MRI signal intensity of anterior cruciate ligament graft after transtibial versus anteromedial portal technique (TRANSIG): A randomised controlled clinical trial

BackgroundTwo primary surgical femoral drilling techniques are used to reconstruct the anterior cruciate ligament (ACL): the transtibial (TT) technique and the anteromedial portal (AMP) technique. Currently there is no consensus on which surgical technique elicits the best clinical and functional outcomes. MRI-derived measures of the signal intensity (SI) of the ACL graft have been described as an independent predictor of graft properties. The purpose of this study was to assess MRI-derived SI measurements of the ACL graft one year after ACL reconstruction, in order to compare graft maturation of both AMP and TT ACL reconstruction techniques.MethodsThis randomised controlled trial included 33 patients admitted for primary unilateral ACL reconstruction. Primary outcome was MRI Signal intensity ratio (SIR) of the ACL graft one year after ACL reconstruction. Differences in MRI SIR were assessed on two MRI sequencies: sagittal Proton Density Turbo Spin Echo weighted images (PDTSE) and 3D T2 Gradient Echo (T2*) weighted images. Analysis of interobserver and intraobserver variability was conducted for the SIR measurements.ResultsNo difference in signal intensity of the graft was found between the TT and AMP techniques one year after ACL reconstruction (PDTSE p = 0.665, T2* p = 0.957). Both interobserver and intraobserver variability showed strong agreement (ICC 0.64–0.94).ConclusionNo differences in signal intensity of the graft on MRI were seen between the femoral drilling techniques one year after ACL reconstruction, suggesting similar graft maturation at that time. Follow-up studies are needed to determine whether graft intensity changes in the long term.Level of evidenceTherapeutic study with level of evidence I.     

Under-correction of preoperative varus alignment does not lead to a difference in in-vivo bone loading in 3D-SPECT/CT compared to neutral alignment

BackgroundThe aim was to investigate the correlation of bone tracer uptake (BTU) in SPECT/CT and changes in coronal knee alignment after total knee arthroplasty (TKA). We questioned if undercorrection of preoperative varus alignment leads to a difference in BTU compared to neutral alignment.MethodsConsecutive 66 patients who received SPECT/CT before and after TKA were retrospectively included. Adjusted mechanical alignment was the alignment target. The alignment of the knee was measured on 3D-CT by selecting standardized landmarks. Maximum (mean ± SD) and relative BTU (ratio to the reference) were recorded using a previously validated localization scheme (p < 0.05).ResultsIn the native group, 20 knees were aligned (30.3%) in valgus (HKA > 181.5°), 12 (18.2%) in neutral (178.5°-181.5°) and 34 (51.5%) in varus (HKA < 178°). Overall TKA changed the alignment towards neutral. 48.5% remained in the same groups, whereas 50% of native valgus and 33% of varus knees changed to neutral after TKA. In native varus alignment mean BTU was significantly higher in some medial tibial and femoral regions (fem1ia (p = 0.010), fem1ip (p = 0.002), tib1a.mid (p = 0.005), tib1a.tray (p = 0.000), tib1p.tray (p = 0.000)); in native valgus alignment mean BTU was higher in the corresponding lateral tibial and femoral regions (fem2ip (p = 0.001), tib2a.tray (p = 0.011), tib2p.tray (p = 0.002)). After TKA, a significant decrease in femoral and tibial BTU (femoral preoperative BTU 1.64 +/-0.69; femoral postoperative BTU 0.95 +/-0.42; p = 0.000// tibial preoperative BTU 1.65 +/- 0.93; tibial postoperative BTU 1.16 +/- 0.48; p = 0.000) and an increase in patellar BTU was observed (p = 0.025). Native varus alignment correlated with a higher medial BTU decrease medially. Undercorrection of preoperative varus alignment showed no higher BTU after TKA.ConclusionPreoperative varus alignment correlated with a higher decrease in BTU in specific femoral and tibial medial regions. Preoperative valgus alignment correlated with a higher decrease in the corresponding lateral regions. Undercorrection of preoperative varus alignment did not lead to higher bone loading reflected by BTU after TKA.     

