Early but not late allograft nephrectomy reduces allosensitization after transplant failure

Introduction:

Allosensitization is a significant obstacle to retransplantation for patients with primary renal graft failure.

Methods:

We assessed the impact of allograft nephrectomy (Group I) and weaning of immunosuppression (Group II) on percent panel reactive antibody (%PRA) at various time points after graft failure in 132 patients with a median follow-up of 47 months. Of these, 68% had allograft nephrectomy while 32% were placed on the waiting list and were either taken off immunosuppression, left on prednisone or on low-dose immunosuppressive therapy.

Results:

When groups were stratified into early (<6 months) and late (>6 months) graft failure, patients who had transplant nephrectomy for early failure demonstrated a decline in %PRA from 46% at time of graft failure to 27% at last follow-up (p = 0.02); conversely, %PRA continued to rise in Group II experiencing early allograft failure. Both Groups I and II patients with late graft failure maintained elevated %PRA at last follow-up.

Conclusion:

Allograft nephrectomy may play a role in limiting allosensitization in patients with early but not late graft failures.     

A prospective study to assess the outcomes of revision anterior cruciate ligament reconstruction

Purpose

Continuously increasing numbers of primary anterior cruciate ligament (ACL) reconstructions invites a parallel increase in graft failures and need for revision ACL reconstruction surgery. High failure rates has previously stigmatised the revision surgery. We performed this study using multiple outcome measures together with clinical examination to offer a full assessment of the outcomes of this procedure.

Methods

Twenty patients, with mean age of 29.4 years (17–50 years), were included in this study prior to their revision ACL reconstruction surgery. All patients were followed prospectively collecting the Knee injury and Osteoarthritis Outcome (KOOS), International Knee Documentation Committee (IKDC) and Tegner-Lysholm scores pre- and post-operatively together with clinical assessment of the antero-posterior knee laxity.

Results

After a mean follow up interval of 30 months (16–60 months) significant post-operative improvement of IKDC, Tegner-Lysholm scores and knee antero-posterior laxity together with the Symptoms, Activities of Daily Living (ADL) and Quality of Life (QOL) components of the KOOS score was noticed (P < 0.05). However, there was no similar improvement in pain and sports components of the KOOS score (P > 0.05). There was no difference in the outcomes of different graft types.

Conclusion

Good outcomes of revision ACL reconstruction surgery are achievable. The use of different graft types did not affect the outcome of the procedure. Most of the patients opted to less aggressive sports participation after the revision procedure.     

Improved outcomes after anterior cruciate ligament reconstruction with quadrupled hamstring autografts and additional bone plug augmentation at five year follow-up

Purpose

Hybrid fixation has been proposed to improve outcomes of anterior cruciate ligament (ACL) reconstructions. This study evaluated midterm outcomes after transfemoral graft fixation using either a conventional or a modified technique using additional bone plug augmentation (BPA) of the femoral tunnel aperture.

Methods

Seventy-one consecutive patients undergoing ACL reconstruction using a quadrupled hamstring autograft with transfemoral graft fixation and tibial interference screw fixation were included. Of these, 56 patients could be followed up 61 months (range 52–69 months) after ACL reconstruction both clinically and by magnetic resonance imaging (group A, conventional technique, n = 34; group B, modified technique, n = 22). Anteroposterior (AP) laxity measurements and International Knee Documentation Committee (IKDC), Lysholm and Tegner activity scoring were performed, while imaging included assessment of bone tunnel diameters, graft condition and graft filling at the femoral bone tunnel aperture.

Results

Patients with additional BPA had a significantly higher degree of graft filling at the femoral bone tunnel aperture (p = .0135) and ‘healthier’ grafts (p = .0495). They also tended to display less AP laxity difference in terms of mean differences and total patient numbers. Lysholm, IKDC and Tegner activity index scores and bone tunnel diameters were not significantly different.

Conclusions

Additional BPA is an easy-to-perform, cheap and safe manoeuvre, which has the capacity to improve morphological and clinical outcomes at five year follow-up. However, femoral tunnel widening is unaffected by additional BPA.     

