPWT experienced partial nipple graft loss (n=9/72) compared to 24.7% in those receiving SWC (n=47/190; p=0.031). Additional analysis found that patients receiving NPWT experienced a lower incidence of partial nipple graft necrosis within all BMI categories. Conclusions: Our study findings illustrate that NPWT may help in reducing partial nipple graft necrosis as a postoperative complication in those undergoing chest masculinization with FNG compared to those receiving SWC. Prospective randomized studies can help further elucidate the outcomes of NPWT use following top surgery.

Free Skin Grafting to Reconstruct Donor Sites after Radial Forearm Flap Harvesting: A Prospective Study with Platelet-Rich Fibrin (PRF).

Reconstruction of the donor site after radial forearm flap harvesting is a common procedure in maxillofacial plastic surgery. It is normally carried out with split-thickness or full-thickness free skin grafts. Unfortunately, free skin graft transplantation faces wound healing impairments such as necrosis, (partial) graft loss, or tendon exposure. Several studies have investigated methods to reduce these impairments and demonstrated improvements if the wound bed is optimised, for example, through negative-pressure wound therapy or vacuum-assisted closure. However, these methods are device-dependent, expansive, and time-consuming. Therefore, the application of platelet-rich fibrin (PRF) to the wound bed could be a simple, cost-effective, and device-independent method to optimise wound-bed conditions instead. In this study, PRF membranes were applied between the wound bed and skin graft. Results of this study indicate improvements in the PRF versus non-PRF group (93.44% versus 86.96% graft survival, p = 0.0292). PRF applied to the wound bed increases graft survival and reduces impairments. A possible explanation for this is the release of growth factors, which stimulate angiogenesis and fibroblast migration. Furthermore, the solid PRF membranes act as a mechanical barrier (“lubrication” layer) to protect the skin graft from tendon motion. The results of this study support the application of PRF in donor-site reconstruction with free skin grafts.

Reconstruction and Outcome of Foot Defects Following Oncological Resection-Experience from a Cancer Centre in North-East India.

Solid tumours around the foot are rare and include soft tissue sarcomas, skin and bone malignancies. Extended soft tissue defects due to oncological resection result in the loss of shock-absorbing and friction resistant tissue, which leads to altered walking patterns and pain. Replacement of plantar tissue requires soft tissue resistant to weight, pressure and shear stress. The other important desired goal of foot reconstruction is short wound healing time in order to allow adjuvant therapy at stipulated time. This is a retrospective study from March 2016 to October 2019. A total of twenty-one (n = 21) patients were operated for foot malignancies during this period in our institute and the resulting defects were reconstructed using various methods. Different reconstructive surgeries were performed depending on tumour size, location and general health status of patients. The length of hospitalization and the presence of local postoperative complications were assessed. Functional outcomes were measured in terms of MSTS score. Average age of the series is 53.1years. Sixty-six percent of the patients (n = 14) presented with tumour at the weight bearing areas and 33% patients (n = 7) at the non-weight bearing areas of the foot. Fifty-seven percent of patients (n = 12) presented with malignant melanoma of foot, squamous cell carcinoma was seen in 33% (n = 7) patients and 4% patients (n = 1 each) presented as osteosarcoma and malignant peripheral nerve sheath tumour respectively. The mean MSTS score in patients with weight bearing areas (location) is statistically significant (p = 0.031). There is a significant correlation between the surgical complications and follow up MSTS score (p = 0.046) which signifies that flap related complications result in lower MSTS score. The mean MSTS score was 22.71/30. Complications were observed in three cases which included partial flap necrosis, graft loss and foot stiffness. Simple skin grafts to local flaps maybe a viable option in a limited resource setting based on the location of defect. Free tissue transfer is the ideal choice in case of weight bearing areas to achieve acceptable outcomes.

Liver transplantation of partial grafts after ex situ splitting during hypothermic oxygenated perfusion-The HOPE-Split pilot study.

