Graft Position Research Articles

Approach for outflow reconstruction and reperfusion in LDLT with a right lobe graft

Presenter: Nicolas Goldaracena MD | University of Virginia Health System Background: Living donor liver transplantation (LDLT) emerged to overcome the organ shortage and reduce waitlist mortality. However, is a technically demanding operation that requires careful preoperative preparation, as well as a meticulous surgery. To reduce the risk of small for size syndrome, a balance between a sufficient graft size, the degree of the recipient’s portal hypertension and adequate outflow reconstruction to avoid venous congestion of the graft are mandatory. Different approaches are being utilized to perform an optimal outflow reconstruction during LDLT. However, proper graft positioning, enlarged outflow openings and reconstruction of venous outflow of all liver sectors are crucial to achieve a congestion-free graft. Methods: A video abstract is presented illustrating the approach used for venous outflow reconstruction and graft reperfusion during LDLT with a right lobe graft. Results: The living donor graft consisted of a right lobe without the middle hepatic vein (MHV). As venous outflow, the graft had a dominant right hepatic vein (RHV), an accessory segment 6/7 vein and a segment 8 vein that needed reconstruction for optimal graft venous drainage. The approach used consists of performing a total caval clamping that facilitates a wide opening of the recipient’s vena cava, as anastomosis sites, while ensuring an optimal graft positioning and orientation. Once the RHV and segment 6/7 vein are reconstructed, the outflow of the anterior sector (segment 8 vein) is temporarily clamped to be reconstructed sequentially to the MHV following graft reperfusion. Therefore, portal vein anastomosis is then performed and following the release of the caval clamps the graft is reperfused via the portal vein. Once the graft is reperfused, the anastomoses of the graft segment 8 vein to the recipient’s MHV is performed with an interposition cadaveric iliac vein that was previously anastomosed to the segment 8 vein of the graft in the backtable. Conclusion: In our opinion, total caval clamping in LDLT ensures the possibility of providing enlarged outflow openings without compromising graft positioning and orientation. Therefore, this approach allows an optimal venous outflow and a congestion free graft in LDLT. In addition, in order to shorten the total caval clamping time, sequential reconstruction of the anterior sector veins of right lobe grafts can be safely performed following reperfusion of the graft.

Open repair of a type II endoleak facilitated by temporary disconnection of graft components.

Endoleaks are a frequent indication for reintervention after endovascular repair of an abdominal aortic aneurysm. Here we present a method of open repair of a persistent type II endoleak involving graft component separation and reconstruction, in a patient with symptomatic interval aneurysmal sac enlargement despite endovascular coiling and embolization. This case report demonstrates an alternative open technique of endograft component separation and reconstruction that may be required in cases where open repair with sac exploration and vessel oversewing is hindered by the graft position.

Biliary reconstruction during right lobe living donor liver transplantation: state of the problem, options and classification

Objective. To study the features and results of biliary reconstruction in right lobe living donor liver transplantation. To propose a classification of biliary reconstruction, which allows reflecting all its existing and possible variants, taking into account the anatomy of the bile ducts of the graft and recipient and technical features of reconstruction. Materials and methods. From May 2010 to June 2019 a retrospective and prospective analysis of the results of the right lobe living donor liver transplantation was performed for 256 recipients and their donors. One observation was excluded due to lack of data. Results. When the right lobe liver transplantations were performed, grafts with two bile ducts requiring biliary reconstruction most often (52%) were observed, less often grafts with one duct (32%), three ducts (12%), four ducts (3%) and in one case five ducts (<1%) were observed. With the multiple nature of the ducts in 31 cases (12% of all operations) unification ductoplasty was used. Moreover, in the group of reconstructions with the presence of two ducts and in the group with the presence of three or more ducts ductoplasty was used with equal frequency – in 18% of cases. The duct-to-duct anastomoses was formed in 157 cases (61%), bilio-entero anastomoses – in 91 cases (36%) and the combined variant – only in 7 cases (3%). In the first variant (duct-to-duct) during reconstruction in 43 cases (27% of all formed duct-to-ducts, 17% of all transplants performed), the so-called high-order bile ducts (right or left lobar, as well as cystic bile ducts) were used. This article proposes a coding and classification system for the technical features of biliary reconstruction in right lobe living donor liver transplantation. Conclusion. Right lobe living donor liver transplantation accompanied by high variability of the stage of biliary reconstruction, depending on the number of bile ducts in the graft, their condition and relative position. The analysis of our own material made it possible to propose a universal classification and coding method for the types of biliary reconstruction during right lobe living donor liver transplantation. The classification allows to reflect all existing options for biliary reconstruction, depending on the anatomy of the bile ducts of the graft and recipient, the technical features of its implementation. It also simplifies the analysis and statistical processing of the bile duct reconstruction stage in liver transplantation.

