Outcomes of surgical treatment of patellar instability in children with Down syndrome.

BACKGROUND: patellar instability is a relatively frequent musculoskeletal disorder in children with Down syndrome (DS). However, such a condition has seldom been studied in the literature, even less its surgical treatment. Different techniques have been offered for this condition; the evidence for surgical options is scarce and primarily based on case reports or case series with few patients and heterogeneous techniques. Given this background, we aimed to evaluate the outcomes of a uniform kind of surgical procedure for such a condition that combined lateral soft tissue release, medial patellofemoral ligament (MPFL) reconstruction (using a partial-thickness quadriceps tendon autograft), the Roux-Goldthwait procedure, and V-Y quadricepsplasty (if needed). MATERIALS AND METHODS: This retrospective study involved 11 skeletally immature patients (12 knees; 9 males and 2 females), 5.5 to 14.1 years of age, with DS who had patellofemoral instability (PFI) and were managed by this technique between October 2018 and March 2020. Preoperative radiography, CT scan, and MRI were performed to evaluate the physis status, lower limb alignment, patellar height, trochlear morphology, and any associated knee pathology. A functional knee assessment was done by using the Kujala score and the modified Lysholm score. RESULTS: The mean time of follow-up (± SD) was 47.7 ± 5.8 months (range: 39-56). Pre-operatively, the Kujala score (± SD) was 52.6 ± 14.3 (range: (31-74), and at final follow-up, it was 92.2 ± 4.4 (range: (88-98), showing a significant improvement (P < 0.001). The preoperative modified Lysholm score (± SD) was 54.3 ± 8.1 (range: 39-62), and at final follow-up it was 92.4 ± 5.3 (range: 82-96), showing a significant improvement (P < 0.001). All patients had a stable patella without a recurrence of instability and regained full ROM. There was no incidence of a patellar fracture or femoral physis injury. CONCLUSIONS: Our proposed technique of combined soft tissue procedures, including lateral soft tissue release, MPFL reconstruction (using a partial-thickness quadriceps tendon autograft), the Roux-Goldthwait procedure, and V-Y quadricepsplasty, was an effective method for treating patellar instability in children with DS while avoiding physeal injury and patellar fracture. Functional scores and radiological outcomes were improved. LEVEL OF EVIDENCE: IV; retrospective case series.

Optimal design of bone tumor ablation device based on radio frequency heating using Taguchi method.

This study investigated the optimal design of a radio-frequency (RF) bone tumor ablation device to achieve uniform heating. In a previous study, we confirmed the feasibility of this device, which could heat all regions of the bone to 70 °C or higher and maintain this temperature for more than 30 min. However, the temperature in each part was non-uniform. To address this issue, the shape of the electrode must be modified to create a uniform electric field. The design of the electrode was optimized to reduce temperature deviations. It is difficult to analytically model the relationship between the shape of the electrode and the electric field. The electrode's design factors were fine-tuned using the Taguchi method, a robust design of experiment approach. The primary objective in this optimization was to maximize the signal-to-noise ratio for temperature in each component, aiming for higher values. After four trials, the signal-to-noise ratio increased in comparison with the initial modified shape from 68.3 to 98.6. The experiment was conducted using an experimental device fabricated using the optimal design factors. In comparison to the previous experiment, the temperature standard deviation per part over time decreased from 10.56 °C 4.28 °C. The experimental results demonstrated the validity of the proposed optimal design approach. In the future, the proposed method can be used to optimize the design factors when a product is advanced to develop a device that can be applied to the human body.

Hamstring Anterior Cruciate Ligament Autograft Contributes to a Delayed Symptomatic Cyclops Lesion: A Case Report.

Cyclops lesions are characterized as fibroid nodules with granulation tissue that looks similar to a cyclops eye during arthroscopy. These are rare postoperative complications following anterior cruciate ligament reconstruction (ACLR), presenting typically within six months of their reconstruction. This case report presents a 21-year-old male, three years following hamstring autograft ACLR, with a symptomatic cyclops lesion. Contrary to the reported literature, this delayed presentation showed a painful flexion contracture of the knee and intraoperative findings consistent with a cyclops lesion. The treatment consisted of surgical debridement and notchplasty with subsequent posterior medial and lateral meniscal horn repairs. This case report presents a lesson to indicate that cyclops lesions can occur in a delayed setting following ACLR and to show a technique for successful surgical management of the lesion.