Partial liver grafts from ex situ splitting are considered marginal due to prolonged static cold storage. The use of ex situ hypothermic oxygenated perfusion (HOPE) may offer a strategy to improve preservation of ex situ split grafts. In this single-center pilot study, we prospectively performed ex situ liver splitting during HOPE (HOPE-Split) for adult and pediatric partial grafts over a 1-year period (November 1, 2020 to December 1, 2021). The primary safety endpoint was based on the number of liver graft-related adverse events (LGRAEs) per recipient, including primary nonfunction, biliary complications, hepatic vascular complications, and early relaparotomies and was compared with consecutive single-center standard ex situ split transplantations (Static-Split) performed from 2018 to 2020. Secondary endpoints included preservation characteristics and early outcomes. Sixteen consecutive HOPE-Split liver transplantations (8 HOPE-Split procedures) were included and compared with 24 Static-Splits. All HOPE-Split grafts were successfully transplanted, and no graft loss nor recipient death was encountered during the median follow-up of 7.5 months (interquartile range, 5.5-12.5). Mean LGRAE per recipient was similar in both groups (0.31 ± 0.60 vs. 0.46 ± 0.83; p=0.78) and split duration was not significantly increased for HOPE-Split (216 vs. 180 min; p=0.45). HOPE-Split grafts underwent perfusion for a median of 125 min, which significantly shortened static cold storage (472 vs. 544 min; p=0.001), whereas it prolonged total ex vivo preservation (595 vs. 544 min; p=0.007) and reduced neutrophil infiltration on reperfusion biopsies (p=0.04) compared with Static-Split. This clinical pilot study presents first feasibility and safety data for transplantation of partial liver grafts undergoing ex situ split during HOPE and suggests improved preservation compared with static ex situ splitting. These preliminary results will allow to set up large-scale trials on the use of machine perfusion in pediatric and split-liver transplantation.

Experimental Clinical Model of Liver Transplantation in Large White Pigs Without Venovenous Bypass: Pre-, Intra-, and Maintenance Care

Liver transplantation in an animal model is challenging due to hemodynamics and intraoperative anesthetic care. Several models are described in the literature employing different techniques such as venovenous bypass or aortic cross-clamping to maintain hemodynamic stability, although few groups keep the animal alive in the postoperative period. This study aims to evaluate a liver transplantation clinical model in pigs without venovenous bypass or aortic cross-clamping. Male pigs weighing 20 to 35 kg underwent liver transplantation surgery without using venovenous bypass or aorta cross-clamping. Protocols were approved by the Animal Care and Use Committee of the University of São Paulo, Brazil. Ten LTs were performed. Cold ischemia and warm ischemia were 119 ± 33.28 minutes and 26 ± 9.6 minutes, respectively. Hemodynamic changes were significantly higher after the postrevasculazation phase: heart rate (P < .001), medium arterial pressure (P < .001), and cardiac output (P=.03). Hypotension was treated with intravenous fluids and, in some cases, with vasoactive drugs especially during the post-reperfusion period. No animals died during the procedure and almost survival until the first postoperative day. Serum aspartate aminotransferase and lactate increased their values in the post-reperfusion phase. Practice-based on laboratory animals improves surgical skills and the development of experimental models aimed at new advances in this field. Perfecting our technique on the swine model, we could move forward to create a small-for-size model, test new therapeutic strategies, and define the boundaries for safely performing an enlarged liver resection or a partial liver graft transplant.

Tear pattern after superior capsular reconstruction using an acellular dermal matrix allograft.

The healing rate and tear pattern of grafts in superior capsular reconstruction (SCR) using acellular dermal matrix (ADM) allograft are poorly understood, and clinical results based on the graft status remain controversial. Fifty-one consecutive patients undergoing arthroscopic SCR with ADM between October 2017 and February 2020 were enrolled. Range of motion, strength, and the visual analog scale pain (PVAS) score, American Shoulder and Elbow Surgeons (ASES) score, and Constant score were evaluated preoperatively and at the last follow-up. Postoperative magnetic resonance imaging was performed in all patients and was obtained at least 6 months (mean, 8.9±3.6 months) after surgery. The graft tear status was analyzed on magnetic resonance imaging, and the numbers of patients who achieved the minimal clinically important difference and patient acceptable symptomatic state were analyzed to determine the differences in outcome according to graft tear status. The range of motion and clinical results improved at a minimum of 1 year (mean, 18±5.4 months), whereas strength in forward flexion and external rotation did not (P=.676 and P=.995, respectively). The graft was intact in 36 of 51 patients (70.6%), 9 patients (17.6%) showed an incomplete graft tear with maintained continuity (partial graft rupture at 1 anchor on either the glenoid or humeral side), and 6 patients (11.8%) showed complete graft rupture (5 on the glenoid side and 1 on the humeral side). In cases with a tear (either incomplete or complete), the odds of achieving the minimal clinically important difference for the PVAS score (P=.047) and ASES score (P=.020) was significantly lower than that of the intact graft. However, when the continuity of the graft was maintained, even in cases with a partial tear, patients who reached the patient acceptable symptomatic state showed significantly higher odds for the PVAS score and trends for the ASES score. After SCR using ADM, the graft status could be classified as intact, an incomplete graft tear (where the continuity between the glenoid and humerus was maintained), or an complete tear. When the graft continuity was maintained, even in incomplete graft tears, patients were generally satisfied with postoperative pain and function at 1 year following SCR.