Competitive Exclusion of Flavescence dorée Phytoplasma Strains in Catharanthus roseus Plants.

Flavescence dorée phytoplasmas (FDp, 16SrV-C and -D) are plant pathogenic non-cultivable bacteria associated with a severe grapevine disease. The incidence of the two reference strains on cultivated grapevines is unbalanced, and mixed infections are rare. To investigate the interaction between the two strains, Catharanthus roseus plants were graft-infected with both strains, either simultaneously or sequentially. Different combinations of lateral and apical grafting were applied to avoid possible benefits due to graft position. The infection was monitored for four months through a new diagnostic protocol developed for differentiation and relative quantification of the two strains. Regardless of the temporal or spatial advantage at grafting, FD-C generally outcompeted FD-D. The prevalence of FD-C increased over time and, at the end of the experiment, FD-C was the unique strain detected in the aerial part and the roots of 74% and 90% of grafted plants, respectively. These data indicate that the interaction between the two strains results in competitive exclusion. Understanding the bases of the competition between FD-C and FD-D may contribute to explain the biology of the coexistence of different FDp strains under field conditions, aiming at identifying potential suppressor strains, which can provide alternative and environmentally sustainable solutions for FD control.

Cuistow: Chinese Unique Inlay Bristow: A Novel Arthroscopic Surgical Procedure for Treatment of Recurrent Anterior Shoulder Instability with a Minimum 3-Year Follow-Up.

The prevalence of nonunion after the Latarjet procedure remains high. The purpose of the present study was to investigate healing and clinical outcomes after a novel arthroscopic coracoid process transfer procedure. Sixty-three patients who underwent the arthroscopic inlay Bristow procedure combined with Bankart repair were identified, and 51 patients who met the inclusion criteria were enrolled in this study. The key feature of this technique was that the coracoid process was trimmed and fixed into a trough (5 to 10 mm deep) in the glenoid neck with a metal screw. Bone graft union and positioning accuracy were assessed with use of postoperative computed tomography (CT) imaging. Clinical examinations, return to sport, and functional scores (American Shoulder and Elbow Surgeons [ASES] and Rowe scores) were recorded. The mean duration of follow-up (and standard deviation) was 41.5 ± 7.7 months (range, 36 to 48 months). Postoperative CT scans showed that the position of coracoid graft was at 4:10 (from 3:50 to 5:00) (referencing the right shoulder) in the sagittal view. The α angle was 16.4° ± 9.5°, with 4 (7.8%) of 51 screws being over-angulated (α > 25°). On the axial view, the graft position was considered to be flush in 33 patients (64.7%), medial in 11 (21.6%), congruent in 7 (13.7%), and lateral or too medial in none. At 1 year, the coracoid graft had healed in 49 patients (96.1%) and had failed to unite in 2 patients. CT scanning, performed for 47 patients, showed grade-0 osteolysis in 9 patients, grade-1 osteolysis in 21 patients, and grade-2 osteolysis in 17 patients. At the time of the latest follow-up, there was a significant increase in the Rowe score (from 35.5 ± 8.3 to 95.7 ± 7.2) and the ASES score (from 71.2 ± 9.7 to 91.5 ± 4.4), and 87.0% of patients were able to return to sport. No arthropathy was observed in any patient. After a minimum 3-year follow-up, the arthroscopic inlay Bristow procedure resulted in a high rate of graft healing, excellent clinical outcomes, and a high rate of return to sports. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Osseous Healing With Nonrigid Suture Fixation in the Arthroscopic Latarjet Procedure.

