Histological Compatibility in Distal Neurotizations: A Systematic Review.

Considering the importance of defining the minimum number of axons between recipient and donor branches, that is, the definition of histological compatibility in distal neurotizations for the success of the procedure and the surgeon's freedom to choose individualized strategies for each patient, this systematic review was conducted to find out the most recent studies on the subject. The objective of this systematic review was to determine the importance of the number of axons and the relationship between axon counts in the donor and recipient nerves in the success of nerve transfer. A literature review was performed on five international databases: Web of Science, Scopus, Wiley (Cochrane Database), Embase, and PubMed. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed (2020 version), a guide designed to guide the elaboration of systematic literature reviews. One hundred and fifty-seven studies were found, and 23 were selected based on the eligibility criteria. The articles presented were conclusive in determining the importance of the number of axons in the success of nerve transfer. Still, the relationship between the number of axons in the donor and recipient nerves seems more relevant in the success of transfers and is not always explored by the authors. The review of the articles has provided compelling evidence that the number of axons is a critical determinant of the success of nerve transfer procedures. However, the relationship between the number of axons in the donor nerve and that in the recipient nerve appears to be even more crucial for successful transfers, a factor that is not always adequately explored by authors in the existing literature. Level of evidence : Level IV, therapeutic study.

Peri-operative risk factors for complications of free flaps in traumatic wounds - a cross-sectional study.

INTRODUCTION: Indication of free tissue transfer for limb reconstruction continues to grow, and despite the good results with this treatment option, complications can impair the functional results and cause a raise in health costs, with prolonged hospitalization. Therefore, peri-operative surgical information and comorbidities were described and analyzed, for identification of independent risk factors for complications of free flaps results for traumatic wounds. For our knowledge, intraoperative ischemia time of free flap was not previously studied for post-traumatic limb reconstruction, which could influence results, in these traumatic cases, with the highest rates of complications among microsurgical flap reconstructions. METHODS: From July 2014 to January 2017, all patients with free flaps for limb reconstruction were consecutively included. Data on personal medical history, intra-operative microsurgical procedure, and laboratory tests were collected and complications analyzed. Descriptive and inferential statistics were performed. RESULTS: Sixty-two free flaps for traumatic limb reconstruction in 60 patients were studied. We observed a higher rate of complications in patients who underwent surgery > seven days after the trauma, patients with obesity, when used recipient veins from the superficial system for drainage of the flap, and in those in whom the ischemia time of the free flap was higher in univariate analyzes. After logistic regression, the remaining independent risk factors for complications were ischemia time of free flap > two hours  and obesity. The presence of thrombocytosis was associated with partial flap loss. CONCLUSIONS: The independent risk factors for complications were ischemia time of free flap > two hours  and obesity.

A reinforcement of the sutured microvascular anastomosis with fibrin glue application: A retrospective comparative study with the standard conventional technique.

PURPOSE: Although a reasonable number of studies report satisfactory results with fibrin glue application in microvascular anastomosis since 1977, its utilization in the clinical setting has being scant in the literature. The aim of this study was to report the cumulated experience with the fibrin glue in free flaps over a period of 10 years, comparing the survival rate with the standard sutured anastomosis. PATIENTS AND METHODS: From August 2001 through November 2014, 83 consecutive free flaps were performed by a team of surgeons from two hospitals. About 56 flaps were performed in 56 patients using the fibrin glue augmented microvascular anastomosis and 27 flaps were performed in 27 patients using the conventional anastomosis technique. The decision on whether or not the fibrin glue should be used at the anastomoses was based on its availability and whose surgeon was performing the anastomoses. About approximately 60% of sutures stitches were used that would be used in a conventional anastomosis, when fibrin glue application was anticipated (ranging from 5 to 7 sutures in the arteries and 5 to 8 in the veins). RESULTS: The overall survival rate of the flaps performed with fibrin glue application was 92.85%. In one case, a revision of the venous anastomosis was required due to early flap congestion. Four cases (7.14%) had failure of the first free flap and two of them were submitted to another free flap without fibrin glue application. In the flaps performed with the conventional anastomosis technique the survival rate was 92.59%. This difference was not statistically significant (P = 0.97). CONCLUSION: The application of fibrin glue in microvascular anastomoses did not increase the rate of flap loss and had a potential to reduce the number of sutures required to complete an anastomosis by its sealing effect. © 2016 Wiley Periodicals, Inc. Microsurgery 37:218-221, 2017.

Intercostal nerve transfer to the biceps motor branch in complete traumatic brachial plexus injuries.

The purpose of this report is to critically evaluate our results of two intercostal nerve transfers directly to the biceps motor branch in complete traumatic brachial plexus injuries. From January 2007 to November 2012, 19 patients were submitted to this type of surgery, but only 15 of them had a follow-up for ≥2 years and were included in this report. The mean interval from trauma to surgery was 6.88 months (ranging from 3 to 9 months). Two intercostals nerves were dissected and transferred directly to the biceps motor branch. The mean follow-up was 38.06 months (ranging from 24 to 62 months). Ten patients (66.6%) recovered an elbow flexion strength ≥M3. Four of them (26.66%) recovered a stronger elbow flexion ≥M4. One patient (6.25%) recovered an M2 elbow flexion and four patients (26.66%) did not regain any movement. We concluded that two intercostal nerve transfers to the biceps motor branch is a procedure with moderate results regarding elbow flexion recovery, but it is still one of the few options available in complete brachial plexus injuries, especially in five roots avulsion scenario.