Biliary reconstruction with localized creation: One case report of repairing bile duct injury and defect with autografts.

INTRODUCTION: Bile duct injuries caused by any reason are a disaster for patients and pose a significant psychological and technical challenge for surgeons. The use of Ligamentum teres hepatis and gallbladder flap as autografts is showing promising results in the repair of bile duct injury. CASE PRESENTATION: This article presents a challenging case of a patient with Mirizzi syndrome who experienced a complex bile duct defect and injury during cholecystectomy. We describe the successful reconstruction of the bile duct using ligamentum teres hepatis and remnant gallbladder flap simultaneously. DISCUSSION: Ligamentum teres hepatis and remnant gallbladder flap are ideal repair materials for repairing and reconstructing bile duct injuries due to their easy availability, good tissue compatibility, and low incidence of postoperative complications. It is essential to seek the assistance of an experienced biliary surgeon when bile duct injury occurs during operation. CONCLUSION: Ligamentum teres hepatis and gallbladder flap, as suitable autologous tissues, are viable options for repairing bile duct injuries and defects.

The marine sponge, Hymeniacidon sinapium, displays allorecognition of siblings during post-larval settling and metamorphosis to juveniles.

Marine sponges, including the crumb of bread sponge, Hymeniacidon sinapium, display allorejection responses to contact with conspecifics in both experimental and natural settings. These responses have been used to infer immunocompetence in a variety of marine invertebrates. However, larvae and juveniles from several marine sponge species fuse and form chimeras. Some of these chimeras persist, whereas others eventually break down, revealing a period of allogeneic non-responsiveness that varies depending on the species. Alternatively, for H. sinapium, most pairs of sibling post-larvae and juveniles that settle in contact initiate immediate allorecognition and show the same morphological response progression as the adults. This indicates that allorecognition and response occurs during early metamorphosis. Results from H. sinapium and other sponge species, in addition to annotations of sponge genomes, suggest that allorecognition and immunocompetence in sponges are mediated by distinct systems and may become functional at different times during or after metamorphosis for different species. Consequently, allorecognition may not be a good proxy for the onset of immunocompetence.

Femoral interference screw divergence as a result of anteromedial portal insertion and outside-in FlipCutter femoral tunnel drilling: A cadaveric study.

Aims and objectives: To investigate whether interference screw fixation through an anteromedial portal into an outside-in drilled femoral tunnel via a flip cutter results in acceptable hardware position. Materials & methods: 10 cadaveric knees underwent ACL-reconstruction with patellar BTB autograft. Femoral tunnel drilling was performed utilizing an outside-in flip cutter drill and interference screws for femoral fixation. Lateral and anterior-posterior (AP) fluoroscopic images were taken to measure screw divergence within the femoral tunnel. The means of AP and lateral divergence angles were compared using two-tailed t-tests. Results: Using the flip cutter, the AP and lateral divergence angles were 7.3° ± 4.5° and 9.3° ± 9.3°, respectively, while the total divergence angles were 16.6° ± 11.8°. Divergence angles using a cannulated reamer were found to be 14.4° ± 2.5° and 6.8° ± 2.8° for AP and lateral, respectively and 21.1° ± 5.2° for the total divergence. The AP divergence angles using the flip cutter were significantly less than those reported using a cannulated reamer (p = 0.001). Conclusions: The flip cutter method resulted in significantly reduced divergence angle between the screw and graft when compared to previous cadaveric studies in the coronal plane. There was no significant difference in divergence angle in the sagittal plane. Both methods appear to result in divergence angles below the threshold which would be considered to significantly decrease pull-out strength. Large standard deviations also reflect limited sample size but may also suggest more variability in divergence when compared to historical control set. This study clearly establishes the outside-in technique using a retrograde reamer as a viable independent femoral drilling solution for ACL reconstruction when using a BTB autograft with a femoral interference screw.

The Use of Glenoid Structural Allografts for Glenoid Bone Defects in Reverse Shoulder Arthroplasty.

