Primary Grafting Research Articles

Time-programmed release of curcumin and Zn2+ from multi-layered RSF coating modified PET graft for improvement of graft-host integration

Artificial graft serves as the primary grafts used in the clinical management of sports-related injuries. Until now, optimizing its graft-host integration remains a great challenge due to the excessive inflammatory response during the inflammatory phase, coupled with an absence of tissue-inductive capacity during the regeneration phase. Here, a multi-layered regenerated silk fibroin (RSF) coating loaded with curcumin (Cur) and Zn2+ on the surface of the PET grafts (Cur@Zn2+@PET) was designed and fabricated for providing time-matched regulation specifically tailored to address issues arising at both inflammatory and regeneration phases, respectively. The release of Cur and Zn2+ from the Cur@Zn2+@PET followed a time-programmed pattern in vitro. Specifically, cellular assays revealed that Cur@Zn2+@PET initially released Cur during the inflammatory phase, thereby markedly inhibit the expression of inflammatory cytokines TNF-a and IL-1β. Meanwhile, a significant release of Zn2+ was major part during the regeneration phase, serving to induce the osteogenic differentiation of rBMSC. Furthermore, rat model of anterior cruciate ligament reconstruction (ACLR) showed that through time-programmed drug release, Cur@Zn2+@PET could suppress the formation of fibrous interface (FI) caused by inflammatory response, combined with significant new bone (NB) formation during regeneration phase. Consequently, the implementation of the Cur@Zn2+@PET characterized by its time-programmed release patterns hold considerable promise for improving graft-host integration for sports-related injuries.

Kommentar zu "Combined Reconstruction of the Ulnar Nerve after its wide Resection by Nerve Grafting at the Site of the Resection and distal Transfer of the Anterior Interosseus Nerve to the deep Branch of the Ulnar Nerve".

The authors present the case of a 46 year old patient who was treated for recurrent neurofibroma of the proximal ulnar nerve by complete resection and primary grafting in combination with transfer of the anterior interosseous nerve (AIN) to the deep motor branch of the ulnar nerve (DMBUN) [1]]. Although motor recovery did not occur, the authors conclude that this approach should always be considered in proximal injuries of the ulnar nerve.

Gluteal Fold V-Y Advancement Flap for Genital Reconstruction following Radical Vulvectomy with Bilateral Inguinofemoral Lymphadenectomy in Vulvar Cancer: A Case Report

Background: Vulvar cancer is a rare malignancy representing about 4% of all genital cancers in women. Historically, the gold standard for treatment of squamous cell carcinoma of the vulva was en bloc radical vulvectomy with bilateral inguinofemoral lymphadenectomy. For the reconstruction the options are primary closure, skin grafts, or local and distant flaps. In this case we used the gluteal fold fasciocutaneous V-Y advancement flap that is sensate and thin with a reliable blood supply, can be advanced easily, and can be performed in a single-stage procedure. Care Report: We present a clinical case of an 82- year old female patient who had an exophytic vulvar lesion, which grew progressively with the histopathologic diagnosis of invasive vulvar squamous cell carcinoma. It was decided to perform radical vulvectomy with right unilateral lymphadenectomy and reconstruction with Gluteal Fold V-Y Advancement Flap. During the post-surgical period it recurred with wound dehiscence and finally skin necrosis developed in the area of the left thigh. Surgical debridement, escharectomy, harvesting and application of skin graft, and closure of the femoral hernia with omentum patch were performed with no associated complications. Follow-up was carried out during the next 3 months after surgery. She presented adequate evolution of the flap and left thigh area. Conclusions: The Gluteal Fold V-Y Advancement Flap is an excellent option for the reconstruction of the vulvovaginoperineal area after a radical vulvectomy. It provides us with a good prognosis and quality of life for the patient. Article Details Issue

