Machine Perfusion or Straight to Transplant? Predictive Value of Flavin Mononucleotide Levels in Flush Solution of Human Liver Allograft.

OBJECTIVE: This study examined the predictive value of Flavin Mononucleotide (FMN) levels in the flush solution used during cold storage of donor livers on outcomes post-transplantation. BACKGROUND: Static cold storage for liver grafts induces hypoxia with subsequent impaired mitochondrial function and Flavin Mononucleotide (FMN) release upon reperfusion. METHODS: This study enrolled 62 recipients who received whole liver grafts from donation after brain death (n=50) and circulatory death donors (n=12) between June 2022 and July 2023. FMN concentrations were measured in flush solutions on the back-table. ROC-curve analysis identified an FMN level cut-off for graft survival. Post-transplant outcomes were examined according to FMN levels. RESULTS: FMN level was significantly associated with graft survival, with an area-under-the-curve (AUC) of 0.858 (95%CI: 0.754-0.963, P<0.001), outperforming the donor risk index (AUC 0.571, 95%CI: 0.227-0.915, P=0.686). The study cohort was divided into low-FMN (<37.5 ng/mL, n=40) and high-FMN groups (≥37.5 ng/mL, n=22). The low-FMN group had superior one-year graft survival compared with the high-FMN group (100% vs. 77%, P=0.003). Levels of transaminases within 7 days post-transplant were significantly higher in the high-FMN group (P=0.003). The high-FMN group developed acute rejections (41% vs. 15%, P=0.023) and early allograft dysfunction (50% vs. 20%, P=0.014) more frequently. Median comprehensive complication index in the high-FMN group was significantly higher (54 [interquartile range, 40-78] vs. 42 [interquartile range, 28-52], P=0.017). CONCLUSION: The FMN level measured in donor livers' cold storage flush solution is a valid biomarker to predict post-transplant outcomes. Liver grafts with high FMN levels may benefit from machine perfusion to improve outcomes.

Expanding Selection Criteria in Deceased Donor Liver Transplantation for Hepatocellular Carcinoma: Long-term Follow-up of a National Registry and 2 Transplant Centers.

BACKGROUND: This study compares selection criteria for liver transplant (LT) for hepatocellular carcinoma (HCC) for inclusivity and predictive ability to identify the most permissive criteria that maintain patient outcomes. METHODS: The Scientific Registry of Transplant Recipients (SRTR) database was queried for deceased donor LT's for HCC (2003-2020) with 3-y follow-up; these data were compared with a 2-center experience. Milan, University of California, San Francisco (UCSF), 5-5-500, Up-to-seven (U7), HALT-HCC, and Metroticket 2.0 scores were calculated. RESULTS: Nationally, 26 409 patients were included, and 547 at the 2 institutions. Median SRTR-follow-up was 6.8 y (interquartile range 3.9-10.1). Three criteria allowed the expansion of candidacy versus Milan: UCSF (7.7%, n = 1898), Metroticket 2.0 (4.2%, n = 1037), and U7 (3.5%, n = 828). The absolute difference in 3-y overall survival (OS) between scores was 1.5%. HALT-HCC (area under the curve [AUC] = 0.559, 0.551-0.567) best predicted 3-y OS although AUC was notably similar between criteria (0.506 < AUC < 0.527, Mila n = 0.513, UCSF = 0.506, 5-5-500 = 0.522, U7 = 0.511, HALT-HCC = 0.559, and Metroticket 2.0 = 0.520), as was Harrall's c-statistic (0.507 < c-statistic < 0.532). All scores predicted survival to P < 0.001 on competing risk analysis. Median follow-up in our enterprise was 9.8 y (interquartile range 7.1-13.3). U7 (13.0%, n = 58), UCSF (11.1%, n = 50), HALT-HCC (6.4%, n = 29), and Metroticket 2.0 (6.3%, n = 28) allowed candidate expansion. HALT-HCC (AUC = 0.768, 0.713-0.823) and Metroticket 2.0 (AUC = 0.739, 0.677-0.801) were the most predictive of recurrence. All scores predicted recurrence and survival to P < 0.001 using competing risk analysis. CONCLUSIONS: Less restrictive criteria such as Metroticket 2.0, UCSF, or U7 allow broader application of transplants for HCC without sacrificing outcomes. Thus, the criteria for Model for End-stage Liver Disease-exception points for HCC should be expanded to allow more patients to receive life-saving transplantation.

Survey of awareness and attitudes to the management of fragility fractures among the membership of the Asia Pacific Orthopaedic Association.