Median nerve fascicle transfer versus ulnar nerve fascicle transfer to the biceps motor branch in C5-C6 and C5-C7 brachial plexus injuries: nonrandomized prospective study of 23 consecutive patients.

The purpose of this study was to observe whether the results of the median nerve fascicle transfer to the biceps are equivalent to the classical ulnar nerve fascicle transfer, in terms of elbow flexion strength and donor nerve morbidity. Twenty-five consecutive patients were operated between March 2007 and July 2013. The patients were divided into two groups. In Group 1 (n = 8), the patients received an ulnar nerve fascicle transfer to the biceps motor branch. In Group 2 (n = 15), the patients received a median nerve fascicle transfer to the biceps motor branch. Two patients with follow-up less than six months were excluded. Both groups were similar regarding age (P = 0.070), interval of injury (P = 0.185), and follow-up period (P = 0.477). Elbow flexion against gravity was achieved in 7 of 8 (87.5%) patients in Group 1, versus 14 of 15 (93.3%) patients in Group 2 (P = 1.000). The level of injury (C5-C6 or C5-C7) did not affect anti-gravity elbow flexion recovery in both the groups (P = 1.000). It was concluded that the median nerve fascicle transfer to the biceps is as good as the ulnar nerve fascicle transfer, even in C5-C7 injuries.

REPLANTATION OF THE THUMB OR REVISION OF AMPUTATION: AN EPIDEMIOLOGICAL STUDY.

OBJETIVE: This article presents a retrospective cohort study analyzing patients from IOT-FMUSP who underwent replantation or revision amputation procedures for traumatic thumb amputation between 2013 and 2020. METHODS: The study included 40 patients in the replanted group and 41 patients in the amputed group. The patients were divided according to the level of amputation and their medical records were analyzed. RESULTS: A total of 81 patients with digital amputation were analyzed, consisting of 79 males and 2 females, with mean ages of 43 and 49 for the amputed and replanted groups, respectively. According to the Biemer classification, 28.4% had proximal amputation, while 71.6% had distal amputation. The most common occupation was bricklayer (19.75%), and 80.24% were manual workers. Of the patients, 65% returned to their previous work, with 77.77% of them having amputation on their non-dominant hand, mostly caused by circular saw accidents (77.77%). The replantation success rate was 78%, with an average ischemia time of 9 hours and door-to-room time of 2 hours. CONCLUSION: the study findings revealed that traumatic thumb amputation predominantly affects working-age males with a low education level and the success rate of replantation was high in this ischemia time and door-to-room conditions. Level of Evidence II, Retrospective study.

OBJETIVO: Este artigo consiste em um corte retrospectivo que analisou vítimas de amputação traumática do polegar submetidas a reimplante ou procedimentos de regularização da amputação no Instituto de Ortopedia e Traumatologia do Hospital das Clínicas da Faculdade de Medica da Universidade de São Paulo (IOT-FMUSP). Métodos: Foram analisados 40 pacientes reimplantados e 41 pacientes regularizados, que foram separados conforme o nível da amputação e, após, tiveram seus prontuários médicos analisados. RESULTADOS: Foram analisados 81 pacientes com amputação digital (79 homens e 2 mulheres), com idade média de 43 anos e 49 anos (Grupo Amputado e Grupo Reimplante, respectivamente) e 28,4% deles tinham amputação proximal, de acordo com a classificação de Biemer, enquanto 71,6% tinham amputação distal. A ocupação mais comum foi a de pedreiro (19,75%), mas 80,24% eram trabalhadores manuais. 65% dos pacientes retornaram ao trabalho anterior. 77,77% dos pacientes afetaram a mão não dominante, e a serra circular causou 77,77% das amputações. A taxa de sucesso para reimplantes foi de 78%. O tempo de isquemia foi de 9 horas e o tempo de porta-quarto foi de 2 horas. Conclusão: O estudo revelou que as taxas de reimplante foram altas nas condições de isquemia e tempo porta-sala, e a maioria dos pacientes vítimas de amputação traumática do polegar são homens em idade de trabalho e com baixa escolaridade. Nível de Evidência II, Estudo retrospectivo.

Microsurgical Reconstruction in an Orthopedic Hospital: Indications and Outcomes in Adults.