Background: The use of reverse shoulder arthroplasty as a primary and revision implant is increasing. Advances in implant design and preoperative surgical planning allow the management of complex glenoid defects. As the demand for treating severe bone loss increases, custom allograft composites are needed to match the premorbid anatomy. Baseplate composite structural allografts are used in patients with eccentric and centric defects to restore the glenoid joint line. Preserving bone stock is important in younger patients where a revision surgery is expected. The aim of this article is to present the assessment, planning, and indications of femoral head allografting for bony defects of the glenoid. Methods: The preoperative surgical planning and the surgical technique to execute the plan with a baseplate composite graft are detailed. The preliminary clinical and radiological results of 29 shoulders which have undergone this graft planning and surgical technique are discussed. Clinical outcomes included visual analogue score of pain (VAS), American Shoulder and Elbow Surgeons score (ASES), Constant-Murley score (CS), satisfaction before and after operation, and active range of motion. Radiological outcomes included graft healing and presence of osteolysis or loosening. Results: The use of composite grafts in this series has shown excellent clinical outcomes, with an overall graft complication rate in complex bone loss cases of 8%. Conclusion: Femoral head structural allografting is a valid and viable surgical option for glenoid bone defects in reverse shoulder arthroplasty.

Autogenous structural bone graft reconstruction of ≥ 10-mm-deep uncontained medial proximal tibial defects in primary total knee arthroplasty.

BACKGROUND: Management of uncontained medial proximal tibial defects during primary total knee arthroplasty (TKA) can be challenging, especially for defects ≥ 10 mm in depth. This study sought to assess the outcomes of autogenous structural bone grafts to address these defects. MATERIALS AND METHODS: In this prospective study, patients with uncontained medial proximal tibial defects ≥ 10 mm in depth undergoing TKA were managed by autogenous structural bone grafts fixed by screws and were followed up for at least 36 months. Patients were followed-up clinically with Knee Society Score (KSS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Additionally, radiological follow-up was done to assess bone graft union and implant stability. RESULTS: The study included 48 patients with a mean age of 69.2 ± 4.5 years. The mean body mass index (BMI) was 31.4 ± 3.7 kg/m2. The mean defect depth was 17 ± 3.6 mm. With a mean follow-up period of 52.2 ± 12.3 months, the median KSS improved significantly from 30 preoperatively to 89, P < 0.001. The median WOMAC score reduced significantly from 85 preoperatively to 30.5, P < 0.001. The mean ROM increased significantly from 73 ± 12.4 preoperatively to 124 ± 8.4 degrees, P < 0.001. The mean graft union time was 4.9 ± 1 months. No significant complications were reported. CONCLUSIONS: Autogenous bone graft reconstruction is a safe and effective method of addressing uncontained medial proximal tibial defects in primary TKA. LEVEL OF EVIDENCE: Level IV.

Frozen inactivated autograft replantation for bone and soft tissue sarcomas.

Background: The frozen inactivation of autologous tumor bones using liquid nitrogen is an important surgical method for limb salvage in patients with sarcoma. At present, there are few research reports related to frozen inactivated autograft replantation. Methods: In this study, we retrospectively collected the clinical data of patients with bone and soft tissue sarcoma treated with liquid nitrogen-frozen inactivated tumor bone replantation, and analyzed the safety and efficacy of this surgical method. The healing status of the frozen inactivated autografts was evaluated using the International Society of Limb Salvage (ISOLS) scoring system. Functional status of patients was assessed using the Musculoskeletal Tumor Society (MSTS) scale. Results: This study included 43 patients. The average length of the bone defect after tumor resection is 16.9 cm (range 6.3-35.3 cm). Patients with autograft not including the knee joint surface had significantly better healing outcomes (ISOLS scores) (80.6% ± 15% vs 28.2% ± 4.9%, P<0.001) and limb function (MSTS score) (87% ± 11.6% vs 27.2% ± 4.4%, P<0.001) than patients with autografts including the knee joint surface. The healing time of the end of inactivated autografts near the metaphyseal was significantly shorter than that of the end far away from the metaphyseal (9.8 ± 6.3 months vs 14.9 ± 6.3 months, P=0.0149). One patient had local recurrence, one had an autograft infection, five (all of whom had an autograft including the knee joint surface) had joint deformities, and seven had bone non-union. Conclusion: Frozen inactivated autologous tumor bone replantation is safe and results in good bone healing. But this method is not suitable for patients with autograft involving the knee joint surface.