Allograft versus autograft for anterior cruciate ligament reconstruction: an up-to-date meta-analysis of prospective studies

Purpose

Although a large number of anterior cruciate ligament (ACL) reconstructions are performed annually, there remains a considerable amount of controversy over whether an autograft or an allograft should be used. The aim of this meta-analysis was to compare the clinical outcomes of allograft and autograft in primary ACL reconstruction.

Methods

The authors systematically searched electronic databases to identify prospective studies which compared allografts with autografts for primary ACL reconstruction. The results of the eligible studies were analysed in terms of instrumented laxity measurements, Lachman test, Pivot Shift test, objective International Knee Documentation Committee (IKDC) Scores, Lysholm Scores, Tegner Scores, and clinical failures. Study quality was assessed and relevant data were extracted independently by two reviewers. A random effect model was used to pool the data. Statistical heterogeneity between trials was evaluated by the chi-square and I-square tests.

Results

Nine studies, with 410 patients in the autograft and 408 patients in the allograft group, met the inclusion criteria. Five studies compared bone-patellar tendon-bone (BPTB) grafts, and four compared soft-tissue grafts. Four studies were randomized controlled trials, and five were prospective cohort studies. The results of the meta-analysis showed that there were no significant differences between allograft and autograft on all the outcomes in terms of instrumented laxity measurements (P = 0.59), Lachman test (P = 0.41), Pivot Shift test (P = 0.88), objective IKDC Scores (P = 0.87), Lysholm Scores (P = 0.79), Tegner Scores (P = 0.06), and clinical failures (P = 0.68). These findings were still robust during the sensitivity analysis. However, a subgroup analysis of Tegner scores by involving only BPTB grafts showed a statistical difference in favour of autografts (P = 0.005).

Conclusions

There was insufficient evidence to identify which of the two types of grafts was significantly better for ACL reconstruction, though the subgroup analysis indicated that reconstruction with BPTB autograft might allow patients to return to higher levels of activity in comparison with BPTB allograft. More high-quality randomized controlled trials with specified age and activity level are highly required before drawing a reliable conclusion.     

Who Gets a Second Heart? A Current Picture of Cardiac Retransplantation

Background

Heart retransplantation (HRT) accounts for 2.6% of heart transplantation (HT) indications. We performed a retrospective analysis of our recent HRT experience.

Methods

From January 2000 to June 2012, 820 HTs were performed; 798 (97.3%) were primary HTs and 21 (2.5%) 2nd HTs. Indications for HRT included: 57% cardiac allograft vasculopathy, 33% nonspecific graft failure, 5% primary graft failure (PGF), and 5% refractory acute rejection. The primary outcome was overall survival. Our results were compared with the most representative publications reporting HRT experiences before January 2000.

Results

Mean age at HRT was 39.9 ± 14.3 years, and there was a predominance of male patients (62%). Overall mortality was 52%; 30-day mortality was 19%. Eight patients (38%) developed PGF after HRT and 3 of them (38%) died within 30 days. Overall actuarial survivals at 1 month and 1, 3, and 5 years were 81.0%, 70.8%, 59.9%, and 53.3%, respectively. No significant risk factors for mortality could be identified.

Conclusions

We observed improved short- and medium-term survival after HRT. This finding is probably related to changing recipient profiles, with less patients being retransplanted for PGF and more patients undergoing late retransplantation. Higher rates of PGF after HRT reflect our efforts to broaden the allograft pool by using marginal donors.     

Comparison of Kidney Transplantation Results From the Same Deceased Donor Between Patients With the First Transplantation and Retransplanted Patients

Background

It has been determined that there are about 25% patients with renal allograft failure on the waiting lists.

Risk of graft fracture after dorso-ventral thoraco-lumbar spondylodesis: is there a correlation with graft size?

Study design

Retrospective clinical study in patients with dorso-ventral thoraco-lumbar spondylodesis.

Objective

To investigate whether the ratio between graft cross sectional area and the surface area of the adjacent endplates has any effect on the midterm stability of the spondylodesis.

Summary of background data

Dorso-ventral spondylodesis in the region of the thoraco-lumbar spine is one of the most frequent operations in orthopaedic surgery. Anterior stabilization with autologous iliac crest graft currently is a standard approach in many hospitals. Although numerous recommendations are given how to perform this technique, no clinical advice is available with regard to minimum graft size.