The effects of initial graft tension on femorotibial relationship following anatomical rectangular tunnel anterior cruciate ligament reconstruction using bone–patellar tendon–bone graft

BackgroundThe purpose of this study was to elucidate the effects of the difference of initial graft tension on the femorotibial relationship on an axial plane and its chronological change following anatomical anterior cruciate ligament (ACL) reconstruction.MethodsA total of 63 patients who underwent anatomical ACL reconstruction were included in this study. The graft was fixed at full knee extension with manual maximum (higher graft tension; group H) and 80 N (lower graft tension; group L) pulls in 31 and 32 patients, respectively. The femorotibial positional relationship in axial computed tomography at 1 week and 1 year postoperatively were retrospectively evaluated. The side-to-side differences (SSDs) and the amount of changes of SSDs over 1 year were compared between groups.ResultsThe SSDs of the external rotational angle of the tibia in group H were significantly larger than those in group L at postoperative 1 week (2.7 ± 3.9° vs. 0.3 ± 3.3°; P < 0.01). The amount of internal rotational changes of SSDs of the internal–external rotational angles over 1 year in group H was significantly larger than that in group L (−3.6 ± 3.9° vs. − 0.3 ± 2.7°; P < 0.01). No significant differences were observed on the anterior–posterior translation distance and medial–lateral shift distance.ConclusionThe application of higher initial graft tension resulted in excessive external rotation of the tibia to the femur at 1 week postoperatively in anatomical ACL reconstruction, and the excessive early external tibial rotation had resolved over 1 year.     

Effect of ultrasound-guided selective sensory nerve blockade of the knee on pain management compared with periarticular injection for patients undergoing total knee arthroplasty: A prospective randomized controlled trial

BackgroundUltrasound-guided selective sensory nerve blockade (SSNB) of the knee, including an adductor canal block (ACB), anterior femoral cutaneous nerve block, and infiltration between the popliteal artery and posterior capsule of the knee may provide effective motor-sparing knee analgesia for total knee arthroplasty (TKA). We hypothesized that the SSNB would manage pain better on ambulation 24 hours postoperatively compared to periarticular infiltration (PAI), when combined with postoperative continuous ACB.MethodsSeventy-two patients undergoing elective TKA under spinal anesthesia were randomly assigned to either SSNB (SSNB group) or intraoperative PAI (PAI group). All patients received postoperative multimodal analgesia, including continuous ACB. The primary outcome was pain on ambulation 24 hours postoperatively. Secondary outcomes included rest and dynamic numerical rating scale pain score, intravenous morphine requirement, functional performance measures, adverse events, satisfaction, and length of stay.ResultsThere was no difference in pain score during movement between the groups (mean difference −0.48 [−1.38 to 0.42], p = 0.3) and other immediate overall pain scores 24 hours postoperatively. Patients in the SSNB group had significantly lower intravenous morphine requirement than the PAI group for 48 hours postoperatively (0 [0, 0] vs. 0 [0, 2]; p = 0.008). There was no intergroup difference in the performance-based measures, satisfaction, and length of stay.ConclusionsThe SSNB did not provide superior postoperative analgesia, or improvement in immediate functional performance. However, it may result in lower opioid consumption postoperatively when compared with the intraoperative PAI.     

Mid-term results of complex primary total knee arthroplasty using a rotating-hinge implant

BackgroundThe indications and outcomes of semi- or fully-constrained knee implants in primary total knee arthroplasty (TKA) are still controversially discussed. The present study aims to evaluate the mid-term results and complications of a modular/non-modular rotating-hinge implant in complex primary TKA.MethodsEighty-two patients (86 knees) following primary TKA were retrospectively evaluated with a mean follow-up of 63 months. The functional outcome was assessed using the American Knee Society Score (AKSS) and the Oxford Knee Score (OKS). A Visual Analog Scale (VAS) was used to determine pain levels. Implant survival and reoperation rates were estimated using competing risk analysis. Cox regression analysis was performed to evaluate the influence of modularity on implant survival.ResultsThe survival rate with the endpoint implant revision was 90% (95 %CI:83–98%) and the survival rate with the endpoint all reoperations was 84% (95 %CI:75–94%) at 7 years. The AKSS improved significantly from 24 (SD 14.9, range:0–69) preoperatively to 83 (SD 14.3, range:57–100) postoperatively (p < 0.001); functional AKSS improved significantly from 27 (SD 24.3, range:0–100) to 46 (SD: 32.9, range 0–100) (p = 0.003), and OKS from 19 (SD: 8.3, range:5–43) to 29 (SD: 10.7, range:6–48), respectively (p < 0.0001). VAS decreased significantly from 8 (SD: 2.6, range:0–10) preoperatively to 3 (SD: 2.9, range:0–9) postoperatively (p < 0.0001). There was no significant influence of modularity on revision rates comparing modular to non-modular implants (p = 0.072).ConclusionsThe present rotating-hinge implant provides substantial improvement in function and reduction of pain with good implant survival in the mid-term. Modularity was not associated with higher rates of revision.     