Background:The Latarjet procedure is a popular means to surgically address anterior glenohumeral joint instability. Although the Latarjet procedure is becoming increasingly common, challenges persist and include postoperative complications secondary to use of the conventional 2 bicortical fixation screws. Recently, a novel surgical technique using a guided surgical approach for graft positioning with nonrigid fixation via a suture suspensory system has been described.Purpose:To evaluate healing rates and stability of the grafts in patients who underwent this new Latarjet technique.Study Design:Case series; Level of evidence, 4.Methods:We retrospectively gathered anonymized computed tomography (CT) data sets from a total of 107 patients who underwent nonrigid suture fixation using a cortical button fixation for anterior glenohumeral instability. Of the 107 patients, 45 had CT scans performed at 2 different time periods. The CT scans of each patient were compared by 2 fellowship-trained musculoskeletal radiologists. Data recorded included age, sex, date of scan, initial graft position on the glenoid, presence and degree of graft migration relative to the equator on follow-up scan, and percentage of osseous healing (as assessed by osseous bridging) on the follow-up scan. Descriptive statistics were calculated to evaluate the average migration and average percentage of healing at both time points.Results:Our population (n = 45) consisted of 38 men (84.4%) and 7 women (15.6%). The mean age was 27.1 ± 1.1 years. The mean time between initial CT scan (2 weeks postoperatively) and follow-up CT scan was 26 ± 2 weeks. On follow-up scan, reviewer 1 found 75.6% of patients had greater than 75% healing, and reviewer 2 found 70.2% of patients had greater than 75% healing. The center of the graft was measured at or below the equator on follow-up examination in 43 of 45 (95.6%) patients by reviewer 1 and 44 of 45 (97.8%) patients by reviewer 2.Conclusion:Based on these findings, nonrigid suture fixation using a cortical button device offers an effective alternative to traditional screw fixation for the Latarjet procedure with a high level of osseous healing and minimal graft migration.

Excellent Clinical and Radiological Midterm Outcomes for the Management of Recurrent Anterior Shoulder Instability by All-Arthroscopic Modified Eden-Hybinette Procedure Using Iliac Crest Autograft and Double-Pair Button Fixation System: 3-Year Clinical Case Series With No Loss to Follow-Up

PurposeTo evaluate the clinical, functional, and radiological midterm outcomes of the all-arthroscopic modified Eden-Hybinette procedure in patients with recurrent anterior shoulder instability. MethodsA retrospective, single-center case series with prospectively collected data was conducted. The inclusion criterion was traumatic recurrent anterior shoulder instability with significant glenoid bone loss; patients with atraumatic or multidirectional instability were excluded. An all-arthroscopic modified Eden-Hybinette procedure using iliac crest autograft and double-pair button fixation was carried out. All patients were postoperatively assessed for recurrence and apprehension. Shoulder range of motion values and functional scores, including American Shoulder and Elbow Surgeons Score, Oxford instability, Rowe instability, and Walch-Dupplay, were recorded. Graft positions, healing, and absorption were evaluated with computed tomography. Comparisons of values were performed with paired t tests for normally distributed differences and with nonparametric Wilcoxon’s signed rank test otherwise. ResultsThe final study cohort included 28 patients, mean age 36 ± 10 years, and mean follow-up period 43 ± 6 months (range 36 to 53). Median glenoid bone loss was 12.4% (range 8% to 33%). No recurrence occurred, no subjective shoulder instability was reported, and no major complications were documented through the last follow-up. Postoperative shoulder range of motion had no significant differences compared with the healthy side. All final postoperative functional scores significantly increased to show excellent results compared with preoperative values. All grafts were positioned and healed optimally, and none was completely reabsorbed. ConclusionsThe all-arthroscopic modified Eden-Hybinette procedure is safe, leading to excellent clinical and radiological midterm outcomes in patients with recurrent anterior shoulder instability. This technique restores glenoid bone defects and preserves the normal shoulder anatomy. Level of EvidenceIV, therapeutic, retrospective case series