Methods

Sixty-four-slice CT-scans were obtained from 82 patients 4–12 months after posterior spondylodesis with anterior implantation of iliac crest graft and stabilization with an internal fixator. The scans were analyzed using image analysis software. First, the cross sectional area of the graft was calculated and then the surface area of the adjacent endplates. The ratio between graft cross sectional area and endplate surface area was then calculated from these two values. The grafts were then evaluated in sagittal reconstruction for signs of fracture.

Results

The probability for graft fracture in autologous tricortical grafts was >0.1% (p < 0.001) if the graft cross sectional area exceeded 23.9% of the surface area of the adjacent endplates. Patients with lower ratio values had a higher fracture risk and below a value of 10% all grafts fractured.

Conclusion

The relationship between graft cross sectional area and adjacent endplate area has an important effect on graft midterm stability in ventral spondylodesis of the thoraco-lumbar spine. In our opinion, the risk of graft fractures in dorso-ventral spondylodesis can be reduced by implantation of an appropriately sized graft without any additional procedures or instrumentation.     

Should peritoneal dialysis catheters be removed at the time of kidney transplantation?

Background:

Delayed graft function (DGF) following transplantation necessitates support in the form of hemodialyis (HD) or peritoneal dialysis (PD). However, post-transplant PD-related complication and failure rates are unknown.

Methods:

We studies patients who were on PD at the time of kidney transplantation over a 4-year period at two separate institutions.

Results:

Of the 137 PD patients, 19 had their catheters removed at the time of transplant. Of the remaining 118 patients, 89% had immediate graft function. PD-related complications in this group included peritonitis (n=5), catheter-related infections (n=2) and emergency laparotomy (n=1). Of the 15 patients requiring post-transplant PD, 33% developed peritonitis and 20% had fluid-leaks necessitating HD. Overall, leaving a PD catheter in situ post- transplantation is associated with 7% rate of peritonitis versus 0% if removed (p < 0.05).

Conclusions:

PD catheter removal should be considered at the time of renal transplantation, as postoperative PD-related failure/complication rates are high.     

Sex Differences in Mortality After CABG Surgery

INTRODUCTION

Numerous studies have shown that women undergoing coronary artery bypass graft surgery present higher mortality rate during hospitalization, and often complications when compared to men.

OBJECTIVE

To compare the mortality of men and women undergoing coronary artery bypass graft surgery and identify factors related to differences occasionally found.

METHODS

Retrospective cohort study conducted with 215 consecutive patients who underwent coronary bypass surgery.

RESULTS

Women had a higher average age. Low body surface and dyslipidemia were more prevalent in women (1.65 vs. 1.85, P <0.001: 53% vs. 30%, P =0.001), whereas history of smoking and previous myocardial infarction were more prevalent in men (35% vs.14.7%, P =0.001; 20% vs. 2.7%, P =0.007). Regarding complications in the postoperative period, there was a higher rate of blood transfusions in women. The overall mortality rate was 5.6%, however there was no statistically significant difference in mortality between men and women. It was observed that among the patients who died, the average body surface area was lower than that of patients who did not have this complication.

CONCLUSION

There was no difference in mortality between the sexes after coronary artery bypass graft in this service.     

Retransplantation after single lung transplantation

Objective

Our lung transplant program started in June 1989 with primary grafts including 21 heart-lung, 11 single lung, and 5 bilateral sequential single lung transplantation. Three patients required retransplantation for single lung and 2 patients for heart-lung grafts. The primary cause of death after lung transplantation is chronic graft dysfunction—bronchiolitis obliteran—though other causes, namely acute graft failure, have been mentioned. Retransplantation is considered to be the only treatment option. In experienced centers, the 1- and 5-year survivals are not as good as for other organ transplantations and for retransplantations the outcome is even worse. Our objective herein was to describe factors to be taken into account for retransplantation in our program, including the timing and indication for retransplantation and the presence of comorbidities.

Patients and Methods

In our experience of 11 single lung transplantations, 3 (27.3%) were retransplantations. The 3 patients were 3, 5, and 2 years after primary transplantation. The indications were overexpansion of the remaining lung compressing the new lung in one and bronchiolitis obliterans in the others.