Anterior cruciate ligament reconstruction with ultrasound-guided femoral nerve block does not adversely affect knee extensor strength beyond that seen with intravenous patient-controlled analgesia at 3 and 6 months postoperatively

BackgroundThis study aimed to investigate the effect of anterior cruciate ligament (ACL) reconstruction with an ultrasound-guided femoral nerve block (FNB) on knee extensor strength weakness 3 and 6 months, and graft rupture in the 1 year following ACL reconstruction.MethodsOne hundred and seven patients who underwent ACL reconstruction were included in this retrospective study. The patients were divided into two groups stratified by the method of postoperative pain management. The FNB group included 66 patients, and there were 41 patients in the intravenous patient-controlled analgesia (iv-PCA) group. The isokinetic peak torque of knee flexor and extensor was measured preoperative, 3 and 6 months after ACL reconstruction. Muscle strength measurements were performed using the BIODEX dynamometer at a velocity of 60°/s and 180°/s. Peak torque of knee extensor and flexor strength, estimated pre-injury capacity (EPIC), body weight ratio (BW), and graft rupture incidence were compared between the two groups.ResultsThere were no statistically significant differences in the knee extensor and flexor strength for all items at 3 and 6 months after ACL reconstruction. There was also not a statistically significant difference in the graft rupture incidence between the two groups: FNB group was two patients, 3.0% vs. iv-PCA group was one patient, 2.4% (p = 0.86).ConclusionACL reconstruction with ultrasound-guided FNB does not affect knee extensor strength at 6 months, nor graft rupture at 1 year postoperatively.     

Midterm follow-up results of two different types of implants in opening wedge high tibia osteotomy

BackgroundThis retrospective study investigated the midterm results of medial opening wedge high tibia osteotomy, with a monoplanar or a biplanar osteotomy using two types of implant system.MethodsOsteotomies were performed on 241 knees (231 patients). The mean follow-up period was 6.0 years (SD 3.0, range 0.2–12.8 years). Two types of implant system were used, a precountered non-locking plate (PP) (n = 74) and a precountered locking plate (LP) (n = 167). A Kaplan-Meier cumulative survival curve and a Cox regression model were used to analyse and revise survival and risk factors.ResultsCumulative survival estimates for LP were 80% at 5 years, and 64% at 10 years (SE = 0.4, CI 95%: 9.0–10.5), and for PP, they were 68% at 5 years and 49% at 10 years (SE = 0.5, CI: 95% 6.3–8.2) (p = 0.024). The revision rate was 26% (44/167) for the LP group, and 47% (35/74) for the PP group (p = 0.001). Reoperations on LP osteotomies occurred for the tibial monoplanar cut and biplanar cut groups, in 19/52 (37%) and 25/167 (16%) osteotomies, respectively (p = 0.04). Our Cox regression model showed that PP had a higher risks (RR = 1.7; CI: 95% 1.1–2.6) of revision, when compared with LP (p = 0.026).ConclusionsThe risk of revision for any reason and that of early conversion to total knee arthroplasty (TKA) after high tibia osteotomy were significantly increased for PP, when compared with LP.     

