Arthroscopic extra-articular Bankart procedure

The arthroscopic extraarticular Bankart procedure tries to imitate the open Bankart procedure. An anterior-inferior transmuscular approach through the subscapular muscle permits to implant self-locking tacks into the anterior inferior third of the glenoid rim. The extraarticular location of the implants makes a superomedial capsular shift possible, if required. A total of 257 arthroscopic repairs following traumatic recurrent anterior shoulder dislocation have been carried out between 1992 and 1996. 177 patients were treated only with bioabsorbable Suretac device. Clinical and radiological follow up was possible in 165 patients. According to the Rowe score 69.7% were classified as excellent, 10.9% as good, 9.7% fair and 9.7% poor. Postoperative complications: the recurrence rate was 9.7%, allergic reactions representing a foreign body reaction to the synthetic material were seen in 5 cases (3%) and a frozen shoulder in 6 cases 3.6%). 61% of the patients involved in overhead or contact sports returned to their preoperative sport activities.     

Ab initio quantum mechanical and X-ray crystallographic studies of gemcitabine and 2''-deoxy cytosine

Thirty-seven of 41 consecutive patients with recurrent anterior instability of the shoulder were retrospectively observed for a mean of 5.6 years (range, 4 to 10) after an arthroscopic stabilization procedure had been performed. The operative technique involved the use of transglenoid sutures to repair the capsule and labrum. According to the criteria established by Rowe, 27 patients (74%) had good or excellent results, and 3 patients (7%) were graded as fair. Seven patients (19%) developed recurrent instability after the procedure and had failed results. Failure rates were equal in patients with a history of recurrent dislocation and those with recurrent subluxation. Absence of a Bankart lesion at operation was associated with postoperative instability (P = 0.03). The presence or size of humeral head defects did not influence the result. Eight of 12 athletes who engaged in sports requiring repetitive overhead shoulder motion returned to full activity, and none of the 12 developed instability after operation. Four of the 13 patients who participated in contact sports or recreational skiing developed postoperative instability (P = 0.21). All failures occurred within 2 years of the procedure.     

In vitro synthesis and characterization of a cartilaginous meniscus grown from isolated temporomandibular chondroprogenitor cells

Between 1984 and 1991, 57 patients with diagnosis of an acute or recurrent patellar dislocation were treated operatively using proximal realignment with vastus medialis transfer and lateral release (Insall operation). A total of 45 patients (15 with acute and 30 with recurrent patellar dislocation) were reviewed at an average follow-up of 6.5 years (2-9.6 years). The average age at injury was 21.5 years, with a predominance of female patients. Follow-up examination included routine knee examination, clinical review using the modified knee scoring scale of Larsen and Lauridsen, sports activity level and subjective satisfaction. Radiographics from 27 patients (60%) were evaluated. One patient from each group suffered recurrence of patellar dislocation. All patients had stable knee joints and a full range of motion. There was no statistical difference in the pre- and postoperative sports activity level in both groups. Three patients (19.9%) with acute patellar dislocation and seven patients (23.3%) with recurrent patella dislocation had excellent results using the Larsen and Lauridsen score scale. Ten patients (66.6%) with acute and 12 (39.9%) with recurrent dislocation had good results. One patient with recurrent patellar dislocation had a fair result. Subjective evaluation revealed the operative result in 93% of cases as very good, good or satisfactory. Patellofemoral osteoarthritis was seen in 11 (40.7%) of 27 patients. Our results show good clinical results for the treatment of acute patellar dislocation in young, active patients with the proximal realignment procedure. The recurrence rate of patellar dislocation can be reduced for acute and recurrent patellar dislocation. Subjective satisfaction with this procedure is rated very good.     

Acute shoulder dislocation. Indications and techniques for operative management

The acute management of the initial, anterior shoulder dislocation is dependent on the age and activity demands of the patient. After a thorough examination and appropriate radiographs, a gentle closed reduction is the initial treatment. Previous authors have recommended a period of immobilization followed by a rehabilitation program emphasizing rotator cuff strengthening. Restricting return to athletic activities to allow adequate soft tissue healing is also recommended. This will effectively treat the vast majority of patients with this injury. In patients older than 25 years of age, one would expect a relatively low recurrence rate, especially in patients with low activity demands or in patients willing to modify activity. In active, young patients desiring a return to strenuous activity, however, most studies and our own experience demonstrate high recurrence rates. In the authors' experience, the examination under anesthesia and arthroscopic evaluation have confirmed an avulsion of the anterior-inferior capsulolabral complex as the primary injury component. The special circumstances of an initial dislocation with a hemarthrosis and excellent tissue quality make it ideal for arthroscopic stabilization. Our early results are encouraging and we believe this approach is a viable option in the management of this common injury in young athletes. As arthroscopic techniques for glenohumeral instability improve, we would expect an improvement on these initial results. Acute operative stabilization for the initial anterior dislocation is considered for: (1) initial dislocation that requires a reduction; (2) a young, athletic, high demand patient (<25 years of age) who is unwilling to modify his lifestyle; (3) subjects with no prior shoulder subluxation or impingement history; (4) subjects with no neurologic injury; and (5) subjects with no greater tuberosity fracture.     