Repeated use of fibrin sealants kept at room temperature in conjunctival autografting: An animal study.

Purpose:In this study, our aim was to investigate if fibrin adhesives used in conjunctival wound surgery with autologous conjunctival grafts could be used repeatedly at different times after surgical opening.Methods:40 New Zealand rabbits were used in the study. These animals were divided into four groups, each consisting of 10 rabbits, and hence 20 eyes. In the first group (control group), Tisseel fibrin sealant was used on the day the eye was first opened surgically; in the second group, it was used on the seventh day; on the third group, it was used on the 14th day; and in the fourth group, it was used 28 days after surgical opening. The graft from the inferior bulbar conjunctiva was attached using Tisseel fibrin glue to the superior scleral bed at the location where the superior bulbar conjunctiva was excised in the same eye.Results:No microbial growth was detected in the cultures of the samples tested. There were two partial graft loss in group 2 and there was one partial graft loss in each group of the other groups, and further total graft loss was present in one rabbit in group 3. None of the rabbits had any complications like granuloma, Corneal dellen or infection.Conclusion:Based on these results, fibrin sealants can be used repeatedly by storing them at room temperature. Repeated use of fibrin adhesives will reduce the cost of ophthalmologic surgeries and non-ophthalmologic surgeries.

Evaluation of Bacterial Cellulose Dressing versus Vaseline Gauze in Partial Thickness Burn Wounds and Skin Graft Donor Sites: A Two-Center Randomized Controlled Clinical Study.

Objective Bacterial cellulose (BC) dressing, which can maintain a moist environment and prevent the invasion of pathogens, has become a competitive dressing material for burn wound treatment. This study was conducted to evaluate the treatment efficacy of a novel China-made BC dressing for the treatment of second-degree burn wounds and skin graft donor sites. Methods 212 patients with second-degree burn wounds or skin graft donor sites were enrolled from two research centers. They were randomly assigned to the BC dressing group (study group) or the Vaseline gauze (VG) dressing group (control group). Wound conditions were assessed before and after treatment. Dressings were changed according to the condition of the wound bed. Healing rate and healing time were recorded as primary endpoints to evaluate the efficacy of BC dressing against VG dressing. Erythema, swelling, exudation, bleeding, subeschar purulence, and pain were assessed as secondary endpoints. Results 207 participants completed the trial and their wounds all healed within 28 days. The average healing times for superficial and deep secondary burn wounds and skin graft donor sites in the BC group were 8.12, 15.77, and 10.55 days, respectively. In the VG group, the average healing times for superficial and deep secondary burn wounds and skin graft donor sites were 9.30, 15.27, and 11.19 days, respectively. The healing time of superficial burn wounds in the BC group was statistically shorter than that in the VG group. There was no difference in the frequency of dressing changing between two groups. The BC dressing showed equal efficacy with the VG dressing at all secondary endpoints. Conclusion The novel BC dressing could be used for the management of second-degree burn wounds and skin graft donor sites. With a shorter healing time in superficial secondary burn wound than that of the VG dressing, the BC dressing showed noninferiority in the treatment of superficial and deep secondary burn wounds and skin graft donor sites versus the VG dressing. This study is registered with the Chinese Clinical Trial Registry (registry number: ChiCTR1800014377 (http://www.chictr.org.cn)).

Satisfactory functional results and complication rates after anterior glenoid bone block reconstruction in recurrent shoulder dislocation: a mean 4-year follow-up comparative study

