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Objectives: Osteochondral allograft transplantation (OCAT) can be a successful joint restoration treatment option for large post-traumatic articular defects but is still associated with significant revision and failure rates. Despite recent advances that have improved OCAT success, insufficient osteochondral allograft (OCA) osseointegration remains a major cause of failure. Deferoxamine (DFO) is an effective angiogenic and osteo-anabolic iron chelator that consistently promotes bone neovascularization and regeneration. This study was designed to investigate local delivery of DFO for augmenting OCA osseointegration using a preclinical canine model for OCAT in the knee and hip as commonly affected joints., Methods: On Institutional Animal Care and Use Committee (IACUC) approval, 12 purpose-bred dogs underwent OCAT of the femoral head or femoral condyles with DFO or DFO-free (controls) microspheres in recipient sites. OCA revascularization, cellular repopulation, and integration were evaluated based on functional, diagnostic imaging, microcomputed tomography, histology, and immunohistochemistry outcome measures., Results: Local delivery of DFO into OCAT recipient sites was associated with maintained or improved joint function, superior radiographic appearance, significantly greater trabecular thickness, higher bone volume, and new bone ingrowth compared with DFO-free controls., Conclusion: OCA osseointegration is dependent on cellular repopulation and neovascularization, resulting in new bone ingrowth through creeping substitution, and insufficient osseointegration with resorption and subsidence of the OCA remains a major cause of failure after transplantation. The results of this study suggest that local delivery of DFO using a controlled microsphere release system may reduce resorption and improve revascularization and cellular repopulation to increase new bone ingrowth, potentially expediting OCA osseointegration after transplantation., Competing Interests: J. L. Cook receives research support from AANA; receives research support from AO Trauma; receives IP royalties, is a paid consultant, and receives research support from Arthrex, Inc, Naples, FL; is a paid consultant for Bioventus; is a paid consultant for Boehringer Ingelheim; is a paid consultant and receives research support from Collagen Matrix Inc; receives research support from GE Healthcare; is on the editorial or governing board for the Journal of Knee Surgery; is a board or committee member for Midwest Transplant Network; is a board or committee member, receives IP royalties and research support for Musculoskeletal Transplant Foundation; receives research support from National Institutes of Health (NIAMS and NICHD); receives research support from OREF; receives research support from Orthopaedic Trauma Association; receives research support from PCORI; receives research support from Regenosine; receives research support from SITES Medical; receives publishing royalties, financial or material support from Thieme; is a paid consultant for Trupanion; and receives research support from US Department of Defense. A. M. Stoker receives IP royalties from Musculoskeletal Transplant Foundation. J. P. Stannard is a board or committee member for American Orthopaedic Association; is a board or committee member for AO Foundation; is a board or committee member for AO North America; is a paid consultant and research support from Arthrex, Inc; is a paid consultant for DePuy, A Johnson & Johnson Company; is on the editorial or governing board for Journal of Knee Surgery; is a board or committee member of Mid-America Orthopaedic Association; receives research support from National Institutes of Health (NIAMS and NICHD); is a paid consultant for Orthopedic Designs North America; is a paid consultant for Smith & Nephew; receives publishing royalties, financial or material support from Thieme; and receives research support from US Department of Defense. C. R. Cook receives IP royalties, is a paid consultant, paid presenter or speaker and receives research support from Arthrex, Inc; receives IP royalties, is a paid consultant, paid presenter or speaker, and receives research support from Collagen Matrix Inc; receives IP royalties, is a paid consultant, paid presenter or speaker and receives research support from Musculoskeletal Transplant Foundation. B. D. Crist is a board or committee member for AO Trauma North America; is a paid consultant for Curvafix; receives IP royalties for Globus Medical; is a board or committee member for International Geriatric Fracture Society; is on the editorial or governing board for the Journal of Hip Preservation; is on the editorial or governing board for the Journal of Orthopaedic Trauma; is a paid consultant, presenter or speaker for KCI; has stock or stock options for the Orthopaedic Implant Company; is a board or committee member for Orthopaedic Trauma Association; is an unpaid consultant for Osteocentric; has stock or stock options from RomTech; is on the editorial or governing board for SLACK Incorporated; is a paid consultant and receives research support from Synthes. The remaining authors report no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Prospective porcine animal model., Objective: Determine if injecting FloSeal into pedicles for hemostasis causes emboli., Summary