Evaluation of different coatings of the tibial tray in uncemented total knee arthroplasty. A randomized controlled trial with 5 years follow-up with RSA and DEXA

BackgroundRegenerex® is a porous titanium construct with a 3D interconnecting pore structure and biomechanical characteristics close to that of normal trabecular bone. This study aimed to compare the Regenerex (VR) to the non-interconnecting pore structure Porous Plasma Spray (VP) on tibial implants for total knee arthroplasty (TKA) at 5 years.MethodsWe enrolled and randomized 61 patients (mean age = 63(49–71) years, Female/Male = 35/26) who were planned for an uncemented Vanguard TKA (Biomet, Warsaw, Indiana, USA) to receive either a VR or a VP coated tibial component (31/29). We performed radiostereometric analysis (RSA) and Dual Energy X-ray Absorptiometry (DEXA) postoperatively, and at three, six, 12, 24 and 60 months with measurements of migration. In total 55 patients attended the 5-year follow-up.ResultsOne patient died and four were reoperated during the 60-months period; none due to aseptic loosening. All reoperations were in the VR-group. The mean (range) 60-months MTPM was 1.4 mm (0.5–3.7) for the VP-group and 1.8 mm (0.4–4.9) for the VR-group (p = 0.8). The 24 to 60-months mean (range) MTPM was −0.3 mm (−5 to 1.24) in the VP-group and 0.2 mm (−0.4 to 3.5) in the VR-group (p = 0.8).ConclusionWe did not find any statistically significant differences between the VP- and VR-group and both groups show recognizable migration. We will continue to follow the groups for years to come.     

Trauma mechanism and patient reported outcome in tibial plateau fractures with posterior involvement

IntroductionPosterior tibial plateau fractures (PTPF) have a high impact on functional outcome and the optimal treatment strategy is not well established. The goal of this study was to assess the relationship between trauma mechanism, fracture morphology and functional outcome in a large multicenter cohort and define possible strategies to improve the outcome.MethodsAn international retrospective cohort study was conducted in five level-1 trauma centers. All consecutive operatively treated PTPF were evaluated. Preoperative imaging was reviewed to determine the trauma mechanism. Patient reported outcome was scored using the Knee injury and Osteoarthritis Outcome Score (KOOS).ResultsA total of 145 tibial plateau fractures with posterior involvement were selected with a median follow-up of 32.2 months (IQR 24.1–43.2). Nine patients (6%) sustained an isolated posterior fracture. Seventy-two patients (49%) sustained a two-column fracture and three-column fractures were diagnosed in 64 (44%) patients. Varus trauma was associated with poorer outcome on the ‘symptoms’ (p = 0.004) and ‘pain’ subscales (p = 0.039). Delayed-staged surgery was associated with worse outcome scores for all subscales except ‘pain’. In total, 27 patients (18%) were treated with posterior plate osteosynthesis without any significant difference in outcome.ConclusionsFracture morphology, varus trauma mechanism and delayed-staged surgery (i.e. extensive soft-tissue injury) were identified as important prognostic factors on postoperative outcome in PTPF. In order to assess possible improvement of outcome, future studies with routine preoperative MRI to assess associated ligamentous injury in tibial plateau fractures (especially for varus trauma) are needed.     

Intraoperative changes in medial joint gap after posterior femoral condylar resection,posterior osteophyte removal,and femoral component placement during primary total knee arthroplasty

Background“Mid-flexion stability” is important for superior patient satisfaction following total knee arthroplasty (TKA). Thus, it is important to control medial joint gap intraoperatively as a countermeasure. However, reports on the precise intraoperative changes in medial joint gap during TKA are scarce. This study evaluated the intraoperative changes in medial joint gap during TKA.MethodsWe studied 167 knees with varus osteoarthritis that underwent 80 cruciate-retaining (CR) and 87 posterior-stabilized (PS) TKAs between January 2018 and December 2020. We measured the intraoperative changes in medial joint gap with a tensor device at 137.5 N.ResultsThe medial joint gap after posterior femoral condylar resection was significantly increased not only at 90° of flexion but also at 0° of extension in CR and PS TKAs (p < 0.01). The medial joint gap after posterior osteophyte removal was significantly increased not only at 0° of extension but also at 90° of flexion in CR and PS TKAs (p < 0.01). The medial joint gap at 0° of extension was reduced by 0.60 mm after femoral component placement in PS TKA.ConclusionSurgeons need to pay close attention to these intraoperative changes in medial joint gap by measuring the medial joint gap before and after each procedure or assuming the changes in those values before bone cutting to achieve superior patient satisfaction following TKA.     