BackgroundAnterior recurrent instability of the glenohumeral joint is a common clinical problem among the young population. Glenoid reconstruction with bone graft has become the treatment of choice, particularly in significant deficiency (˃20%). This study aims to assess the functional results of glenoid reconstruction using Latarjet and iliac bone graft in the management of glenoid insufficiency associated with recurrent anterior dislocation of the glenohumeral joint. MethodsPatients suffering from anterior shoulder instability with glenoid defect >20% were included in this study between 2016 and 2021. The university of California at Los Angeles (UCLA) shoulder scale and Constant score were used to assess the functional improvement. Preoperative and final postoperative continuous outcomes were compared with a one-tailed paired t-test and the outcomes across groups were compared using a two-tailed independent t-test. A P-value of <0.05 was considered statistically significant for both tests. ResultsThis trial included 50 patients; twenty-five underwent mini-open Latarjet, and 25 underwent arthroscopic tricortical iliac crest bone grafting (ICBG). The mean follow-up durations were 50.1 ± 5.9 months for Laterjet and 51.6 ± 6.8 months for ICBG. Both techniques showed statistically significant improvement in the final UCLA (31.1 ± 2.1 in Laterjet and 30.2 ± 2.2 in ICBG) and Constant (90.2 ± 4.6 in Laterjet and 89 ± 5.01 in ICBG) scores. There was no statistically significant difference regarding mean age, sex, side of injury, mechanism of injury, follow-up period and clinical outcome between both surgical treatments. At the end of the study, both groups demonstrated statistically significant improvement in the range of motion (p ˂ 0.00001). Only one, non-adherent patient in Laterjet group had post-operative dislocation. In ICBG group, two patients had partial bone graft resorption, 3 graft site morbidities and 1 hardware prominence. ConclusionBoth Laterjet and iliac bone graft procedures had satisfactory functional results in reconstruction of glenoid defect >20% in unstable shoulders with a mean 4-year follow-up. No statistically significant difference was reported in the last postoperative Constant and UCLA scores between both techniques, but Latarjet procedure had fewer complications (4%) than ICBG (24%).Level of evidence: Prospective non-randomized comparative study; level II

Postoperative progress of modified grid incision and sealing with collagen fleece for treatment of Peyronie's disease

ABSTRACT Introduction Recently, there have been reports on partial plaque excision and grafting with collagen fleece technique regarding long term efficacy. However, there is still concern regarding complete regeneration of tunical defect from collagen fleece graft in terms of regenerative medicine. Previously, we introduced a less invasive modified technique by multiple grid incisions of Peyronie's plaque to minimize weakness of regenerated tunica from the collagen fleece graft and consequent veno-occlusive erectile dysfunction. Objective To assess the efficacy of Modified Grid Incision of plaque and sealing with Collagen Fleece through post-operative progress of 31 patients with prospective follow-up study. Methods From Aug 2018, 31 patients with stable Peyronie's disease (PD) were included. Surgical technique was composed 3 major steps; 1) dissection of the neurovascular bundle or urethra according to the location of plaque, 2) multiple deep grid plaque incisions for complete correction of curvature and deformity and 3) sealing with collagen fleece (TachoSil®) without suturing. Prospectively, we assessed the stretched penile length (SPL), totally straightness, penile sono, erectile function preoperatively and 6, 12, 24, 36 months postoperatively. This study was approved by the Institutional Review Board of the Korea University Hospital. Results Mean patient age was 58.5 years (range: 46–75). The mean curvature was 45.95 (15-90) degrees, 8 with hinge and 7with hourglass deformity. Inflatable penile prosthesis(IPP) was inserted in 4 patients and postoperative 30 months in a patient for poor erectile function. Mean follow-up was 15 months (6-36). Daily massage softened the hard thickening of penis gradually from 3 months until 2 year. On follow-up sonography, subcutaneous thickening gradually decreased to near normal at 1 year and the breakage of tunica by grid incision reunited at postoperative 10-12 months. All patients achieved totally straightness. All patients gained preoperative length after 1.6 year. 96% of patients satisfied in GAQ at 1 year. Minor skin problem was occurred in three patients of IPP. Subcutaneous bulging hematoma was occurred in 2 patients but subsided within 3 months. In postoperative erectile function of 27 patients without IPP, spontaneous hard erection was recovered in 10 and the rest are satisfied with PED5 inhibitors. Conclusions Our prospective progress reports with technical modification of various plaque incisions shows that one can achieve a sufficient surgical effect without making defect of tunica albuginea. Precise understanding of the postoperative progressions are necessary for physician's confidence and encouraging the patients for successful clinical outcomes. Disclosure Work supported by industry: no.

Reconstruction of complex oro-mandibular defects by four different modifications of free fibula osteomyocutaneous flap: A prudent alternative to multiple flaps

