Shearing-force injury of a kidney transplant graft during cesarean section: a case report and review of the literature.

BACKGROUND: With an increasing number of reproductive-aged women undergoing renal transplantation coupled with improved fertility post-transplantation, more women are becoming pregnant with a kidney transplant in place. This leads to increased risk of perinatal complications such as pre-eclampsia, gestational diabetes, preterm delivery and Cesarean section. Given that kidney transplants are often placed extra-peritoneally in the iliac fossa, there is also a risk of damage to the transplanted kidney at the time of Cesarean section. CASE PRESENTATION: We present a case of shearing-force injury to a transplanted kidney at the time of repeat Cesarean section due to adherence of the organ to the overlying fascia. This is the first known case of an injury by this mechanism. CONCLUSION: Pre-operative planning with organ mapping and incision planning is imperative, with consideration for a vertical midline incision to avoid direct or shearing forces on the transplant kidney. Preoperative collaboration with the Transplant Surgery team is also important so they are available in case of emergency or need for intraoperative consultation.

No clinical difference in 10-year outcomes between standard and minimal graft debridement techniques in patients undergoing anterior cruciate ligament reconstruction using autologous hamstrings: a randomized controlled trial.

PURPOSE: Delayed ligamentization following anterior cruciate ligament reconstruction (ACLR) may result in reduced graft stiffness and strength, and an increased risk of secondary re-tear. Remnant sparing ACLR may accelerate ligamentization and proprioceptive function, theoretically reducing re-injury risk. This study sought to investigate 10-year graft failure rates and patient perceived knee functioning in those undergoing ACLR with remnant preservation (RP), versus remnant debridement (RD). METHODS: A prospective RCT allocated 49 patients to ACLR with a hamstrings autograft together with a RD (n = 25) or RP (n = 24) procedure, of which 86% were clinically evaluated at 10 years (22 RD, 22 RP). A detailed chart review and patient phone consultation was undertaken with all patients at 10 years to evaluate the incidence (and timing) of subsequent re-tear and/or contralateral ACL tear, as well as other knee injuries/surgeries, the patient's ability to perform full work/sport duties and their perceived knee function using a numerical rating scale (NRS). RESULTS: No significant differences existed between groups in descriptive variables. There were 2 graft ruptures (10.0%) in the RP group and 3 (13.6%) in the RD group, with an earlier mean time to graft failure in the RD group (RD 7.7 ± 4.5 months, RP 49.5 ± 17.7 months), albeit the size of this sub-sample was too small for statistical comparison. There was a significantly higher number of patients requiring ≥ 1 additional ipsilateral knee surgery in the RP group (RP = 10, RD = 4, p = 0.048). At 10 years, there were no significant group differences in the percentage of patients returning to unrestricted activity, with 16 (72.7%) and 15 (75.0%) patients in the RD and RP ACLR groups, respectively, unrestricted in work/sport duties. There were no significant group differences in the functional NRS ratings. CONCLUSIONS: No long term clinical benefit of RP ACLR could be determined by this study with similar re-tear incidence and perceived knee function. A statistically higher number of re-operations were observed in RP ACLR patients and, while re-tears were observed later after RP versus RD ACLR, the study was underpowered to detect statistical significance. LEVEL OF EVIDENCE: Level II (prospective randomized controlled trial).

Graft tears after arthroscopic superior capsule reconstruction (ASCR): pattern of failure and its correlation with clinical outcome.

