Thrombophilia and Preoperative Deep Venous Thrombosis and Their Effect on Free Flap Survival: A Scoping Review.

Background: A proper preoperative planning is essential to prevent flap failure. However, venous workup for flaps has not been commonly performed or utilized as a preoperative screening tool. A scoping review was conducted to explore preoperative venous system screening, including deep vein thrombosis diagnosis, and its effect on flap survival rate. This review identified existing gaps of knowledge and emphasized potential research areas for future studies. Methods: Two independent reviewers searched 3 electronic databases from inception to September 2020. Retrieved appropriate articles were selected systematically by title, abstract, and full review of the article. Studies were included if they enrolled patients who had thrombophilia or deep venous thrombosis (DVT) preoperatively and had undergone a free flap reconstruction. For eligible studies, the following information was extracted: basic demographics (sex, age, comorbidities), preoperative scans type, free flap type, clotting mode (causes), wound type, and flap survival. Results: Seventeen articles were found eligible for this review. Traumatic aetiology was found in 63 (33.6%) patients, while 124 (66.3%) patients had a non-traumatic aetiology. Preoperative screening for patients with non-traumatic aetiology was reported in 119 patients. In these patients, the flap survived in 107 (89.91%) patients. Four studies investigating patients with traumatic DVT aetiology, 60 patients (out of 63) had a preoperative computed tomography angiography or duplex. Those patients had 100% flap survival rates. Conclusion: Further investigations are required to identify venous thrombosis incidence in patients with non-traumatic thrombosis aetiology as this cohort of patients is at high risk of flap failure. Finally, the prognostic validity of available preoperative screening tools to identify high-risk patients should be assessed, such as imaging techniques, which would include venous duplex scanning, may prevent failure in free flap surgery.

Historique: Il est essentiel de procéder à une planification préopératoire appropriée pour prévenir l'échec du lambeau. Cependant, il n'est pas fréquent que le bilan veineux des lambeaux soit effectué ou utilisé comme outil de dépistage préopératoire. Les chercheurs ont réalisé une analyse exploratoire pour évaluer le dépistage du système veineux préopératoire, y compris un diagnostic de thrombose veineuse profonde et son effet sur le taux de survie des lambeaux. Cette analyse a permis de repérer les lacunes et de faire ressortir des domaines de recherche potentiels. Méthodologie: Deux analystes indépendants ont fait des recherches dans trois bases de données électroniques entre leur création et septembre 2020. Ils ont extrait systématiquement les articles appropriés en fonction de leur titre, de leur résumé et de leur analyse complète. Ils les ont conservés s'ils comprenaient des patients qui présentaient une thrombophilie ou une thrombose veineuse profonde avant l'opération et qui avaient subi une reconstruction par lambeau libre. Ils ont tiré l'information suivante des études admissibles: caractéristiques démographiques de base (sexe, âge, maladies associées), type d'imagerie préopératoire, type de lambeau libre, mode de coagulation (causes), type de plaie et survie du lambeau. Résultats: Les chercheurs ont trouvé 17 articles admissibles à l'analyse. Ils ont constaté une étiologie traumatique chez 63 patients (33,6 %), et une étiologie non traumatique chez 124 patients (66,3 %). Au total, 119 patients présentant une étiologie non traumatique ont été soumis à un dépistage préopératoire. Le lambeau a survécu chez 107 d'entre eux (89,91 %). Dans les quatre études sur les patients ayant une étiologie de thrombose veineuse profonde traumatique, 60 (sur 63) ont subi une angiographie tomographique ou un échodoppler duplex. Le taux de survie des lambeaux atteignait 100 % chez ces patients. Conclusion: D'autres explorations s'imposent pour déterminer l'incidence de thrombose veineuse chez les patients présentant une étiologie de thrombose non traumatique, car cette cohorte de patients est très vulnérable à un échec du lambeau. Enfin, il faudra évaluer la validité pronostique des outils de dépistage préopératoire visant à détecter les patients à haut risque, tels que les technologies d'imagerie, qui incluraient un échodoppler duplex, pour prévenir l'échec d'une opération à lambeau libre.

Ankle fractures in the elderly: an overlooked burden.

Ankle fractures in the elderly are a complex under-recognized burden which require a multidisciplinary approach to management. This article discusses the holistic approach required, including the up-to-date surgical management options and the areas for future development.

Modulating angiogenesis: more vs less.

