Editorial Commentary: Time-Zero Biomechanical Studies Show Suture Augmentation of a Soft-Tissue Graft Improves Its Properties, But They Need to Be Interpreted With Caution.

There is emerging evidence in biomechanical studies that suture augmentation of a soft-tissue graft can improve its elongation, stiffness, and load to failure. However, all biomechanical studies have the intrinsic drawback of not considering loosening, accommodation, and mainly, healing. In the past, many very strong and stiff synthetic grafts produced poor results for anterior cruciate ligament reconstruction, and synthetic material inside the joint was abandoned for awhile. Recent studies have shown that it is possible to use synthetic material to augment the graft instead of being the graft itself. But the question we need to ask ourselves is: Does it really work in the clinical scenario? Undoubtedly, there is still a way to go to incorporate suture augmentation into soft-tissue grafts in knee reconstruction, and it is mandatory to start high-level clinical studies to prove its real benefit to ligament reconstruction results.

Reoperation rates for pelvic organ prolapse repairs with biologic and synthetic grafts in a large population-based cohort.

INTRODUCTION AND HYPOTHESIS: As the long-term complications of synthetic mesh become increasingly apparent, re-evaluation of alternative graft options for pelvic organ prolapse (POP) repairs is critical. We sought to compare the long-term reoperation rates of biologic and synthetic grafts in POP repair. METHODS: Using the California Office of Statewide Health Planning and Development database, we identified all women who underwent index inpatient POP repair with either a synthetic or biologic graft between 2005 and 2011 in the state of California. ICD-9 and CPT codes were used to identify subsequent surgeries in these patients for either recurrent POP or a graft complication. RESULTS: A total of 14,192 women underwent POP repair with a biologic (14%) or synthetic graft (86%) during the study period. Women with biologic grafts had increased rates of surgery for recurrent pelvic organ prolapse (3.6% vs 2.5%, p = 0.01), whereas women with synthetic grafts had higher rates of repeat surgery for a graft complication (3.0 vs 2.0%, p = 0.02). There were no significant differences between the overall risk of repeat surgery between the groups (5.7% vs 5.6%, p = 0.79). These effects persisted in multivariate modeling. CONCLUSIONS: We demonstrate in a large population-based cohort that biologic grafts are associated with an increased rate of repeat surgery for POP recurrence whereas synthetic mesh is associated with an increased rate of repeat surgery for a graft complication. These competing risks result in an equivalent overall any-cause repeat surgery rate between the groups. These data suggest that neither type of graft should be excluded from use and encourage a personalized risk assessment.

The Failing Kidney Transplant Allograft. Transplant Nephrectomy: Current State-of-the-Art.

PURPOSE OF REVIEW: This review provides a critical literature overview of the risks and benefits of transplantectomy in patients with a failed allograft. Additionally, it offers a summary of related problems, primarily alloantibody sensitization in the event of nephrectomy and immunosuppression weaning. RECENT FINDINGS: Transplant nephrectomy has high morbidity and mortality rates. The morbidity of transplant nephrectomy (4.3 to 82%) is mostly due to hemorrhage or infection. Mortality rates range from 1.2 to 39%, and most are due to sepsis. Transvascular graft embolization has been described as a less invasive alternative technique for the management of symptomatic graft rejection, with minimal complications compared with transplantectomy. The number of patients with a failed allograft returning to dialysis is increasing. The role of allograft nephrectomy in the management of asymptomatic transplant failure is still controversial and up today continues to depend on the usual clinical practice of each institution. The less invasive transvascular embolization could have applicability in asymptomatic patients with the obvious lower morbidity and mortality rate.

Management of Renal Cell Carcinoma and Other Renal Masses in the Kidney Graft.

PURPOSE OF REVIEW: Renal masses in the kidney graft pose an important clinical dilemma, balancing graft function against the need for cancer control. RECENT FINDINGS: Donor origin cancers in the renal graft can be classified as 'donor transmitted' or 'donor derived'. The landmark TracerX Renal changed our understanding of renal cell carcinoma oncogenesis, demonstrating that key mutations in childhood lead to clinically apparent tumours in later life. Identified pre-operatively, contemporary evidence suggests that masses excised prior to transplantation result in acceptable oncologic safety and graft function. Identified post-operatively management mirrors that for a mass in a solitary kidney in the non-transplant population, with focus on a nephron-sparing approach. With growing number of kidney transplants each year, ageing donors, and increasing graft survival, masses in the renal graft are likely to become a more prevalent clinical conundrum.