MRI of superior capsular reconstruction graft and associated short-term clinical outcomes in patients with massive irreparable rotator cuff tears

ObjectiveTo assess MRI appearance of the dermal allograft and its correlation with clinical outcome following superior capsular reconstruction (SCR). Materials and methodsThis is a retrospective study of patients who underwent SCR between 2015 and 2018. Patients with postoperative MRI and clinical follow-up were included. Exclusion criteria were preoperative shoulder instability, advanced glenohumeral arthritis, and lack of postoperative MRI or clinical follow-up. Radiographs and MRIs were evaluated for graft integrity and position, acromiohumeral interval, superior subluxation distance (SSD), and glenohumeral cartilage loss. Correlation between imaging and clinical outcome measures were assessed. Results24 shoulders (23 patients) met the inclusion criteria at a mean clinical and MRI follow-up of 9.1 months. There were 12 intact grafts (50%) and 12 torn grafts (50%), most commonly at the glenoid attachment (8/12). Patients with graft tear had greater SSD (mean 10.5 ± 6.1 mm) than those without tear (mean 6.1 ± 3.8 mm) (p = 0.028). SSD > 7.9 mm had a 79% sensitivity and 91% specificity for graft tear. The intact grafts were more commonly covering the superior humeral head (91.7%) compared with the torn grafts (41.7%) (p = 0.027). There was improvement of clinical outcome measures including American Shoulder and Elbow Surgeons score (p = 0.005) and forward elevation (p = 0.021) although there was no correlation between clinical outcome and integrity of the graft. ConclusionSCR results in significant short-term clinical improvement even in the presence of graft tear on postoperative MRIs on current study. Gap between graft and the anchors, non-superior position of the graft, and humeral head superior subluxation can be associated with tear.

Dextroplantation of Left Liver Graft in Infants.

The position of the left side liver graft is important, and it could lead to complications of the hepatic vein (HV) and portal vein (PV), especially in a small child using a variant left lateral section (vLLS) graft. The purpose of this study was to evaluate the outcome of a novel technique for the implantation of a vLLS graft to the right side (dextroplantation) in infants. For 3years, 10 consecutive infants underwent dextroplantation using a vLLS graft (group D). The graft was implanted to the right side of the recipient after 90° counterclockwise rotation; the left HV graft was anastomosed to inferior vena cava using the extended right and middle HV stump, and PV was reconstructed using oblique anastomosis without angulation. Surgical outcomes were compared with the historical control group (n=17, group C) who underwent conventional liver transplantation using a vLLS during infancy. Group D recipients were smaller than group C (body weight <6kg: 50.0% versus 11.8%; P=0.03). The rate of graft-to-recipient weight ratio >4% was higher in group D (60.0%) than C (11.8%; P=0.01). Surgical drains were removed earlier in group D than in group C (15 versus 18 postoperative days [PODs]; P=0.048). Each group had 1 PV complication (10.0% versus 5.9%); no HV complication occurred in group D, but 3 HV complications (17.6%) occurred in group C (P>0.05). Hospital stay was shorter in group D than in group C (20 versus 31 PODs; P=0.02). Dextroplantation of a vLLS graft, even a large-for-size one, was successful in small infants without compromising venous outcomes, compared with conventional vLLS transplantation. We could remove the surgical drains earlier and reduce hospital stays in cases of dextroplantation.

Does Graft Position Affect Subsidence After Anterior Cervical Discectomy and Fusion?

