Search

Background: Open offers (OOs) in liver transplantation (LT) result from bypassing the traditional allocation system. Little is known about the trends of OOs or the differences in donor/recipient characteristics compared to traditionally placed organs. We aim to quantify modern practices regarding OOs and understand NMP's impact, focusing on social determinants of health (SDH), cost, and graft‐associated risk. Methods: LTs from 1/1/2018 to 12/31/2023 at a single center were included. NMP was implemented on 10/1/2022. The CDC (centers for disease control)‐validated social vulnerability index (SVI) and donor risk index (DRI) were calculated. Comprehensive complications index (CCI), Clavien‐Dindo grades, patient and graft survival, and costs of transplantation were included. Results: 1162 LTs were performed; 193 (16.8%) from OOs. OOs were more common in the post‐NMP era (26.5% vs. 13.3%, p < 0.001). Pre‐NMP, patients receiving OOs had longer waitlist times (118 vs. 69 days, p < 0.001), lower MELDs (17 vs. 25 points, p < 0.001), and riskier grafts (DRI = 1.8 vs. 1.6, p = 0.004) compared to standard offers. Post‐NMP, recipients receiving OOs demonstrated no difference in waitlist time (27 vs. 20 days, p = 0.21) or graft risk (DRI = 2.03 vs. 2.23, p = 0.17). OO recipient MELD remained lower (16 vs. 22, p < 0.001). OO recipients were more socially vulnerable (SVI), pre‐NMP (0.41 vs. 0.36, p = 0.004), but less vulnerable after NMP (0.23 vs. 0.36, p = 0.019). Despite increased graft risk, pre‐NMP OO‐LTs were less expensive in the 90‐day global period ($154 939 vs. $178 970, p = 0.002) and the 180‐days pre‐/post‐LT ($208 807 vs. $228 091, p = 0.021). Cost trends remained similar with NMP. Conclusion: OOs are increasingly utilized and may be appealing due to demonstrated cost reductions even with NMP. Although most OO‐related metrics in our center remain similar before and after machine perfusion, programs should take caution that increasing use does not worsen organ access for socially vulnerable populations. [ABSTRACT FROM AUTHOR]

Simple Summary: This review article serves to update physicians on what biomarker tests are available for the surveillance and follow up of hepatocellular carcinoma. Our goal is to provide an update on newly arising tests and their diagnostic accuracy when compared to the standard protocol. Findings from this article hope to promote further investigation into high utility tests and continue the pursuit of clinical utility for emerging biomarkers such as circulating tumor DNA. Hepatocellular carcinoma (HCC) is the third leading cause of cancer-related death and the sixth most diagnosed malignancy worldwide. Serum alpha-fetoprotein (AFP) is the traditional, ubiquitous biomarker for HCC. However, there has been an increasing call for the use of multiple biomarkers to optimize care for these patients. AFP, AFP-L3, and prothrombin induced by vitamin K absence II (DCP) have described clinical utility for HCC, but unfortunately, they also have well established and significant limitations. Circulating tumor DNA (ctDNA), genomic glycosylation, and even totally non-invasive salivary metabolomics and/or micro-RNAS demonstrate great promise for early detection and long-term surveillance, but still require large-scale prospective validation to definitively validate their clinical validity. This review aims to provide an update on clinically available and emerging biomarkers for HCC, focusing on their respective clinical strengths and weaknesses. [ABSTRACT FROM AUTHOR]

