Free gracilis muscle transfer with ulnar nerve neurotization for elbow flexion restoration.

PURPOSE: In upper and chronic brachial plexus injuries for which neurological surgery is not a good treatment option, one possibility for gaining elbow flexion is free functional muscle transfer. The primary aim of our study was to evaluate the elbow flexion gain achieved by free gracilis muscle transfer with partial ulnar nerve neurotization. METHODS: This surgery was performed in 21 patients with upper and chronic (> 12 months) brachial plexus injuries. The level of injury, patient age, the time between trauma and surgery, the affected side, and the aetiology of the lesion were recorded. The primary outcome evaluated was elbow flexion muscle strength, which was measured using the British Medical Research Council (BMRC) scale, in patients with a minimum follow-up period of 12 months. The criterion used to classify elbow flexion as good was a grade of M4 or higher. RESULTS: An M4 elbow flexion strength gain was observed in 61.9% of the patients. A gain of M2 or higher was observed in 95.2% of the patients. The mean range of active motion was 77° (range 10 minimum-110 maximum). CONCLUSION: In patients with upper and chronic brachial plexus injuries, free gracilis muscle transfer with ulnar nerve neurotization yields a satisfactory gain in elbow flexion strength and is therefore a good treatment option.

Influence of age and sex on the blood biochemical constituent values of broiler breeders during the egg-laying stage.

This study aimed to evaluate the influence of age and sex on the blood biochemical constituents of broiler breeders during the egg production stage. The analysis was performed in an industrial broiler breeder farm, and blood samples were collected from males and females at five different ages. Biochemical elements analysed in each serum sample were total proteins, albumin, globulins, uric acid, total cholesterol and triglycerides, alanine aminotransferase (ALT) and aspartate aminotransferase (AST), gamma-glutamyltransferase (GGT), creatine kinase (CK), alkaline phosphatase (PAL), calcium and phosphorus, beside the glycaemic status. At most ages, females had higher values of total proteins, albumin, globulins, triglycerides, cholesterol, glucose, calcium, phosphorus, Ca/P (calcium and phosphorus) ratio and gamma-glutamyltransferase (GGT). The values of uric acid, aspartate aminotransferase (AST), creatine kinase (CK) and alkaline phosphatase (PAL) were higher in males. The lowest protein values were found at 28 and 60 weeks old. The mean albumin values were significantly higher at 44 and 52 weeks old in males and females. A trend of increasing globulin values with increasing age up to 52 weeks old was observed. Although calcium and phosphorus did not vary according to age, the Ca/P ratio was lowest at 36 weeks old. Comparing the means of both sexes, the AST and GGT values were significantly higher in 60-week-old birds. The highest serum levels of CK occurred at 28 and 52 weeks old. The physiological levels of serum biomarkers presented in this work are important for evaluating productivity performance, welfare and disease indication in breeding flocks.

Comparison between donor nerves to motorize the free functional gracilis muscle transfer for elbow flexion: Retrospective study of 38 consecutive cases in traumatic adult brachial plexus injuries.

PURPOSE: Elbow flexion deficit is a frequent problem in traumatic brachial plexus injuries and reestablishment of this function is the primary treatment goal. When management is delayed, or the initial acute approach fails, free functional transfer of the gracilis muscle for elbow flexion is the treatment of choice. In this report, the authors present the results of a comparison study on different donor nerves (spinal accessory and ulnar) in elbow flexion reconstruction with gracilis flap for traumatic adult brachial plexus injuries. METHODS: Retrospective analysis of patients with both total or partial traumatic brachial plexus injuries was carried out. Of the 38 patients enrolled, 37 were male (97.4%) with a mean age of 28.3 years. The mean follow-up period was 25 months. Postoperative function of the gracilis muscle flap was recorded and patients were divided into two groups according to donor nerve: spinal accessory nerve (SAN) (18 cases), and motor fascicles of the ulnar (ULNAR) (20 cases). RESULTS: Twenty-six cases obtained elbow flexion strength M3 or M4 (68.4%): 0 M0 (0.0%), 4 M1 (10.5%), 8 M2 (21.1%), 9 M3 (23.7%) and 17 M4 (44.7%). The mean interval to first recorded M3 muscular strength was 12.4 months. Functional elbow flexion strength (≥ M3) had the following distribution: SAN 83.3% (15/18) and ULNAR 55.0% (11/20) (p = .086). CONCLUSION: No statistical difference for final muscle strength was found between donor nerve groups.

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.

Reduction of Morbidity With a Reverse-Flow Sural Flap: A Two-Stage Technique.