INTRODUCTION: Arthroscopic superior capsule reconstruction (ASCR) using fascia lata autograft is a new surgical technique developed to overcome irreparable rotator cuff tears. There is little information about graft tear after ASCR and its impact on clinical outcome. This study is to investigate the graft tear rate, pattern of failure, and its correlation with clinical outcomes after arthroscopic superior capsule reconstruction (ASCR). MATERIALS AND METHODS: From June 2013 to June 2016, 31 shoulders in 31 consecutive patients (mean 65.3 years) underwent ASCR using fascia lata autograft for irreparable large-to-massive tears. Magnetic resonance imaging (MRI) was performed before surgery and at mean 12.8 months (12-24 months) after surgery to assess fatty infiltration progression and graft integrity. Graft tear was defined as the loss of graft continuity and was categorized as medial and lateral rows according to the failure location. Acromiohumeral distance (AHD) was pre- and postoperatively measured with the standard radiograph. Pain visual analog scale (VAS) score, American Shoulder and Elbow Surgeons (ASES) score, constant score, and physical examination were used to assess clinical outcomes. Average follow-up was 15 months (range 12-24 months) after surgery. RESULTS: Mean active forward elevation increased from 133° to 146° (P = 0.011). Mean VAS score, ASES score, and constant score significantly improved: from 6 to 2.5, 54.4 to 73.7, and 51.7 to 63.7, respectively (P < 0.001). There was no remarkable progression of fatty infiltration after surgery. AHD increased from 5.3 mm preoperatively to 6.4 mm postoperatively (P < 0.016). Nine patients (29%) showed graft tear on follow-up MRI: 7 and 2 at the medial and lateral rows, respectively. Although the intact graft group showed better outcomes than the graft tear group (pain VAS score 2.3 vs. 3.0; ASES score 74.1 vs. 69.8; constant score 63.4 vs. 57.9), the results were not statistically significant. CONCLUSIONS: Graft tear rate after ASCR assessed by MRI was 29%, and failures mostly occurred at the medial row. The graft tear group showed clinical improvement despite the recurred superior capsule defect. LEVEL OF EVIDENCE: IV, case series, treatment study.

Outcomes of Anterior Cruciate Ligament Reconstruction in Females Using Patellar-Tendon-Bone versus Hamstring Autografts: A Systematic Review and Meta-Analysis.

The current review aims to compare the outcomes of anterior cruciate ligament (ACL) reconstruction in the female population after patellar-tendon-bone and hamstring grafts. The review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All original randomized controlled trials and prospective cohort studies that compared clinical outcomes after female ACL reconstruction using hamstring versus patellar-tendon-bone grafts were included. All clinical outcomes reported by three or more studies were included. Fifteen publications, with 948 female patients, were included. Most outcomes were reported to have no significant graft differences by all studies that reported the outcome. These included all the outcomes for objective knee scores (International Knee Documentation Committee [IKDC] objective knee score), neuromuscular testing (quadriceps strength, hamstring strength, and single hop test), graft rupture or failure, and subjective knee scores (Lysholm score and IKDC subjective knee score). The pivot shift test, flexion deficit, and presence of crepitus were also reported to have no significant graft differences by all studies. Some studies reported a significant difference in anteroposterior laxity (Lachman's test and instrumented laxity), range of motion deficits (extension deficit), and sports and activity level (Tegner score). However, these statistically significant differences were noted to be clinically insignificant due to the normal population variation or standard error of measurement of these tools of evaluation. Patients reconstructed with patellar-tendon-bone grafts have a higher risk of kneeling pain. There was no significant difference in the incidence of crepitus. Most of the outcomes following female ACL reconstructions showed no clinically and statistically significant difference when either patellar-tendon-bone or hamstring autograft was used. These included outcomes for anteroposterior laxity, objective knee scores, neuromuscular testing, graft rupture or failure, subjective knee scores, sports and activity level, and crepitus. This a level II study.

A Case of Successful Simultaneous Pancreas-Kidney Transplantation Using the Injured Pancreas Graft.