The concept of manipulation of the vascular bed to either increase or decrease the number of blood vessels has attracted considerable interest. This review focuses on angiogenesis as a therapeutic target, particularly in the context of cancer and arthritis, as well as on promoting angiogenesis in cardiovascular disease and the healing of bone fractures. Although once touted almost as a panacea for treatment of tumors, as well as other diseases associated with angiogenesis, such as diabetic retinopathy or rheumatoid arthritis, it is now clear that such enthusiasm was somewhat premature. Similarly, some clinical trials of therapeutic angiogenesis for the management of cardiovascular disease have been disappointing. Nevertheless, this exciting field of research holds promise for more targeted therapies.

Comparison of the vascularity of fasciocutaneous tissue and muscle for coverage of open tibial fractures.

BACKGROUND: Early coverage with vascularized soft-tissue flaps has dramatically improved the outcome in open tibial fractures. However, the ideal tissue for covering open fractures remains controversial. Several clinical studies suggest that muscle is superior to fasciocutaneous tissue; this is attributed to the presumed higher vascularity of muscle, although experimental evidence is inconclusive. The authors' previously described novel murine fracture model, which allows exclusive comparison of both tissues, demonstrated enhanced healing beneath muscle. The present study was undertaken to compare the vascularity of muscle and fasciocutaneous tissues over the course of fracture healing. METHODS: Two experimental groups comprised mice with tibial fractures in contact with either muscle or fasciocutaneous tissues exclusively. Controls included a nontrauma group and those where soft tissues and periosteum were dissected but the tibia was not fractured. Animals were harvested between 3 and 28 days after fracture (n = 170 in total). The vascular density of the soft tissues was assessed using immunohistochemical techniques. RESULTS: Fasciocutaneous tissue was found to have a higher vascular density compared with muscle in contact with the fracture site at all time points (p < 0.0001, two-way analysis of variance), despite accelerated healing of fractures covered by muscle. CONCLUSIONS: The authors' data show that the more advanced healing of fractures covered by muscle compared with fasciocutaneous tissue is not related to the vascularity of the tissues, as the latter had a higher vascular density at all time points. Therefore, provided that a flap has sufficient vascularity to effectively reconstitute the soft-tissue envelope, other factors may be important in specifically promoting fracture healing.

Comparison of the healing of open tibial fractures covered with either muscle or fasciocutaneous tissue in a murine model.

The objective of this study was to compare the effects of soft tissue coverage by either muscle or fasciocutaneous tissue on the healing of open tibial fractures in a murine model. An open tibial fracture, stripped of periosteum with intramedullary fixation, was created in mice. Experimental groups were devised to allow exclusive comparison of either muscle alone or skin plus fascia in direct contact with healing bone. To exclusively assess the relative efficacy of muscle and fasciocutaneous tissue to promote healing of a fracture stripped of periosteum, a piece of sterile inert material (polytetrafluoroethylene) was positioned anteriorly, excluding skin and fascia (muscle group) or posteriorly, excluding muscle (fasciocutaneous group). Skeletal repair was assessed histologically and quantified by histomorphometry; quantitative peripheral computed tomography (pQCT) and mechanical testing using a four-point bending technique. This standardized, reproducible model allowed characterization of the morphology of open fracture healing. At 28 days postfracture, there was faster healing in the experimental muscle coverage group compared to skin and fascia alone. Furthermore, there was almost 50% more cortical bone content and a threefold stronger union beneath muscle compared to fasciocutaneous tissue (p < 0.05 by one-way ANOVA). Exclusive comparison of muscle and fasciocutaneous tissue in our novel murine model demonstrates that muscle is superior for the coverage of open tibial fractures for both the rate and quality of fracture healing.

From the cradle to the clinic: VEGF in developmental, physiological, and pathological angiogenesis.

Formation of new blood vessels, which is fundamental in embryonic development, occurs through a combination of angiogenesis and vasculogenesis. Angiogenesis also plays a vital role postnatally, especially in reparative processes such as wound and fracture healing. Some of these events, especially in fracture healing, recapitulate processes observed in developmental angiogenesis. However, dysregulated angiogenesis is well documented to underlie a number of pathological disorders, including rheumatoid arthritis (RA). The vascular endothelial growth factor (VEGF)/VEGF receptor system is the best characterized regulator of angiogenesis. VEGF is expressed in a range of cells in response to soluble mediators (such as cytokines and growth factors), cell-bound stimuli (such as CD40 ligand), and environmental factors (such as hypoxia). As a consequence, this molecule is vital in the modulation of physiological and pathological angiogenesis. This review will focus in particular on the role played by VEGF in embryogenesis and skeletal growth, in fracture healing (in which increased angiogenesis is likely to be beneficial in promoting union), and in RA (in which excessive angiogenesis is thought to play a significant role in disease pathogenesis). In the not-too-distant future, targeting VEGF may prove to be of benefit in the treatment of diseases associated with excessive or aberrant angiogenesis, such as malignancies and RA.