Osteoarticular allograft reconstruction of the distal radius after bone tumour resection

Resection of the distal end of the radius is indicated in the treatment of locally aggressive primary benign and malignant bone tumours. The aim of this study was to evaluate the technique of osteoarticular allograft reconstruction of this bone defect. We analysed 12 patients retrospectively with a minimum follow-up of 2 years (range 26-145 months, median 52 months). Three patients had a malignant tumour and nine had a giant cell tumour. The patients ages ranged from 13 to 65 years. The mean resected length of the radius was 6.6 (range 4-14)cm. Non-union of the osteotomy line was diagnosed 6 months after surgery in one case and needed bone grafting. Distal radio-ulnar joint instability was observed in eight cases. Subchondral bone alterations and joint narrowing were present in all cases but were painful in only one patient. The mean range of motion was 51 degrees of flexion and 37 degrees of extension.     

Osteoarticular allograft in surgery for high-grade malignant tumours of bone

We assessed the results of 17 limb-salvage procedures using osteoarticular allografts after wide resection of high-grade malignant bone tumours. All patients received chemotherapy. At the five-year follow-up, three patients had died from metastases. The allografts survived for five years in only seven patients all of whom had good function, ranging from 73% to 90% of normal. The allografts were removed because of fracture in seven patients and infection in one, and in all of these a second limb-salvage procedure was undertaken. With such a low rate of survival of osteoarticular allografts, we believe that their use in the management of high-grade malignant bone tumours should, at best, be considered a temporary solution.     

Anatomical reconstruction of reverse hill-sachs lesions using the underpinning technique

Posterior glenohumeral joint dislocation is an uncommon injury and is associated with bony and ligamentous disruption. It requires prompt diagnosis and early treatment to prevent acute or recurrent instability and subsequent dysfunction. Reverse Hill-Sachs lesions associated with this injury are challenging to treat, and optimal treatment is controversial. Treatment methods can be divided into those that achieve stability through muscle transfers, osteotomies, or posterior bone-block procedures (glenoid augmentation) and those that restore the sphericity of the humeral head. Joint replacement is often suggested for large head lesions (>50%) considered beyond reconstruction. Restoration of stability, preservation of the proximal humeral anatomy, and salvage of the humeral head sphericity should be the treatment goals in the younger population.This article describes the surgical technique of elevation of the impressed osteochondral fragment followed by filling the lesion with Allomatrix bone graft putty (Wright Medical Technology, Arlington, Tennessee) in 2 patients. The size of the head lesion was ≤35%. Underpinning raft screws were used to provide subchondral support and prevent the collapse of the elevated fragment. Postoperatively, the sphericity of the humeral head and glenohumeral stability were restored. No evidence of collapse, osteonecrosis, or osteoarthritis progression was seen at latest follow-up. Functional results were excellent, with a minimum follow-up of 2 years.This technique is an alternative method of restoring humeral head sphericity in patients with acute posterior glenohumeral joint dislocations with medium (20%-40%) reverse Hill-Sachs lesions.     

Osteoarticular allograft reconstruction of post-traumatic defect of distal femur in a pediatric patient: A case report and literature review

Successful results of osteoarticular allografts in reconstruction of periarticular bone defect after tumor resection encouraged its utilization in post-traumatic defects. Here we describe a case of post-traumatic skeletal defect in a 4 year-old girl treated with osteoarticular allograft reconstruction. Due to severity of the associated soft tissue injury and contamination at presentation staged treatment with antibiotic spacer followed by the reconstruction was carried out. At the end of one year the patient achieved ‘Musculoskeletal tumor society‘ functional score of 27 points and radiographic score of 93%. Reconstruction immediately after healing of soft tissues prevented development of any varus or valgus deformity of the knee. Our case demonstrates utility of osteoarticular allograft in a pediatric post-traumatic skeletal defect.     

Angiokeratoma of clitoris: a rare lesion in an adolescent girl

Angiokeratoma is a benign vascular lesion. It is the result of dilation of ectatic subdermal vessels and congested capillaries. Weakness of the vessel walls, either from acquired or congenital reasons, can cause formation of the lesion. Angiokeratoma is more common in males, in whom it forms on the scrotal wall. An equivalent form can occur in females, generally on the vulva. The clitoris is an extremely rare location. We present the case of a 14-year-old girl with a clitoral angiokeratoma. To our knowledge, this is the first presented case of clitoral angiokeratoma in a child in English published reports.     

Proximal femur reconstruction by an allograft prosthesis composite.