Troubleshooting Complex Vascular Cases in the Kidney Graft: Multiple Vessels, Aneurysms, and Injuries During Harvesting Procedures.

PURPOSE OF THE REVIEW: To update the most relevant literature regarding complex vascular cases in kidney transplant setting involving the graft, especially during the harvesting procedure and back-table preparation from the subsequent implant. RECENT FINDINGS: Challenging situations affecting the kidney graft such as multiple vessels, renal artery aneurysms, kidney anatomical anomalies, or major injuries do not contraindicate the transplant, but require an exhaustive graft viability assessment and several bench surgery techniques. Graft vessel conditioning in the back-table might include simple anastomosis between them, enlarging with venous patch or reconstruction with donor or synthetic grafts. Compared with conventional transplant, literature reports longer warm ischemia time (40 vs 32 min) and slightly increased rates of delayed graft function (10.3% vs 8.2%) and vascular complications (10.8% vs 8.1%), but similar graft and patient survival. Kidney graft vascular complex cases require exhaustive assessment, meticulous harvesting, good surgical technique in the bench table, and proper surgery in the recipient. Despite its complexity, vascular complex kidney transplant offers comparable outcomes in the long term to conventional population when technically well performed, with slightly increased rates of vascular complications and delayed graft function.

Troubleshooting Complex Vascular Cases in the Kidney Transplant Recipient: Vascular Anomalies, Challenging Vessel Diseases, and Procedural Disasters.

PURPOSE OF REVIEW: To update the most relevant literature regarding complex cases during kidney transplant setting that recipient presents by himself, especially during implantation surgery due to vascular diseases and/or urinary tract anomalies. RECENT FINDINGS: Increasing age of donors and recipients is leading to an increased complexity of kidney transplant implantation surgery. In addition, the high peripheral vascular disease prevalence worldwide increases difficulty of surgery and decreases long-term outcomes as well. Moreover, it also increases transplant morbidity and mortality, both overall and cardiovascular, and finally clearly decreases graft survival. However, dialysis alternative has even worse outcomes in terms of mortality, with a proportional risk of death 2.66 higher compared with transplanted patients. Aorto-iliac prosthesis and 3rd and 4th transplants in occupied iliac fossae do also represent a challenging situation with a clearly increased morbidity and mortality. In some of those particular conditions, orthotopic kidney transplant technique is an alternative with good functional and survival outcomes, but not exempt of complications. Kidney transplant in vascular complex recipients has worse outcomes compared with conventional non-risky population. It remains a challenging surgical and medical procedure with higher morbidity and mortality, and decreased graft survival. However, dialysis mortality is still even greater and a transplant attempt might be justified. Orthotopic kidney transplant technique might play a role in selected patients with aorto-iliac unworkable segments or even in patients with special urinary tract conditions.

Surgical treatment for saphenous vein graft aneurysm without redo sternotomy.

BACKGROUND: Saphenous vein graft aneurysm (SVGA) is a rare complication after coronary artery bypass grafting; however, it may lead to fatal conditions. A redo sternotomy poses a high risk of injury to the patent graft. CASE REPORT: A 59-year-old man with chest pain was diagnosed with a giant SVGA (67 mm) anastomosed to the right coronary artery (RCA) and compressing the right atrium. Considering the high risk of injury to a patent graft through the sternum, a surgical procedure was planned without redo sternotomy. Through an upper midline abdominal incision, redo bypass grafting was performed to the distal RCA using the right gastroepiploic artery, followed by resection of the aneurysm using the right anterior lateral thoracotomy approach. The postoperative course was uneventful. CONCLUSION: In patients with an SVGA anastomosed to the right coronary system, our surgical strategy may be a useful alternative to redo sternotomy to avoid injury to the patent graft.

Protocol for the first clinical trial to investigate safety and efficacy of corneal xenotransplantation in patients with corneal opacity, corneal perforation, or impending corneal perforation.

