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A further report is made on patients with primary and delayed repair of digital nerves with autogenous denatured muscle grafts. There was evidence of continued improvement in threshold response to tactile stimuli, and discriminative function. These results were superior to those in 24 patients with conventional end-to-end sutures on clinical testing.
During a 3-year period from 1983 to 1986, a polyurethane-coated Dacron mesh tray (Xomed Inc, Jacksonville, FL) was used in 27 cases for temporary mandibular reconstruction in patients who had undergone jaw resection for oral carcinoma. Delayed mandibular reconstruction using the Dacron mesh tray combined with rib grafts was performed in three cases. The Dacron mesh tray technique provides good functional and esthetic results and offers several advantages when compared with metal trays. The success rate was 74%; intraoral perforation was the main reason for early removal of the tray.
BACKGROUND: Almost 9% of tibial shaft fractures occur in the proximal third of the bone. In order to address the problems of mal-alignment and late loss of fixation, all the specific surgical techniques described in the literature were used in nailing these fractures in our study. METHODS: From December 2001 to December 2003, 45 consecutive patients with fracture of the proximal third of the tibial shaft underwent nailing. The clinico-radiological outcome of these cases and the complications encountered were analysed. RESULTS: The average time to knee mobilisation and partial weight-bearing walking was 3.2 days. The fractures had united at an average of 4.3 months. At the last follow up, the average lower extremity functional score was 96%. There were seven cases of malunion (15.56%), with three valgus and four apex anterior angulations. Delayed union necessitated open bone grafting in three cases, at an average of 6.3 months. At 8 months, one patient with delayed union experienced nail breakage across the weakest point, i.e. the dynamic screw hole. He underwent reamed exchange nailing and, 3 months later, the fracture had united. CONCLUSION: Meticulous intramedullary nailing of fractures of the proximal third of the tibial shaft, using all current surgical principles and techniques, has excellent clinico-radiological outcome and is relatively safe. We recommend a nail similar to a Sirus nail, but with a more proximal bend of the nail and no dynamic interlocking screw hole.
PURPOSE: To review the clinical and radiographic outcome of dorsal trans-scaphoid perilunate fracture-dislocations treated with screw fixation of the scaphoid and repair of the lunotriquetral ligament with bone anchors. METHODS: Twenty-five patients treated over an 11-year period for dorsal trans-scaphoid perilunate fracture-dislocations were reviewed retrospectively at a mean of 44.3 months. The mean age of the patients was 28.6 years, and 22 patients were men. Delay to surgery was 3.5 days. Five scaphoids had bone grafting from the distal radius. Six patients developed carpal tunnel syndrome requiring release. The functional outcome was determined by comparing the range of motion of the injured extremity with the uninjured extremity, grip strength, ability to return to pre-injury employment, and overall patient satisfaction. Radiographic evaluation comprised time to scaphoid union, any changes in the lunotriquetral interval, development of a volar intercalated segmental instability pattern, and any development of arthritis over time. RESULTS: Total range of motion achieved was 91% of the uninjured wrist and grip strength was 80%. Average extension was 54 degrees with an average flexion of 60 degrees . Ulnar deviation was 23 degrees with radial deviation averaging 18 degrees . The average supination was 76 degrees and the average pronation was 76 degrees . All scaphoids united primarily. The average time to union of the scaphoid was 16 weeks. For those scaphoids with bone grafting the union time was an average of 18.4 weeks. The average postreduction lunotriquetral gap was 1.8 +/- 0.4 mm. The average lunotriquetral gap at the last follow-up evaluation was 1.9 +/- 0.6 mm. None of the patients developed a volar intercalated segmental instability deformity. All but 2 patients returned to their pre-injury occupation. All patients, however, returned to some type of employment. Complications included 1 superficial pin track infection that resolved with removal of the pin and a short course of oral antibiotics. CONCLUSIONS: A dorsal approach to the wrist provides adequate exposure for reduction of carpal bones, internal fixation of the scaphoid, and lunotriquetral repair. Although perilunate fracture-dislocations are challenging problems to treat, all of the patients had acceptable pain relief and achieved sufficient range of motion and strength to return to gainful employment.