Atypical patterns of STAT3 phosphorylation in subpopulations B cells in patients with common variable immunodeficiency

BackgroundCommon Variable Immunodeficiency (CVID) is a heterogeneous disorder characterized by defective B cell differentiation and antibody production. Interleukin (IL)-21 activates STAT3, a potent regulator of B cell differentiation into plasma cells. We have studied the phosphorylation of STAT3 in CVID patients and its contribution to B cells subsets.MethodsWe studied 23 CVID patients and 14 healthy donors (HD), determining pSTAT3 in naïve and memory B cells, stimulated with IL-21 at 15 and 60 min.ResultspSTAT3 was increased in total (p = 0.044), naïve (p = 0.023), and memory (p = 0.001) B cells at 60 min in CVID patients compared with HD. We classified patients by the percentage of isotype-switched memory B cells. We observed an increase in pSTAT3 at 60 min in memory B cells in both CVID groups of patients (p = 0.026, p = 0.007, respectively). Interestingly, the analysis of each group individually; demonstrated that patients with decreased memory B cells exhibited an increase in pSTAT3 at 60 min (p = 0.023), while HD had an expected decrease in pSTAT3 (p = 0.045).ConclusionCVID patients showed an increased atypical of pSTAT3, which could affect the differentiation of B cells. Further studies in the IL-21 pathway are necessary to understand how this alteration could promote differentiation defects in patient B cells.     

Comparison of the clinical and patient-reported outcomes between medial stabilized and posterior stabilized total knee arthroplasty: A systematic review and meta-analysis

BackgroundTotal knee arthroplasty (TKA) is effective in relieving pain and improving function in patients with end-stage knee osteoarthritis. Both medial stabilized total knee arthroplasty (MS-TKA) and posterior stabilized total knee arthroplasty (PS-TKA) can achieve satisfactory clinical results, but comparisons between MS-TKA and PS-TKA have yielded contradictory conclusions. This systematic review and meta-analysis were performed to investigate the differences in clinical and patient-reported outcomes (PROMs) between MS-TKA and PS-TKA.MethodsIn December 2020, systematic searches of the following databases were undertaken: Pubmed, Embase, Cochrane Library, Clinical Trials.gov. Studies with PROMs comparing MS-TKA to PS-TKA were included. Meta-analysis was conducted for range of motion (ROM), Knee Society Score (KSS), Knee Society Functional Score (KFS), Forgotten Joint Score (FJS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Oxford Knee Score (OKS).ResultsThere were 17 studies included in this review, 13 studies used for quantitative analysis, and 4 studies used for qualitative synthesis. Meta-analysis concluded that the WOMAC mean difference (MD) for MS-TKA was 1.55 higher than for PS-TKA (MD = −1.55; 95 %CI = −2.45 to −0.64, P = 0.0008); however, this difference was less than the minimum clinically important difference (MCID) value of 15. Assessment using the OKS determined that the MD for PS-TKA was 0.58 higher than for MS-TKA (MD = 0.58; 95 %CI = 0.25 to 0.91, P = 0.0006); again, this MD was less than the MCID value of 5. There were no significant differences between MS-TKA and PS-TKA when assessed by ROM (P = 0.23), KSS (P = 0.13), KFS (P = 0.61), or FJS (P = 0.22).ConclusionDerived from numerous sources, utilizing a multitude of validated functional and patient-reported outcome assessment tools, there was no clinically evident advantage of MS-TKA compared to PS-TKA.RegistrationThe registration number on PROSPERO is CRD42021228555.     

Insufficient lateral joint laxity after bicruciate-retaining total knee arthroplasty potentially influences kinematics during flexion: A biomechanical cadaveric study

BackgroundSoft tissue balancing in bicruciate-retaining (BCR) total knee arthroplasty (TKA) is a challenge that must be overcome to achieve excellent clinical outcomes. However, the optimal degree of joint laxity has yet to be clarified. This cadaveric study sought to examine joint laxity after BCR TKA using a navigation system.MethodsKnee joint laxity was quantified using an image-free navigation system in 8 intact fresh frozen cadavers under three conditions: the native knee, BCR TKA knee, and BCR TKA knee after anterior cruciate ligament resection. Rotational kinematics in the BCR TKA knee during flexion were compared according to whether joint laxity was increased or decreased.ResultsKnee joint laxity after BCR TKA under varus-valgus movement, anterior translation, and internal-external rotation loadings was similar to that of the native knee. However, lateral joint laxity was decreased during flexion in some cases. BCR TKA-treated knees with decreased lateral joint laxity at 90° of flexion demonstrated more limited tibial internal rotation in deep flexion than the native knee (p < 0.05). The loss of internal rotation in deep flexion was partly recovered by using a lateral insert with a posterior slope of +3°.ConclusionsRestoring optimal joint laxity was not always straightforward in BCR TKA if the 4 ligaments were preserved. Lateral joint laxity was potentially decreased in BCR TKA and may result in kinematic conflict during flexion. Surgeons should be aware of the need to achieve sufficient lateral joint laxity in this type of BCR TKA.     