BACKGROUND: Xenotransplantation using fresh porcine corneas has been suggested as a feasible alternative to overcome the shortage of human donor corneas. Successful long-term survival of grafts without evidence of xenozoonosis in clinically applicable pig-to-non-human primate corneal transplantation model has brought researchers close to human clinical trials. Accordingly, we aimed to prepare a clinical trial protocol to conduct the first corneal xenotransplantation. METHODS: We developed the clinical trial protocol based on international consensus statement on conditions for undertaking clinical trials of corneal xenotransplantation developed by the International Xenotransplantation Society. Detailed contents of the protocol have been modified with reference to comments provided by ophthalmologists and multidisciplinary experts, including an infectionist, an organ transplantation specialist, a clinical pharmacologist, a neuropsychiatrist, a laboratory medicine doctor, and a microbiologist. RESULTS: Two patients with bilateral legal corneal blindness (best-corrected visual acuity ≤20/200 in the better eye and ≤20/1000 in the candidate eye) or with (impending) corneal perforation will be enrolled. During the screening period, participants and their family members will have two separate deep consideration periods before signing informed consent forms. Each patient will undergo corneal xenotransplantation using fresh corneas from Seoul National University miniature pigs. Commercially available immunosuppressants will be administered and systemic infection prophylaxis will be performed according to the program schedule. After transplantation, each patient will be monitored at a specialized clinic to investigate safety up to 2 years and efficacy up to 1 year. CONCLUSIONS: A detailed clinical trial protocol for the first corneal xenotransplantation reflecting the global guidelines is provided.

Effectiveness of Saphenous Vein Y-Grafts in Patients Undergoing Off-Pump Complete Myocardial Revascularization.

BACKGROUND To evaluate perioperative and mid-term outcomes of saphenous vein Y-grafts in patients with multi-vessel coronary artery disease. MATERIAL AND METHODS Sixty patients who underwent off-pump coronary surgery with Y-graft between 2005 and 2016 were enrolled, including 38 patients with natural Y-graft. Sixty patients with multi-vessel lesions in the same period were randomly selected as a control group. RESULTS A total of 484 conduits were employed. The intraoperative variables were insignificantly different between groups, but Y-graft group compared with control group had more grafts (4.2±0.84 vs. 3.87±0.85) and anastomoses (6.30±1.39 vs. 5.62±1.15). No patient died during coronary artery bypass grafting and no episode of perioperative myocardial infarction was found. Follow-up duration lasted from 1 to 137 (40.0±27.7) months. No significant difference between Y-graft group and control group was found in Kaplan-Meier 3-year survival rate (93.4% vs. 88.0%) or 5-year survival rate (81.4% vs. 88.0%). CONCLUSIONS Saphenous vein Y-graft is a feasible and safe revascularization strategy for multi-vessel coronary artery disease patients and brings about satisfactory outcomes.

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.

Arteriovenous Graft for Hemodialysis: Effect of Cryotherapy on Postoperative Pain and Edema.

BACKGROUND: Arteriovenous grafting offers an alternative for patients whose vessels are unsuitable for arteriovenous fistula. However, as a result of subcutaneous tunnel dissection, postoperative pain and edema of the operated limb present early after surgery. As a traditional therapeutic approach, cryotherapy has the ability to suppress postoperative pain and edema. AIMS: The purpose of the study was to investigate the feasibility of cryotherapy after arteriovenous graft surgery to decrease perioperative medication usage. DESIGN: This study was a randomized controlled trial. SETTING: A large integrated health care facility in South China. PARTICIPANTS/SUBJECTS: A total of 85 hemodialysis patients who received arteriovenous graft surgery from March 2011 to February 2017 were enrolled. METHODS: The participants were divided into an intervention group and a control group according to the postoperative management. Ice packs were applied covering the operative forearm for 120 minutes after wound closure in the intervention group. General information, pain score, analgesic consumption, wound inflammation, forearm edema, and participant satisfaction were compared between the two groups. RESULTS: Cryotherapy-treated patients required less analgesia (26.19% vs. 48.84%, p < .05), reported lower pain score from 30 minutes to 48 hours postoperative (p < .05), less wound inflammation (11.90% vs. 25.58%, p < .05), and higher participant satisfaction (8.92 ± 0.57 vs. 6.52 ± 0.63, p < .05), whereas the incidence of forearm edema was equivalent (p > .05). No adverse events were reported in either group. CONCLUSIONS: Cryotherapy is a preferable intervention for patients after arteriovenous graft implantation as a result of its favorable cost, convenience, and fewer side effects.