MR arthrography of the shoulder joint in a postoperative patient sample

Indications of MR arthrography were analyzed in this prospective study. The aim was to evaluate possible advantages over conventional MRI, establish diagnostic criteria and to analyze its meaning further for the therapeutic management of postoperative patients. MR arthrography was performed in eight patients who had undergone surgical repair of rotator cuff lesions (modified Neer acromioplasty) and in six patients who had undergone arthroscopic therapy of recurrent unidirectional dislocation of the shoulder by combined arthroscopic intra- and extracapsular repair. MR investigations were performed before and after application of a contrast solution (2 mmol Gd-DTPA). All patients suffered from chronic postoperative pain. In patients with rotator cuff lesions, a partial tear could be verified in one patient and excluded in all others. In patients after arthroscopic therapy by combined intra- and extracapsular repair, a radiologically patulous-appearing capsule correlated with clinically recurrent dislocations. In all other patients diagnostic criteria, such as distribution of the intra-articular contrast solution, proliferation of scar tissue, nodular appearance of the glenohumeral ligaments and capsule thickness, correlated with a regular postoperative status. MR arthrography of the shoulder represents a promising method in the evaluation of the postoperative shoulder. It might further improve the evaluation of reactive capsule alterations, scar tissue proliferation, and the labroligamentous complex, as well as the ability to differentiate partial and complete rerupture from degenerative changes of the rotator cuff.     

Simultaneous bilateral fractures of the hip following a grand mal seizure. An unusual complication

Pathological fractures as a consequence of convulsive seizures without direct trauma occur in 0.3% of cases. Some lesions such as bilateral posterior dislocation of the shoulder, fracture-dislocation of the shoulder or fracture and/or dislocation of the hip strongly suggest a seizure as the aetiology. We report on a patient with simultaneous central dislocation of one hip with fracture of the contralateral femoral neck provoked by spontaneous seizures. Unrecognized associated injuries following a convulsion may result in long-term functional disability and legal consequences.     

The unstable shoulder in young subjects. Surgical experience

The stability of the scapulo humeral joint depends on three anatomical factors: bony: surface and integrity of the glenoid cavity. ligamentous: joint capsula and labrum gleno?dale. muscular: coordination and condition of the components of the rotator cuff that maintains the humeral head in the center of the joint, whatever be the position of the arm. Clinically, the most frequent aspect is the anterior recurrent dislocation, occurring in young patients.... Other forms are possible: posterior, multi directional, associated with a lesion of the rotator cuff in elderly patients.... Lately a new aspect was described: the painful and unstable shoulder. It is observed in high level sportsmen, who practice throwing sports. The only treatment is surgical. Two kinds of techniques are currently used: preglenoid transfer of the coracoid process, and different kinds-of capsuloplasty. Arthroscopy allows a more precise diagnose, but is not yet a good therapeutic procedure. Surgical treatment avoids recurrence in more than 95% of cases, but clinical osteoarthritis of the gleno humeral joint is observed in about 10% of cases after a long follow up (more than 10 years).     

Arthroscopic shoulder stabilization using transglenoid sutures

The results of arthroscopic stabilization using multiple transglenoid sutures in 24 patients with posttraumatic recurrent anterior shoulder instability are presented with a minimum follow-up of 2 years. No serious complications were recorded. There were 2 recurrences. The remaining 22 patients had good or excellent results according to the modified Rowe score, with a median score of 89. The median value for loss of external rotation was 5 degrees. Seventeen patients were active in sports and 11 returned to the same sports at the same competitive level.     