The impact of a comprehensive pharmaceutical care intervention in addition to cardiac rehabilitation program on outcomes of post-acute coronary syndrome patients: A pilot study

ObjectiveTo test the efficacy of Comprehensive pharmaceutical care intervention added to cardiac rehabilitation program(CR programs) in improving echocardiographic parameters, nutritional status and High sensitivity C-Reactive Protein(hs-CRP), in post-acute coronary syndrome patients.MethodsA prospective; randomized, controlled study. 40 post-acute coronary syndrome patients, participating in CR program, were randomly allocated to either the control group(n = 20) or the intervention group(n = 20). Pharmaceutical care intervention included face-to-face education about the disease, healthy lifestyle, medication adherence, drug related problems management and goal setting. hs-CRP and cardiac parameters were measured at baseline and after 3 months.ResultsAfter three months,the intervention group showed a significant decrease in left ventricular end systolic volume (p = 0.0026) and left ventricular end diastolic volume (p = 0.0009) compared to the control group. Also, intervention group showed a significant increase in nutritional status (p = 0.037) and the patients' knowledge about the disease and drugs (p = 0.0001). However, there was no significant change in hscrp level between groups.ConclusionOur findings indicate that Comprehensive pharmaceutical care intervention added to CR programs significantly improved cardiac parameters and nutritional status. This is best explained by increasing adherence to cardiovascular medications and to healthier lifestyle and optimizing medication knowledge and doses.Practice implicationsImplementing Comprehensive pharmaceutical care intervention added to CR programs could improve the cardiac function and nutritional status of post-acute coronary syndrome patients.     

Patellofemoral joint cartilage restoration with particulated juvenile allograft in patients under 21 years old

BackgroundPatellofemoral joint cartilage defects are difficult to treat due to their unique thickness and topography.PurposeTo report the postoperative outcomes of patients age 21 and younger treated with particulated juvenile allograft cartilage (PJAC) for full-thickness cartilaginous defects of the patellofemoral joint. The primary aim was to report surgical outcomes and complication rates, as well as return to sport activity. A secondary aim was to provide objective scores of defect restoration by magnetic resonance imaging (MRI) assessment.MethodsA retrospective review of all PJAC cases conducted between 2012 and 2019 at a single tertiary care urban musculoskeletal institution was conducted. Patients 21 years old or younger with minimum clinical follow up of 1 year and postoperative MRI at a minimum of 6 months were included. Cartilage restoration by MRI was independently assessed using the International Cartilage Repair Society’s (ICRS) standardized system.ResultsThirty four patients, 36 knees, were included, with mean age 16.1 ± 3.1 years old. Return to sport rate among patients who participated in a sport preoperatively was 100%. On independent MRI assessment, two thirds of defects achieved an overall grade of normal or nearly normal, while 28 patients (78%) had majority defect fill. Primary graft failure occurred in two cases and one patient experienced a surgical complication.ConclusionRestoration of patellofemoral chondral defects in young patients with particulated juvenile allograft results in satisfactory short-term outcomes and postoperative MRI appearance, along with high rates of return to sport and low rate of complications and graft failure.What is known about the subject: Patellofemoral joint cartilage defects are difficult to treat due to their unique thickness and topography. Several cartilage restoration techniques are available, but these rarely achieve the same mechanical properties as native hyaline cartilage. PJAC is a cell-based technique that has demonstrated promise since its introduction in 2007.What this study adds to existing knowledge: This series of patients adds the largest single cohort of pediatric and adolescent patients who receive PJAC for defects of the patellofemoral joint. Surgeons treating patients in this age group should be aware of every technique, and their respective outcomes.     