We report our experience of renal transplantation in three patients treated for Wilms' tumor (with lung metastasis in two of them), and review 26 previously reported cases in order to define the current indications of transplantation in this setting. Our patients, aged 5-12 years, were transplanted 13-95 months after completion of Wilms' tumor treatment. All three are alive and tumor-free, two with a functioning graft 20 and 97 months after transplantation. Two findings emerge from the review of the literature. First, posttransplant mortality is influenced by the delay between completion of tumor treatment and transplantation. Mortality reaches 79% when that delay is less than one year but falls to 27% when that delay exceeds one year. Second, the prognostic value of pretransplant metastasis depends on its location. All four patients with pretransplant abdominal metastasis died with active metastatic disease. By contrast, of three patients treated before transplantation for metastasis confined to the lung, two are alive and tumor free. We conclude that renal transplantation should be offered to patients successfully treated for Wilms' tumor for at least one year, even if the disease has been complicated by pulmonary metastasis. Several long-term survivors attest that the disease can be cured even under maintenance immunosuppression.
In this study, insulin was injected into Theracyte immunoisolation devices to analyze changes in the permeability of the device over time after implantation. The recovery of insulin was studied after subcutaneous implantation of the devices in rats, using the microdialysis technique. The area under the insulin concentration vs. time curves (AUC) after insulin injection in devices implanted 1 day previously did not differ significantly from the AUC after subcutaneous injection. At 1, 2 and 4 weeks after implantation, the recovery of insulin was significantly reduced, but at 3 months, the AUC was not significantly different from that in the control group. Histological examination showed that the number of vascular profiles within 15 microm of the device were significantly higher at 2, 4 weeks and 3 months after transplantation when compared to numbers at 1 week. The design of the device allows transplantation of cells at a chosen time point after its implantation. Delayed filling of the device would allow neovascularization of the device surface before graft implantation and we suggest that such a schedule might improve function of the encapsulated graft.
Currently, most dental implants are placed in the esthetic zone with a delayed surgical protocol. This delay can result in loss of both soft and hard oral tissues following the healing period, necessitating guided tissue regeneration, distraction osteogenesis, or bone expansion and grafting procedures either prior to or at the time of implant placement. If a delayed placement protocol is used, or if grafting procedures are ineffectual, the prosthetic phase of implant dentistry must restore the missing structures artistically and functionally to integrate with the patient's existing dentition. This article presents the option of using a removable implant prosthesis for an esthetic anterior restoration of soft and hard tissues. A computer-assisted camera was used to record speaking, smiling, and active facial positions, with digital imaging to achieve realism for tooth position during the prosthetic phase. The captured patient images with the esthetic setups were transmitted by e-mail for direct viewing by both dentist and dental technician prior to case completion. These images were viewed as reference files during laboratory construction of the prosthesis to achieve the desired esthetic and functional results.
The application of high-dose immunoglobulins during xenoperfusion of the isolated rat heart resulted in a significantly higher pressure and heart rate. The coronary flow was also elevated as compared to untreated controls. The heart function during xenoperfusion without treatment was reduced to 50% of the baseline values within 11 min. With immunoglobulin treatment the occurrence of this deficit was delayed to 30 min. A concentrate of immunoglobulins was able to reduce the early functional damage of xenoperfused hearts by interfering with complement related graft destruction.