A survey of awareness and attitudes to the management of fragility fractures among the membership of the Asia Pacific Orthopaedic Association conducted in 2022 found considerable variation in care across the region. A Call to Action is proposed to improve acute care, rehabilitation and secondary fracture prevention across Asia Pacific. PURPOSE: Fragility fractures impose a substantial burden on older people and their families, healthcare systems and national economies. The current incidence of hip and other fragility fractures across the Asia Pacific region is enormous and set to escalate rapidly in the coming decades. This publication describes findings of a survey of awareness and attitudes to the management of fragility fractures among the membership of the Asia Pacific Orthopaedic Association (APOA) conducted in 2022. METHODS: The survey was developed as a collaboration between the Asia Pacific Osteoporosis and Fragility Fracture Society and the Asia Pacific Fragility Fracture Alliance, and included questions relating to aspects of care upon presentation, during surgery and mobilisation, secondary fracture prevention, and access to specific services. RESULTS: In total, 521 APOA members completed the survey and marked variation in delivery of care was evident. Notable findings included: Fifty-nine percent of respondents indicated that analgesia was routinely initiated in transit (by paramedics) or within 30 minutes of arrival in the Emergency Department. One-quarter of respondents stated that more than 80% of their patients underwent surgery within 48 hours of admission. One-third of respondents considered non-hip, non-vertebral fractures to merit assessment of future fracture risk. One-third of respondents reported the presence of an Orthogeriatric Service in their hospital, and less than a quarter reported the presence of a Fracture Liaison Service. CONCLUSION: A Call to Action for all National Orthopaedic Associations affiliated with APOA is proposed to improve the care of fragility fracture patients across the region.

Risk assessment in liver transplantation for hepatocellular carcinoma: long-term follow-up of a two-centre experience.

BACKGROUND: Liver transplantation (LT) is a well-established treatment for hepatocellular carcinoma (HCC), but there are ongoing debates regarding outcomes and selection. This study examines the experience of LT for HCC at a high-volume centre. METHODS: A prospectively maintained database was used to identify HCC patients undergoing LT from 2000 to 2020 with more than or equal to 3-years follow-up. Data were obtained from the centre database and electronic medical records. The Metroticket 2.0 HCC-specific 5-year survival scale was calculated for each patient. Kaplan-Meier and Cox-regression analyses were employed assessing survival between groups based on Metroticket score and individual donor and recipient risk factors. RESULTS: Five hundred sixty-nine patients met criteria. Median follow-up was 96.2 months (8.12 years; interquartile range 59.9-147.8). Three-year recurrence-free (RFS) and overall survival (OS) were 88.6% ( n =504) and 86.6% ( n =493). Five-year RFS and OS were 78.9% ( n =449) and 79.1% ( n =450). Median Metroticket 2.0 score was 0.9 (interquartile range 0.9-0.95). Tumour size greater than 3 cm ( P =0.012), increasing tumour number on imaging ( P =0.001) and explant pathology ( P <0.001) was associated with recurrence. Transplant within Milan ( P <0.001) or UCSF criteria ( P <0.001) had lower recurrence rates. Increasing alpha-fetoprotein (AFP)-values were associated with more HCC recurrence ( P <0.001) and reduced OS ( P =0.008). Chemoembolization was predictive of recurrence in the overall population ( P =0.043) and in those outside-Milan criteria ( P =0.038). A receiver-operator curve using Metroticket 2.0 identified an optimal cut-off of projected survival greater than or equal to 87.5% for predicting recurrence. This cut-off was able to predict RFS ( P <0.001) in the total cohort and predict both, RFS ( P =0.007) and OS ( P =0.016) outside Milan. Receipt of donation after brain death (DBD) grafts (55/478, 13%) or living-donor grafts (3/22, 13.6%) experienced better survival rates compared to donation after cardiac death (DCD) grafts ( n =15/58, 25.6%, P =0.009). Donor age was associated with a higher HCC recurrence ( P =0.006). Both total ischaemia time (TIT) greater than 6hours ( P =0.016) and increasing TIT correlated with higher HCC recurrence ( P =0.027). The use of DCD grafts for outside-Milan candidates was associated with increased recurrence ( P =0.039) and reduced survival ( P =0.033). CONCLUSION: This large two-centre analysis confirms favourable outcomes after LT for HCC. Tumour size and number, pre-transplant AFP, and Milan criteria remain important recipient HCC-risk factors. A higher donor risk (i.e. donor age, DCD grafts, ischaemia time) was associated with poorer outcomes.

Combined Liver Transplant and Cardiac Surgery: Long-Term Outcomes and Predictors of Success.