Skin Substitutes and Autograft Techniques: Temporary and Permanent Coverage Solutions.

Coverage of burn wounds is crucial to prevent sequalae including dehydration, wound infection, sepsis, shock, scarring, and contracture. To this end, numerous temporary and permanent options for coverage of burn wounds have been described. Temporary options for burn coverage include synthetic dressings, allografts, and xenografts. Permanent burn coverage can be achieved through skin substitutes, cultured epithelial autograft, ReCell, amnion, and autografting. Here, we aim to summarize the available options for burn coverage, as well as important considerations that must be made when choosing the best reconstructive option for a particular patient.

Use of Tibial Cortical Autograft for the Osteotomy Site in Medial Opening-Wedge High Tibial Osteotomy.

Background: Medial opening-wedge high tibial osteotomy (OWHTO) is a useful treatment option in patients with medial compartment osteoarthritis. Typically, the osteotomy site is filled with material such as autologous bone graft, allograft, or synthetic bone substitute. However, all these options have disadvantages. Purpose/Hypothesis: The purpose of this study was to describe tibial cortical autograft as an alternative to conventional graft options. It was hypothesized that the tibial rectangular cortical bone that is removed from the proximal medial cortical surface of the distal tibial fragment longitudinally could be a reliable option for recovery of the gap in the osteotomy area. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 520 patients with medial compartment osteoarthritis who underwent OWHTO between June 2009 and March 2019 were retrospectively analyzed. Patients were divided into 3 groups according to the graft material used to fill the osteotomy site: allograft in group A, iliac crest autograft in group B, and tibial autograft in group C. Bone union, evaluated by radiographs performed at 2 weeks, 4 weeks, 2 months, 3 months, 6 months, and 1 year postoperatively, was defined as occurring when at least 50% of the gap site was bridged with callus. Clinical assessment was performed using the International Knee Documentation Committee (IKDC) and Lysholm scores. Results: Included were 122 patients: 40 patients in group A, 42 patients in group B, and 40 patients in group C. The mean correction was 13.87°± 3.58° in group A, 12.33°± 3.92° in group B, and 14.10°± 2.99° in group C. The mean time for radiological bone union was 6.95 ± 1.40 months in group A, 4.48 ± 1.02 months in group B, and 5.07 ± 1.70 months in group C. Patients in all groups had similar IKDC and Lysholm scores at the final follow-up. Conclusion: This is the first report of this specific procedure in the literature. All clinical and radiological findings showed that use of tibial cortical autograft was an efficient method in patients undergoing OWHTO.

Medial Collateral Ligament Reconstruction With Autograft Versus Allograft: A Systematic Review.

BACKGROUND: Medial collateral ligament (MCL) reconstruction (MCLR) is performed after failed nonoperative treatment or high-grade MCL injury with associated valgus instability. PURPOSE: To evaluate clinical outcomes after MCLR with autograft versus allograft. STUDY DESIGN: Systematic review, Level of evidence, 4. METHODS: A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The authors conducted a search of the PubMed, CINAHL, EMBASE, and Cochrane databases to identify studies comparing outcomes of MCLR with autograft versus allograft. Studies were included if they evaluated clinical outcomes after MCLR using autograft and/or allograft. Any study that included concomitant knee ligament injury other than the anterior cruciate ligament injury was excluded. A quality assessment was performed using the modified Coleman Methodology Score. RESULTS: The initial search identified 746 studies, 17 of which met the inclusion criteria and were included in this review. The studies included 307 patients: 151 (49.2%) patients received autografts, and 156 (50.8%) received allografts. The most used autograft was the semitendinosus tendon (136 grafts; 90.1% of specified allografts), and the only allograft used was the Achilles tendon (110 grafts; 100% of specified autografts). The mean follow-up of the studies was 25.6 months. Postoperative pain (Lysholm scores) ranged from 82.9 to 94.8 in patients receiving autografts and 87.5 to 93 in patients receiving allografts. Postoperative range of motion was full in 8 of 15 (53.3%) patients receiving autografts compared with 82 of 93 (88.2%) patients receiving allografts. Five of the 151 (3.3%) patients who had MCLR with autografts had complications such as infection, instability, and prominent screws. Two of the 156 (1.3%) MCLRs with allografts developed complications of prominent screws and nonhealing incisions. CONCLUSION: MCLR with either autografts or allografts leads to improved patient-reported, radiographic, and clinical outcomes. Patient-reported postoperative pain was similar in patients receiving either graft type. Other outcomes were difficult to compare between graft types because of nonstandardized reporting and a lack of pre- and postoperative measurements. Therefore, there is no evidence of significantly improved outcomes in the use of either autograft or allograft with MCLR.