OBJECTIVE: Graft injuries sometimes occur and may cause complications such as the leakage of pancreatic secretions, which is often lethal. We report our experience of a case of successful simultaneous pancreas-kidney transplantation using injured pancreas graft. PATIENTS AND METHODS: The recipient was a 57-year-old woman with type 1 diabetes mellitus, and the donor was a 30-year-old man with a brain injury. In the donation, the pancreas parenchyma, splenic artery, and gastroduodenal artery were injured iatrogenically. We therefore reconstructed these arteries using vessel grafts and then performed simultaneous pancreas-kidney transplantation. RESULTS: Five days after transplantation, we noted a high titer of amylase in the ascites; therefore, we performed an urgent laparotomy. The origin of the amylase was the injured pancreatic parenchyma, and continued washing and drainage were carried out. We reconstructed the duodenojejunostomy using the Roux-en-Y technique to separate the passage of food from the pancreas graft to prevent injury to other organs due to exposure to pancreatic secretions. Thereafter, we inserted a decompression tube into the anastomosis thorough the blind end of the jejunum. Finally, we inserted 3 drainage tubes for lavage. Following this procedure, the patient recovered gradually and no longer required hemodialysis and insulin therapy. She was discharged from our hospital 56 days after transplantation. CONCLUSION: The restoration of the injured graft was possible by management of pancreatic secretions and use of the donor's vessel grafts. Shortage of donors is a problem throughout the world; thus, it is important to use injured grafts for transplantation if possible.

The influence of femoral tunnel length on graft rupture after anterior cruciate ligament reconstruction.

BACKGROUND: For ACL reconstruction, the minimum length of the femoral tunnel and the flexor tendon graft length needed within the tunnel for proper integration have not been defined. The aim of this study was to assess whether a short tunnel is a risk factor for poor prognosis and re-rupture by comparing the outcomes of patients with short femoral tunnels to those of patients with longer tunnels. MATERIALS AND METHODS: A retrospective observational study of 80 patients who underwent ACL reconstruction using flexor tendons via the medial transportal or transtibial technique was performed. Patients were categorized according to the amount of graft within the tunnel: ≤1.5 versus >1.5 cm; ≤2 versus >2 cm; ≤2.5 versus >2.5 cm; and ≤1.5 versus >2.5 cm. Patients were evaluated 2 years after surgery by performing a physical examination (Lachman, pivot shift and anterior drawer tests), using a KT1000 arthrometer, calculating objective and subjective International Knee Documentation Committee scores, conducting the Lysholm score, and recording re-ruptures. RESULTS: Of the 80 operated patients, nine were lost to follow-up. Comparative assessment of the patients with different amounts of graft within the tunnel indicated no significant differences in the evaluated outcomes, except for positive Lachman test results, which were more frequent in patients with tunnels with ≤2 cm of graft than in those with tunnels with >2 cm of graft. CONCLUSION: The amount of graft within the femoral tunnel does not appear to be a risk factor for clinical instability of the knee or re-rupture of the graft. LEVEL OF EVIDENCE: case series, level IV. LEVEL OF EVIDENCE: Case series, level IV.

Geometric Risk Factors Associated With Noncontact Anterior Cruciate Ligament Graft Rupture.

BACKGROUND: Anterior cruciate ligament (ACL) graft rupture occurs at a high rate, especially in young athletes. The geometries of the tibial plateau and femoral intercondylar notch are risk factors for first-time ACL injury; however, little is known about the relationship between these geometries and risk of ACL graft rupture. HYPOTHESIS: The geometric risk factors for noncontact graft rupture are similar to those previously identified for first-time noncontact ACL injury, and sex-specific differences exist. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Eleven subjects who suffered a noncontact ACL graft rupture and 44 subjects who underwent ACL reconstruction but did not experience graft rupture were included in the study. Using magnetic resonance imaging, the geometries of the tibial plateau subchondral bone, articular cartilage, meniscus, tibial spines, and femoral notch were measured. Risk factors associated with ACL graft rupture were identified using Cox regression. RESULTS: The following were associated with increased risk of ACL graft injury in males: increased posterior-inferior-directed slope of the articular cartilage in the lateral tibial plateau measured at 2 locations (hazard ratio [HR] = 1.50, P = .029; HR = 1.39, P = .006), increased volume (HR = 1.45, P = .01) and anteroposterior length (HR = 1.34, P = .0023) of the medial tibial spine, and increased length (HR = 1.18, P = .0005) and mediolateral width (HR = 2.19, P = .0004) of the lateral tibial spine. In females, the following were associated with increased risk of injury: decreased volume (HR = 0.45, P = .02) and height (HR = 0.46, P = .02) of the medial tibial spine, decreased slope of the lateral tibial subchondral bone (HR = 0.72, P = .01), decreased height of the posterior horn of the medial meniscus (HR = 0.09, P = .001), and decreased intercondylar notch width at the anterior attachment of the ACL (HR = 0.72, P = .02). CONCLUSION: The geometric risk factors for ACL graft rupture are different for males and females. For females, a decreased femoral intercondylar notch width and a decreased height of the posterior medial meniscus were risk factors for ACL graft rupture that have also been found to be risk factors for first-time injury. There were no risk factors in common between ACL graft injury and first-time ACL injury for males.