Results

One patient with emphysema died in hospital after retransplantation because of acute myocardial infarction. One patient with lymphangioleiomyomatosis (LAM) disease died of lung complication after sudden cardiac arrest at 1.5 years after retransplantation. One patient with idiopathic pulmonary fibrosis is still alive at 5 years after retransplantation.

Conclusions

Bronchiolitis obliterans was a common reason for retransplantation among our patients as well as in other reports. Bronchiolitis exists with superimposed infection for years if it is the mild form. However, the clinical setting is progressively worse if it could not be controlled leading to retransplantation. At this stage, progressive deterioration of lung function must be considered because of inadequate therapy for infection. Finally, when there is infection usually both lungs are involved. The decision whether to replace the transplanted lung or the remaining lung is a concern, especially when the donor availability is scarce. In conclusion, lung retransplantation is the only treatment option for severe graft dysfunction, if there is no other therapy that can prolong life. Though bronchiolitis obliterans often is the indication for retransplantation, bronchiolitis itself is the signal of retransplantation.     

Postoperative changes of early-phase inflammatory indices after uncomplicated anterior cervical discectomy and fusion using allograft and demineralised bone matrix

Purposes

We investigated sequential levels of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) in uncomplicated ACDF (anterior cervical discectomy and fusion) using allograft and DBM (demineralised bone matrix) for primary cervical spondylosis and/or disc herniation. To our knowledge, there has been no study to investigate the diagnostic value of CRP and ESR for postoperative infection in ACDF using allograft and DBM.

Methods

Blood samples of 85 patients, who underwent one- (n = 51) or two-level (n = 34) ACDF, were obtained and evaluated before surgery and on the first, third, fifth, seventh, 14th, 30th, and 90th postoperative days. No infection was found in any patient for at least one year follow-up period.

Results

Mean CRP value increased significantly on the first postoperative day and reached a peak on the third postoperative day. The peak level rapidly decreased but remained elevated on the fifth, seventh, and 14th postoperative days. Mean ESR value increased significantly and reached a peak on the third postoperative day. The peak level gradually decreased but remained elevated on the fifth and seventh postoperative days. One- and two-level ACDF exhibited similar postoperative changes in CRP and ESR values and no significant difference in mean levels of CRP and ESR throughout the follow-up periods.

Conclusions

This study demonstrates that uncomplicated ACDF using allograft and DBM showed significant abnormal values of CRP and ESR during the early postoperative period. This result suggests that abnormal values of CRP and ESR in the early postoperative period do not indicate acute postoperative infection after ACDF using allograft and DBM. Straying from the normal course, such as a second rise or a failure to decrease, of CRP and ESR is more important to signpost acute postoperative infection in ACDF using allograft and DBM.     

Grafting Using Injectable Calcium Sulfate in Bone Tumor Surgery: Comparison with Demineralized Bone Matrix-based Grafting

Background

Injectable calcium sulfate is a clinically proven osteoconductive biomaterial, and it is an injectable, resorbable and semi-structural bone graft material. The purpose of this study was to validate the clinical outcomes of injectable calcium sulfate (ICS) grafts as compared with those of a demineralized bone matrix (DBM)-based graft for filling in contained bony defects created by tumor surgery.

Methods

Fifty-six patients (41 males and 15 females) with various bone tumors and who were surgically treated between September 2003 and October 2007 were included for this study. The patients were randomly allocated into two groups, and either an ICS graft (28 patients) or a DBM-based graft (28 patients) was implanted into each contained defect that was developed by the surgery. The radiographic outcomes were compared between the two groups and various clinical factors were included for the statistical analysis.

Results

When one case with early postoperative pathologic fracture in the DBM group was excluded, the overall success rates of the ICS and DBM grafting were 85.7% (24/28) and 88.9% (24/27) (p > 0.05), respectively. The average time to complete healing was 17.3 weeks in the ICS group and 14.9 weeks in the DBM group (p > 0.05). Additionally, the ICS was completely resorbed within 3 months, except for one case.