BACKGROUND: Bone marrow transplantation (BMT) is the best curative approach for younger patients with severe aplastic anemia (SAA). Major obstacles to success of allogeneic BMT include graft-versus-host disease (GVHD), graft rejection and treatment related toxicities. Experience with 14 SAA patients who received BMT is reported here. METHODS: From December 1986 to May 1995, 14 patients with SAA were treated with BMT; 13 were allogeneic, and 1 was syngeneic. There were nine males and five females whose average age was 24.7 years (range 15-36 years). The median pretransplant disease duration was 93 days (range 7-610 days). Five patients were nontransfused before BMT. The pretransplant conditioning regimen consisted of 200 mg/kg cyclophosphamide (CY) intravenously, divided over four consecutive days, followed by 300 cGy total-body irradiation (TBI) on the day before BMT. Two untransfused, one transfused patient and one syngeneic transplant received CY only as preconditioning. For GVHD prophylaxis, the 13 patients were given a combination of cyclosporine and a short course of methotrexate. RESULTS: Of the 14 patients, 11 were still alive 10 to 90 months later, with functional engraftment; the median survival of 39 months. There were three deaths including one with primary graft failure with intracranial hemorrhage, and two with delayed graft rejection and sepsis. The patient who received syngeneic BMT developed late graft failure six months post-transplant, but was successfully treated with a second BMT. Acute GVHD occurred among 5 of the 13 engrafted patients, only one of whom was Grade III clinically. Chronic GVHD was observed in 2 out of 10 evaluable patients. CONCLUSIONS: The combination of CY and TBI is an effective, well-tolerated conditioning regimen for BMT in patients with SAA. The acute GVHD rate was low in our patients receiving cyclosporine. BMT is the treatment-of-choice for patients under the age of 40 with SAA, for those with human leucocyte antigen (HLA)-identical siblings or an identical twin and particularly for those patients who have not received transfusion.
Mice harboring a targeted disruption of the epidermal growth factor receptor (EGFR) allele exhibit a severely disorganized hair follicle phenotype, fuzzy coat, and systemic disease resulting in death before 3 weeks. This skin phenotype was reproduced in whole skin grafts and in grafts of EGFR null hair follicle buds onto nude mice, providing a model to evaluate the natural evolution of skin lacking the EGFR. Hair follicles in grafts of null skin did not progress from anagen to telogen and scanning electron micrografts revealed wavy, flattened hair fibers with cuticular abnormalities. Many of the EGFR null hair follicles in the grafted skin were consumed by an inflammatory reaction resulting in complete hair loss in 67% of the grafts by 10 weeks. Localization of follicular differentiation markers including keratin 6, transglutaminase, and the hair keratins mHa2 and hacl-1 revealed a pattern of premature differentiation within the null hair follicles. In intact EGFR null mice, proliferation in the interfollicular epidermis, but not hair follicles, was greatly decreased in the absence of EGFR. In contrast, grafting of EGFR null skin resulted in a hyperplastic response in the epidermis that did not resolve even after 10 weeks, although the wound-induced hyperplasia in EGFR wild-type grafts had resolved within 3 to 4 weeks. Thus, epithelial expression of the EGFR has complex functions in the skin. It is important in delaying follicular differentiation, may serve to protect the hair follicle from immunological reactions, and modifies both normal and wound-induced epidermal proliferation but seems dispensable for follicular proliferation.