Structural and functional analysis of gp64, a membrane protein of the cellular slime mold Polysphondylium pallidum

We examined 38 patients with an arthroscopic bioabsorbable tack repair for anterior shoulder instability in a prospective evaluation. The mean follow-up was 22 months (range 12 to 33). The average age was 28.4 years (range 15 to 57), the operation was performed at average of 50 months (3 to 244 months) after injury. Assessment using the Rowe score revealed excellent results in 33 and good results in 3 patients. 1 patient had a fair result and 1 had a poor result. 26 should obtained full range of motion, 11 had minor (< 10 degrees) loss of external rotation, 1 experienced greater (< 20 degrees) loss of external rotation. 3 of the 38 patients (8%) had recurrent instability, 1 patient with 2 preceding operations and atraumatic and voluntary dislocation, respectively. The recurrence rate of arthroscopic Bankart repair with bioabsorbable tacks are comparable to open Bankart procedures. Success of the procedure depends on appropriate surgical technique and suitable selection of patients with unidirectional, posttraumatic, anterior instability who are found to have well-developed ligamentous tissue.     

Occupational health status of sawmill workers in Nigeria

Primary traumatic anterior dislocation of the shoulder in young patients has a high recurrency rate. There are varying opinions on the pathology behind the recurrences. The aim of this study was to describe the MRI characteristics of the acute lesion, and at 6-month follow-up. Thirty patients aged 18-30 years with primary traumatic anterior dislocation of the shoulder were randomized into two groups. One group was treated with acute arthroscopic lavage within 10 days. The control group was treated with traditional non-operative therapy. All patients underwent acute MRI within 10 days and before the arthroscopic lavage, and again at the 6-month follow-up, for evaluation of the lesions. The acute MRI verified Hill-Sachs lesions in all patients. At the 6-month follow-up MRI, there was no change in the size of the Hill-Sachs lesion. This was also the case with the six patients in the control group with recurrent dislocations during the first 6 months. Twenty-nine patients (97%) had joint effusion at the acute MRI, which was very useful for evaluation of the soft tissue pathology. The glenohumeral ligaments were detached in 20/30 patients (66%), and the labrum in 22/30 patients (70%). A capsulolabral detachment classified as a Baker 3 lesion was seen in 16/30 (53%) of the patients, including all six patients with recurrent dislocation. At the 6-month control only 3/30 (10%) of the patients had joint effusion for adequate evaluation of the labrum and ligamentous pathology. A Hill-Sachs lesion was found in 100% of the patients after primary dislocation, and recurrent dislocations did not change the size of the lesion. The study supports the opinion that this lesion is overlooked in the clinical situation. The joint effusion at the acute MRI was of utmost importance for evaluation of the soft tissue pathology. The 6-month MRI control was therefore considered inconclusive when evaluating capsulolabral lesions, due to lack of effusion. MRI arthrography with contrast administration would have been very helpful at the 6-month examination.     

Interscalene brachial plexus catheter for anesthesia and postoperative pain therapy. Experience with a modified technique

OBJECTIVES: This study was conducted to evaluate a modified technique of interskalene brachial plexus anaesthesia (ISB) and postoperative catheter analgesia for shoulder surgery. The original method described by Winnie bears some rare but life-threatening complications (inadvertent subarachnoid or intra-arterial injection, pneumothorax). MATERIALS AND METHODS: Ninety-one patients with chronic rheumatoid arthritis who were scheduled for open or closed shoulder surgery received a modified ISB with catheter insertion. The injection site was more cephalad than that described by Winnie and the cannula was directed towards the junction between the medial and lateral third of the clavicle. Intra- and postoperative management, complications, and patients' satisfaction were recorded and evaluated. RESULTS: Implementation of ISB was possible in all cases, however, 3% of these presented technical problems. Anaesthesia with 300 mg mepivacaine 1% was successful in 94% of patients without and in 96% with augmentation after an average of 32 min; 10% of the patients suffered a drop in blood pressure after being placed in the beach-chair position for surgery. Postoperatively, all patients received 20 ml bupivacaine 0.25% for pain management via the catheter; 11% needed an additional analgesic drug. The catheter was removed after an average of 5 days. Signs of superficial local infection were noticed in 8 cases. Side effects occurred in 13% as Horner's syndrome, in 6.5% as recurrent laryngeal nerve block, and in 3.3% as phrenic nerve block. The acceptance of this anaesthetic technique among the patients was very high (96.7%). CONCLUSION: We consider the modified ISB with catheter a safe and effective procedure for anaesthesia and postoperative pain management of open and closed shoulder surgery.     