Conclusions

Although the rate of resorption of ICS is a concern, the injectable calcium sulfate appears to be a comparable bone graft substitute for a DBM-based graft, with a lower cost, for the treatment of the bone defects created during surgery for various bone tumors.     

Impact of laparoscopic right hemicolectomy for colon cancer

INTRODUCTION

This study specifically examined right colonic cancer resection, a common operation for colorectal surgeons starting laparoscopic resection, to assess the impact of commencing laparoscopy.

PATIENTS AND METHODS

A total of 56 patients undergoing open (n = 34) and attempted laparoscopic (n = 22) elective right hemicolectomy for colorectal cancer between November 2003 and March 2007 were compared. Postoperative stay was the primary outcome. Secondary outcomes included analgesic requirements, bowel recovery, morbidity and mortality. Frequency of laparoscopic versus open surgery over time was also examined.

RESULTS

Resections attempted laparoscopically increased from 9.1% to 75% in the first and last quarters of the study period, respectively (P = 0.0002). Uptake of ‘enhanced recovery’ was mainly in the laparoscopic group. Conversion was required in two of 22 patients. Attempted laparoscopic cases had a shorter median postoperative stay (6 vs 10 days; P < 0.0001), duration of parenteral or epidural analgesia (48 vs 72 h; P < 0.0001) and time to first bowel action (3 vs 4 days; P = 0.001) compared with open cases. Demography, tumour characteristics, morbidity and mortality were comparable between groups. Multivariate analysis identified decreased age, attempted laparoscopic surgery, use of enhanced recovery and absence of complications as independently shortening postoperative stay.

CONCLUSIONS

Advantages of laparoscopic surgery and enhanced recovery, even early in a surgeon''s experience, suggest this is the preferred mode for elective right colon cancer resection.     

Single-bundle versus double-bundle anterior cruciate ligament reconstruction: an up-to-date meta-analysis

Purpose

The aim of this meta-analysis was to compare the results of arthroscopic single-bundle and double-bundle anterior cruciate ligament (ACL) reconstruction.

Methods

We systematically searched electronic databases to identify randomised controlled trials (RCTs) in which arthroscopic single-bundle was compared with double-bundle for ACL reconstruction. The search strategy followed the requirements of the Cochrane Library Handbook. The outcomes of these studies were analysed in terms of graft failures, Lysholm score, negative pivot-shift test, KT1000 arthrometer measurements, knee extensor and flexor peak torques, knee extension and flexion deficit, and subjective and objective International Knee Documentation Committee (IKDC) final score. Methodological quality was assessed and data were extracted independently. Standard mean difference (SMD) or odds ratio (OR) with 95 % confidence interval (CI) was calculated by a fixed effects or random effects model. Heterogeneity across the studies was assessed with the I-square and chi-square statistic. Forest plots were also generated.

Results

We identified 17 RCTs comprising 1,381 patients who were treated by arthroscopic single-bundle versus double-bundle ACL reconstruction. The results of meta-analysis of these studies showed that arthroscopic double-bundle reconstruction was associated with a lower risk of graft failures (P = 0.002) and a lower rate of positive pivot-shift test (P < 0.0001). Compared with single-bundle reconstruction, double-bundle reconstruction had a lower KT1000 arthrometer measurement (P < 0.00001), a lower knee extension deficit (P = 0.006) and a higher subjective IKDC score (P = 0.03). There was no statistically significant difference between single-bundle and double-bundle reconstruction in Lysholm score (P = 0.91), knee extensor peak torques (P = 0.97), knee flexor peak torques (P = 0.96), knee flexion deficit (P = 0.30) and objective IKDC score (P = 0.18).

Conclusions

Considering the more favourable outcomes of graft failures, knee joint stability and knee joint function in double-bundle reconstruction, we concluded that arthroscopic double-bundle reconstruction should be considered as the primary treatment in ACL reconstruction.     

Should We Pursue Patients Who Fail to Attend Colorectal Clinics? A 9-Year Study

INTRODUCTION

No uniform protocol exists on how to deal with patients who fail to attend colorectal clinics. Our aim was to identify whether the tendency to ‘failure to attend’ (FTA) in the colorectal clinic was associated with FTA in other clinics and also whether FTA patients have serious pathology.