Objective Advances in reconstructive microsurgery in orthopedic surgery provided better functional and aesthetic results and avoided many indications for amputation. In high-volume trauma and orthopedic hospitals, microsurgical reconstruction is essential to reduce costs and complications for these complex orthopedic defects. We describe a microsurgical approach to traumatic wounds, tumor resection, bone defects, and free muscle transfer, performed by an orthopedic microsurgery unit. The objective of the present study was to evaluate predictor factors for outcomes of microsurgical flaps for limb reconstruction, and to provide a descriptive analysis of microsurgical flaps for orthopedic indications. Methods Cross-sectional prospective study that included all consecutive cases of microsurgical flaps for orthopedic indications from 2014 to 2020. Data were collected from personal medical history, intraoperative microsurgical procedure, and laboratory blood tests. Complications and free-flap outcomes were studied in a descriptive and statistical analysis. Results We evaluated 171 flaps in 168 patients; the indications were traumatic in 66% of the patients. Type III complications of the Clavien-Dindo Classification were observed in 51 flaps. The overall success rate of the microsurgical flaps was 88.3%. In the multivariate analysis, the risk factors for complications were ischemia time ≥ 2 hours ( p = 0.032) and obesity ( p = 0.007). Partial flap loss was more common in patients with thrombocytosis in the preoperative platelet count ( p = 0.001). Conclusion The independent risk factors for complications of microsurgical flaps for limb reconstruction are obesity and flap ischemia time ≥ 2 hours, and presence of thrombocytosis is a risk factor for partial flap loss.

Comparative Analysis of the Treatment of Skin Lesions of the Lower Limbs with Sural Flap versus Propeller Flap.

Objective The objective of the present study was to prospectively compare the sural and propeller flaps for soft-tissues coverage of the lower extremity. The following variables were evaluated: incidence of complete or partial flap loss and donor area morbidity (primary closure versus skin graft). Methods Prospective and randomized analysis of data collected from all patients presenting with soft tissue defects of the lower third of the leg and heel treated with reverse sural or propeller flaps. Results Twenty-four patients aged between 4 and 60 years old were evaluated between 2011 and 2017. Complete coverage was obtained in 22 of the 24 patients (91.6%). Two flaps failed (8.4%). The sural flap, being the most popular option, continues to represent a safe and versatile alternative for skin defects of the lower third of the leg and heel region. Likewise, the propeller flap was a comparable option to treat these challenging defects. Conclusion Sural and propeller flaps are good options for soft tissues coverage of the lower extremity, with low complication rates (partial or total flap loss).

Orthoplastic reconstruction in children: are the risk factors similar to those observed in adults?

Free flaps in the pediatric population are less common and when indicated the expectations to avoid amputation are high. The objective of this study is to describe indications and results of free flaps for limb reconstruction. Patients undergoing microsurgical free flaps in an orthopedic hospital were consecutively included in this cross-sectional study, from 2014 to 2020. Data regarding personal medical history, intraoperative microsurgical procedure and laboratory tests were collected. Patients under 18 years of age were included. Complications and free flap outcomes were observed during follow-up. This study included 23 free flaps in 23 patients with orthoplastic reconstruction. The free flap was performed as a reconstructive elevator concept. The most common indications were skin or bone defects caused by trauma (nine patients), tumor (six patients) and congenital pseudarthrosis of the tibia (four patients). The most indicated flap was a vascularized fibular flap in 10 patients, followed by an anterolateral thigh flap in 5 patients. Complications were observed in five patients. In total 93% of patients with inferior limb reconstruction walked at the final evaluation. Among risk factors studied, cases had a higher incidence of complications (P = 0.03) when only the superficial venous system was used. Free flaps in children are well-tolerated and indications are restricted to precise indications to provide alternatives to amputations and improve patient's function. We observed an increase in the incidence of complications when only superficial veins were used for free flap outflow in children.

Structured evaluation of a comprehensive microsurgical training program.

OBJECTIVES: This study proposed a structured microsurgical training program and evaluated it with the assistance of a large sample of surgeons. METHODS: The practical course comprised 16 sessions of approximately 4 hours each. This included two sessions for suturing rubber gloves and two sessions for suturing arteries, veins, and nerves in chicken thighs. The other sessions were performed on the femoral vessels of rats: 5 sessions for end-to-end arterial anastomosis, 5 for end-to-end venous anastomosis, 1 for arterial grafting, and 1 for end-to-side anastomosis. We conducted a structured assessment of the microsurgical skills in each training session. RESULTS: In this study, 89 surgeons were evaluated. The mean scores for the different procedures were as follows: glove suturing, 33.3±0.59; chicken nerve end-to-end anastomosis, 40.3±0.49; chicken artery suturing, 40.9±0.36; chicken vein suturing, 42.3±0.36; graft interposition, 44.8±0.7; and end-to-side anastomosis, 43.7±0.63 (p<0.05 for all). The chicken thigh suturing scores were significantly higher than the rubber gloves suturing scores (p<0.01). There were no differences between scores of the rat artery and chicken thigh suturing procedures (p=0.24). The rat venous anastomosis scores were higher than the rat arterial anastomosis scores (p=0.02), as were graft interposition scores when compared with end-to-end venous anastomosis scores. The end-to-side anastomosis scores did not differ significantly from the grafting scores (p=0.85). The most common errors were inadequate knotting technique and suture rupture due to inadequate technique (both n=88 [98.9%]). CONCLUSION: We propose a 16-step, progressive microsurgical training program to learn the basic microsurgical techniques comprehensively and reliably. The program was evaluated in a large sample of trainees, and it demonstrated the adequacy of the training sequence and results.