Study Design:Retrospective cohort study.Objective:Implant subsidence is an important prognostic factor after anterior cervical discectomy and fusion (ACDF). Our purpose in this study was to investigate whether graft position affects subsidence after ACDF and to determine if there is a difference in clinical results based on allograft subsidence and position.Methods:We reviewed 92 patients who underwent single-level ACDF with allograft and plate between January 2012 and October 2018. Treatment levels were divided based on allograft position within 2 mm of the posterior margin of the augmented plate (Anterior group) or at greater than 2 mm (Center group). Subsidence was defined as segmental vertebral body height decrease of 2 mm or more at 1 year compared to 1 week after surgery.Results:Overall subsidence prevalence was 15 (16%) cases. Subsidence was 11% in the Anterior group (8/73) and 39% in the Center group (7/19; P = .012). The subsidence group showed smaller graft footprint size (graft/endplate ratio) compared with the nonsubsidence group, and pseudarthrosis occurred frequently in the subsidence. There was no significant difference in clinical results according to graft position. These findings indicate that anterior graft position reduces risk of subsidence (95% confidence interval = 0.085-0.949).Conclusion:To minimize risk of subsidence, the graft should be positioned on the anterior position of the surgical-level endplate. In addition, using a graft appropriate for endplate size will further reduce subsidence.

Arthroscopic Anatomic Glenoid Reconstruction Using Distal Tibial Allograft for Recurrent Anterior Shoulder Instability: Clinical and Radiographic Outcomes

Background: The all-arthroscopic anatomic glenoid reconstruction technique using a distal tibial allograft avoids damage to the subscapularis muscle and allows repair of the capsulolabral tissue. Purpose: To analyze the clinicoradiologic outcomes of patients who underwent this procedure to treat anterior shoulder instability with glenoid bone loss with a minimum 2-year follow-up. Study Design: Case series; Level of evidence, 4. Methods: Over 6 years, 73 patients (52 male and 21 female; mean age, 28.8 years) under the care of the same surgeon underwent arthroscopic stabilization with capsulolabral Bankart repair and bony allograft augmentation of the glenoid for recurrent shoulder instability with significant bone loss. Pre- and postoperative patient-reported functional assessment was performed using 2 questionnaires, the Western Ontario Shoulder Instability Index (WOSI) and the Disabilities of the Arm, Shoulder and Hand, and radiological assessment was performed using radiographs and computed tomography scans obtained preoperatively and approximately 1 year later (mean ± SD, 0.9 ± 1.1 years). Results: The mean follow-up was 4.7 ± 1.1 years. The mean pre- and postoperative WOSI scores were 71.1 ± 17.5 and 25.6 ± 21.9, respectively (P < .001). There were no recurrences of dislocation, although 1 patient had symptoms of subluxation; however, 5 patients had hardware complications that required screw removal. There were no cases of nerve injury. Postoperative computed tomography scans were available for 66 patients. Seven patients were lost to follow-up. The graft union rate was 100%. Overall, graft resorption was <50% in 86% of patients (57/66). Eighteen patients (27%) had no resorption (grade 0), 39 (59%) had <50% (grades 1 and 2), and 9 (14%) had ≥50% (grade 3); however, none had symptoms of instability. The mean alpha angle of the screw between the screw shaft axis and the native glenoid axis was 18.3°± 5.7°. Graft positioning was flush with the glenoid in 61 of 66 patients (92.4%), and vertical positioning was excellent in 64 of 66 patients (97.0%) (3- to 5-o’clock position). Conclusion: Arthroscopic stabilization using distal tibial allograft augmentation resulted in excellent clinicoradiologic outcomes at a 2-year follow-up. This procedure has the advantages of being an anatomic reconstruction that addresses bony and soft tissue instability. However, long-term follow-up studies are necessary for better assessment of outcomes.

