Immune response to nonspecific and altered tissue antigens in soft tissue allografts.

Soft tissue allografts have many uses in orthopaedic surgery, including knee ligament reconstruction, hand tendon surgery, shoulder instability, and rotator cuff reconstruction. The predictable biologic incorporation of soft tissue allografts without rejection or fear of disease transmission continues to be a goal of basic science researchers. A review of the current knowledge if the immune system response to donor specific, nonspecific, and altered tissue antigens in soft tissue or tendon allografts is presented. An in vitro study was done in an attempt to decrease immunogenicity of a frozen bone-ligament graft by adding irrigation with Betadine scrub solution and hydrogen peroxide to the conventional storage process of freezing. Although the irrigation with cytotoxic agents would undoubtedly further decrease immunogenicity, it also decreased stiffness and maximum load by 15%. Whether this decreased strength and stiffness would compromise the incorporation and long term success of soft tissue allografts would need to be studied by in vitro experiments.

Complications in proximal tibial osteotomies in children with presentation of technique.

Proximal tibial osteotomies in children have been associated with a number of complications, including peroneal nerve palsies, compartment syndromes, deep and superficial infections, vascular injuries, iatrogenic fractures, apophyseal or growth plate damage, and recurrence of deformity. A retrospective review of the results of 22 children who had 30 primary and seven repeat proximal tibial osteotomies was performed to assess the frequency of complications at our institution. Using a specified technique that included prophylactic anterior compartment fasciotomy and distal fibulectomy, there were three superficial wound infections and one delayed union but no peroneal nerve palsies, vascular injuries, compartment syndromes, or fixation failures. There were no sequelae from the superficial infections. This is a lower rate of complications than previously reported in the literature and suggests a relationship to our current surgical technique and attention to detail. We believe that proximal tibial osteotomies can be performed successfully and safely in children when the surgeon recognizes the potential problems and takes steps to prevent them.

Anterior labrum reconstruction with mini-capsular shift procedure.

An anterior labrum reconstruction and mini-capsular shift (ARMS) procedure was performed in 64 patients (69 shoulders) with traumatic anterior or anterior-inferior glenohumeral instability between 1984 and 1990. Sixty-three of the sixty-nine stabilizations were performed for recurrent dislocation and six were performed for recurrent subluxation. Eighty-eight percent of the patients (61 shoulders) were available for clinical follow-up at an average of 36 months (range 28-78). There were 44 males and 12 females with an average age of 28 years (range 15-46). Excellent range of motion was recorded at follow-up for the operated shoulder with an average of 180 degrees of forward elevation, 72 degrees of external rotation with the arm at the side, 92 degrees of external rotation with the arm in the 90 degree abducted position and 90 degrees of internal rotation with the arm in the 90 degree abducted position. The range of motion of the normal shoulder was 180 degrees, 76 degrees, 101 degrees and 94 degrees respectively. Utilizing the rating scale from the American Shoulder and Elbow Society, pain improved from 3.1 to 4.4, stability improved from 1.1 to 4.5, and function improved from 2.5 to 3.8 on the average. Subjective rating revealed 95% of the patients to be satisfied with the operative procedure. According to the criteria of Rowe et al, 90% of the results were good or excellent. Five patients (8%) suffered a recurrent dislocation at an average of 32 months after the surgery. Four resulted from significant trauma (6%). One patient (2%) complained of a single episode of subluxation during early recovery. Two patients required shoulder manipulations to improve motion. No other complications occurred. The patients reviewed in this study were actively involved in sports. The majority of pre- and postoperative Tegner ratings exceeded 7.0.

Anterior and anterior-inferior shoulder instability: Treatment by glenoid labrum reconstruction and a modified capsular shift procedure.

An anterior glenoid labrum reconstruction in conjunction with a modified anterior-inferior capsular shift is described and was performed in 64 patients (69 shoulders) with traumatic anterior or anterior-inferior glenohumeral instability. Sixty-three operations were performed for recurrent dislocation and six for recurrent subluxation. The patients in this study were extremely active in sports, with the majority of Tegner ratings exceeding 7.0. Fifty-six patients with 61 operated shoulders were available for clinical follow-up at an average of 36 months (range 28 to 78 months). With rating scales from the American Shoulder and Elbow Surgeons, pain improved from an average of 3.1 to an average of 4.4, stability improved from 1.1 to 4.5, and function improved from 2.5 to 3.8. Postoperative average ranges of motion were 180° of forward elevation, 72° of external rotation with the arm at the side, 92° of external rotation with the arm at 90° of abduction, and 90° of internal rotation with the arm at 90° of abduction. Ninety-five percent of the patients were satisfied with the procedure. Five patients suffered a recurrent dislocation, four from significant trauma. One additional patient experienced an episode of subluxation early in the recovery period. According to the criteria of Rowe, 90% had excellent or good results.

Anaphylactic shock associated with chymopapain skin test. A case report and review of the literature.

The allergic response to chymopapain intradiscal therapy has been well documented. The most serious of these reactions is anaphylactic shock, which may result in death. Various screening methods, including skin tests, have been proposed to identify susceptible patients. Anaphylactic shock occurred in a 40-year-old woman from application of the screening skin test. Appropriate therapeutic intervention should be readily accessible when this test is performed.

Human lymphocyte reaction to freeze-dried allograft and xenograft ligamentous tissue.

Decisions made before reconstruction of the ACL include patient selection, choice of operative procedure, and selection of proper reconstructive material. Research in the use of allograft material for reconstructive grafts is of great interest for many reasons, including the advantage of not violating the patient's normal anatomy for donor tissue. A group of eight patients who received arthroscopically inserted freeze-dried bone-patellar tendon-bone allograft tissue for ACL reconstruction were selected for a prospective study. These patients were matched against a group of four autograft controls. Immunologically, the lymphocyte blast transformation test was used to evaluate the host reaction to implanted donor graft. Lymphocytes drawn from each patient were tested for their reaction against a panel of human allograft tendon and goat xenograft tendon homogenates. A stimulation index of greater than 3 was considered a positive reaction. It was hypothesized that a consistent lack of antigenicity would be observed with allograft extracts and that an antigenic reaction would be observed with the xenograft extracts. Six patients (75%) showed an immunologic reaction to the goat xenograft, and four patients (50%) showed an immunologic reaction to at least one human allograft test cell after allograft insertion. One patient had such an intense clinical immunologic response that she required removal of the allograft. All four of the autograft controls had a nonimmunogenic response to testing, as had been expected.(ABSTRACT TRUNCATED AT 250 WORDS)