The use of bilateral mammary artery in myocardial revascularization. The risk factors emergent from a multivariate analysis conducted on 474 patients

Between January 1989 and March 1997, 175 patients with traumatic shoulder dislocation were treated by conservative means (median age 41 years, 39 F, 136 M). In 78 patients (17 F, 61 M) a clinical and radiological follow up (median 50 months, range 6-106) could be obtained. Additionally, a diagnostic ultrasound was carried out in all patients. The recurrence rate in the group younger than 30 years (G < 30; n = 35) was 86%; in the group older than 30 years (G > 30; n = 43) it was 21% (P < 0.05). Persisting neurological deficits were found in 6 patients (8%). According to the Rowe score, 16 patients (46%) of the G < 30 achieved excellent or good results, in the G > 30, 29 patients (67%). In 17% of cases, a glenohumeral arthrosis was diagnosed be radiological means. 18% had radiological signs of a previous fracture of the greater tuberosity. Hill-Sachs lesions were identified in 19% of cases. Rotator cuff tears were diagnosed in 9% by ultrasound. No relationship between the duration of immobilization and the recurrence rate was found (P = 0.95). The recurrence rate following primary shoulder dislocation depends primarily on the patients' age.     

Long-term results of the Latarjet procedure for the treatment of anterior instability of the shoulder

We performed ninety-five consecutive Latarjet procedures for the treatment of recurrent anterior instability of the shoulder between 1969 and 1983. In 1993, we retrospectively reviewed the clinical and radiographic results that were available for fifty-six patients (fifty-eight shoulders) who had been followed for an average of 143 years (range, ten to twenty-three years). The purpose of the study was to determine the prevalence of glenohumeral osteoarthrosis and the factors related to its development after the Latarjet procedure. The procedure was performed for the treatment of recurrent anterior dislocation in fifty shoulders and painful recurrent anterior subluxation in eight. All patients had a radiographic evaluation (three anteroposterior radiographs, with the humerus in external, neutral, and internal rotation, and one lateral radiograph) before the operation and at the latest follow-up examination. At the time of the latest follow-up, none of the patients had recurrent dislocation, six patients had apprehension with regard to possible dislocation, and one had occasional subluxation. According to the system of Rowe et al., fifty-one (88 per cent) of the fifty-eight shoulders had an excellent or good result; five (9 per cent), a fair result; and two (3 per cent), a poor result. Twenty-two shoulders had no glenohumeral osteoarthrosis. Thirty-four shoulders had centered glenohumeral osteoarthrosis (the humeral head remained in front of the center of the glenoid cavity), which was grade 1 in twenty-five shoulders, grade 2 in four, grade 3 in three, and grade 4 in two, and two shoulders had grade-4 eccentric glenohumeral osteoarthrosis (the humeral head was more proximal than normal in relation to the center of the glenoid cavity). Postoperative grade-1 glenohumeral osteoarthrosis, unlike the higher grades, had no effect on the function of the shoulder.     

Neuroimaging in the high-risk infant: relationship to outcome

PURPOSE OF THE STUDY: Dislocation following total hip arthroplasty (THA) continues to be a problem. An innovative treatment is described with the intermediate Bousquet's prosthesis. This study reported 13 cases and demonstrates its high reliability despite the origins of the dislocation. Recurrent dislocation following initial dislocation, occurs in between 25 to 60 per cent of the cases reported in the literature. The main cause is a malpositioned prosthetic component and especially a retroverted acetabulum. The other reasons for dislocation were: trochanteric non-union, bone or cement impingement, previous surgery, age and neurologic disorder. In every case the instability of the hip may be caused or increased by muscular insufficiency. Various methods are described to control recurrent dislocation: repositioning the component, posterior acetabular wall component, trochanteric advancement, retentive acetabular component, bracing. When the cause is clear and isolated, the rate of success may be 70-80 per cent. This study examines the results of a revision procedure with the intermediate Bousquet's prosthesis. MATERIAL AND METHODS: 13 recurrent dislocations were treated with the intermediate Bousquet's prosthesis. There were 10 women and 3 men with an average age at operation of 73 years. The main cause in 7 cases was an abductor insufficiency including 4 trochanteric non unions. The other causes were 6 component malpositions, 7 previous surgery, 1 impingement. The average delay between the first dislocation and revision was one year. The Bousquet's acetabular component is an steel cup covered with alumina, impacted without cement. The polyethylene component is free in the cup and retentive on the femoral head. The femoral positioning was not modified. RESULTS: The revision did not correct all of the causes of luxation, however we noted only one case of dislocation and no recurrent dislocations. DISCUSSION: At last follow-up, all recurrent dislocations were controlled. Nevertheless, there remained 7 abductor insufficiencies and 4 femoral malpositionings. In the literature the rate of success depends on the cause. The main difficulty is the treatment of joint laxity. Some authors propose trochanteric advancement, a larger head, a posterior wall acetabular component, retentive acetabular component. Success is not uniform. The Bousquet's acetabular component supports joint laxity and femoral malpositioning. This allows to keep the same original femoral component when the risk is too high for a cemented prosthesis or impossible for a non cemented prosthesis. CONCLUSION: This treatment of the recurrent dislocation is reliable with a short and simple operation.     