The reverse sural flap has often been used for cutaneous coverage of the distal region of the leg and ankle. When the flap is performed in 2 stages, the vascular pedicle is exteriorized and later resected. Our goal was to assess the reverse sural flap performed in 2 stages regarding its viability and low morbidity along the flap-donor area. Eleven patients with cutaneous coverage loss found in the area between the distal third of the leg and ankle underwent cutaneous coverage surgery with a reverse-flow sural flap with an exteriorized pedicle, without violation of the skin between the base of the flap pedicle to the margin of the wound. After a minimum period of 15 days with flap autonomy, the pedicle was resected. The flap dimensions, its viability before and after the pedicle ligature, and the distance from the intact skin between the flap base and the margin of the wound were evaluated. Any losses were measured as a percentage of the total flap size. The respective length and width of the flap were a mean average of 7.45 cm × 4.18 cm. All the flaps survived. Partial loss of the flap occurred in 3 patients, ranging from 20% to 30%. The mean average distance of the intact skin between the pedicle base and the margin of the wound was 5.59 (range 4 to 8) cm. Our results showed that the 2-stage reverse sural flap ensures good flap survival and low morbidity.

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.

Safety and feasibility of same-day discharge of patients with hepatocellular carcinoma treated with transarterial chemoembolization with drug-eluting beads in a liver transplantation program.

PURPOSE: To evaluate the safety and feasibility of same-day discharge of patients with hepatocellular carcinoma (HCC) treated with transarterial chemoembolization with the use of drug-eluting beads (DEBs) and elucidate the prognostic factors for hospital admission. MATERIALS AND METHODS: A total of 266 DEB chemoembolization procedures in 154 consecutive patients listed for liver transplantation or identified for potential HCC downstaging were performed with the outpatient treatment protocol. Endpoints evaluated were admission to the hospital after the procedure for clinical reasons, readmission to the hospital within 1 month of the procedure, and procedure-related morbidity and mortality. In the evaluation of prognostic factors for admission, parameters of patients discharged the same day were compared with those of patients admitted overnight. RESULTS: Same-day discharge was feasible in 238 cases (89.5%), and 28 (10.5%) needed overnight admission. The main reason for overnight admission was postprocedural abdominal pain (n = 23; 67.8%). The procedure-related complication rate was 2.6%, and there were no readmissions or deaths during the first 30 days after chemoembolization. Chemoembolization performed for downstaging and the use of more than one vial of embolic agent were associated with an increased need for overnight admission (P = .012 and P = .007, respectively). CONCLUSIONS: Same-day discharge of patients with HCC treated with DEB chemoembolization in a liver transplantation program is safe and feasible, with low complication and admission rates. Treatment for HCC downstaging and the use of more than one vial of embolic agent were associated with an increased need for hospital admission.

Functional Free Muscle Transfer for Reconstruction of Traumatic Adult Brachial Plexus Injuries.

Traumatic brachial plexus injury is the most common indication for functional free muscle transfer, and elbow flexion recovery is the functional target, followed by shoulder stability and hand reanimation. In this article, we provide a literature review of functional free muscle transfer (FFMT) for adult traumatic brachial plexus injuries and the surgical technical recommendations to achieve the best functional results with FFMT for adult traumatic brachial plexus injuries.

Transfer of Second Toe for the Treatment of Traumatic Thumb Amputation in a Four-year-old Child: A Case Report.

Microsurgical toe transfer for thumb reconstruction is a challenging procedure, considering the technical skills necessary to perform it, as well as the difficult postoperative evaluation of esthetical and functional aspects. The present is the report of the case of a 3-year-old child who suffered a traumatic thumb amputation. Thumb reconstruction was performed through microsurgical toe transfer months after replantation failure. Subjective and objective outcome assessments were performed five years after the procedure. The functional outcome was evaluated through the Childhood Health Assessment Questionnaire (CHAQ) and the Jebsen-Taylor Hand Function Test (JTHFT). The Jamar dynamometer (Sammons Preston, Bolingbrook, IL, US) and the Jamar Pinch Gauge (Sammons Preston) devices were used to assess the handgrip and pinch strength respectively. The Semmes-Weinstein monofilament and two-point discrimination tests were performed. The patient presented an excellent functional outcome, partial recovery of strength, complete sensory recovery, and minimal donor site morbidity. A radiographic evaluation was also performed, and it demonstrated the preservation of the epiphyseal plate and the growth potential of the transplanted toe. In all aspects, the data observed reinforce the benefits and indications of toe transfer for thumb reconstruction in children.