Technical considerations and sizing of external annuloplasty in the Ross procedure.

Pure aortic regurgitation and dilation of aortic annulus are the most significant risk factors for the failure of pulmonary autograft after the Ross procedure. Aortic annuloplasty has a positive effect on the durability of the autograft. Previously, we described a technique for external annuloplasty with dedicated CORONEO ring. In the present manuscript, we suggest the sizing of annuloplasty based on the diameter of pulmonary autograft annulus.

Tumor-induced Osteomalacia Successfully Treated by En Bloc Tumor Excision and Reconstruction Using a Tumor-bearing Frozen Autograft: A Case Report.

BACKGROUND/AIM: Tumor-induced osteomalacia (TIO) is a rare pathology caused by overproduction of fibroblast growth factor 23 (FGF23). Its common clinical features include generalized muscle weakness, bone pain, and fractures. Complete resection of the offending tumor is the mainstay treatment. In this report, we present the first case of TIO by an FGF23 producing tumor treated using a tumor-bearing autograft treated with liquid nitrogen. CASE REPORT: A 63-year old female presented with generalized body pain, particularly in the left arm. The patient was diagnosed with a FGF23 producing tumor of the left humerus. Wide resection of the involved tumor was performed using a tumor-bearing autograft that was treated with liquid nitrogen. Postoperatively, the FGF23 and alkaline phosphatase (ALP) levels significantly decreased and inorganic phosphate normalized. There was also subsequent relief of generalized body pain. Immediately after the operation, range of motion of the left shoulder and elbow was initiated. The patient was instructed to perform forward flexion and abduction up to 90° with a rotational restraint. Almost complete bone union was observed at 12 months post procedure. Postoperative functional results were as follows: Musculoskeletal Tumor Society (MSTS) score of 27/30, 90% and International Society of Limb Salvage (ISOLS) score of 26/30, 87%. Ten years after the surgery, osteotomy line was completely obscured based on radiographs. The patient was disease free and without activity limitation. CONCLUSION: This is the first case report of wide excision of a FGF23 producing tumor and reconstruction using a tumor-bearing frozen autograft performed with excellent outcomes.

Fungal Keratitis Post-FemtoLASIK: A Novel Therapeutic Approach with LASIK Flap Autograft and Penetrating Keratoplasty: A Case Report.

Introduction: This case report describes a rare case of fungal keratitis following femtoLASIK. Despite targetted antifungal therapy, this case necessitated an innovative surgical approach to manage an unexpected corneal perforation. Case Presentation: A 35-year-old male presented 3 weeks post-femtoLASIK for myopic astigmatism with discomfort and reduced vision in his right eye. He was diagnosed with fungal keratitis surgery caused by Purpureocillium lilacinum and was treated with a myriad of therapy. Unfortunately, the patient developed corneal perforation during flap lift and flap bed irrigation. An innovative approach involving a tectonic autograft using a viable LASIK flap, followed by prompt penetrating keratoplasty, was utilised. Conclusion: This technique was effective and able to mitigate the progression to an open globe.

Clinical and Functional Results Following Posterior Cruciate Ligament Reconstruction in Young Patients.