Simple Summary: Circulating tumor DNA (ctDNA) is emerging as a diagnostic and surveillance tool in cancer and recurrence. The recurrence rates after liver transplant for cancer are significant, highlighting the need for early detection and treatment. We report a cohort of patients who underwent liver transplant for hepatocellular carcinoma, cholangiocarcinoma, or colorectal cancer liver metastasis and received ctDNA testing pre- and/or post-transplant. We aim to show how ctDNA testing can be incorporated into pre-transplant work-up and post-transplant surveillance and discuss the benefits of this testing modality in the identification of genetic targets and surveillance of recurrence. Introduction: Circulating tumor DNA (ctDNA) is emerging as a promising, non-invasive diagnostic and surveillance biomarker in solid organ malignancy. However, its utility before and after liver transplant (LT) for patients with primary and secondary liver cancers is still underexplored. Methods: Patients undergoing LT for hepatocellular carcinoma (HCC), cholangiocarcinoma (CCA), and colorectal liver metastases (CRLM) with ctDNA testing were included. CtDNA testing was conducted pre-transplant, post-transplant, or both (sequential) from 11/2019 to 09/2023 using Guardant360, Guardant Reveal, and Guardant360 CDx. Results: 21 patients with HCC (n = 9, 43%), CRLM (n = 8, 38%), CCA (n = 3, 14%), and mixed HCC/CCA (n = 1, 5%) were included in the study. The median follow-up time was 15 months (range: 1–124). The median time from pre-operative testing to surgery was 3 months (IQR: 1–4; range: 0–5), and from surgery to post-operative testing, it was 9 months (IQR: 2–22; range: 0.4–112). A total of 13 (62%) patients had pre-transplant testing, with 8 (62%) having ctDNA detected (ctDNA+) and 5 (32%) not having ctDNA detected (ctDNA-). A total of 18 (86%) patients had post-transplant testing, 11 (61%) of whom were ctDNA+ and 7 (33%) of whom were ctDNA-. The absolute recurrence rates were 50% (n = 5) in those who were ctDNA+ vs. 25% (n = 1) in those who were ctDNA- in the post-transplant setting, though this difference was not statistically significant (p = 0.367). Six (29%) patients (HCC = 3, CCA = 1, CRLM = 2) experienced recurrence with a median recurrence-free survival of 14 (IQR: 6–40) months. Four of these patients had positive post-transplant ctDNA collected following diagnosis of recurrence, while one patient had positive post-transplant ctDNA collected preceding recurrence. A total of 10 (48%) patients had sequential ctDNA testing, of whom n = 5 (50%) achieved ctDNA clearance (+/−). The remainder were ctDNA+/+ (n = 3, 30%), ctDNA−/− (n = 1, 10%), and ctDNA−/+ (n = 1, 11%). Three (30%) patients showed the acquisition of new genomic alterations following transplant, all without recurrence. Overall, the median tumor mutation burden (TMB) decreased from 1.23 mut/Mb pre-transplant to 0.00 mut/Mb post-transplant. Conclusions: Patients with ctDNA positivity experienced recurrence at a higher rate than the ctDNA- patients, indicating the potential role of ctDNA in predicting recurrence after curative-intent transplant. Based on sequential testing, LT has the potential to clear ctDNA, demonstrating the capability of LT in the treatment of systemic disease. Transplant providers should be aware of the potential of donor-derived cell-free DNA and improved approaches are necessary to address such concerns. [ABSTRACT FROM AUTHOR]

Purpose: This study reports the five-year functional outcomes from a prospective cohort study comparing robotic-arm assisted total knee arthroplasty (RO TKA) versus conventional manual total knee arthroplasty (CO TKA). Methods: This prospective single-surgeon study included 120 patients with symptomatic end-stage knee arthritis undergoing primary TKA. This included 60 consecutive patients undergoing CO TKA followed by 60 consecutive patients undergoing RO TKA using a semi-automated robotic device. Study patients were reviewed at one, two, and five years after surgery and the following outcomes recorded: The University of California at Los Angeles activity-level (UCLA), Knee Society Score (KSS), Oxford Knee Score (OKS) Forgotten Joint Score (FJS), and any complications. Results: There were no statistical differences between RO TKA and CO TKA in the median UCLA score (p = N.S), median KSS (p = N.S), and median OKS (p = N.S) at five-year follow-up. RO-TKA was associated with statistically significant improvements in the FJS at one (p = 0.001), two (p = 0.003), and five (p = 0.025) years of follow-up compared with CO TKA. There was no statistical difference in the incidence of knee stiffness requiring manipulation under anesthesia between the two treatment groups (p = N.S). Conclusion: Patients in both treatment groups had excellent functional outcomes with comparable patient reported outcomes at five-year follow-up. RO TKA was associated with statistically significant improvements in the FJS compared with CO TKA, but these differences did not reach the minimal clinically important difference at any follow-up interval. There was no overall difference in complications between the two treatment groups at five-year follow-up. Level of evidence: II (Prospective cohort study). [ABSTRACT FROM AUTHOR]