PRIMARY BONE GRAFTING AND K-WIRE FIXATION: A PREFERABLE OPTION TO TREAT ACUTE UNSTABLE SCAPHOID FRACTURE

Objective: The Objective of this study is to analyze the radiological, clinical and functional outcome of patients with acute unstable scaphoid fracture treated with primary bone grafting and K (Kirschner)-wire fixation Methods:Based on inclusion and exclusion criteria , a prospective observational study was carried out on 21 patients with acute unstable scaphoid fracture who had been treated with primary bone grafting and K-wire fixation from November 2017 to March 2020 and were followed up for a minimum of 24 weeks. The average patient age was 26.9 years. The time from injury to treatment averaged 11days. Surgery was done under Bier’s Block using volar approach. Bone graft was harvested from distal Radius. The mean operating time was 24 minutes.Clinical parameters like tenderness, grip strength and Range of Movement (ROM) at wrist was assessed. The functional outcome was evaluated using Modified Mayo wrist score. Bone union was assessed using serial plain radiographs. Results:Union was achieved in all (100%) at 12 weeks. There was no evidence of Avascular necrosis (AVN) or arthrosis at latest follow up. As per Modified Mayo wrist score, there were 15 excellent,03 good and 03 fair results at the final follow-up. Individuals resumed their routine work at 12 weeks and all were comfortable with heavy works/ sports activity by 24 weeks. Conclusion: Primary bone grafting has a definite role in the management of acute unstable scaphoid fracture by which aquicker and higher rate of union isachieved with minimal complications. Open reduction allows thorough assessment of fracture for better anatomic reduction. Although the type of fixation device hardly contributes for quicker and higher union, but then the use of K-wire for fixation is the only viable option for smaller bony fragments and is more forgiving in terms of its positioning. It has an added advantage in terms of requirement of minimal inventory and thus is a cost-effective modality. This procedure also confirms that the patients could get back to their work earlier hence decreasing economic burden.

Primary angiosarcoma of the aorta in association with an endurant stent graft

Introduction: Angiosarcomas are extremely rare tumors, especially those arising in the aorta. Case Report: We uniquely present a case where primary aortic angiosarcoma was found in a 68-year-old woman in association with an Endurant stent graft. Conclusion: Only a handful of cases have shown an association between the development of primary angiosarcoma and other endovascular grafts, such as a Dacron stent graft. However, this may be the first case to report an association with an endurant stent graft.

Antiplatelet therapy after pancreaticoduodenectomy with portal vein resection as the optimal preventative strategy for maintaining primary vein patency

Aim: Anticoagulation after pancreaticoduodenectomy with portal vein resection is relevant to maintaining vein patency; however, no uniformly accepted algorithm exists for anticoagulant selection. We evaluated patients undergoing pancreaticoduodenectomy with various degrees of portal venous resection and reconstruction to determine the optimal regimen for anticoagulation therapy. Methods: A retrospective review of 51 patients with pancreatic adenocarcinoma who underwent pancreaticoduodenectomy with venous resection was performed (2006 through 2016). Venous resections were categorized as tangential, segmental with primary anastomosis, or segmental with vein graft. Type of anticoagulation selected by the surgeon was noted. The primary outcome was vein patency measured through the first year postoperatively. Results: Of 33 patients eligible for study, 7 underwent tangential resection, 16 underwent segmental resection, and 10 underwent vein graft. Vein patency rates at 2, 4, 6, and 11 months were 96.9%, 93.1%, 89.3%, and 62.5%, respectively. All patients with tangential resection showed patency at six months, regardless of the use of anticoagulation or not. For segmental resection, patency was higher with antiplatelet/warfarin (62.5%) compared with no treatment (25%). For segmental resection with vein graft, patency at 10 months was higher with antiplatelet therapy (80%) compared with warfarin (33%). Conclusion: For patients undergoing pancreaticoduodenectomy with portal vein resection, anticoagulation therapy may be guided by the degree of resection and reconstruction required. Although anticoagulation therapy may be unnecessary with tangential vein resection, anticoagulation in the form of antiplatelet therapy may be preferable in patients who have segmental vein resections with primary anastomoses and vein grafts.

Five Years Pathological Evaluation of Corneal Regrafts: A Study from Southern Iran.