of Background Data: Bleeding from spinal deformity cases can be substantial, especially when surgical procedures involve bilateral fixation at multiple segments. It is not unusual to observe hemorrhage from vascular pedicles during each step of pedicle screw tract preparation. When multiple fixation points are required, blood loss can be excessive. To minimize estimated blood loss and associated morbidity, surgeons have injected liquefied gelatin into pedicles after drilling, palpating, and/or tapping. FloSeal is one of the most popular commercially available injectable agents and we sought to investigate the potential for embolization when used as an intrapedicular hemostatic agent., Methods: Two adult minipigs were anesthetized and underwent sequential bilateral pedicle cannulation from T-spine to sacrum. At every level, tracts were cannulated, palpated, and tapped. In every tract, FloSeal was injected into each pedicle until back pressure was detected on the syringe or to a maximum volume of 2 mL, then pedicle screws were inserted. The right ventricular outflow tract was visualized real time using transesophageal echocardiography. Postmortem evaluation of heart and lungs was performed., Results: FloSeal injected into pedicles caused a consistent large showering of the right ventricular outflow tract in both pigs as visualized on intraoperative transesophageal echocardiography. A second large showering occurred during screw insertion after FloSeal was injected. Microscopic examination of lungs clearly identified amphophilic amorphous material in many small vessels consistent with FloSeal., Conclusion: This study suggests caution when injecting gelatin hemostatic agents into pedicles to stop bleeding during spinal surgery as we saw clear evidence of fat and gelatin emboli when used in this animal model. Further investigation into how to minimize this embolic showering may help the cardiopulmonary at risk patient who requires spinal surgery, especially when multiple points of pedicle screw fixation are used., Level of Evidence: N/A.

Heart disease is the primary cause of nonobstetric mortality in pregnancy, occurring in 1%-3% of pregnancies and accounting for 10%-15% of maternal deaths. Congenital heart disease has become more prevalent in women of childbearing age, representing an increasing percentage (up to 75%) of heart disease in pregnancy. Untreated maternal heart disease also places the fetus at risk. Independent predictors of neonatal complications include a maternal New York Heart Association heart failure classification >2, anticoagulation use during pregnancy, smoking, multiple gestation, and left heart obstruction. Because cardiac surgical morbidity and mortality in the parturient is higher than nonpregnant patients, most parturients with cardiac disease are first managed medically, with cardiac surgery being reserved when medical management fails. Risk factors for maternal mortality during cardiac surgery include the use of vasoactive drugs, age, type of surgery, reoperation, and maternal functional class. Risk factors for fetal mortality include maternal age >35 yr, functional class, reoperation, emergency surgery, type of myocardial protection, and anoxic time. Nonetheless, acceptable maternal and fetal perioperative mortality rates may be achieved through such measures as early preoperative detection of maternal cardiovascular decompensation, use of fetal monitoring, delivery of a viable fetus before the operation and scheduling surgery on an elective basis during the second trimester. Additionally, fetal morbidity may be reduced during cardiopulmonary bypass by optimizing maternal oxygen-carrying capacity and uterine blood flow. Current maternal bypass recommendations include: 1) maintaining the pump flow rate >2.5 L x min(-1) x m(-2) and perfusion pressure >70 mm Hg; 2) maintaining the hematocrit > 28%; 3) using normothermic perfusion when feasible; 4) using pulsatile flow; and 5) using alpha-stat pH management.

Objective: To evaluate management recommendations from the current literature for patients whose fetuses are certain to have lethal anomalies or absent (or virtually absent) cognitive function. These recommendations include termination of pregnancy or, for cases in the third trimester, nonaggressive intrapartum management, avoiding cesarean delivery for fetal indications., Methods: We report our experience with several patients who voiced opposition to nonaggressive intrapartum care and present a rationale for selectively aggressive, intrapartum management for some of these cases., Results: Four women whose fetuses had lethal anomalies requested aggressive intrapartum management. For three of the four, standard aggressive management of labor resulted in vaginal delivery of live-born infants who died shortly thereafter. The patients found comfort in the live births. The fourth patient accepted a recommendation to avoid fetal monitoring during labor, and the fetus was stillborn. This patient found the intrapartum experience to be very stressful., Conclusion: When a patient's desire to avoid an intrapartum stillbirth is strong enough that substantial psychological harm might result from one, the physician's beneficence-based obligation to her and respect for maternal autonomy justify selectively aggressive intrapartum therapy, even if no beneficence-based obligation to the fetus exists.