Do technical components of microanastomoses influence the functional outcome of free gracilis muscle transfer for elbow flexion in traumatic brachial plexus injury?

INTRODUCTION: The traumatic lesions of the brachial plexus in adults are devastating injuries causing continuous severe functional impairment for both work and daily living activities. The restoration of elbow flexion is one of the most important movements for patient recovery to previous activities. Free gracilis muscle transfer has good outcomes for cases with late presentation or as a rescue surgery to regain elbow flexion, however, bad results are present in all cohorts with insufficient recovery of muscle strength for elbow flexion. A number of hypotheses can be postulate to explain the fair results observed in some cases of free gracilis muscle transfer for elbow flexion. Most studies in the current literature compare the choice of the donor nerve used in neurotization and nerve grafts. The aim of this study is to evaluate if technical components of microvascular anastomosis could influence the functional outcome of free functional muscle transfer for elbow flexion in adult patients with traumatic brachial plexus injury. MATERIAL AND METHODS: Included all adult patients with traumatic brachial plexus injury submitted to free functional gracilis muscle transfer for elbow flexion. The complications and functional results according to British Medical Research Council (BMRC) score were recorded. RESULTS: We assessed 26 patients with mean age of 32.8 years. The most common donor nerve for gracilis muscle was the accessory nerve in 18 patients. Eighteen patients presented with good result (M3/M4). The mean ischemia time was higher for patients with bad results (132 minutes) comparing with patients with good results (122 minutes). Patients with only one venous anastomosis had 41% of poor functional outcome compared with 22% of cases with two venous anastomoses. No statistically significant difference in the ischemia time of the cases with good or poor functional outcome was observed (p=0.657), as for the number of venous anastomoses (p=0.418). CONCLUSION: Our study observes that patients with only one venous anastomoses for drainage of free gracilis and those with longer intraoperative ischemia time had higher incidence of poor functional outcome of free gracilis muscle transfer for elbow flexion, but not statistically significant. LEVEL OF PROOF: II; prospective cross-sectional study.

GRACILIS MUSCLE TRANSFER TO ELBOW FLEXION IN BRACHIAL PLEXUS INJURIES.

OBJECTIVE: Brachial plexus injury can lead to significant functional deficit for the patient. Elbow flexion restoration is a priority in surgical treatment. Free functional muscle transfer is an option for early or late treatment failure. This study evaluated patient characteristics and elbow flexion muscle strength after gracilis functioning muscle transfer. METHODS: Medical records of 95 patients operated from 2003 to 2019 were analyzed and the following variables recorded: age, gender, nerve transfer used to motorize the gracilis muscle, time between trauma and surgery, age at surgery and elbow flexion strength after a minimum of 12 months following functioning muscle transfer. RESULTS: 87 patients were included, averaging 30 years of age (17 to 57 years). Fifty-five achieved elbow flexion muscle strength ≥ M3 (55/87, 65%), with a mean follow-up of 37 months. The nerves used for activation of the transferred gracilis were: 45 spinal accessory, 10 intercostal, 8 median n. fascicles, 22 ulnar n. fascicles and 2 phrenic nerves. CONCLUSION: Functional muscle transfer is a viable surgical procedure for elbow flexion in chronic traumatic brachial plexus injuries in adults. Level of Evidence II, Retrospective study.

OBJETIVO: A lesão do plexo braquial pode determinar sequelas para o paciente. A restituição da flexão do cotovelo é prioridade no tratamento cirúrgico. A transferência muscular funcional livre é opção na falha do tratamento precoce ou tardio. Este estudo avaliou características dos pacientes e força muscular de flexão do cotovelo após transferência muscular funcional livre. MÉTODOS: Prontuários de 95 pacientes, operados de 2003 a 2019, foram analisados e as seguintes variáveis registradas: idade, sexo, transferência nervosa utilizada para motorizar o músculo grácil, tempo entre o trauma e a cirurgia, idade na cirurgia, força de flexão do cotovelo após prazo mínimo de 12 meses da transferência muscular livre. RESULTADOS: 87 pacientes foram incluídos no estudo, com idade média de 30 anos (17 a 57 anos). Cinquenta e cinco pacientes obtiveram força muscular de flexão de cotovelo ≥ M3 (55/87, 65%), com tempo de seguimento médio pós-operatório de 37 meses. Os nervos utilizados para ativação do músculo grácil foram: 45 espinhais acessórios, 10 intercostais, oito fascículos do n. mediano, 22 fascículos do n. ulnar e dois frênicos. CONCLUSÃO: A transferência muscular funcional livre é um procedimento cirúrgico viável para flexão do cotovelo nas lesões traumáticas crônicas do plexo braquial no adulto. Nível de Evidência II, Estudo retrospectivo .