Upside-down kidney placement: An alternative in pediatric renal transplantation

Purpose“Upside-down” kidney placement has been reported as an acceptable alternative in cases of technical difficulty in kidney transplantation but there are few reports in the pediatric population.The aim of our study is to analyze whether the placement of the upside-down kidney could affect graft outcome or produce more complications. Materials and methodsA retrospective study was conducted of pediatric kidney transplants performed in our center between 2005 and 2017 with at least 6 months' follow-up.Epidemiological and anthropometric data, type of donor (deceased/living), graft position (normal/upside-down), reason for the upside-down placement, early, medium and long-term complications and renal function were analyzed and compared with patients transplanted in the same period with a normal graft placement. ResultsFrom 181 transplants, 167 grafts were placed in a normal position (mean age: 10 y and mean weight: 30 kg) and 14 were placed upside-down (10 y, 37 kg) mainly because of vessel shortness after laparoscopic nephrectomy. Male predominance was observed in both groups.57% of grafts from the control group and 64% of those from study group came from a living donor.Four vascular and two ureteral re-anastomoses were recorded in the control group and two vascular and one ureteral re-anastomosis in the study group (p > 0.05). In the latter group, no grafts have been lost due to vascular or urological causes and no patients have required dialysis. ConclusionsWhen necessary, an upside-down placement for the renal graft is a safe alternative in the pediatric population. Level of evidenceLevel III.

Early postoperative complications after Latarjet procedure: a single-institution experience over 10 years

The Latarjet procedure is an effective procedure for the treatment of anterior glenohumeral joint instability; however, the complications are concerning. The purpose of this study was to review a single institution's experience with the Latarjet procedure for recurrent anterior glenohumeral instability specifically focusing on early complications. This was a retrospective review of all Latarjet procedures performed at a single institution from August 2008 to July 2018. The 90-day complication rate and associated risk factors for all complications and graft failure were recorded. Postoperative radiographs were reviewed for coracoid graft position and screw divergence. During the study period, 190 Latarjet procedures were performed with 90-day follow-up. The average age was 28.7 ± 11.3 years, male patients comprised 84.2% of the population, and 62.6% of patients had undergone a prior stabilization procedure. We observed 15 complications, for a 90-day complication rate of 9.0%; of the patients, 8 (4.2%) underwent reoperations. Graft or hardware failure occurred in 9 patients (4.7%) with loosened or broken screws, and 6 required reoperations (revision Latarjet procedure in 4, distal tibia allograft in 1, and iliac crest autograft in 1). Fixation with only 1 screw (P < .001) and an increased screw divergence angle (37° ± 8° vs. 24° ± 11°, P = .0257) were statistically associated with graft failure, whereas the use of cannulated screws (P = .487) was not. There were 6 nerve injuries (3.2%), including 2 combined axillary and suprascapular nerve injuries, 1 musculocutaneous nerve injury, 1brachial plexopathy, 1 peripheral sensory nerve deficit (likely axillary), and 1 sensory plexopathy. Suprascapular nerve injury at the spinoglenoid notch was associated with a longer superior screw (41.0 ± 1.4 mm vs. 33.5 ± 3.5 mm, P = .035) and increased screw divergence angle (40° ± 6° vs. 24° ± 11°, P = .0197). The coracoid graft was correctly positioned in the axial plane in 71% of cases and in the coronal plane in 73% of cases. The Latarjet procedure is a procedure that can reliably restore shoulder stability; however, graft- and nerve-related complications are relatively common. Two-thirds of the graft failures required reoperations, and half of the nerve injuries in this study led to residual symptoms. Fixation with only 1 screw and an increased screw divergence angle were significant predictors of graft failure. Suprascapular nerve injury at the spinoglenoid notch was associated with an increased screw divergence angle and longer superior screw.

REMNANT PRESERVATION DOES NOT AFFECT ACCURACY OF TIBIAL TUNNEL POSITIONING IN ACL RECONSTRUCTION - A 3D-CT STUDY OF SINGLE-BUNDLE RECONSTRUCTIONS

Introduction: Remnant preservation, in anterior cruciate ligament (ACL) reconstruction, has potential biological advantages. However, graft positioning remains vital to functional outcome and the prevention of failure. The aim of this study was to investigate the accuracy and precision of tibial tunnel positioning in remnant preservation single-bundle hamstring reconstruction.