BACKGROUND: Interaction of chemokine receptor CXCR3 with its ligand IP-10 mediates effector cell trafficking to sites of allograft rejection in murine models of whole organ allotransplantation. We hypothesized that blocking the CXCR3/IP-10 interaction would impair posttransplantation leukocyte trafficking to and delay rejection of pancreatic islet allografts. METHODS: A/J strain murine islets were implanted to the kidney capsule of H-2 disparate, streptozotocin-induced diabetic wild type (WT), CXCR3 deficient (CXCR3(-/-)) or IP-10 antibody-treated WT (alphaIP-10) C57BL/6 recipients. Representative grafts from each group were harvested at day 7. Ribonuclease protection assay was used to determine gene expression for cell markers F4/80 (macrophages), CD8 (type I T cells), CD4 (type II T cells), and CD 19 (natural killer cells), and for chemokines IP-10, MIP-1alpha, MIP-1beta, MCP-1, and RANTES. Immunohistochemistry was used to confirm ribonuclease protection assay infiltrate data. Graft-site chemokine gene expression and cellular infiltrate were correlated with time to functional graft rejection. RESULTS: Untreated WT recipients demonstrated heavy graft-site cell infiltrates and increased graft-site gene expression for cell markers F4/80, CD8, CD4, and CD19, and for chemokines RANTES, IP-10, and MIP-1beta at day 7. In comparison with untreated WT, alphaIP-10-treated WT and CXCR3(-/-) recipients demonstrated the same degree of chemokine gene expression but less lymphocytic infiltrate. The mean length of allograft survival was 12.7 +/- 3.1 days in untreated WT versus 20.2 +/- 2.7 days (P <.05) for CXCR3(-/-)- and 19.7 +/- 2.3 days (P <.05) for alphaIP-10-treated WT recipients. CONCLUSIONS: CXCR3 gene deletion or alphaIP-10 antibody therapy modulates posttransplantation lymphocytic graft infiltration and statistically prolongs graft survival in murine islet allograft recipients.
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T-cell reconstitution following allogeneic stem cell transplantation may involve thymic education of donor-derived precursors or peripheral expansion of mature T cells transferred in the graft. T cell-receptor excision circles (sjTRECs) are generated within the thymus and identify new thymic emigrants and those that have not divided. We measured quantitative and qualitative immunologic reconstitution and sjTREC levels in adult and pediatric recipients of umbilical cord blood transplants (UCBTs). sjTRECs were detected at normal levels in all children, starting 12 months after transplantation. sjTRECs were not detected until 18 months after transplantation in adults, and then only at a 3-fold lower level than expected for age. We used complementarity-determining region 3 (CDR3) spectratyping to measure changes in T cell-receptor diversity occurring with restoration of thymic function. T-cell repertoires were skewed in adults and children at 12 to 18 months after transplantation but recovered to near-normal diversity at 2 to 3 years post-UCBT. T-cell repertoires appeared more diverse earlier in children (at 1 to 2 years post-UCBT) than in adults (at 3 to 4 years post-UCBT). We conclude that early T-cell recovery after UCBT occurs primarily through peripheral expansion of adoptively transferred donor T cells and results in skewing of the T-cell repertoire. The reappearance of sjTREC-containing cells after UCBT is associated with increasing numbers of phenotypicaly naive T cells, improved mitogen and recall antigen responses, and diversification of the T-cell repertoire. The delay in central T-cell recovery in adults relative to children may be due to differences in thymic function resulting from age-related atrophy, graft-versus-host disease, or the pharmacologic effects of prophylaxis and treatment of graft-versus-host disease.
There is currently no consensus as to the most appropriate means by which children with posterior urethral valves (PUV) are to be managed prior to transplantation. We compared (i) renal allograft survival and function in patients with PUV vs. those with non-obstructive causes of ESRD and (ii) graft outcomes in children who had limited interventions (Group 1) vs. those with more extensive urologic surgeries to decompress the urinary tract (Group 2). Twenty-six pediatric renal transplant recipients had ESRD due to PUV (Group 1, n = 16; Group 2, n = 10). The study group was compared to 23 matched controls with ESRD due to non-obstructive causes. Five yr patient and graft survival was similar in all patients with PUV (Groups 1 and 2) when compared to all other kidney recipients in the transplant program, 96.2% vs. 98.0% and 87.5% vs. 87.0%, respectively. Although calculated creatinine clearance (Ccr), was similar between the PUV group and controls for the first 4 yr, the 5 yr graft function was significantly lower in the PUV group. (53.7 +/- 15.7 vs. 70.2 +/- 21.0 mL/min/1.73 m2; p = 0.03). When the two PUV groups were compared, graft survival was equivalent, but graft function was significantly better at 5 yr in Group 1(60.4 +/- 10.8 vs. 33.8 +/- 9.3 mL/min/1.73 m2; p = 0.02). Thus, patients with PUV managed by a limited intervention approach of vesicostomy with delayed valve ablation or primary valve ablation, had better outcomes. When ESRD is virtually certain, additional pre-transplant surgeries affecting the urinary tract should be avoided.