Association between SARS-CoV-2 infection and de novo HLA donor specific antibody production in lung transplant recipients: Single-center study

The COVID-19 pandemic has led to significant morbidity and mortality in lung transplant recipients. Respiratory viral infections may be associated with de-novo HLA donor-specific antibody production and impact lung transplant outcome. Since one of the immunomodulation strategies post-SARS-CoV-2 infection in lung transplant recipients include decreasing or holding anti-metabolites, concerns have been raised for higher incidence of de-novo HLA donor specific antibody production in lung transplant recipients. We performed a retrospective chart review of 24 consecutive lung transplant recipients diagnosed with COVID-19 to investigate this concern. We observed no significant differences in the CPRA or MFI levels of HLA class I and II antibodies pre- COVID-19 compared to 1 and 6 months post-COVID-19 diagnosis in 11/24 (45.8 %) LTR (p = 0.98 and p = 0.63 respectively). HLA class I and II DSA were detected in 5/24 LTR pre-COVID-19 diagnosis and persisted with no significant differences in the median MFI levels at 1 and 6 months post-COVID-19 diagnosis (p = 0.89). De-novo HLA class I and II DSA were detected in 1/24 (4.2 %) LTR at one month post-COVID-19 diagnosis and persisted with no significant differences in the median MFI levels at 1 and 6 months post-COVID-19 diagnosis (p = 0.54). Our results suggest that there was no significant association between SARS-CoV-2 infection and immunomodulation on pre-existing or de novo HLA donor specific antibodies.     

Assessment of popliteal neurovascular safety during all-inside suturing of the posterior horn of the lateral meniscus using Upright MRIs of the knee joint

BackgroundTo examine the risk of injury to the popliteal neurovascular bundle (pNVB) during all-inside repair of the posterior horn of the lateral meniscus (PHLM) using Upright-MRIs.MethodsUpright-MRIs of 61 knees in extension (ext) and 90°-flexion (flex) were included. Distance D from the PHLM to the pNVB was compared between extended and 90°-flexed position, subgroups with/without joint-effusion and evaluated according to demographics. Portal safety was assessed simulating suturing of the PHLM via four arthroscopy portals. Distance d (shortest space from the simulated suturing-device trajectory lines to the pNVB) was compared among portals in increasing distances from the posterior cruciate ligament (PCL).ResultsD is longer in flex (17.3 ± 6.0 mm) than in ext (11.3 ± 4.2 mm, p < 0.0001). MRIs with joint-effusion displayed longer values of D than scans without joint-effusion (flex: 20.4 ± 7.1 mm vs. 16.1 ± 5.2 mm, p = 0.012). Shorter distances are associated with female gender, lower body weight and lower BMI. At 0 mm from the PCL, the 1 cm-lateral portal was the safest (p < 0.0001) whereas at 3 mm/6mm/9mm/12 mm the 1 cm-medial portal showed the longest d values (p < 0.0001 each).ConclusionAll-inside suturing of the PHLM is safer in 90°-flexion, in presence of intraarticular fluid and in male patients with increasing weight/BMI. Sutures of the PHLM at 0 mm from the PCL are safer from a 1 cm-lateral portal whereas for tears located ≥ 3 mm from the PCL a 1 cm-medial portal involves a lower neurovascular risk. Upright-MRI proves excellent for preoperative planning to minimize neurovascular risks.     

Effectiveness of hepatitis A vaccination among people living with HIV in Taiwan: Is one dose enough?

BackgroundSingle dose hepatitis A virus (HAV) vaccine had been proven its efficacy in immunocompetent but not immunocompromised hosts. We aim to investigate the effectiveness of one dose versus 2 doses HAV vaccine among people living with HIV (PLHIV).MethodWe conducted a 1:1 single center retrospective case–control study for PLHIV in Northern Taiwan. Case patients were those who received single dose HAV vaccine and controls were those who completed standard 2 doses HAV vaccine. Nationwide campaign of single dose HAV vaccine had been practiced for high risk population including PLHIV and those who had newly diagnosed sexually transmitted diseases.ResultsDuring February 2016 and December 2017, 90 cases received single dose HAV vaccine provided while the other 90 age-matched controls received 2 doses vaccine were enrolled. We found more injection drug users (22.22% vs. 1.11%, p < 0.0001), more co-infection with viral hepatitis C (28.89% vs. 5.56%, p < 0.0001), and history of syphilis infection (56.67% VS 30%, p = 0.0003) in single dose group than 2 doses group. Seroconversion rate at one year was significantly higher in 2 doses group (97.78% vs 56.67%, p < 0.0001). Among single dose group, people with hepatitis B or C virus co-infection (HBV: p = 0.02, aOR: 0.03, 95% CI: 0.002–0.55; HCV: p = 0.002, aOR: 0.22, 95% CI: 0.08–0.58) were less likely to achieve seropositivity, while those who had higher CD4 count at baseline and one year, had better response to vaccine.ConclusionTwo doses HAV vaccine is necessary among PLHIV to achieve sustained seroresponse rather than single dose.     