Purpose Corneal regrafts sometimes needed to restore the transparency after graft failure. The aim of the study is five years epidemiologic and histopathological evaluation of corneal regrafts. Methods In this cross-sectional study, all corneal regrafts during 5 years (2012–2016) were assessed in the Khalili Ophthalmology Center at Shiraz city. Demographic data including age, area of residence, primary disease, type of graft, cause of regraft, interval between primary and subsequent grafts (IPSG), associated eye diseases or surgeries, and systemic diseases were recorded. Also, microscopic findings of corneas were reviewed. Results Among a total of 1190 corneal grafts, 76 of them (6.38%) were regrafts. The most common type of grafting was penetrating keratoplasty (PK). The shortest IPSG was observed in fungal keratitis. Main causes of graft failure were endothelial dysfunction, infection, immunologic rejection, technical problems, and recurrence of primary disease, respectively. The most common histopathological finding in failed grafts was severe endothelial cell loss (89.8%). Also, more than half and one-third of cases had Descemet membrane changes and stromal ingrowth, respectively. Conclusion Endothelial cell loss was the major cause of failure in our study. Also, recurrence rate in infective cases, especially fungal keratitis, was very high. Considerable presence of histopathological changes such as doubling of Descemet membrane and retrocorneal fibrous ingrowth need further investigations. Perhaps, modification in techniques of corneal grafting and assessment of donor tissue and recipient bed along with any need for longer medical treatment are the basis for future studies in order to increase graft survival.

Long-Term Review of Penetrating Keratoplasty: A 20-Year Review in Asian Eyes

To review the long-term outcomes of optical, therapeutic and tectonic forms of penetrating keratoplasty over a 20-year period in Asian eyes. Prospective cohort study involving the Singapore Corneal Transplant Study (SCTS). All penetrating keratoplasties (PK) performed at the Singapore National Eye Centre (SNEC) from January 1991 to December 2010 were analyzed using records from the computerized database of the SCTS. This database includes preoperative, intraoperative, and postoperative patient data and donor cornea data. Only primary grafts were included. Patient demographics, donor cornea source, indications for grafting, complications, graft survival rate, and causes of graft failure were analyzed. A total of 1,206 primary PKs were performed. The mean age of the patients was 55 years (range: <1-101 years). The overall corneal graft survival rates at 1, 5, 10, 15, and 20 years were 91%, 66.8%, 55.4%, 52%, and 44%, respectively. For optical grafts, pseudophakic bullous keratopathy, postinfectious corneal scarring and thinning and keratoconus were the most common diagnoses. Graft survival for optical grafts was significantly better than therapeutic and tectonic grafts at all time points. Multivariate analysis suggested that a younger donor cornea age and higher donor endothelial cell count are associated with better long-term graft survival for optical grafts. Irreversible allograft rejection and late endothelial failure accounted for more than 60% of graft failures. Graft survival decreased over time from 91% at 1 year to 44% at 20 years' follow-up. Allograft rejection and late endothelial failure accounted for more than 60% of graft failures.

Outcome of primary tendon grafts for open Zone 3 extensor tendon injuries

Open injuries of the extensor mechanism in Zone 3 (dorsum of the proximal interphalangeal joint) have poor outcomes. We retrospectively analysed the outcomes of treating 19 Zone 3 extensor tendon injuries in 17 patients. The treatment comprised wound excision and debridement, primary tendon graft to reconstruct the damaged/missing extensor tendon, skeletal fixation when required, local flaps to vascularize the zone of injury and immediate short arc motion therapy. Using the criteria defined by Geldmacher etal., the outcome was predicted to be poor in nine, satisfactory in seven and good in three cases. In this study the outcomes were excellent in 10, good in six and satisfactory in three cases. Mean range of motion was 75° (range 25°-115°) at the proximal interphalangeal joint. We conclude that using the protocol described there should no longer be the perception of a dismal outcome for these complex Zone 3 extensor tendon injuries.Level of evidence: IV.

Haploidentical stem cell transplantation with post-transplant cyclophosphamide for osteopetrosis and other nonmalignant diseases.