HYPOALBUMINEMIA IN MICROSURGICAL FLAPS OF THE MUSCULOSKELETAL APPARATUS.

OBJECTIVE: To evaluate if the levels of serum total protein and serum albumin are risk factors for surgical complications of free flap limb reconstruction. METHODS: Consecutive inclusion of all patients undergoing microsurgical flaps for limb reconstruction of complex injuries. We recorded epidemiological and laboratory data, including total proteins and fractions, for descriptive and analytical statistics. RESULTS: Our study analyzed one microsurgical flap from 35 patients that underwent complex injuries of the limbs. In total, 23 patients were men, and mean age of all patients was 35 years. After statistical analysis, no influence of pre or postoperative hypoalbuminemia was observed on the incidence of complications. Patients with hypoalbuminemia had a higher length of stay than those with normal albumin levels (p = 0.008). CONCLUSION: We observed that 71% of patients had hypoalbuminemia in early postoperative period and we suggest a nutritional support for patients requiring complex traumatic limb reconstruction. Hypoalbuminemia in patients subjected to microsurgical flaps for the treatment of complex traumatic limb injuries did not influence the complications that required surgical reintervention; However, it was associated with prolonged hospital stay. Level of Evidence II, Retrospective study.

OBJETIVO: Avaliar a influência dos níveis totais de proteína sérica e albumina como fator de risco para complicações de retalhos microcirúrgicos para reconstrução de membros. MÉTODOS: Inclusão consecutiva de todos os pacientes submetidos a retalhos microcirúrgicos para reconstrução de membros de lesões complexas. Foram registrados dados epidemiológicos e laboratoriais, incluindo proteínas e frações totais, para fins estatísticos descritivos e analíticos. RESULTADOS: 35 retalhos microcirúrgicos foram estudados em 35 pacientes com lesões complexas dos membros. A idade média dos pacientes foi de 35 anos, e 23 pacientes eram do sexo masculino. Após análise estatística, não foi observada influência da hipoalbuminemia pré ou pós-operatória na incidência de complicações. Pacientes com hipoalbuminemia permaneceram mais tempo hospitalizados do que aqueles com níveis normais de albumina (p = 0,008). CONCLUSÃO: Observamos 71% dos pacientes com hipoalbuminemia no início do período pós-operatório e sugerimos fornecer suporte nutricional para pacientes que necessitam de reconstrução traumática complexa dos membros. A presença de hipoalbuminemia em pacientes submetidos a retalhos microcirúrgicos para o tratamento de lesões traumáticas complexas nos membros não influenciou a presença de complicações que exigiam reintervenção cirúrgica, mas foi associada ao tempo de hospitalização prolongado. Nível de Evidência II, Estudo retrospectivo .

RANDOMIZED CONTROLLED TRIAL OF LIMITED FASCIOTOMY WITH INJECTION OF ADIPOSE GRAFT FOR DUPUYTREN'S DISEASE.

OBJECTIVE: Dupuytren's disease is a genetic disorder related to the proliferation of myofibroblasts. The pluripotent property of stem cells present in adipose tissue inhibits myofibroblast proliferation. Our study sought to evaluate the effect of stem cell-rich fat grafts in patients that underwent limited fasciotomy. METHODS: We studied 45 patients, in a single-blind, prospective, randomized clinical trial. All patients underwent limited fasciotomy. In one group, fat graft was injected. RESULTS: The total passive extension deficit results did not exhibit a significant difference. Fat group exhibited worse functional score at 6 months and 1 year postoperatively, such as higher complication rates (43%), when compared with control group (8%), and more pain at 6 weeks follow-up. CONCLUSION: Fat grafting associated with limited fasciotomy promotes worse functional results compared to conventional limited fasciotomy in the short term. However, long-term results and recurrence rates should be further assessed. Level of Evidence II, Prospective comparative study.

OBJETIVO: A moléstia de Dupuytren (MD) está associada a um distúrbio genético relacionado à proliferação de miofibroblastos. Acredita-se que a propriedade totipotente das células-tronco, presentes no tecido adiposo, seria capaz de inibir a formação dos miofibroblastos. O objetivo deste estudo foi avaliar o efeito do enxerto de gordura, rico em células-tronco, nos pacientes com MD, submetidos à fasciectomia parcial. MÉTODOS: Estudamos 45 pacientes, em um ensaio clínico prospectivo, randomizado e cego. No grupo-controle, era realizada apenas a fasciectomia parcial. No grupo com gordura, era realizada a fasciectomia parcial e injetado o enxerto de gordura. Os desfechos foram avaliados pelo Déficit de Extensão Passiva Total (DEPT) e escore funcional Brief Michigan Hand Questionnaire (BMHQ). RESULTADOS: Os resultados do déficit de extensão passiva total não apresentaram diferença significativa. O grupo com gordura apresentou pior escore funcional após 6 meses e 1 ano, como maiores taxas de complicações (43%) em comparação ao grupo controle (8%) e mais dor com 6 semanas de seguimento. CONCLUSÃO: O uso de enxerto de gordura associado à fasciectomia parcial promove piores resultados funcionais em comparação com a fasciectomia parcial convencional, a curto prazo. No entanto, a recidiva e os resultados a longo prazo devem ser avaliados. Nível de Evidência II, Estudo prospectivo comparativo.