Bicruciate lesion biomechanics, Part 2-treatment using a simultaneous tensioning protocol: ACL fixation first is better than PCL fixation first to restore tibiofemoral orientation.

PURPOSE: An uncommon technique for bicruciate ligament reconstruction involving simultaneous tensioning of the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) grafts with ACL graft fixation first has been pointed out as superior to the "gold-standard" PCL graft fixation first. The purpose of this study was to compare tibiofemoral biomechanics between ACL fixation first and PCL fixation first in a simultaneous tensioning protocol for bicruciate ligament reconstruction. METHODS: 12 fresh-frozen cadaveric knees (six matched pairs) were tested using a custom testing system. Neutral tibial position representing tibiofemoral orientation, anterior-posterior (AP) tibial translation, varus-valgus laxity, and internal-external rotation were measured using a Microscribe 3DLX at 0°, 30°, 60°, and 90° of knee flexion. The following knee conditions were evaluated: intact, bicruciate deficient and following bicruciate reconstruction. A simultaneous tensioning protocol was used for bicruciate reconstruction and PCL fixation first was compared to ACL fixation first. PCL graft fixation was always performed at 90° of flexion and ACL graft fixation was always performed at full extension. RESULTS: ACL fixation first achieved a tibiofemoral orientation closer to the intact knee than PCL fixation first at 90° flexion (1.8 ± 1.6 mm versus 6.1 ± 3.2 mm, p = 0.016). PCL fixation first had a larger decrease in AP translation than ACL fixation first at 30° flexion (64.6 ± 3.5% vs. 58.3 ± 2.4%, p = 0.01). No significant differences were found for varus/valgus, external-internal rotation decrements after bicruciate reconstruction nor for AP translation, varus/valgus and internal/external rotation increase after bicruciate lesion comparing ACL fixation first to PCL fixation first. CONCLUSION: Bicruciate ligament reconstruction using a simultaneous tensioning protocol with ACL fixation first resulted in a closer to normal tibiofemoral orientation. This study will help guide surgeons in decision making for the graft tensioning protocol and fixation sequence in a bicruciate ligament reconstruction. LEVEL OF EVIDENCE: V therapeutic study.

Vancomycin pre-soaking of the graft reduces postoperative infection rate without increasing risk of graft failure and arthrofibrosis in ACL reconstruction.

PURPOSE: To investigate whether pre-soaking the graft in vancomycin during anterior cruciate ligament reconstruction (ACLR) reduces the postoperative infection rate and if this technique is associated with an increased rate of complications, including graft failure or arthrofibrosis. METHODS: A retrospective review of a prospective database was performed in 1779 patients who underwent ACLR over a period of 5 years, analysing the rate of postoperative deep knee infection. Group 1 and 2 both received perioperative IV antibiotics, while only group 2 underwent ACLR with grafts pre-soaked in a 5 mg/ml vancomycin solution. To analyse possible side effects associated with vancomycin use, 500 patients out of the overall study population (100 patients per year) were randomly selected and retrospectively interviewed for further postoperative complications including graft failure and arthrofibrosis as well as subjective evaluation of their knee by completing the IKDC form with a minimum mean follow-up of 37 months. RESULTS: In group 1, 22 out of 926 (2%) patients suffered a postoperative deep knee infection. In contrast, there were no postoperative infections in the second group of 853 patients (0%). 16 of 22 infections (73%) were caused by coagulase-negative Staphylococcus. Statistical analysis revealed a significantly reduced postoperative infection rate when bathing the autograft in vancomycin (p < 0.01). Analysis of the random sample revealed a significant decrease of graft failure with 8 reruptures in 257 patients (3%) in the vancomycin group compared to 16 cases of graft failure in 167 patients (10%) in the control group (p < 0.05). No differences were found in the rate of postoperative arthrofibrosis, Tegner or subjective outcome scores. CONCLUSION: Prophylactic vancomycin pre-soaking of autografts during ACLR appears to be a viable, cost-effective and safe option to reduce the rate of deep infection compared to systemic antibiotics alone. LEVEL OF EVIDENCE: III.