Allogeneic hematopoietic stem cell transplantation (HSCT) is curative for a variety of nonmalignant disorders including osteopetrosis, bone marrow failures, and immune deficiencies. Haploidentical HSCT is a readily available option in the absence of a matched donor, but engraftment failure and other post-transplant complications are a concern. Post-transplant cyclophosphamide (PT-Cy) regimens are gaining popularity and recent reports show promising results. We report our experience with nine pediatric patients with nonmalignant diseases who were transplanted from a haploidentical donor with PT-Cy. From 2015 to 2019, nine children with nonmalignant diseases underwent haploidentical HSCT with PT-Cy, two as a second transplant and seven as primary grafts after upfront serotherapy and busulfan-based myeloablative conditioning. Patient’s diseases included osteopetrosis (n = 5), congenital amegakaryocytic thrombocytopenia (n = 2), hemophagocytic lymphohistiocytosis (n = 1), and Wiskott Aldrich syndrome (n = 1). Two patients failed to engraft following upfront PT-Cy transplants, one was salvaged with a second PT-Cy transplant, and the other with a CD34+ selected graft. None of the patients suffered from graft-versus-host disease. Three patients died from early posttransplant infectious complications and six patients are alive and well. In conclusion, haploidentical HSCT with PT-Cy is a feasible option for pediatric patients with nonmalignant diseases lacking a matched donor.

Pluripotent stem cell-derived skeletal muscle fibers preferentially express myosin heavy-chain isoforms associated with slow and oxidative muscles

BackgroundSkeletal muscle function is essential for health, and it depends on the proper activity of myofibers and their innervating motor neurons. Each adult muscle is composed of different types of myofibers with distinct contractile and metabolic characteristics. The proper balance of myofiber types is disrupted in most muscle degenerative disorders, representing another factor compromising muscle function. One promising therapeutic approach for the treatment of these diseases is cell replacement based on the targeted differentiation of pluripotent stem cells (PSCs) towards the myogenic lineage. We have previously shown that transient induction of Pax3 or Pax7 in PSCs allows for the generation of skeletal myogenic progenitors endowed with myogenic regenerative potential, but whether they contribute to different fiber types remains unknown.ResultsHere, we investigate the fiber type composition of mouse PSC-derived myofibers upon their transplantation into dystrophic and non-dystrophic mice. Our data reveal that PSC-derived myofibers express slow and oxidative myosin heavy-chain isoforms, along with developmental myosins, regardless of the recipient background. Furthermore, transplantation of the mononuclear cell fraction re-isolated from primary grafts into secondary recipients results in myofibers that maintain preferential expression of slow and oxidative myosin heavy-chain isoforms but no longer express developmental myosins, thus indicating postnatal composition.ConclusionsConsidering oxidative fibers are commonly spared in the context of dystrophic pathogenesis, this feature of PSC-derived myofibers could be advantageous for therapeutic applications.

The Use of Angioscopy in Vascular Access Surgery: Shedding New Light

Introduction: Angioscopy is a well-recognised surgical technique used in luminal assessment of native vessels and grafts. It allows direct visualisation of the lumen and its internal surface. It is increasingly being utilised in coronary arteries, lower limb vessels and vascular grafts. However, its role in vascular access for haemodialysis is still uncertain. Methods: Operative notes of angioscopies for dysfunctional AV fistula in a district general hospital were analysed. A Pubmed search was also performed from inception to September 2018 for English-language studies on the use of angioscopy and vascular access for haemodialysis. Outcomes such as identification of luminal abnormalities and additional surgical intervention needed were extracted and analysed. Results: A total of 13 angioscopies for AV fistula were performed from January 2001 to September 2018. Abnormalities identified include the presence of thrombus and irregular surface of the intima. Retrieval of thrombus using a fogarty catheter or biopsy forceps via the operating port of the angioscope under direct vision was also performed. Only 4 retrospective observational studies met the inclusion criteria. A total of 131 patients were included in the eligible studies with 185 angioscopies performed. 97 angioscopies were performed during revision of grafts and 88 in primary grafts. Fibrescopes with outer diameter ranging from 0.8mm to 2.8mm and 300W xenon light source were used. Indications for angioscopies include assessment of suitability of native vessels in primary procedure and identifying site of stenosis and occlusion, and retained thrombus in revision procedures. 94 (97%) revision angioscopies successfully identified abnormalities i.e. thrombus or stenosis, which led to additional surgical intervention including repeated thrombectomies and angioplasties. Conclusion: Angioscopy is a valuable technique in the assessment and management of vascular access for haemodialysis which allows direct visualisation on the luminal surface of the graft or native vessels. It also allows retrieval of thrombus under direct vision. The limited available data on this subject provides opportunity for further studies. Disclosure: Nothing to disclose