Twenty-seven patients who had resection of the proximal femur for bone tumors and reconstruction with an allograft prosthesis composite are reported. In most of the patients, the prosthesis was a long-stem revision type, cemented in the allograft and uncemented in the femoral shaft. The abductor muscles and iliopsoas were sutured to the corresponding tendons on the allograft. Implant-related complications and functional results were evaluated and are reported. Twenty-two patients achieved a minimum followup of 36 months (range, 36-126 months; average, 58 months). The implant was removed in two patients (one for infection, one for intraoperative fracture of the allograft). One patient experienced nonunion, whereas in the remaining 24 patients, the allograft eventually united to the host bone. A frequent late complication (17 patients) was fracture of the greater trochanter of the allograft. In the whole series, only four new operations were done for implant-related complications. In 22 patients who could be evaluated, the functional evaluation according to the Musculoskeletal Tumor Society System was excellent in 16 (73%) patients, good in four (18%), and fair in two (9%). These results compare favorably with those of megaprostheses for tumor resection of the proximal femur, where a Trendelenburg gait almost always is present.     

Right ventricular outflow tract reconstruction with an allograft conduit

BACKGROUND: Allograft conduits are used for reconstruction of the right ventricular outflow tract in patients with congenital heart disease and in the pulmonary autograft procedure. A retrospective evaluation of our experience with the use of allograft conduits for reconstruction of the right ventricular outflow tract was conducted. METHODS: Between August 1986 and March 1999, 316 allografts (246 pulmonary, 70 aortic) were implanted in 297 patients for reconstruction of the right ventricular outflow tract. Main diagnostic groups were aortic valve pathology (n = 112, 35%), tetralogy of Fallot (n = 71, 22%), and pulmonary atresia with ventricular septal defect (n = 46, 14%). Kaplan-Meier analyses were done for survival, valve-related reoperation, and valve-related events. In addition, Cox regression analysis was used for evaluation of potential risk factors. RESULTS: Mean age at operation was 18 years (range, 7 days to 61 years). Mean follow-up was 4 years (range, 2 days to 12 years). Twelve patients (4%) died within 30 days after operation. Patient survival was 90% (95% confidence interval [CI], 86% to 94%) at 5 years and 88% (95% CI, 83% to 94%) at 8 years. Twenty-four reoperations were required for allograft dysfunction in 23 patients; 21 allografts were replaced. Freedom from valve-related reoperation was 91% (95% CI, 86% to 95) at 5 years and 87% (95% CI, 81% to 93%) at 8 years. Twenty-nine valve-related events were reported (2 deaths, 24 reoperations, 2 balloon dilatations, and 1 endocarditis). Freedom from valve-related events was 90% (95% CI, 85% to 94%) at 5 years after implantation, and 84% (95% CI, 77% to 91%) at 8 years. Risk factors for accelerated allograft failure were extra-anatomic position of the allograft (p = 0.03; hazard ratio, 9.7) and the use of an aortic allograft (p = 0.02; hazard ratio, 2.4). CONCLUSIONS: Right ventricular outflow tract reconstruction with an allograft conduit has good medium-term results, although progression of allograft degeneration is noted. Aortic allografts should preferably not be used for reconstruction of the right ventricular outflow tract.     

Telescopic mating technique for bulk allograft reconstruction

Bulk allograft reconstruction plays an important role in limb-salvage reconstructive surgery but is complicated by nonunion in up to one-third of cases. Because allograft-host healing is mediated via creeping substitution, intimate bone contact is desirable. Intraoperative assessment and optimization of the allograft-host junction site using a conventional transverse osteotomy is challenging and may result in slight gapping. Speculatively, this may result in longer healing times and may contribute to the high rate of non-union. Minimizing the nonunion rate and time to union are of value. This article describes the telescopic mating technique, which allows for substantially greater bone contact across the allograft-host junction site.     

Revitalized and synovialized allograft for intrasynovial flexor tendon reconstruction in an in vivo canine model

This study was to test our hypothesis that flexor tendon reconstruction with an allograft revitalized with bone marrow stromal cells (BMSCs) and synovialized with carbodiimide derivatized autologous synovial fluid (cd‐SYN) would result in better digit functional restoration than the conventional allograft tendon. A total of 32 flexor digital profundus tendons from the second and fifth digit of 16 dogs were created a repair failure model first. Then, failed‐repaired tendons were reconstructed with either a revitalized‐synovialized allograft tendon or a clinical standard autograft tendon (control group). The allograft tendon was seeded with autologous BMSCs in multiple slits and the graft surface was coated with cd‐SYN. A 6 weeks after tendon reconstruction, the digits were harvested and evaluated for digit function, adhesion status, tendon gliding resistance, attachment strength, cell viability, and histologic factors. The allograft group had significantly improved digit function compared with the control group through decreased work of flexion, increased digit range of motion under 2‐Newton force, and less adhesion score (p < .05). However, the distal attachment‐site strength and stiffness in the allograft tendon were significantly weaker than the autografts (p < .05). No significant difference was found for gliding resistance. Histologically, allograft tendons coated with allograft had smoother surfaces and showed tendon‐to‐bone and tendon‐to‐tendon incorporation. Viable BMSCs were found in the tendon slits 6 weeks after the graft. In conclusion, cellular lubricant‐based modification of allograft tendons improved digit function and reduced the adhesions compared with autograft for flexor tendon reconstruction. However, improvement of graft‐to‐host tendon healing is still challenging. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2218–2227, 2018.