Significant anterior enlargement of femoral tunnel aperture after hamstring ACL reconstruction, compared to bone-patellar tendon-bone graft.

PURPOSE: This study aimed to retrospectively compare the enlargement and migration of the femoral tunnel aperture after anatomic rectangular tunnel anterior cruciate ligament (ACL) reconstruction with a bone-patella tendon-bone (BTB) or hamstring tendon (HT) graft using three-dimensional (3-D) computer models. METHODS: Thirty-two patients who underwent ACL reconstruction and postoperative computed tomography (CT) at 3 weeks and 6 months were included in this study. Of these, 20 patients underwent ACL reconstruction with a BTB graft (BTBR group), and the remaining 12 with an HT graft (HTR group). The area of the femoral tunnel aperture was extracted and measured using a 3-D computer model generated from CT images. Changes in the area and migration direction of the femoral tunnel aperture during this period were compared between the two groups. RESULTS: In the HTR group, the area of the femoral tunnel aperture was significantly increased at 6 months compared to 3 weeks postoperatively (P < 0.05). The average area of the femoral tunnel aperture at 6 months postoperatively was larger by 16.0 ± 12.4% in the BTBR group and 41.9 ± 22.2% in the HTR group, relative to that measured at 3 weeks postoperatively (P < 0.05). The femoral tunnel aperture migrated in the anteroinferior direction in the HTR group, and only in the inferior direction in the BTBR group. CONCLUSIONS: The femoral tunnel aperture in the HTR group was significantly more enlarged and more anteriorly located at 6 months after ACL reconstruction, compared to the BTBR group. LEVEL OF EVIDENCE: IV.

Endovascular management of endotension by graft reinforcement followed by direct sac embolization.

Purpose: To assess the efficacy of graft reinforcement followed by percutaneous direct sac embolization (PDSE) for the treatment of endotension after endovascular abdominal aortic aneurysm repair (EVAR). Materials and methods: A total of 290 patients underwent elective EVAR. All patients regularly underwent scheduled surveillance with contrast-enhanced computed tomography (CT). Two hundred thirty-five patients were followed for ≥24 months after EVAR. Aneurysmal sac expansion of ≥10 mm was observed in 20 patients. The patients with sac expansion of ≥10 mm with no evidence of endoleak were treated with graft reinforcement. Graft reinforcement consisted of graft extension and graft relining. The patients with sac expansion at 6 months after graft reinforcement received PDSE using metallic coils and n-butyl cyanoacrylate-Lipiodol mixture. The aneurysm diameter was measured by CT performed 6 months and every year after the final intervention. Results: Seven patients (7 men, 0 women; mean age, 69.1 ± 4.2 years, Zenith®:5/Excluder®:1/Powerlink®:1) underwent graft reinforcement. Two patients underwent graft reinforcement alone, and five patients underwent PDSE after graft reinforcement. Mean follow-up time after the final intervention was 21.1 months. The sac diameter stabilized after the final intervention in all patients. Conclusion: Graft reinforcement followed by complementary PDSE could be a useful treatment strategy for endotension.

Combined liver-kidney perfusion enhances protective effects of normothermic perfusion on liver grafts from donation after cardiac death.

It has been shown that combined liver-kidney normothermic machine perfusion (NMP) is able to better maintain the circuit's biochemical milieu. Nevertheless, whether the combined perfusion is superior to liver perfusion alone in protecting livers from donation after circulatory death (DCD) is unclear. We aimed to test the hypothesis and explored the mechanisms. Livers from 15 DCD pig donors were subjected to either static cold storage (group A), liver-alone NMP (group B), or combined liver-kidney NMP (group C). Livers were preserved for 6 hours and reperfused ex vivo for 2 hours to simulate transplantation or were transplanted in situ. During perfusion, group C showed an improved acid-base and biochemical environment in the circuit over group B. After reperfusion, the architecture of the liver grafts was best preserved in group C, followed by group B, then group A, as shown by the histology and terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labeling staining of both hepatocytes and biliary epithelium. Ki-67 staining showed substantial hepatocyte proliferation and biliary epithelial regeneration after perfusion in group B and group C. Group C produced more bile in the reperfusion phase than those in group A and group B, with more physiological bile composition and less severe biliary epithelium injury. Von Willebrand factor-positive endothelial cells and E-selectin expression decreased in both group B and group C. Combined liver-kidney NMP not only produced more adenosine triphosphate, protected the nitric oxide signaling pathway, but also diminished oxidative stress (high mobility group box-1 protein and 8-hydroxy-2-deoxy guanosine levels) and inflammatory cytokine (IL6 and IL8) release when compared with liver-alone NMP and CS. In addition, the 7-day survival rate of liver transplant recipients was higher in group C than that in groups A and B. In conclusion, combined liver-kidney NMP can better protect DCD livers from warm ischemia and reperfusion injury probably by maintaining the stability of the internal environment and by abolishing oxidative stress injury. Liver Transplantation 24 67-79 2018 AASLD.