Fibrin glue application in microvascular anastomosis: comparative study of two free flaps series.

BACKGROUND: Since the first experiments with fibrin glue application in microvascular anastomoses in 1977, several studies have reported its benefits on suture reduction and anastomosis decreased time. In spite of that, clinical experience has been limited to two neurosurgical and two replantation case series, all of them with good results. This study was conducted to evaluate the feasibility and the potential benefits of fibrin glue application in free flaps. METHODS: We performed 24 free flaps in 24 patients, from March 2005 to June 2006. Twenty were included in this study. They were divided into two groups according to the anastomosis technique: conventional group (n = 7 patients) and fibrin glue group (n = 13 patients). In the conventional group, the anastomosis was performed with interrupted sutures, whereas in the fibrin glue group, they were performed using less sutures and fibrin glue application. RESULTS: The application of fibrin glue cut by half the number of sutures required to complete the anastomoses. The mean arterial and venous anastomotic times in the conventional group were 27.2 and 24.0 minutes, respectively. In the fibrin glue group, they were 13.6 and 12.6 minutes, respectively. All these differences were statistically significant. There was no significant difference of ischemic time between two groups (P = 0.26). The survival rate of the flaps was similar in both groups: 84.6% (11 of 13) in the fibrin glue group and 85.7% (6 of 7) in the conventional group (P = 1.0). CONCLUSIONS: Fibrin glue application in free flaps was feasible and allowed us to complete the anastomoses with fewer sutures and less time. The survival rate of the flaps was not adversely affected by the fibrin glue.

IS OBESITY A RISK FACTOR FOR FREE VASCULARIZED FIBULAR FLAP COMPLICATIONS?

OBJECTIVE: Although our knowledge of bone reconstruction through microsurgery has increased, the vascularized fibula flap remains one of the most difficult free flap reconstructions to perform, and complications remain a challenge. The incidence of obesity is increasing and is associated with higher rates of free flap complications, which can lead to disastrous results. Since there is no consensus in literature regarding the influence of obesity on free flap outcomes in orthopedic surgeries that require segmental bone reconstruction, the objective of this study was to determine whether obesity increases the risk of post-operative complications (Clavien-Dindo grade III) after free vascularized fibular flap surgery. METHODS: A cohort study was conducted in all patients undergoing free flap limb reconstructions between July 2014 and July 2018. Patients were separated in two groups based on their body mass index (BMI): non-obese and obese (BMI≥30 kg/m2). RESULTS: Twenty-three free vascularized fibular flaps were studied. The indications included trauma in 13, tumors in 7, and congenital pseudarthrosis of the tibia in 3. Obese patients were associated with an increase in surgical complications (p=0.038). During the final follow-up, consolidation was obtained in 17 patients (74%). CONCLUSION: Obesity is a risk factor for complications in free vascularized fibular flap surgery. Level of evidence IV, original article.

OBJETIVO: Apesar do crescente conhecimento em reconstrução óssea por meio de microcirurgia, o retalho livre de fíbula vascularizada ainda permanece como uma das reconstruções mais difíceis de ser executada, e suas complicações ainda são um desafio. A incidência da obesidade tem aumentado e está associada a taxas mais altas de complicações de retalhos livres, o que pode levar a resultados desastrosos. Uma vez que não há consenso na literatura a respeito da influência da obesidade nos desfechos dos retalhos livre em cirurgias ortopédicas que requeiram reconstrução de segmento ósseo, o objetivo deste estudo foi avaliar se a obesidade aumenta o risco de complicações pós-operatórias (Clavien-Dindo grau III) após a cirurgia de retalho livre de fíbula vascularizada. MÉTODOS: Foi realizado um estudo de coorte transversal, com a inclusão de todos os pacientes submetidos à reconstrução de membros com retalho livre de fíbula vascularizada, entre julho de 2014 e julho de 2018. Os pacientes foram separados em dois grupos, com base no índice de massa corporal: não obesos e obesos (no índice de massa corporal ≥ 30 kg/m2). RESULTADOS: Foram analisados 23 retalhos livres de fíbula vascularizada. As indicações foram trauma em 13 casos, tumor em sete e pseudoartrose congênita da tíbia em três. Pacientes obesos foram associados a aumento nas complicações cirúrgicas (p = 0,038). No final do acompanhamento, a consolidação óssea foi obtida em 17 pacientes (74%). CONCLUSÃO: A obesidade é um fator de risco para complicações no retalho livre de fíbula vascularizada. Nível de evidência IV, artigo original.