OBJECTIVE: We aim to report our institutional outcomes of single-staged combined liver transplantation (LT) and cardiac surgery (CS). SUMMARY BACKGROUND DATA: Concurrent LT and CS is a potential treatment for combined cardiac dysfunction and end-stage liver disease, yet only 54 cases have been previously reported in the literature. Thus, the outcomes of this approach are relatively unknown, and this approach has been previously regarded as extremely risky. METHODS: Thirty-one patients at our institution underwent combined cardiac surgery and liver transplant. Patients with at least one-year follow-up were included. The Leave-One-Out Cross-Validation (LOOCV) machine-learning approach was used to generate a model for mortality. RESULTS: Median follow-up was 8.2 years (IQR 4.6-13.6 y). One- and five-year survival was 74.2% (N=23) and 55% (N=17), respectively. Negative predictive factors of survival included recipient age>60 years (P=0.036), NASH-cirrhosis (P=0.031), Coronary Artery Bypass-Graft (CABG)-based CS (P=0.046) and pre-operative renal dysfunction (P=0.024). The final model demonstrated that renal dysfunction had a relative weighted impact of 3.2 versus CABG (1.7), age ≥60y (1.7) or NASH (1.3). Elevated LT+CS risk score was associated with an increased five-year mortality after surgery (AUC=0.731, P=<0.001). Conversely, the widely accepted STS-PROM calculator was unable to successfully stratify patients according to 1- (P>0.99) or 5-year (P=0.695) survival rates. CONCLUSIONS: This is the largest series describing combined LT+CS, with joint surgical management appearing feasible in highly selected patients. CABG and pre-operative renal dysfunction are important negative predictors of mortality. The four-variable LT+CS score may help predict patients at high risk for post-operative mortality.

Quality improvement initiatives in the care and prevention of fragility fractures in the Asia Pacific region.

This narrative review summarises ongoing challenges and progress in the care and prevention of fragility fractures across the Asia Pacific region since mid-2019. The approaches taken could inform development of national bone health improvement Road Maps to be implemented at scale during the United Nations 'Decade of Healthy Ageing'. PURPOSE: This narrative review summarises recent studies that characterise the burden of fragility fractures, current care gaps and quality improvement initiatives intended to improve the care and prevention of fragility fractures across the Asia Pacific region. METHODS: The review focuses on published studies, reports and quality improvement initiatives undertaken during the period July 2019 to May 2022. RESULTS: Epidemiological studies conducted in countries and regions throughout Asia Pacific highlight the current and projected increasing burden of fragility fractures. Recent studies and reports document a persistent and pervasive post-fracture care gap among people who have sustained fragility fractures. Global initiatives developed by the Fragility Fracture Network and International Osteoporosis Foundation have gained significant momentum in the Asia Pacific region, despite the disruption caused by the COVID-pandemic. The Asia Pacific Fragility Fracture Alliance has developed educational resources including a Hip Fracture Registry Toolbox and a Primary Care Physician Education Toolkit. The Asia Pacific Osteoporosis and Fragility Fractures Society-a new section of the Asia Pacific Orthopaedic Association-is working to engage orthopaedic surgeons across the region in the care and prevention of fragility fractures. The Asia Pacific Consortium on Osteoporosis developed a framework to support national clinical guidelines development groups. Considerable activity at the national level is evident in many countries across the region. CONCLUSION: Development and implementation of national Road Maps informed by the findings of this review are urgently required to respond to the epidemiological emergency posed by fragility fractures during the United Nations 'Decade of Healthy Ageing'.

A comparative study on the accuracy of noninvasive thermometers.

BACKGROUND: This study assessed the concordance of the temperatures of the digital, liquid crystal forehead and digital infrared tympanic thermometers with the mercury in glass thermometer. METHODS: Temperatures in degrees celsius were taken simultaneously using the four thermometers in 207 patients at the casualty department of a Malaysian hospital. The Bland Altman statistical test was used to assess the concordance by the 95% limits of agreement between the three newer thermometers and the mercury in glass thermometer. RESULTS: The digital thermometer gave the best concordance (limits of agreement 0.48-0.59 degrees C). The liquid crystal forehead thermometer gave the least concordance (limits of agreement -1.14-0.98 degrees C). The digital infrared tympanic was in between (limits of agreement -0.88-0.85 degrees C). DISCUSSION: The digital thermometer provides the best agreement with the mercury in glass thermometer. The infrared tympanic thermometer may be a preferable option for the uncooperative patient. The liquid crystal forehead thermometer is best used at home.

Acromioclavicular joint dislocation: a comparative biomechanical study of the palmaris-longus tendon graft reconstruction with other augmentative methods in cadaveric models.