Management of portal hypertension before and after liver transplantation.

Orthotopic liver transplantation (OLT) represents a curative treatment option for end-stage liver disease (ESLD). Although epidemiology of ESLD has recently changed due to the rising prevalence of nonalcoholic fatty liver disease and the decreased burden of hepatitis C virus infections due to highly effective antiviral regimens, the management of portal hypertension (PHT) remains a clinical challenge in the pre- and post-OLT setting. The measurement of the hepatic venous pressure gradient represents the most reliable but invasive tool for assessment of the severity of PHT. Although novel liver ultrasound and magnetic resonance-based elastography methods have been developed, their value to screen for liver fibrosis and PHT in transplanted patients remains to be established. Nonselective beta-blockers represent the cornerstone of medical treatment of PHT, but more studies on their effects on clinical endpoints after OLT are needed. Statins are widely used to treat hyperlipidemia, which is a common condition after OLT. Although a growing body of evidence suggests that statins decrease portal pressure and PHT-related complications in ESLD, studies on potential benefits of statins after OLT are lacking. Finally, transjugular intrahepatic portosystemic shunts (TIPS) are effective in decreasing PHT and seem to decrease mortality on the OLT waiting list. Moreover, TIPS does not have an impact on liver function nor complicate the transplant surgical procedures. TIPS may also be used after OLT, but the evidence is limited. In conclusion, whereas the management of PHT in patients with ESLD is based on strong evidence, further data on the value of noninvasive monitoring tools as well as on medical and invasive treatment options in the post-OLT setting are needed to improve management strategies in patients with recurrent PHT after liver transplantation. Liver Transplantation 24 112-121 2018 AASLD.

The value of glycated albumin for the prediction of graft outcome in the non-human primate porcine islet transplantation model.

BACKGROUND: The development of a precise and easy-to-use tool for monitoring islet graft function is important in clarifying the causes of graft loss, identifying appropriate therapy, and ensuring graft survival in the nonhuman primate (NHP) model of porcine islet transplantation (PITx). Glycated albumin (GA) is an indicator of intermediate-term changes in blood glucose control and is useful in clinical diabetes management. The validity of GA for monitoring graft function in NHP recipients of PITx was evaluated using a retrospective analysis of cohort samples. METHODS: Data from a total of 23 PITxs performed in 20 recipients (3 were retransplanted) were included in this study. Islet clusters purified from adult wild-type pigs were transplanted via the intraportal route into streptozotocin-induced diabetic rhesus monkeys with immune suppression. Blood samples were obtained once per week from the recipients until they lost insulin-independence. Blood samples were also obtained from 69 non-diabetic monkeys that served as a control group. The levels of GA and albumin in stored plasma aliquots were measured using each enzymatic method, and the GA result was expressed as the percentage of GA level to the total albumin level. RESULTS: The median level of GA in the recipients on the day of PITx (median 18.6%, 95% confidence interval [CI] 16.7%-20.4%) was significantly higher than that of healthy controls (median 9.14%, 95% CI 9.0%-9.3%, P < .0001). However, the level decreased after PITx and remained low or increased depending on the extent of residual graft function. The GA level at a nadir (median 11.6%, 95% CI 10.8%-13.0%) and the time to reach a nadir (median 43 days, 95% CI 21.7-69.3 days) both correlated with the duration of insulin-independence (rho [ρ] = -.605, P = .0028 and ρ = .662, P = .0008, respectively). The GA level strongly correlated with KG , the glucose disappearance rate during intravenous glucose tolerance testing (ρ = -.76, P < .0001). At post-transplant week (PTW) 3 and at PTW 4, the GA levels in recipients with long-term insulin-independence (>90 days) were significantly lower than those with short-term insulin-independence, which revealed the excellent performance for the prediction of long-term insulin-independence that is comparable to that of porcine C-peptide (historic data). CONCLUSIONS: As a surrogate indicator for graft function, serial measurement of GA may provide Supporting Information to that obtained from conventional monitoring techniques of graft function for assessing porcine islet grafts in NHP models.