INTRODUCTION:  Posterior cruciate ligament injuries are uncommon, and their management is controversial. However, surgical reconstruction is necessary in case of symptomatic lesions. The present study aimed to analyse patients' reported outcomes and clinical evaluation after isolated posterior cruciate ligament reconstruction. MATERIALS AND METHODS:  The present study includes 12 patients with posterior cruciate ligament rupture. All patients were treated with arthroscopic surgery using single-bundle hamstring autograft ligament reconstruction. The primary outcome was the International Knee Documentation Committee (IKDC) subjective questionnaire; secondary outcomes included the Lysholm score and stability assessment.  Results: At the time of the surgery, the mean age of the study population was 24 years (range: 18-29), with a body mass index (BMI) of 23.2 kg/m2 (range: 21-25), and the mean time from injury was five months (range: 1-8). The follow-up period was at least 24 months. The mean IKDC score significantly increased from 68.0 preoperatively to 92.6 at the final follow-up. The Lysholm score also increased from 68.8 to 95.8. Knee stability was classified as normal in all patients after surgery. CONCLUSION:  The results of this study indicate that the posterior cruciate ligament reconstruction with single-bundle hamstring autograft is an efficient treatment option for managing symptomatic young patients. All patients presented good functional and clinical results at two years of follow-up. However, further studies with more participants and a longer follow-up are needed to validate these data.

The Correlation Between Graft Size and Graft Failure in Hamstring Autograft Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Previous studies have investigated various factors that contribute to graft failure in hamstring anterior cruciate ligament (ACL) reconstruction. However, there is debate about the potential advantages of increasing graft diameters beyond 8 mm. METHODS: In this retrospective cohort study (level of evidence III), we investigated whether increasing graft sizes beyond 8 mm diameter showed any advantages in reducing the risk of graft failure. We utilized univariate Kaplan-Meier analysis and Cox proportional hazard (PH) regression models to compare the risk of failure in the different patient groups. Mutual adjustment was performed for age, gender, body mass index (BMI), and graft strands. Graft sizes ranging between 8 and 10 mm were assessed for their association with graft failure, alongside examining the impact of graft strands, age, and BMI on graft failure. RESULTS: A total of 487 patients underwent hamstring autograft ACL reconstruction at our hospital between January 2016 and December 2020. Our analysis indicated that among patients undergoing hamstring autograft ACL reconstruction, the risk of graft failure was 1.64 times higher for patients with a graft size between 8.5 and 9 mm (95% CI 0.36-7.43, p=0.483) and 2.19 times higher for patients with a graft size between 9.5 and 10.5 mm (95% CI 0.42-11.31, p=0.384) compared to those with an 8 mm graft. However, there was weak evidence against the null hypothesis.  Conclusion: These findings suggest that there is no benefit to increasing graft sizes past 8 mm and that other factors, like surgical technique, should be considered when assessing the risk of graft failure in patients undergoing ACL reconstruction.

Knee Joint Preservation in Tactical Athletes: A Comprehensive Approach Based upon Lesion Location and Restoration of the Osteochondral Unit.

The unique physical demands of tactical athletes put immense stress on the knee joint, making these individuals susceptible to injury. In order to ensure operational readiness, management options must restore and preserve the native architecture and minimize downtime, while optimizing functionality. Osteochondral lesions (OCL) of the knee have long been acknowledged as significant sources of knee pain and functional deficits. The management of OCL is predicated on certain injury characteristics, including lesion location and the extent of subchondral disease. Techniques such as marrow stimulation, allograft and autologous chondrocyte implantation are examined in detail, with a focus on their application and suitability in tactical athlete populations. Moreover, the restoration of the osteochondral unit (OCU) is highlighted as a central aspect of knee joint preservation. The discussion encompasses the biomechanical considerations and outcomes associated with various cartilage restoration techniques. Factors influencing procedure selection, including lesion size, location, and patient-specific variables, are thoroughly examined. Additionally, the review underscores the critical role of post-operative rehabilitation and conditioning programs in optimizing outcomes. Strengthening the surrounding musculature, enhancing joint stability, and refining movement patterns are paramount in facilitating the successful integration of preservation procedures. This narrative review aims to provide a comprehensive resource for surgeons, engineers, and sports medicine practitioners engaged in the care of tactical athletes and the field of cartilage restoration. The integration of advanced preservation techniques and tailored rehabilitation protocols offers a promising avenue for sustaining knee joint health and function in this demanding population.