Replantation of the thumb or revision of amputation: an epidemiological study / Reimplante de polegar ou revisão da amputação: um estudo epidemiológico

ABSTRACT Objetive: This article presents a retrospective cohort study analyzing patients from IOT-FMUSP who underwent replantation or revision amputation procedures for traumatic thumb amputation between 2013 and 2020. Methods: The study included 40 patients in the replanted group and 41 patients in the amputed group. The patients were divided according to the level of amputation and their medical records were analyzed. Results: A total of 81 patients with digital amputation were analyzed, consisting of 79 males and 2 females, with mean ages of 43 and 49 for the amputed and replanted groups, respectively. According to the Biemer classification, 28.4% had proximal amputation, while 71.6% had distal amputation. The most common occupation was bricklayer (19.75%), and 80.24% were manual workers. Of the patients, 65% returned to their previous work, with 77.77% of them having amputation on their non-dominant hand, mostly caused by circular saw accidents (77.77%). The replantation success rate was 78%, with an average ischemia time of 9 hours and door-to-room time of 2 hours. Conclusion: the study findings revealed that traumatic thumb amputation predominantly affects working-age males with a low education level and the success rate of replantation was high in this ischemia time and door-to-room conditions. Level of Evidence II, Retrospective study.

RESUMO Objetivo: Este artigo consiste em um corte retrospectivo que analisou vítimas de amputação traumática do polegar submetidas a reimplante ou procedimentos de regularização da amputação no Instituto de Ortopedia e Traumatologia do Hospital das Clínicas da Faculdade de Medica da Universidade de São Paulo (IOT-FMUSP). Métodos: Foram analisados 40 pacientes reimplantados e 41 pacientes regularizados, que foram separados conforme o nível da amputação e, após, tiveram seus prontuários médicos analisados. Resultados: Foram analisados 81 pacientes com amputação digital (79 homens e 2 mulheres), com idade média de 43 anos e 49 anos (Grupo Amputado e Grupo Reimplante, respectivamente) e 28,4% deles tinham amputação proximal, de acordo com a classificação de Biemer, enquanto 71,6% tinham amputação distal. A ocupação mais comum foi a de pedreiro (19,75%), mas 80,24% eram trabalhadores manuais. 65% dos pacientes retornaram ao trabalho anterior. 77,77% dos pacientes afetaram a mão não dominante, e a serra circular causou 77,77% das amputações. A taxa de sucesso para reimplantes foi de 78%. O tempo de isquemia foi de 9 horas e o tempo de porta-quarto foi de 2 horas. Conclusão: O estudo revelou que as taxas de reimplante foram altas nas condições de isquemia e tempo porta-sala, e a maioria dos pacientes vítimas de amputação traumática do polegar são homens em idade de trabalho e com baixa escolaridade. Nível de Evidência II, Estudo retrospectivo.

Microsurgical Reconstruction in an Orthopedic Hospital: Indications and Outcomes in Adults / Reconstrução microcirúrgica em um hospital ortopédico: Indicações e desfechos em adultos

Abstract Objective Advances in reconstructive microsurgery in orthopedic surgery provided better functional and aesthetic results and avoided many indications for amputation. In high-volume trauma and orthopedic hospitals, microsurgical reconstruction is essential to reduce costs and complications for these complex orthopedic defects. We describe a microsurgical approach to traumatic wounds, tumor resection, bone defects, and free muscle transfer, performed by an orthopedic microsurgery unit. The objective of the present study was to evaluate predictor factors for outcomes of microsurgical flaps for limb reconstruction, and to provide a descriptive analysis of microsurgical flaps for orthopedic indications. Methods Cross-sectional prospective study that included all consecutive cases of microsurgical flaps for orthopedic indications from 2014 to 2020. Data were collected from personal medical history, intraoperative microsurgical procedure, and laboratory blood tests. Complications and free-flap outcomes were studied in a descriptive and statistical analysis. Results We evaluated 171 flaps in 168 patients; the indications were traumatic in 66% of the patients. Type III complications of the Clavien-Dindo Classification were observed in 51 flaps. The overall success rate of the microsurgical flaps was 88.3%. In the multivariate analysis, the risk factors for complications were ischemia time ≥ 2 hours (p= 0.032) and obesity (p= 0.007). Partial flap loss was more common in patients with thrombocytosis in the preoperative platelet count (p= 0.001). Conclusion The independent risk factors for complications of microsurgical flaps for limb reconstruction are obesity and flap ischemia time ≥ 2 hours, and presence of thrombocytosis is a risk factor for partial flap loss.