Clinical outcomes of extra-articular tenodesis/anterolateral reconstruction in the ACL injured knee.

PURPOSE: The role of concomitant extra-articular procedures in improving the outcome of ACL reconstruction has experienced a recent resurgence in interest. The aim of this article is to highlight the differences in philosophies and outcomes of historical lateral extra-articular tenodesis (LET) and contemporary, anterolateral reconstruction. METHODS: A narrative review was performed using PubMed/MEDLINE using the keywords "lateral extra-articular tenodesis" and "anterolateral ligament reconstruction". RESULTS: Results of search strategy: Thirty-seven studies [13 reporting clinical outcomes of isolated LET in ACL deficient knees and 24 comparing isolated anterior cruciate ligament reconstruction (ACLR) with ACLR + LET] and 1 study on anterolateral ligament (ALL) reconstruction were identified as relevant and included in the review. Results of literature review: Isolated extra-articular reconstructions are rarely performed in contemporary practice. They are associated with a high rate of persistent anterior instability and early degenerative change. Combined ACL reconstruction and lateral extra-articular tenodeses results in a significant reduction in the prevalence of residual pivot shift, but the majority of the studies do not demonstrate any significant difference with respect to patient-reported outcome measures and return to sport. Although several authors report a trend towards decreased graft rupture rates, significant differences were not demonstrated in most studies. In a single clinical study, combined anatomic ACL and anterolateral ligament reconstruction was reported to be associated with a threefold reduction in graft rupture rates and improved return to sport compared to isolated ACL graft choices. CONCLUSIONS: Historically performed, combined ACL reconstruction and lateral extra-articular tenodeses are associated with improved knee kinematics. Although trends towards decreased graft rupture rates are reported by several authors, the majority did not demonstrate a significant difference, likely as a result of small and underpowered studies using post-operative immobilisation and delayed rehabilitation protocols. More recently, combined ACLR and ALL reconstruction has been shown to be associated with significant improvements in graft failure and return to sport rates when compared to isolated ACLR. However, these results are from a single clinical series with only medium-term follow-up. LEVEL OF EVIDENCE: IV.

Contact area between femoral tunnel and interference screw in anatomic rectangular tunnel ACL reconstruction: a comparison of outside-in and trans-portal inside-out techniques.

PURPOSE: The purpose of this study was to compare the femoral tunnel length, the femoral graft bending angle at the femoral tunnel aperture, and the contact area between the femoral tunnel wall and an interference screw used for fixation in anatomic rectangular tunnel anterior cruciate ligament (ACL) reconstruction (ART ACLR). METHODS: The study included 149 patients with primary ACL injury who underwent ART ACLR. Preoperatively, flexion angle of the index knee was checked under general anaesthesia. Those of less than 130° of passive flexion were assigned to the outside-in (OI) technique (78 patients), while the others to the trans-portal inside-out (TP) technique (71 patients). The patients underwent computed tomography with multiplanar reconstruction at 3-5 weeks post-operatively. Femoral tunnel length, graft bending angle, and contact ratio between the IFS and femoral tunnel were assessed. P < 0.05 was considered statistically significant. RESULTS: The femoral tunnel length in the OI technique was significantly longer than that in the TP technique (P < 0.001). The femoral graft bending angle in the OI technique was significantly more acute than that in the TP technique (P < 0.001). The contact ratio in the OI technique was significantly larger than that in the TP technique at every point in the femoral tunnel (P < 0.001). CONCLUSIONS: The OI technique resulted in a more acute femoral graft bending angle, longer mean femoral tunnel length, and larger contact ratio than the TP technique after ART ACLR. LEVEL OF EVIDENCE: Retrospective comparative study, Level III.