Resection of advanced oral squamous cell carcinoma results in complex oro-mandibular defects involving external skin, oral mucosa, and bone. Reconstruction of such defects by a single free fibula flap (FFF) is limited by the lack of soft tissue bulk and adequate skin paddle for both intra- and extra-oral coverage. In this study, the reconstruction of large defects was achieved by four modifications of free fibula osteomyocutaneous flap as an alternative to multiple flaps. In this prospective study, 29 patients with complex oro-mandibular defects were reconstructed by FFF from December 2018 to October 2020. Reconstruction was done with any one of the four FFF modifications involving large proximal skin paddle from lateral leg: Strip de-epithelialization (De-Ep), chimeric bipaddle (Ch-Bp), muscle orally and skin extra-orally (Mo-Se), and double microvascular (Db-Mi). Outcome variables assessed were functional and esthetic results, early/late complications, donor site morbidity, and operative time. An algorithm based on Cordeiro's classification is proposed to assist in the selection of appropriate FFF modification. Among 29 patients, De-Ep was used in 13, Ch-Bp in 8, Mo-Se in 7, and Db-Mi in 1 case. None of the flaps underwent total loss. Two cases required re-exploration. The median operative time was 775min. Wound dehiscence and oro-cutaneous fistula were common early and late complications, respectively. Partial split skin graft loss (SSG) was the most common donor site morbidity. Functional and facial aesthetics were acceptable at the end of follow-up. Specific FFF modifications can be recommended in selected scenarios. It is reliable for single-stage reconstruction with satisfactory esthetic and functional outcomes. When used for reconstruction in first primary tumors, the second donor site is preserved, which can prove valuable in the event of a recurrence or second primary.

Irreparable cuff tears: an update on treatment options

The management of irreparable cuff tears can be challenging. Decision-making can be difficult, especially in the young patient, where every effort should be made to preserve the native joint surface and its function. There are a number of options available to the shoulder surgeon, including non-operative and operative. Non-operative options include analgesics, intra-articular steroid injections and physiotherapist-guided rehabilitation. Minimally invasive interventions include arthroscopic debridement, biceps tenotomy, subacromial decompression and suprascapular nerve ablation. Surgical options include partial rotator cuff repair, bridging grafts and superior capsular reconstruction. In the younger patient, various tendon transfer options are available to reduce pain and improve range of motion. In the presence of arthrosis, reverse geometry shoulder arthroplasty offers long-term pain relief and good functional outcome. The surgeon should be aware of the possible treatment options when deciding on management and should tailor the management to the individual's needs and expectations. This article aims to summarize the current practice and literature surrounding this topic.

Postoperative Progress of Modified Grid Incision and Sealing with Collagen Fleece for Treatment of Peyronie's Disease

ABSTRACT Introduction Recently, there have been reports on partial plaque excision and grafting with collagen fleece technique regarding long term efficacy. However, there is still concern regarding complete regeneration of tunical defect from collagen fleece graft in terms of regenerative medicine. Previously, we introduced a less invasive modified technique by multiple grid incisions of Peyronie's plaque to minimize weakness of regenerated tunica from the collagen fleece graft and consequent veno-occlusive erectile dysfunction. Objective To assess the efficacy of Modified Grid Incision of plaque and sealing with Collagen Fleece through post-operative progress of 31 patients with prospective follow-up study. Methods From Aug 2018, 31 patients with stable Peyronie's disease (PD) were included. Surgical technique was composed 3 major steps; 1) dissection of the neurovascular bundle or urethra according to the location of plaque, 2) multiple deep grid plaque incisions for complete correction of curvature and deformity and 3) sealing with collagen fleece (TachoSil®) without suturing. Prospectively, we assessed the stretched penile length (SPL), totally straightness, penile sono, erectile function preoperatively and 6, 12, 24, 36 months postoperatively. This study was approved by the Institutional Review Board of the Korea University Hospital. Results Mean patient age was 58.5 years (range: 46–75). The mean curvature was 45.95 (15-90) degrees, 8 with hinge and 7with hourglass deformity. Inflatable penile prosthesis (IPP) was inserted in 4 patients and postoperative 30 months in a patient for poor erectile function. Mean follow-up was 15 months (6-36). Daily massage softened the hard thickening of penis gradually from 3 months until 2 year. On follow-up sonography, subcutaneous thickening gradually decreased to near normal at 1 year and the breakage of tunica by grid incision reunited at postoperative 10-12 months. All patients achieved totally straightness. All patients gained preoperative length after 1.6 year. 96% of patients satisfied in GAQ at 1 year. Minor skin problem was occurred in three patients of IPP. Subcutaneous bulging hematoma was occurred in 2 patients but subsided within 3 months. In postoperative erectile function of 27 patients without IPP, spontaneous hard erection was recovered in 10 and the rest are satisfied with PED5 inhibitors. Conclusions Our prospective progress reports with technical modification of various plaque incisions shows that one can achieve a sufficient surgical effect without making defect of tunica albuginea. Precise understanding of the postoperative progressions are necessary for physician's confidence and encouraging the patients for successful clinical outcomes. Disclosure No