BACKGROUND: Acromioclavicular injuries are common in sports medicine. Surgical intervention is generally advocated for chronic instability of Rockwood grade III and more severe injuries. Various methods of coracoclavicular ligament reconstruction and augmentation have been described. The objective of this study is to compare the biomechanical properties of a novel palmaris-longus tendon reconstruction with those of the native AC+CC ligaments, the modified Weaver-Dunn reconstruction, the ACJ capsuloligamentous complex repair, screw and clavicle hook plate augmentation. HYPOTHESIS: There is no difference, biomechanically, amongst the various reconstruction and augmentative methods. STUDY DESIGN: Controlled laboratory cadaveric study. METHODS: 54 cadaveric native (acromioclavicular and coracoclavicular) ligaments were tested using the Instron machine. Superior loading was performed in the 6 groups: 1) in the intact states, 2) after modified Weaver-Dunn reconstruction (WD), 3) after modified Weaver-Dunn reconstruction with acromioclavicular joint capsuloligamentous repair (WD.ACJ), 4) after modified Weaver-Dunn reconstruction with clavicular hook plate augmentation (WD.CP) or 5) after modified Weaver-Dunn reconstruction with coracoclavicular screw augmentation (WD.BS) and 6) after modified Weaver-Dunn reconstruction with mersilene tape-palmaris-longus tendon graft reconstruction (WD. PLmt). Posterior-anterior (horizontal) loading was similarly performed in all groups, except groups 4 and 5. The respective failure loads, stiffnesses, displacements at failure and modes of failure were recorded. Data analysis was carried out using a one-way ANOVA, with Student's unpaired t-test for unpaired data (S-PLUS statistical package 2005). RESULTS: Native ligaments were the strongest and stiffest when compared to other modes of reconstruction and augmentation except coracoclavicular screw, in both posterior-anterior and superior directions (p < 0.005).WD.ACJ provided additional posterior-anterior (P = 0. 039) but not superior (p = 0.250) stability when compared to WD alone.WD+PLmt, in loads and stiffness at failure superiorly, was similar to WD+CP (p = 0.066). WD+PLmt, in loads and stiffness at failure postero-anteriorly, was similar to WD+ACJ (p = 0.084).Superiorly, WD+CP had similar strength as WD+BS (p = 0.057), but it was less stiff (p < 0.005). CONCLUSIONS AND CLINICAL RELEVANCE: Modified Weaver-Dunn procedure must always be supplemented with acromioclavicular capsuloligamentous repair to increase posterior-anterior stability. Palmaris-Longus tendon graft provides both additional superior and posterior-anterior stability when used for acromioclavicular capsuloligamentous reconstruction. It is a good alternative to clavicle hook plate in acromioclavicular dislocation.

Revision total hip arthroplasty using impaction bone grafting technique.

A variety of reconstructive options exist for revision of both femoral and acetabular components in total hip replacement surgery. The use of impaction bone grafting with morsellised allograft has shown promising results in revision total hip arthroplasty. It works as a biologic reconstitution of bone stock defects and provides a solid construct with stable fixation. We present a case of bilateral revision total hip arthroplasty with poor bone stock where reconstructive surgery was done by using impaction bone grafting, mesh and C-stem implants.

Mid-term results of tibial plateau fractures.

We studied the factors influencing the mid-term outcomes of tibial plateau fractures treated conservatively (n=21) and surgically (n=27) from December 1994 to December 1997. Joint stability was an important prognostic determinant. In the surgical group, the most important factor was good anatomical reduction. Functional outcomes were comparable between the conservative and surgical groups. We concluded that conservative treatment is a valid option for fractures with minimal displacement and surgical treatment is justified for severely displaced or depressed fractures. Attention must be paid to the recognition and restoration of joint stability and articular surface congruency for a satisfactory outcome.

Early results of Rotating Platform total knee replacement.

We report on our early experiences with the Press Fit Condylar Rotating Platform (PFC-RP) total knee replacement prosthesis at University Malaya Medical Centre. This new prosthesis was introduced to Malaysia in 2001. It combines the rotating platform technology of Low Contact Stress (LCS) and the modularity of Press Fit Condylar (PFC) system. We performed 18 knee replacements using cruciate retaining prosthesis without patellar resurfacing in 10 patients and followed them up over a period of 16-month. A new operative strategy was developed to match the flexion and extension gaps. The pre- and post-operative assessments were made according to the American Knee Society Scores (AKSS). Post-operative pain relief, range of motion, knee score and functional score showed promising early results. The average knee rating improved from 28 to 91 (range 75-94). Average functional assessment improved from 26 to 82 (range 75-90). The radiographic assessments show correction of an average pre-operative varus of 140 to post-operative valgus of 50 (range 4-70). Early infection occurred in two knees. Both responded to aggressive debridement and antibiotics. Stiffness was encountered in one patient. There were no spinouts of the insert. We are satisfied that the implants are performing well at the one-year mark and will continue monitor this cohort.