Use of the suture anchor in open Bankart reconstruction. A follow-up report

We previously reported early results of a new technique using a suture anchor to perform a modified Bankart reconstruction. That study included patients from two medical centers and had an average followup of only 1 year. This report includes patients from a single center with followup extended to a mean of 42 months (range, 33 to 61). Between April 1988 and August 1991, 53 patients with recurrent anterior glenohumeral instability underwent modified Bankart reconstruction with the use of a suture anchor. Thirty-two patients met inclusion criteria (identifiable Bankart lesion, open repair with suture anchors, and minimum followup of 2 years); 4 patients were lost to followup. There have been no complications as a result of this technique. Ninety-three percent of the patients in the study had objectively excellent or good results. There were 2 failures with recurrent anterior dislocation. The use of a suture anchor can simplify the Bankart reconstruction. At average followup of 3 years, 26 patients have returned to presurgery activity levels without recurrent dislocation or subluxation. However, careful attention to anchor placement at the junction of articular cartilage and the glenoid neck is necessary to avoid technical failure.     

Endomyocardial biopsy in heterotopic heart transplant recipients via the femoral vein

The treatment of recurrent anterior shoulder dislocation with the rotational humeral osteotomie by Weber showed best results in the follow-up of 53 operations when combined with a shortening of the capsule and the musculus subscapularis. Rotational humeral osteotomie alone showed in 20% redislocations. The rate of redislocation could significantly be reduced by additional shortening of the soft tissue.     

Antitumor effect of DT-5461, a lipid A derivative, against human tumor xenografts is mediated by intratumoral production of tumor necrosis factor and affected by host immunosuppressive factors in nude mice

PURPOSE OF THE STUDY: The purpose of this report was to study the repercussions of rotator cuff condition on unconstrained shoulder arthroplasty results. METHODS: Between 1986 and 1993, 40 unconstrained shoulder prostheses were performed (24 total and 16 hemiarthroplasties). At the time of the operation, rotator cuff condition was reported to be normal in 15 shoulders, atrophic in 10, scarred in 3, torn in 12. Clinical and radiographical results were analyzed and supplemented with a rotator cuff echography. Postoperative follow-up averaged 42.25 months (12 to 97 months). RESULTS: When the rotator cuff was intact at the time of operation, clinical results were the best at the time of review. Constant score, overall mobility, forward elevation, external rotation with the elbow along the side were better for intact than for atrophic, scarred or torn rotator cuffs (p < 0.01). Ruptures repaired by local tissue transfer or trapezo deltoidal flap substitution (3 cases) gave satisfactory results, whereas two dacron cuff prostheses failed. In the non repaired ruptures (7 cases), arthroplasty resulted in 3/4 fair or poor results. At the time of review, the total incidence of postoperative rotator cuff tears was high (12 cases), functional repercussions were variable. Among the 15 rotator cuff tears observed at the time of the review, the long head of the biceps was present and in place in 9 cases and ruptured in 6 cases. In these latter cases, Constant score (p < 0.01), the forward elevation (p < 0.01), external rotation with elbow along side (p < 0.05) and overall mobility (p < 0.05) were worse; moreover, humeral head superior migration was greater (p < 0.01). DISCUSSION: Our study confirms the superiority of clinical results when the cuff was intact at the time of the operation. The repair of rotator cuff tears seems to be justified. When the rupture has not been repaired, clinical results were fair or poor in 5 cases out of 7, the initial rupture spread to the other tendons in 3 cases out of 7. Secondary ruptures were frequent (12 cases). No predictive factor was identified, but an overlapping of the greater tuberosity appears to be detrimental. Among rotator cuff tears present at the time of review, long head of the biceps rupture jeopardized clinical results and was associated with a proximal migration of the humeral head which was significantly more severe than with an intact non displaced long head of the biceps. CONCLUSION: During unconstrained shoulder prosthesis implantation, it is therefore recommend to systematically repair any associated rotator cuff rupture, in order to avoid any greater tuberosity overlap relative to the prosthetic head and to preserve the long head of the biceps tendon which limits upward migration of the humeral head and improves prosthetic kinetics.     