Introduction: Type 2 diabetes (T2D) is a chronic medical condition that results in significant health implications and reduced life expectancy. The International Diabetes Federation (IDF) estimated that in 2021, 51.8% of all deaths of people under 60 years old in the Middle East and North Africa (MENA) region were related to diabetes. Bariatric surgery has been demonstrated to be a safe and effective treatment for T2D in different populations worldwide, though few specific data exist on outcomes of procedures in the MENA region. The aim of this study was to compare the safety and postoperative outcomes between patients with and without T2D undergoing primary bariatric surgery at a tertiary referral academic medical center in the United Arab Emirates. Methods: All patients who underwent primary metabolic surgery between September 2015 and July 2020 were retrospectively reviewed from a prospective database. Group 1 included patients with T2D, and Group 2 included patients without T2D. Patients undergoing revisional or correctional operations were excluded. The procedure performed was based on surgeon discretion in discussion with a multidisciplinary team and the patient. Demographics as well as perioperative and postoperative results were examined. Results: Our study included 542 patients, 160 (29.5%) with T2D and 382 (70.5%) with non-T2D. Mean age was 44.5 years (range 16–70) in the T2D group and 33.3 years (range 15–63) in the non-T2D group; median BMI was 41.8 ± 7.3 and 43.2 ± 7.2, respectively. The T2D group was 37.5% male and 62.5% female, and the non-T2D group was 38.7% male and 61.3% female. There were no significant differences in comorbidities. In the T2D group, 45.6% of patients underwent Roux-en-Y gastric bypass and 54.4% sleeve gastrectomy. In the non-TD2 group, 42.7% of patients received Roux-en-Y gastric bypass and 57.3% sleeve gastrectomy. There were no statistically significant differences in postoperative ED visits (21.8% vs. 24.3%, p = 0.21), minor complications within 30 days (4.3% vs. 5.2%, p = 0.67), readmission rates (5.6% vs. 4.9%, p = 0.77), re-operation rates (3.7% vs. 1.5%, p = 0.11), median hospital stay (2.0 days vs. 3.0, p = 0.05), or complications after 30 days (6.2% vs. 11.2%, p = 0.07). There were no deaths either group. Conclusions: In this cohort of patients from the MENA region, bariatric surgery in T2D patients is safe and effective, with perioperative outcomes comparable to those of non-T2D patients. To the best of our knowledge, our postoperative findings, which are the first report in the MENA region, are consistent with studies published in North America and Europe. [ABSTRACT FROM AUTHOR]

Background: Up to 2% of THAs are complicated by infection, leading to dissatisfied patients with poor function and major social and economic consequences. The challenges are control of infection, restoration of full function, and prevention of recurrence. Irrigation and débridement with or without exchange of modular components remains an attractive alternative to two-stage reimplantation in acutely infected THAs but with variable results from previous studies.Questions/purposes: We therefore determined the rate at which aggressive early débridement with exchange of modular components controlled acutely infected cemented THAs.Methods: We retrospectively studied all 26 patients presenting with acutely infected cemented THAs (16 primaries, 10 revisions) occurring within 6 weeks of the index operation or of hematogenous spread from a confirmed source of infection elsewhere between 1999 and 2006. Microbiology confirmed bacterial colonization in all patients, with 18 early postoperative infections and eight acute hematogenous infections. Patients underwent aggressive débridement with open complete synovectomy, exchange of all mobile parts, débridement of all aspects of the joint, irrigation with antiseptic solutions, and pulsatile lavage. Minimum followup was 5 years (mean, 6.6 years; range, 5-11 years).Results: Eight patients had multiple washouts with control of infection in four at latest followup. Five patients underwent two-stage revisions and one patient was placed on long-term antibiotic suppression. Twenty patients returned to their expected functional level with no radiographic evidence of prosthetic failure. At minimum 5-year followup, we had a 77% infection control rate.Conclusions: Our data confirm current literature and suggest there may be a role for aggressive early débridement in controlling acute postoperative and hematogenous infections after cemented THA.Level Of Evidence: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: A knee design with a ball-and-socket articulation of the medial compartment has a femoral rollback profile similar to the native knee. Compared to a conventional, posterior-stabilized knee design, it provides AP stability throughout the entire ROM. However, it is unclear whether this design difference translates to clinical and functional improvement. Questions/purposes: We asked whether the medially conforming ball-and-socket design differences would be associated with (1) improved ROM; and (2) improved American Knee Society, WOMAC, Oxford Knee, SF-36, and Total Knee Function Questionnaire scores compared to a conventional, fixed-bearing posterior-stabilized TKA. Patients and Methods: We enrolled 82 patients in a single-center, single-blinded, randomized, controlled trial comparing the medially conforming ball-and-socket design knee prosthesis to a posterior-stabilized total knee prosthesis. Our primary end point was ROM. Our secondary end points were American Knee Society, WOMAC, Oxford Knee, SF-36, and Total Knee Function Questionnaire scores. All patients were followed at 1 and 2 years. Results: The mean ROM was 100.1° and 114.9° in the posterior-stabilized and medially conforming ball-and-socket groups, respectively. The physical component scores of SF-36 and Total Knee Function Questionnaire were better in the medially conforming ball-and-socket group. We found no difference in American Knee Society, WOMAC, and Oxford Knee scores. Conclusions: Both implant designs similarly relieved pain and improved function. The medially conforming ball-and-socket articulation provided better high-end function as reflected by the Total Knee Function Questionnaire. Level of Evidence: Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: There is limited information regarding revision total knee arthroplasty (TKA) with respect to etiology, outcome, and long-term survival comparing different implant types.Questions/purposes: We compared patient outcomes, survivorship and modes of failure and the most common etiologic factors for rerevision between different revision implant types.Methods: We retrospectively reviewed 349 cases of revision TKA in 343 patients whose mean age was 67.8 years. Three implant types were used: posterior stabilized, condylar constrained knee, and rotating hinge. The etiologies included infection (32.7%), aseptic loosening (14.9%), and polyethylene wear (12.3%). The minimum followup was 12 months (mean, 57.7 months; range, 12-120 months).Results: The mean Knee Society scores were 89 (range, 48-94), 88.9 (range, 45-95), and 84 (range, 56-94) and the mean ranges of motion were 110.0 degrees (range, 70 degrees -125 degrees ), 106.1 degrees (range, 70 degrees -120 degrees ), and 111.7 degrees (range, 85 degrees -125 degrees ) for the posterior stabilized, condylar constrained knee, and rotating hinge types, respectively. The rotating hinge group had the highest satisfaction rates (88%). Overall 10-year survivorship was 90.6% with highest survivorship seen in the rotating hinge group. The most common causes for rerevision were infection (2.9% of our cohort), instability (1.7%), and aseptic loosening (1.4%). The mean overall time to rerevision was 69.9 months (range, 11-119 months).Conclusions: In our experience periprosthetic infection is the most common cause of failure of both primary and revision TKA. Functional outcome and range of motion improve irrespective of revision implant type. The rotating hinge prosthesis provides patient satisfaction and survivorship similar to that of other implant types.Level Of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