Surgical Coverage of Diabetic Feet

Historically, patients with chronic diabetic foot ulcers were managed with major lower extremity amputations such as below-knee amputations and above-knee amputations. With the advancement of microsurgical techniques, patients have been able to achieve limb salvage and reap the associated morbidity and mortality benefits. In order to ensure successful limb salvage, a patient’s biomechanic, diabetic, vascular, and infectious profiles need to be optimized. Serial debridement supplemented with antibiotics until negative deep tissue cultures is the gold standard for infection eradication. A surgeon needs to have a good understanding of patient and wound-specific anatomic considerations. Simpler techniques, such as primary closure, skin grafting, and Integra placement, may be used. In complex wounds, more involved reconstructive modalities, such as local flap or free tissue transfer, may be required. Coverage selection depends on an intimate understanding of the patient’s comorbidities, wound characteristics, and vascular status. This review contains 7 figures, 2 tables, and 32 references. Keywords: diabetic foot ulcer, chronic wound, nonhealing vasculopathic wound, local flap, free flap, free tissue transfer, abductor digiti minimi flap, abductor hallicus flap, flexor digitorum brevis flap

Principles of Wound Management and Soft Tissue Repair I

Principles of initial wound management include adequate debridement, bacterial contamination assessment, nutritional optimization, and moist wound healing versus the use of negative-pressure wound therapy. The main goals of coverage procedures are to achieve a healed wound and avoid infection. Aside from allowing to heal by secondary intention, options for wound closure include primary closure, skin grafting, local flaps, and free flaps. Each wound should be evaluated on an individual basis to determine which method of coverage is most appropriate. This review contains 13 figures, 2 tables, and 22 references. Key Words: free tissue transfer, pedicle flaps, soft-tissue coverage, wound closure, wound healing, wound management, wound reconstruction, tissue flaps

Principles of Wound Management and Soft Tissue Repair I

Principles of initial wound management include adequate debridement, bacterial contamination assessment, nutritional optimization, and moist wound healing versus the use of negative-pressure wound therapy. The main goals of coverage procedures are to achieve a healed wound and avoid infection. Aside from allowing to heal by secondary intention, options for wound closure include primary closure, skin grafting, local flaps, and free flaps. Each wound should be evaluated on an individual basis to determine which method of coverage is most appropriate. This review contains 13 figures, 2 tables, and 22 references. Key Words: free tissue transfer, pedicle flaps, soft-tissue coverage, wound closure, wound healing, wound management, wound reconstruction, tissue flaps

Transgenic Expression of hCD47 on Vessels in Porcine GalTKO Lung Grafts in Baboons may Mitigate Acute Vascular Rejection in Baboons

Background Despite recent progress in survival times of xenografts in nonhuman primates, there are no reports of survival beyond 5 days of histologically well-aerated porcine lung grafts in baboons. Here we report our initial results of pig-to-baboon xeno lung transplantation (XLTx). Methods Study 1: Eleven baboons received genetically modified porcine left lungs as primary grafts that were histologically confirmed to be either GalT-KO alone (n=3), GalT-KO/humanCD47(hCD47)/hCD55 (n=3), GalT-KO/hD47/hCD46 (n=4) or GalTKO/hCD39/hCD55/hTBM/hEPCR (n=1) Tg swine. Study 2: Three porcine lung grafts were transplanted to baboons that had received a tolerance-inducing regimen and showed pig specific unresponsiveness in vitro by IFNg ELISPOT and FACS analysis. Two of these were hCD47+ GalTKO lungs and the third was GalTKO alone. Results Study 1: Survivals of primary lung grafts were 1, 1, 2, 3, 5, 5, 6, 7, >7, 9 and 10 days. One baboon with graft survival >7 days, whose entire lung graft remained well-aerated, was euthanized on POD7 due to malfunction of femoral catheters. No statistical difference was seen in preformed nAb cytotoxicity levels between >7 day survivors and others (20% vs 27%). hCD47 expression of donor lungs was detected on both endothelial cells (ECs) and alveoli (Alv) only in the three grafts surviving >7, 9 and 10 days. All other grafts lacked hCD47 expression in endothelial cells and were completely rejected with diffuse hemorrhagic changes and antibody/complement deposition detected in association with early graft loss. Study 2: Delayed pig lung transplant survivals were 2 days (GaTKO alone), 4 days (hCD47+/GalTKO) and 13 days (hCD47+/GalTKO). The lung graft of the 13-day survivor expressed hCD47 on both ECs and Alv while the graft of the 4-day survivor expressed hCD47 only on Alv.Conclusions To our knowledge, this is first evidence of histologically viable porcine lung grafts up to 13 days in baboons. Our results indicate that GalT-KO pig lungs are highly susceptible to acute humoral rejection. Transgenic expression of hCD47 on vascular ECs in porcine GalTKO lung grafts appeared to be important to mitigate acute vascular rejection in baboons. Lung Biotechnology PBC. NIH P01AI45897.