     

Modified vein allograft for small arterial reconstruction in dogs

The ideal graft for peripheral arterial reconstruction has yet to be developed. We evaluated on the effectiveness of porosity to intimization of the graft. Modified vein allografts newly constructed through digestion of vein allografts with elastase, glutaraldehyde tanning and lyophilization were implanted in thirty-nine canine femoral arteries. These grafts had a higher porosity than conventional vein allografts and the overall patency rate was 70 per cent at 6 months after implantation. Microscopic examination showed that graft interstitial healing and subsequent intimization were completed by ingrowth of connective tissue from outside through the graft wall at 3 weeks and later. Aneurysmal change of the modified vein allografts was never evident. These results indicated that porosity of the graft is indeed an important factor for intimization and durability of grafts, even in bioderivative substitutes.     

Modified vein allograft for small arterial reconstruction in dogs

The ideal graft for peripheral arterial reconstruction has yet to be developed. We evaluated on the effectiveness of porosity to intimization of the graft. Modified vein allografts newly constructed through digestion of vein allografts with elastase, glutaraldehyde tanning and lyophilization were implanted in thirty-nine canine femoral arteries. These grafts had a higher porosity than conventional vein allografts and the overall patency rate was 70 per cent at 6 months after implantation. Microscopic examination showed that graft interstitial healing and subsequent intimization were completed by ingrowth of connective tissue from outside through the graft wall at 3 weeks and later. Aneurysmal change of the modified vein allografts was never evident. These results indicated that porosity of the graft is indeed an important factor for intimization and durability of grafts, even in bioderivative substitutes.     

Ilizarov hip reconstruction for the management of advanced osteonecrosis in an adolescent with leukemia

With advances in chemotherapy, long-term survival for childhood leukemia is improving. However, chemotherapy-induced osteonecrosis of the proximal femur remains a challenging problem. We present a case of an adolescent female with advanced osteonecrosis of the proximal femur after chemotherapy for acute lymphoblastic leukemia. She underwent an Ilizarov hip reconstruction with a subtrochanteric valgus extension osteotomy and distal femoral lengthening with varus angulation using an external fixator. At a 3-year follow-up, her symptoms and gait had markedly improved. On the basis of this preliminary report, Ilizarov hip reconstruction is a viable alternative for advanced osteonecrosis of the proximal femur in an adolescent.     

Arterial reconstruction of the pancreatic allograft for transplantation

The shortage of organs is particularly acute in whole pancreas transplantation, because the liver and pancreas often share a common arterial supply, making combined procurement of both organs difficult. A previously described technique of simultaneous whole liver and pancreas procurement depended on "classic" hepatic arterial anatomy, which is present just over half the time. We describe herein our experience with three Y-reconstructions of the splenic and superior mesenteric arteries of the pancreatic allograft using donor allograft internal and external iliac arteries. In situ Doppler ultrasound examination of the pancreatic allograft after surgery demonstrated a patent reconstruction without evidence of stenosis or turbulent flow patterns. We believe this reconstruction is a safe, alternative method to provide arterial flow to the whole donor pancreas.     

Cryopreserved arterial allograft reconstruction for peripheral graft infection

OBJECTIVE: This prospective, observational study evaluated the safety and efficacy of cryopreserved arterial allograft reconstruction in the management of major peripheral arterial graft infections. METHODS: From April 1996 to May 2003, data from patients with major peripheral arterial graft infection who underwent graft excision and cryopreserved arterial allograft reconstruction were prospectively collected. Arterial allografts were harvested from multiple organ donors and cryopreserved at -80 degrees C. The patients were observed for survival, limb salvage, persistence or recurrence of infection, and allograft patency. The results were calculated with the Kaplan-Meier method. RESULTS: During the 7-year study period, 17 patients (14 men, 3 women; mean age, 68 years) with major peripheral graft infection underwent graft excision and cryopreserved arterial allograft reconstruction. Eight patients (47%) had systemic sepsis, 5 (29%) had acute ischemia at the time of the allograft reconstruction, and 9 (53%) had experienced anastomotic rupture. Allograft reconstruction was performed as an emergency procedure in 7 patients (41%). There were no perioperative deaths or early amputations. Two patients had allograft ruptures in the groin during the early postoperative period. The mean follow-up period was 34 months (range, 8 to 80 months). There was no persistent or recurrent infection, and none of the patients received long-term (>3 months) antibiotic therapy. Reoperation for allograft revision, excision, or replacement was performed in 2 patients. The 18-month primary and secondary allograft patency rates were 68% and 86%; the overall limb salvage rate was 82% at 2 years. CONCLUSION: Our experience with cryopreserved arterial allograft in the management of major peripheral bypass graft infection suggests that this technique seems to be a useful option for treating one of the most dreaded vascular complications.