We report an unusual case of femoral fracture from minimal trauma, due to the rapid disappearance of a bioabsorbable interference screw used for reconstruction of the posterolateral corner of the knee. The literature on bone tunnel fractures following knee ligament reconstruction surgery is also reviewed. [ABSTRACT FROM AUTHOR]

Numerous physical tests have been described but their diagnostic accuracy is often questioned. Karachalios et al. described the new ‘Thessaly test’ and concluded that it could be safely used as a first line screening test for the selection of patients who need arthroscopic meniscal surgery. Our objective was to study the role of physical diagnostic tests in screening for meniscal tears and to validate the diagnostic accuracy of the Thessaly test. We examined 109 patients (80 male, 29 female; average age: 39 years; range: 16–56) who were presented with a history suggestive of a meniscal tear. Joint line tenderness, McMurray’s test, and the Thessaly test were assessed by an independent investigator blinded to any imaging data in all patients. MRI and subsequent arthroscopy results were then collated. Our study showed a much lower diagnostic accuracy for the Thessaly test (61% for medial meniscus and 80% for lateral meniscus). It is comparable to McMurray’s test (57% for medial meniscus and 77% for lateral meniscus). The Joint line tenderness test has a far superior diagnostic accuracy (81% for medial meniscus and 90% for lateral meniscus). However, combining the joint line tenderness test with McMurray’s test or the joint line tenderness test with Thessaly test further increased the accuracy of physical diagnosis of meniscal tears. Magnetic resonance imaging (MRI) detected 96% of meniscal tears. Physical tests may not always be diagnostic of meniscal tears. MRI and arthroscopy may be essential in dubious clinical presentations and especially where more than one pathology is suspected. Our study showed that the Thessaly test in isolation was not useful for the detection of meniscal tears but it helps to increase diagnostic certainty when combined with other standard tests. [ABSTRACT FROM AUTHOR]

Numerous physical tests have been described but their diagnostic accuracy is often questioned. Karachalios et al. described the new 'Thessaly test' and concluded that it could be safely used as a first line screening test for the selection of patients who need arthroscopic meniscal surgery. Our objective was to study the role of physical diagnostic tests in screening for meniscal tears and to validate the diagnostic accuracy of the Thessaly test. We examined 109 patients (80 male, 29 female; average age: 39 years; range: 16-56) who were presented with a history suggestive of a meniscal tear. Joint line tenderness, McMurray's test, and the Thessaly test were assessed by an independent investigator blinded to any imaging data in all patients. MRI and subsequent arthroscopy results were then collated. Our study showed a much lower diagnostic accuracy for the Thessaly test (61% for medial meniscus and 80% for lateral meniscus). It is comparable to McMurray's test (57% for medial meniscus and 77% for lateral meniscus). The Joint line tenderness test has a far superior diagnostic accuracy (81% for medial meniscus and 90% for lateral meniscus). However, combining the joint line tenderness test with McMurray's test or the joint line tenderness test with Thessaly test further increased the accuracy of physical diagnosis of meniscal tears. Magnetic resonance imaging (MRI) detected 96% of meniscal tears. Physical tests may not always be diagnostic of meniscal tears. MRI and arthroscopy may be essential in dubious clinical presentations and especially where more than one pathology is suspected. Our study showed that the Thessaly test in isolation was not useful for the detection of meniscal tears but it helps to increase diagnostic certainty when combined with other standard tests. [ABSTRACT FROM AUTHOR]