Radical resection and local coverage of hidradenitis suppurativa - acne inversa: analysis of results.

to evaluate the primary outcome of local complications and late recurrence in patients with hidradenitis suppurativa undergoing radical resection and specific reconstruction. we conducted a retrospective analysis of the medical records of patients attended by the Plastic Surgery Service of the Clinics Hospital, Medical School, USP, between 2010 and 2016. We included patients who underwent radical resection of hidradenitis suppurativa in advanced stage and reconstruction through primary closure, grafts or flaps. we analyzed 34 lesions in 19 patients, of which 64.5% had local complications, though with 73.5% efficient healing after 12 weeks postoperatively. We observed late recurrence in 47%, but in isolation, 22.2% of the reconstructions with locoregional flaps had recurrence after one year. extensive and radical resection of the disease associated with locoregional flap coverage (pedicled or perforating) has been shown to be the best management in terms of late results.

Repeat coronary artery bypass grafting using in combination with resection of post-infarction left ventricular aneurysm off-pump, 10 years after primary autovenous coronary artery bypass grafting.

Repeat coronary artery bypass grafting using in combination with resection of post-infarction left ventricular aneurysm off-pump, 10 years after primary autovenous coronary artery bypass grafting.

Results of Infrageniculate Bypasses Using the Profunda Femoris Artery as Inflow Source

When the common femoral artery is not accessible for infrainguinal bypass grafting, the profunda femoris artery (PFA) can be a valuable alternative inflow source for distal arterial revascularization. The purpose of this retrospective study was to evaluate the results of infrageniculate bypass grafting via the PFA as inflow source for critical limb ischemia. Between 1994 and 2016, 68 patients, 51 men of a mean age of 74years, underwent an infrageniculate arterial bypass grafting for critical limb ischemia, using the PFA as inflow site. PFA was exposed at the Scarpa's triangle in 38 patients (56%) and at its medio-crural segment in 30 patients (44%). The distal anastomosis was performed on the infragenicular popliteal artery in 33 patients (48%), the peroneal artery in 14 patients (20%), the tibioperoneal trunk in 8 patients (12%), the posterior tibial artery in 8 patients (12%), and the dorsalis pedis artery in 5 patients (8%). The graft material consisted of a reversed great saphenous vein (GSV) in 62 patients (91%) and a 6-mm polytetrafluoroethylene graft in 6 patients (9%). The median duration of follow-up was 51months (range, 6-72months). As main results, postoperative mortality and morbidity, overall late patients' survival, primary grafts' patency, and limb salvage rate were considered. Operative mortality and morbidity were 3% and 4%, respectively. Overall patients' survival, primary patency and limb salvage rate, at 36 and 60months were, respectively, 62% and 53%, 66% and 59%, and 92% and 77%. The PFA, both exposed at the Scarpa's triangle and at mid-thigh, is an excellent inflow source for infrageniculate revascularizations. It should remain an important part of the technical armamentarium of vascular surgeons, even in the endovascular era.

Outcomes of penetrating keratoplasty in congenital hereditary endothelial dystrophy

Background/aimTo report the outcome of penetrating keratoplasty (PKP) in Irish patients with congenital hereditary endothelial dystrophy (CHED).MethodsA retrospective case series review of patients with CHED who underwent PKP was conducted....