Treatment of recurrent anterior dislocation of the shoulder with pectoralis minor muscle-bone flap]

We treated 10 patients with recurrent anterior dislocation of the shoulder by transplantation of pectoralis minor muscle-bone flap transplanted to the upper part of the humerus. All patients were followed-up for an average 31 months and no recurrent was found. We consider that the muscle beily exerts a protective effect like a barrier on the weak anterio inferior region of the shoulder and increases the force for extending the shoulder and lifting the arm. The operation is based on biomechanics. Meanwhile, suturing the laxative joint capsule and repairing the weak anteroinfeior region of the shoulder is more beneficial to prevent from redislocation of the humerus head.     

Blood selenium in healthy persons and individuals with malignant diseases

INTRODUCTION: Dislocation of the long head of biceps tendon, including subluxation to displacement out of the bicipital groove, is an uncommon cause of shoulder pain. We investigated the role of US in the diagnosis of this condition. MATERIAL AND METHODS: We examined eight patients with dislocation of the long head of biceps tendon: seven had a displaced, and one a subluxated tendon. All patients had early radiographic and US studies of the shoulder; then, three (37%) were submitted to CT-arthrography and two (25%) to MRI. US was performed at 7.5-13 MHz frequency, CT-arthrography with a volumetric acquisition technique and MRI with a surface coil at 1.5 T. Three patients with tendon dislocation had surgical confirmation of the diagnosis. RESULTS: Dislocation of the long head of biceps tendon was always diagnosed with US in all our eight patients; CT-arthrography and MRI confirmed the US findings. In the patient with subluxation of the long head of biceps tendon, US showed the tendon displaced over the lesser tuberosity whereas, in the 7 cases of complete luxations, the groove was empty and the tendon displaced medially. At CT-arthrography, the tendon was well outlined by contrast medium within its sheath. In dislocations, it was close to the anterior aspect of the humeral head. In two cases of dislocation, MRI showed both the empty bicipital sulcus and the medial tendon displacement. The subscapularis tendon tear was always associated with tendon dislocation; a supraspinatus tendon tear was observed in 6 cases. CONCLUSIONS: When imaging a painful shoulder, we should investigate the integrity and course of the long head of biceps tendon. In clinical practice, dislocation of this tendon can be reliably diagnosed with US. CT-arthrography and MRI should be used only to supplement inconclusive US studies.     

Outcome of en bloc and single kidney transplantation from very young cadaveric donors

BACKGROUND: The optimal use of very young cadaveric kidneys (from donors less than 4 years old) remains controversial. High rates of technical complications and poor functional results compared with adult donor kidneys have been reported. The use of en bloc transplantation to overcome these problems has been advocated, although en bloc transplantation halves the number of potential transplants from very young donors. METHODS: We studied the technical and functional results of 91 transplants from very young donors performed at our institution between 1984 and 1995. This included 59 single and 22 en bloc procedures involving first transplants and 7 single and 3 en bloc procedures involving retransplantation. Individual surgeon preference dictated the use of either the single or en bloc technique. Kidneys smaller than 6 cm tended to be transplanted en bloc, and lighter patients were generally given preference for receiving pediatric kidneys. Patients received sequential cyclosporine-based quadruple immunosuppression. RESULTS: En bloc kidneys had a 1-year and 5-year graft survival of 82% and 70%, respectively. Single kidneys had a 1-year and 5-year graft survival of 64% and 40%. Kidneys that avoided acute rejection episodes and that were transplanted into heavier or male recipients had better long-term survival. Kidneys from donors less than 2 years old did poorly whether transplanted en bloc or singly. Better HLA matching improved short-term, but not long-term, graft survival, whereas cold ischemic time did not have statistically significant association with differences in graft survival. Eleven percent of the transplants had ureteral leaks, but only one kidney was lost. Ten transplants had vascular complications leading to graft loss, whereas two episodes of arterial stenosis were successfully treated with percutaneous angioplasty. CONCLUSIONS: En bloc transplantation optimizes the outcome of transplantation with very young kidneys. We recommend induction therapy and cyclosporine immunosuppression with cyclosporine levels similar to adult target levels to minimize rejection episodes and, thus, improve outcome. These kidneys should be distributed nationally, because better HLA matching is associated with improved short-term graft survival. Our high ureteral leak rate indicates that alternatives to unstented ureteroneocystostomy should be considered.