Resumo Objetivo Os avanços da microcirurgia reconstrutiva na cirurgia ortopédica proporcionaram melhores resultados funcionais e estéticos, evitando as muitas indicações de amputação. Nos hospitais de ortopedia e traumatologia com um grande volume de atendimento, a reconstrução microcirúrgica é essencial, a fim de reduzir os custos e as complicações destes complexos defeitos ortopédicos. Descrevemos uma abordagem microcirúrgica para feridas traumáticas, ressecção tumoral, defeitos ósseos e transferência muscular livre realizada por uma unidade ortopédica especializada em microcirurgia. O objetivo do presente estudo é avaliar os fatores preditivos de resultados dos retalhos microcirúrgicos na reconstrução dos membros, fornecendo uma análise descritiva dos retalhos microcirúrgicos para as indicações ortopédicas. Métodos Estudo prospectivo transversal, que incluiu todos os casos consecutivos de retalhos microcirúrgicos com indicação ortopédica de 2014 a 2020. Foram coletados os dados do histórico clínico pessoal, procedimentos microcirúrgicos intraoperatórios e exames laboratoriais. As complicações e os desfechos de retalho livre foram estudados mediante uma análise descritiva e estatística. Resultados Avaliamos 171 retalhos em 168 pacientes. A indicação mais frequente para a realização de um retalho microcirúrgico foi a traumática, em 66% dos pacientes. Foram observadas complicações cirúrgicas em 51 retalhos, conforme a classificação de Clavien-Dindo do tipo III. A taxa de êxito global dos retalhos microcirúrgicos foi de 88,3%. Na análise multivariada, foram identificados como fatores de risco para complicações tempo de isquemia ≥ 2 horas (p= 0,032) e obesidade (p= 0,007). A perda parcial do retalho foi mais comum em pacientes com trombocitose, com contagem de plaquetas pré-operatória (p= 0,001). Conclusão Os fatores de risco independentes para complicações de retalhos microcirúrgicos para a reconstrução de membro são obesidade e tempo de isquemia do retalho ≥ 2 horas, e a presença de trombocitose como fator de risco para perda parcial do retalho.

Comparative Analysis of the Treatment of Skin Lesions of the Lower Limbs with Sural Flap versus Propeller Flap / Análise comparativa do tratamento de lesões cutâneas dos membros inferiores com retalho sural versus retalho propeller

Abstract Objective The objective of the present study was to prospectively compare the sural and propeller flaps for soft-tissues coverage of the lower extremity. The following variables were evaluated: incidence of complete or partial flap loss and donor area morbidity (primary closure versus skin graft). Methods Prospective and randomized analysis of data collected from all patients presenting with soft tissue defects of the lower third of the leg and heel treated with reverse sural or propeller flaps. Results Twenty-four patients aged between 4 and 60 years old were evaluated between 2011 and 2017. Complete coverage was obtained in 22 of the 24 patients (91.6%). Two flaps failed (8.4%). The sural flap, being the most popular option, continues to represent a safe and versatile alternative for skin defects of the lower third of the leg and heel region. Likewise, the propeller flap was a comparable option to treat these challenging defects. Conclusion Sural and propeller flaps are good options for soft tissues coverage of the lower extremity, with low complication rates (partial or total flap loss).

Resumo Objetivo O objetivo do presente estudo foi comparar prospectivamente os retalhos sural e propeller para cobertura de partes moles da extremidade inferior. Foram avaliadas as seguintes variáveis: incidência de perda total ou parcial do retalho e morbidade da área doadora (fechamento primário versus enxerto de pele). Métodos Análise prospectiva e randomizada de dados coletados de todos os pacientes apresentando defeitos em tecidos moles da extremidade distal da perna e do retropé submetidos aos retalhos em questão. Resultados Foram avaliados 24 pacientes com idades entre 4 e 60 anos, entre 2011 e 2017. Cobertura completa foi obtida em 22 dos 24 pacientes (91,6%) e observamos falha em 2 retalhos (8,4%). O retalho sural, sendo a opção mais popular, continua a representar uma alternativa segura e versátil para defeitos cutâneos do terço distal da perna e da região do calcanhar. O retalho propeller, da mesma maneira, mostrou-se uma opção comparável para o tratamento destas lesões desafiadoras. Conclusão Os retalhos sural e propeller são boas opções para a cobertura de partes moles da extremidade inferior, demostrando baixas taxas de complicações como perda parcial ou total do retalho.

COMPARATIVE STUDY OF MICROANASTOMOSIS WITH DISTINCT 10-0 NYLON SUTURES IN RATS.

OBJECTIVE: The aim of this study is to compare micro-sutures commonly used in our midst. METHODS: In this double-blind study, 30 Wistar rats were operated randomly divided into three groups matched according to the suture used (Nylon 10-0, 75micron, brands Microsuture((r)), Polysuture((r)) and Ethicon((r))). We analyzed the number of surgical nodes required, bleeding, surgical time and histological evaluation. RESULTS: There was no significant difference between the amount of stitches of arterial suture per anastomosis. Surgical time was longer in Microsuture((r)) group as compared to Polysuture((r)) (p ≤ 0.05). Bleeding in Microsuture((r)) group was higher when compared to the others (p <0.01). In the histological analysis, the Microsuture((r)) group showed a greater tendency to develop fibrosis and aneurysm in surgical site than the others (p <0.01 and p≤0,05, respectively). Similarly, the Ethicon((r)) group showed less tendency to myointimal proliferation than the rest. (p = 0.025). CONCLUSION: The results confirm the relevance of the choice of surgical thread as an independent determining factor for the success of the procedure, besides serving as a rational subsidy for a better cost-benefit analysis. Level of Evidence I, Experimental Study, Controlled Animal Study.