PATIENTS AND METHODS

This was a retrospective study of a prospectively recorded list of FTA patients, in colorectal urgent or two-week wait clinics from 1996–2004.

RESULTS

A total of 151 patients, who failed to attend their first appointment, were included in the study. Of these, 61 (40.4%) were colorectal referrals, 76 (50.3%) were general surgical referrals, and for 14 (9.3%) case notes were not available. There were 59 FTA episodes in 61 colorectal patients associated with 59 FTA episodes in other clinics (Pearson correlation: r = 0.411; P = 0.01, two-tailed, SPSS v.12). Of 58 colorectal outcomes, five (8.6%) colorectal cancers (CRC) were diagnosed, 23 (39.6%) were persistent non-attendees, 16 (27.5%) had benign colorectal pathology, two (3.4%) benign non-colorectal outcomes and 12 (20.6%) normal outcomes.

CONCLUSIONS

Tendency to FTA is habitual. Care needs to be exercised in the management of FTAs to avoid delayed presentation of colorectal cancer.     

One Hundred Consecutive Liver Transplants Using Institutes Georges Lopez-1 Preservation Solution: Outcomes and Prognostic Factors

Background

There are only 4 prior studies reporting on outcomes of liver transplantation (LT) using Institutes Georges Lopez-1 (IGL-1) preservation solution. Detection of negative predictors of LT using IGL-1 may help finding strategies to protect selected recipients at higher risk of graft failure and death.

Factors associated with early mortality after cervical spinal cord injury

Background

A relatively high early mortality rate (<30 days post-injury) for cervical spinal cord injury (SCI) has been observed.

Objective

To investigate this early mortality rate observed after cervical SCI and analyze the associated influential factors.

Methods

Medical records for 1163 patients with cervical SCI were reviewed, and the number of patients with early mortality was documented. Through logistic regression analysis, the effects of age, gender, occupation, cause of injury, severity of injury, highest involved spinal cord segment, nutritional condition during hospitalization, surgical treatment, tracheotomy, etc., on early mortality were assessed. Implementation of early treatment (i.e. surgery, tracheotomy, and nutritional support) and its effect on patient prognosis were also analyzed.

Results

Early mortality occurred in 109 of 1163 patients (9.4%). Four factors affected the early mortality rate, including level and severity of SCI, whether or not surgery was performed, the time interval between SCI and surgery, malnutrition, and tracheotomy. Patients with an American Spinal Injury Association grade of A, a high cervical SCI (C1–C3), and/or no surgical intervention were statistically more likely to have early mortality (P < 0.001).

Conclusion

Severe cervical SCI, upper-level cervical cord injury, malnutrition, and inappropriate tracheotomy are risk factors for early mortality in patients with cervical SCI. Surgery can reduce early mortality. Early tracheotomy should be performed in patients with complete upper-level cervical SCI, but patients with incomplete cervical SCI or complete low-level cervical SCI should initially be treated surgically to maintain smooth airway flow.     

Time delay between diagnosis and arthroscopic lavage in septic arthritis. Does it matter?

Purpose

Septic arthritis is a life-threatening emergency with high mortality of up to 11 %. We investigated if delay of arthroscopic lavage of infected major joints would have a bearing on the mortality and morbidity such as admission to an intensive care unit (ICU).

Methods

We retrospectively reviewed patients presenting with septic arthritis to two regional hospitals over a period of seven years from 1 January 2005 to 31 December 2011. We divided our sample of 82 patients into four groups based on the time delay between clinical diagnosis and arthroscopic lavage ranging from less than six hours to more than 24 hours.

Results

We determined that 35.4 % of patients had prosthetic joints. Knee joints were predominantly involved (74.4 %). Staphylococcus aureus was the most commonly isolated pathogen (41.5 %). There were ten (12.2 %) deaths and the same number of admissions to an ICU. Our study revealed there was no statistical significance between the time delay and mortality (P = 0.25) or ICU admission (P = 0.74) or the number of washouts (P = 0.08) in all four groups.

Conclusions

Up to 48 hours delayed arthroscopic lavage for septic arthritis does not increase the risk of mortality. Further prospective large sample studies are recommended to investigate this and the risk of long-term morbidity.