Histologic evaluation of organ preservation injury and correlation with cold ischemia time in 13 intestinal grafts.

Lesions produced in the graft mucosa due to harvesting, storage, and implantation must be graduated to assess the subsequent protocolized biopsy specimens. The aim is to identify type and intensity of graft mucosal lesions observed immediately after implantation. Congestion, hemorrhage, microthrombi, neutrophilic infiltrates, shortening of villi, epithelial detachment, erosion, and crypt loss were separately evaluated by two pathologists in mucosal biopsy specimens from 13 grafts. Each change was assessed as normal, mild, moderate, or severe and by splintering the summation of points a global score was designed. Cold ischemia time was registered. Correlation between the pathologists' evaluations and between final preservation injury degree and cold ischemia time was determined using the "index of correlation rho (ρ)" (Spearman's test). The same changes were assessed in 19 biopsy specimens from day 2 to day 6 (3.6 ± 1.1) to determine their evolution. Congestion was found in 7 biopsy specimens, microthrombi in 2, hemorrhage in 4, neutrophils in 6, villous atrophy in 8, epithelial detachment in 9, erosions in 2 and/or crypt loss in 2. The maximum degree of preservation injury was expressed as intense congestion and hemorrhage associated with epithelial detachment and villous atrophy. The global preservation score was grade 3 in 2 cases, grade 2 in 5, grade 1 in 2, and grade 0 in 4. There was positive correlation (ρ = 0.915) in the evaluation between pathologists (P < .01), total agreement in 9 biopsy specimens, and partial agreement (only 1 point disagreement) in 4. Mean cold ischemia time was 327 ± 101 min. (135-480). There was positive correlation (ρ = 0.694) between preservation score and cold ischemia time (P < .01). In the follow-up biopsy procedures, histological injury decreased by at least one grade in every case. Additionally, karyorrhexis was observed in 3 grafts and very occasional apoptosis in 2 others. This scale achieves good reproducibility and allows graduate preservation injury in intestinal transplantation.

Incidental central tear in Descemet membrane endothelial complex during Descemet membrane endothelial keratoplasty.

Descemet membrane endothelial keratoplasty (DMEK) was performed in a 70-year-old man diagnosed with pseudophakic bullous keratopathy. During Descemet endothelial complex (DEC) preparation, a central tear was noticed in the DMEK graft. However, the surgery was continued. On sixth postoperative day, a small fluid pocket was observed between the DEC and the posterior host stroma in inferior third of the graft area. It was, however, decided to observe it for spontaneous attachment. At 2 weeks, the inferior DEC detachment had increased with overlying corneal oedema. Descemetopexy with 100% air was performed the same day which reattached the DEC. Subsequently, DEC remained attached and at the last follow-up of 2 months, DEC was well opposed with a clear overlying cornea. The final best-corrected Snellen's visual acuity was 20/60. A small tear in the DEC does not necessitate tissue replacement and a good anatomical and visual outcome can be achieved in such cases.