Less Invasive Left Ventricular Assist Device Implantation: One Right Step Toward the Future

Less Invasive Left Ventricular Assist Device Implantation: One Right Step Toward the Future

An Arthroscopic “Inlay” Bristow Procedure With Suture Button Fixation for the Treatment of Recurrent Anterior Glenohumeral Instability: 3-Year Follow-up

Background: Coracoid graft positioning, fixation, and bone union are key factors affecting the clinical outcomes of Bristow and Latarjet procedures. We developed an arthroscopic “inlay” Bristow procedure based on the “mortise-tenon” joint structure concept using suture button fixation to achieve more stable fixation and better bone union of the graft. Purpose: To evaluate the positioning of the coracoid graft, bone union rate, and clinical outcomes of this arthroscopic inlay Bristow procedure with suture button fixation. Study Design: Case series; Level of evidence, 4. Methods: A total of 62 patients who received the arthroscopic inlay Bristow procedure with suture button fixation between June 2015 to June 2016 were eligible for inclusion, and 56 patients who met the inclusion criteria were enrolled in this study. Radiological assessment on 3-dimensional computed tomography scan was performed preoperatively, immediately after the operation, and postoperatively at 3 months, 6 months, 1 year, and the final follow-up. Pre- and postoperative clinical results were also assessed. Results: A total of 56 patients were included in this study. The mean ± SD follow-up time was 36.1 ± 3.7 months. Coracoid grafts (middle point) were positioned at 4 o’clock (range, 123.8°± 12.3°) in the sagittal view. In the axial view, 94.6% (53/56) of the graft positioning was measured as flush and 5.4% (3/56) as medial. Neither lateral nor too medial positioning was noted. The bone union rate was 96.4% at final follow-up. The mean visual analog scale score for pain during motion, American Shoulder and Elbow Surgeons score, and Rowe score all improved significantly after surgery—from 4.8 ± 2.6 to 1.1 ± 1.0, 69.2 ± 12.5 to 92.5 ± 7.0, and 33.5 ± 12.1 to 96.0 ± 4.9 at last follow-up, respectively. Almost all patients (98%; 55/56) returned to sports within 1 year after surgery at the same or higher level as compared with their preinjury performance. The mean subjective value for sports participation was 90.3% ± 7.1% (range, 70%-100%) as compared with the normal shoulder. The overall complication rate was 3.6%. No degenerative changes were noted in any patients. Conclusion: This study reported the first series of an inlay Bristow procedure with suture button fixation for recurrent shoulder dislocation, providing a satisfactory union rate and excellent graft positioning with a low complication rate. The mortise-tenon joint structure can provide excellent graft fixation and healing, while using suture button fixation instead of screw fixation could reduce osteolysis and complications related to hardware implantation.

Comparison of Iliac and Femoral Autograft Practices in Pemberton Pelvic Osteotomy.

There is no consensus in regard to grafts used after pelvic osteotomy in developmental dysplasia of the hip in the literature. The aim of this study was to compare iliac and femoral autografts used after Pemberton pelvic osteotomy (PPO). In this prospective, randomized study, 60 hips with dysplasia of the hip were included. All patients underwent open reduction, PPO, and femoral shortening osteotomy. Iliac autograft (group I; n=30 hips; mean age, 39.07; range, 18 to 72 mo) and femoral autograft (group II; n=30 hips; mean age, 42.53; range, 19 to 70 mo) were used to fill the iliac osteotomy. The height and width of the iliac and femoral autografts were measured intraoperatively. Anteroposterior pelvic radiographs were obtained on the 45th day, and in the 2nd, 3rd, 6th, and 12th months postoperatively. Acetabular index angle, height of the graft, loss of graft position, graft resorption, operative time, blood loss, and union time were compared between the groups. There was a significant difference in each group in terms of loss of graft height between the intraoperative measurement and the postoperative measurement at the 6th week and 3rd month. The intraoperative width of the grafts was significantly greater, loss of graft height was significantly less, and the amount of bleeding was significantly lower in group II (P<0.001 for all 3). However, time to union was significantly shorter in group I (P<0.001). There was no significant difference between the groups in terms of acetabular index angle at the last controls. There were loss of graft position in 2 cases and graft resorption in 1 case for group I, but no such cases occurred for group II. Graft height and position loss, donor site morbidity, and graft resorption were less in the femoral autografts group compared with the iliac autografts group in the treatment PPO with femoral shortening osteotomy. Level II.