Bone plug fixation in anterior cruciate ligament reconstruction: A clinical and radiological assessment of graft-tunnel integration

BackgroundThe decision regarding graft choice and fixation in anterior cruciate ligament (ACL) reconstruction remains controversial. Free cylindrical bone plugs have been used successfully as graft fixation method. However, some concerns continue to exist regarding how well these plugs integrate with the bony walls of the tunnel. The aim of this study was to assess osteo-integration of free cylindrical bone plugs and to evaluate its effect on the clinical outcomes of the procedure.MethodsFrom January 2015 to December 2017, 30 patients (21–40 years old) with torn ACL were operated on and followed up for 24 months after surgery. All patients were assessed clinically (International Knee Documentation Committee score (IKDC) and Tegner–Lysholm knee scoring system), instrumentally (KT 1000 and Rolimeter), and radiologically (X-ray, computed tomography and magnetic resonance imaging). Young active patients with torn ACL were included while those with previous ligamentous injury and/or surgery were excluded.ResultsAll bone grafts showed solid bone healing after 6 months of surgery; incorporation was ‘good to excellent’ (tibial side: 66.6%; femoral side: 86.6%). There was no correlation between age or time interval and graft incorporation. Positive correlation was shown between tibial and femoral graft incorporation within the same patient. Only one patient was abnormal in our final objective IKDC scores (graded C). The mean side-to-side difference with KT 1000 and Rolimeter was 1.9 and 1.8, respectively.ConclusionFree cylindrical bone plugs could be used safely for hamstring tendon graft fixation; it enhances graft tunnel integration within the first 6 months and yields comparable clinical outcomes whilst avoiding the potential hazards of foreign hardware implants.     

Ghrelin level as a biomarker for knee osteoarthritis severity and appearance in HIV + patients

BackgroundKnee Osteoarthritis (KOA) is a multifactorial disease with several mechanisms to promote articular cartilage damage. New molecules, such as ghrelin, have been recently reported to participate in the pathogenesis and progression of KOA. In HIV + patients, arthralgias are the most frequent musculoskeletal manifestations, mainly affecting joints such as the knee. Also, it has been reported that HIV + patients have a reduction of ghrelin even with treatment compared to HIV- patients. However, there is no report in the literature evaluating ghrelin and KOA in the HIV + population. We aimed to evaluate whether serum ghrelin levels can function as a biomarker for OA in HIV + patients.MethodsWe recruited 40 patients, 20 HIV+, and 20 HIV- controls, and grouped as follows: HIV+/KOA+; HIV+/KOA-; HIV-/KOA+; HIV-/KOA-. Clinical features were obtained during clinical visits. Peripheral blood samples were acquired to measure serum ghrelin levels.ResultsThe HIV+/KOA + group significantly reduced serum ghrelin levels when compared with the other groups. Comparing the ghrelin levels with the patients’ nadir of CD4⁺ T-cells count, we identified a statistically significant negative correlation in the KOA- group (r = −0.80, P < 0.007). An ROC curve analysis, for the accuracy of ghrelin levels to identified HIV+/KOA + from HIV+/KOA- patients, found an area under the curve of 0.83 (95 % CI 0.65–0.10; P = 0.017), with a cut-off < 4026 pg/mL serum ghrelin levels, with a sensitivity of 0.62 (95 % CI 0.32–0.86), and a specificity of 0.10 (95 % CI 0.59–0.10).ConclusionThis study shows the potential use of ghrelin levels as a biomarker for KOA in the high-risk HIV population that should be further analyzed.