In this study, we investigated the effects of treatment with monoclonal antibodies against the VLA-4 and LFA-1 adhesion molecules on rat islet allograft rejection. TA-2 and TA-3 are function-blocking mAb against rat VLA-4 and LFA-1, respectively. Lewis rats were made diabetic (plasma glucose levels > 22.2 mmol/L) with streptozotocin. One week later, 1500 freshly isolated Wistar Furth rat islets were transplanted under the left kidney capsule of each rat. Monoclonal antibodies were administered intravenously at a dosage of 2 mg on the day of islet transplantation and then intraperitoneally every second day for 3 weeks or until graft rejection. Plasma glucose levels were monitored at least 3 times a week and blood leukocyte counts were monitored every 4 days. Rejection was defined as 2 plasma glucose levels > 11.1 mmol/L. Mean graft survival times in untreated and control mAb-treated rats were 5.3 and 6.0 days, respectively. Treatment with anti-VLA-4 or anti-LFA-1 resulted in only modest prolongation of mean graft survival time (9.3 and 7.4 days, respectively). However, treatment with the combination of anti-VLA-4 plus anti-LFA-1 resulted in long-term (i.e., 60-day) graft survival in 5 of 7 rats. Graft nephrectomy and histology confirmed islet graft survival at 60 days. A second Wistar Furth rat islet graft under the opposite renal capsule after graft nephrectomy did not show full tolerance; however, the function of the second graft was significantly prolonged without any immunosuppression. Combined blockade of VLA-4 and LFA-1 also markedly prolonged islet graft survival when islets were transplanted via the portal vein. In conclusion, both VLA-4 and LFA-1 play a role in islet allograft rejection and blockade of both prevents or greatly delays graft rejection.
We have investigated the reasons why thymectomized, bone marrow-reconstituted (B) rats do not reject their allografts, by comparing the structure of inflammation and functions of inflammatory cells in nonrejecting allografts to rejecting allografts in normal control recipients. The results demonstrate that B recipients mount a specific cellular response towards the graft. The response in B recipients differs from that in normal controls by a smaller intensity of inflammation, fewer blast cells, and activated mononuclear phagocytes in the inflammatory infiltrate, as well as a delay in the appearance of specific donor-directed lytic activity in the graft. B rats also have fewer blast cells and an inverted CD4/8 ratio in the spleen. There is no obvious absence of any given cell type or cellular function in the graft inflammatory infiltrate. In light of these results no cell type responsible for allograft nonrejection can be pinpointed.
Since October 2000, 56 hips in 48 patients with avascular necrosis of the femoral head were treated with free vascularized fibular transplants. The average follow-up was about 16 months. The Harris hip scores of all stages were improved during follow-up. Most femoral heads showed improvement (39 hips, 69.6%) or were at least unchanged (14 hips, 25.0%) on X-rays. The results show that a free vascularized fibular graft would be a valuable procedure for femoral head necrosis. By this method, we can avoid or delay progress of the disease, and improve the function of the hip and quality of life.
Free jejunal grafts have been used in the surgical treatment of patients with carcinoma of the pharynx and upper esophagus. Post-operative complications, including swallowing difficulty, are frequent and radiographic assessment may be required. In this pictorial paper, we describe the surgical technique of free jejunal grafting of the pharyngoesophagus, and the radiographic appearances and clinical importance of early and delayed complications following the procedure. Dysphagia after placement of a jejunal graft is a common occurrence which is often multifactorial, and may be related to functional, anatomic, or a combination of factors.