3D Planning and Printing of Patient Specific Implants for Reconstruction of Bony Defects.

We are in the midst of the 3D era in most aspects of life, and especially in medicine. The surgical discipline is one of the major players in the medical field using the constantly developing 3D planning and printing capabilities. Computer-assisted design (CAD) and computer assisted manufacturing (CAM) are used to describe the 3D planning and manufacturing of the product. The planning and manufacturing of 3D surgical guides and reconstruction implants is performed almost exclusively by engineers. As technology advances and software interfaces become more user-friendly, it raises a question regarding the possibility of transferring the planning and manufacturing to the clinician. The reasons for such a shift are clear: the surgeon has the idea of what he wants to design, and he also knows what is feasible and could be used in the operating room. It allows him to be prepared for any scenario/unexpected results during the operation and allows the surgeon to be creative and express his new ideas using the CAD software. The purpose of this method is to provide clinicians with the ability to create their own surgical guides and reconstruction implants. In this manuscript, a detailed protocol will provide a simple method for segmentation using segmentation software and implant planning using a 3D design software. Following the segmentation and stl file production using segmentation software, the clinician could create a simple patient specific reconstruction plate or a more complex plate with a cradle for bone graft positioning. Surgical guides can be created for accurate resection, hole preparation for proper reconstruction plate positioning or for bone graft harvesting and re-contouring. A case of lower jaw reconstruction following plate fracture and nonunion healing of a trauma sustained injury is detailed.

Can Surgeons Identify ACL Femoral Ridges Landmark and Optimal Tunnel Position? A 3D Model Study

PurposeTo examine the ability of surgeons to identify the osseous landmarks associated with the femoral anterior cruciate ligament (ACL) footprint and locate optimal tunnel placement on 3-dimensional (3D) printed models compared with intraoperative placement.MethodsTwelve sports fellowship-trained orthopaedic surgeons were asked to identify a femoral landmark and an ACL footprint on 10 different 3D printed knees. The 3D models were made based on 20 real patients with different anatomical morphology who later received ACL reconstructive surgery using independent drilling. ImageJ software was used to quantify the measurements, which were then analyzed using descriptive statistics.ResultsOverall, none of the surgeons were able to consistently identify the junction of the bony ridges. The mean error per participant ranged from 2.81 to 7.34 mm in the proximal direction (P = 3.30e-05) and from 2.42 to 8.05 mm in the posterior direction (P =4.88e-12). None of the surgeons were able to appropriately identify the center of the femoral footprint on the anatomic 3D models. The difference between the center of the footprint surgeons identified on the 3D model and the tunnel graft location in surgery was significantly different (P = .0046). On average, the magnitude of the error when the surgeons performed the actual surgery was 3.72 ± 2.43 mm, whereas on the 3D models it was 5.82 ± 1.97 mm.ConclusionsExperienced sports fellowship-trained orthopaedic surgeons were unable to correctly identify the junction of the intercondylar and bifurcate ridges and the native ACL footprint on 3D models. Operatively placed tunnels were more accurate implying that looking either through a scope or soft-tissue landmarks play a significant role in surgeons ACL footprint localization.Clinical RelevanceThe graft position for ACL reconstruction plays an important role on the kinematics of the knee. This paper shows that soft tissue landmarks are needed to provide reliable reference points for reconstruction.

Three-Dimensional Navigation (O-arm) for Minimally Invasive Shelf Acetabuloplasty

Hip dysplasia is an important cause of osteoarthritis in young adults. For these patients, conservative treatment is an interesting alternative to arthroplasty. The current literature suggests better clinical and functional outcomes when shelf acetabuloplasty is performed for a moderate joint pinch (<50%) associated with an important external coverage defect of the acetabular cup (<25°). Compared with open surgical procedures, minimally invasive surgical techniques or arthroscopy tend to reduce morbidity. To date, the major intraoperative difficulty remains the positioning of the graft. This Technical Note aims to outline a minimally invasive shelf acetabuloplasty, with optimization of the position of the autologous iliac crest bone graft using 3-dimensional navigation.