Evaluation of ACL Graft Remodeling and Prediction of Graft Insufficiency in Sequenced MRI—Two-Year Follow-Up

Background: Postoperative magnetic resonance imaging (MRI) evaluation of anterior cruciate ligament (ACL) graft maturity is a useful and practical tool that allows for assessment of graft status and remodeling stage. The purpose of this study was to evaluate and compare previously described methods of graft evaluation in MRI. We identify factors influencing the maturation and correlating graft appearance in MRI with indirect symptoms of graft insufficiency to identify patients at risk. Methods: Retrospective evaluation was performed in 44 patients who received bone patellar tendon bone (BPTB) ACL reconstruction with nine consecutive postoperative MRIs at 2, 6, 12, 18, 24, 36, 48, 72, and 96 weeks. Graft status was evaluated using signal-to-noise quotient (SNQ) methods in both sagittal and axial planes. We also assessed the homogeneity of the graft by standard deviation (SD) of signal intensity. SNQ was correlated with patient’s age, sex, postoperative weight-bearing, as well as indirect signs of graft insufficiency by MRI including graft appearance, posterior cruciate ligament (PCL) buckling, and measurement of anterior tibia subluxation. Results: We observed that the results of modelling SNQs from both sagittal and axial planes were similar. For both SNQs, the change over weeks quotient was nonlinear where the clinical parameter increased at week 36 and subsequently decreased. The SNQ at week 96 does not reach the levels from week 2. We observed that the model incorporating SNQ and relative SD (rSD) in the sagittal plane predicted the tibia anterior subluxation proportions better than the model with clinical parameters measured in the axial plane. Our results demonstrate that greater SD is associated with less graft homogeneity, which could indicate that this model is a good predictor of graft insufficiency. In addition, the proportion of PCL buckling increased over the course of the study. Conclusions: MRI graft evaluation is very useful for assessing graft ligamentization stage and to predict graft insufficiency.

Sensory outcomes after repair of median and ulnar nerve with nerve graft

Background: Peripheral nerve injuries in upper extremities are common. These injuries have significant impact on patient’s life. Appropriate treatment is important for patients to regain functional recovery.Methods: Study conducted on patients treated on Department of Plastic and Reconstructive surgery from January 2018 to May 2019. Study was done to evaluate the sensory recovery of median and ulnar nerve in the forearm after defects were repair by autologous nerve graft. Evaluation was performed in 24 patients. Rating of sensibility was presented by British medical research council scale. Satisfactory sensory recovery was defined as MRC grading S3+ and S4.Results: We evaluate the result of median and ulnar nerve reconstruction as regards to factors affecting functionally the result of operation, which are age, injury level, graft level, and denervation time. Median nerve grafting done in 14 patients and sensory recovery S4 achieved in 2 patients (14%), S3+ in 4 patients (29%). Ulnar nerve grafting done in 10 patients and sensory recovery S4 achieved in 2 patients (20%), S3+ in 2 patients (20%). There was not statistically significant difference in sensory recovery of median and ulnar nerve. There was not statistically significant difference by age, level of injury, graft length, denervation time.Conclusions: There was no significant difference in sensory recovery of median and ulnar nerves. Mode of injury influences results. Results were comparatively better in younger patients and in patients who had undergone repair within shorter time.

Intraoperative graft assessment with transit-time flow measurement and epicardial ultrasound

Intraoperative bypass graft evaluation for coronary artery bypass graft surgery has now been recommended in three consecutive European guidelines for myocardial revascularization in 2010, 2014, and 2018. The two main modalities consist of transit-time flow measurement which assesses function of grafts and epicardial ultrasound to assess the anatomy of the anastomosis. Functional and morphological assessment are generally considered complementary, although transit-time flow measurement is the most commonly used. Transit-time flow measurement alone may have ambiguous values in 5–15% of grafts and this can lead to unnecessary graft revision. The addition of epicardial ultrasound aids interpretation of intraoperative graft assessment by allowing visualization of the anastomosis and correction of technical errors that, intuitively, will lead to improved patient outcomes.