Management of a large traumatic hemipelvectomy defect following a truck crush injury: a case report.

This case report explores the management of a traumatic hemipelvectomy-a rare and devastating injury characterized by a high mortality rate. The patient, a 12-year-old male, suffered right lower extremity amputation and right hemipelvectomy due to a deglov-ing injury from a non-vehicle-related accident at another institution. Initially, an urgent reconstruction of the right pelvic region and suprapubic tissue defects was performed using a posterior-based fasciocutaneous flap. Following this, the patient was transferred to the pediatric intensive care unit at our hospital with a suspected diagnosis of necrotizing fasciitis. Treatment included broad spectrum antibiotics and multiple debridements to avert the onset of sepsis. Eventually, reconstruction of a 60 x 25 cm defect covering the lower back, abdomen, gluteal, and pubic regions was achieved through serial split-thickness skin grafts and a pedicled anterolateral thigh flap. The patient made a remarkable recovery, regained mobility with the aid of a walker, and was discharged in good health 22 weeks after the initial accident. This case report underscores the importance of serial debridements in preventing sepsis, the use of negative pres-sure vacuum dressing changes, the initiation of broad-spectrum antibiotics based on culture results during debridements, and prompt closure of the defect to ensure survival after traumatic hemipelvectomy. Familiarization with the principles discussed here is crucial to minimizing mortality rates and optimizing outcomes for this rare injury.

Do bilateral procedures further increase the complications for autologous breast reconstruction in obese patients?

BACKGROUND: Obesity is known to be associated with high complication rates. The aim of this study was to evaluate the effect of bilateral procedures on complication rates in obese patients undergoing autologous breast reconstruction with deep inferior epigastric perforator flaps. METHODS: Medical records of patients undergoing autologous breast reconstruction between January 2017 and December 2019 were retrospectively reviewed. Patients were divided into two groups according to their body mass index (BMI): Group 1 (BMI > 30) and Group 2 (BMI < 30). Group 1 was further divided into 3 subgroups: Group 1a (bilateral reconstruction), Group 1b (unilateral reconstruction), and Group 1c (unilateral reconstruction and contralateral symmetrization). Outcomes and complication rates were compared between groups. RESULTS: Ninety-one patients (with 119 free flaps) were followed up between 6 and 12 months. Length of hospital stay, smoking rates, and age were similar in all groups. Group 1 had significantly more rates of wound dehiscence (p = 0.024), mastectomy skin flap necrosis (p = 0.019), and re-operation (p = 0.033). The operation time was significantly higher in group 1 (p = 0.003). There was no significant difference between group 1 and group 2 in terms of hematoma-seroma formation, flap loss, and pulmonary thromboembolism rates. When obese subgroups were compared, no significant difference was observed in terms of complications. CONCLUSION: In our series, microvascular breast reconstruction was associated with more complication rates in obese patients. However, bilateral procedures in the obese patient group did not significantly increase risk of complications as compared to unilateral procedures. By taking appropriate measures bilateral procedures can be performed in obese patients without additional risks.

Safe, fast, and minimally-assisted microsurgical anastomosis with combined open-loop suturing and airborne tying: a clinical and experimental study.

BACKGROUND: The continuous open-loop technique accelerates anastomosis and eliminates the risk of inadvertently catching the back wall, which is the primary cause of technical failure when using interrupted sutures in microsurgical anastomosis. Combined with airborne suture tying, the total anastomosis time is significantly reduced. We conducted an experimental and clinical study to compare this combination to the conventional technique. METHODS: Experimentally, anastomoses were performed on the femoral arteries (0.60 mm) of rats in two groups. The control group used simple interrupted suturing with conventional tying, while the experimental group employed open-loop suturing with air-borne tying. We recorded the total time taken for anastomosis completion and patency rates. Clinically, we retrospectively analyzed replantation and free flap transfer cases using the open-loop suture and airborne tying technique for arterial and venous microvascular anastomoses, assessing total anastomosis time and patency rates. RESULTS: Experimentally, a total of 40 anastomoses were performed in two groups. The control group required 779.65 seconds, and the experimental group needed 527.4 seconds for anastomosis completion; this difference was statistically significant (p<0.001). Immediate and long-term patency rates were similar (p=0.5483). Clinically, 18 replantations were performed on 16 patients, and 17 free flap transfers were performed on 15 patients, totaling 104 anastomoses. The anastomosis success rate was 94.2% (33 of 35) for free flap transfers and 95.1% (39 of 41) for replantation cases. CONCLUSION: The open-loop suture technique with airborne knot tying allows surgeons to complete microvascular anastomoses safely and in less time with minimal assistance when compared to the simple interrupted suture technique.

Long-Term Outcome of 118 Acute Total Brachial Plexus Injury Patients Using Free Vascularized Ulnar Nerve Graft to Innervate the Median Nerve.

BACKGROUND: The restoration of finger movement in total brachial plexus injuries (BPIs) is an ultimate challenge. Pedicled vascularized ulnar nerve graft (VUNG) connecting a proximal root to distal target nerves has shown unpredictable outcomes. We modified this technique by harvesting VUNG as a free flap to reinnervate median nerve (MN). We analyzed the long-term outcomes of these methods. METHODS: From years 1998 to 2015, 118 acute total brachial plexus patients received free VUNG to innervate the MN. Patients were followed up at least 5 years after the initial surgery. Donor nerves included the ipsilateral C5 root (25 patients) or contralateral C7 root (CC7 = 93 patients). Recovery of finger and elbow flexion was evaluated with the modified Medical Research Council system. Michigan Hand Score and Quick-DASH were used to represent the patient-reported outcomes. RESULTS: For finger flexion, ipsilateral C5 transfer to MN alone yielded similar outcomes to MN + MCN (musculocutaneous nerve), while CC7 had significantly better finger flexion when coapted to MN alone than to MN + MCN. Approximately 75% patients were able to achieve finger flexion with nerve transfer alone. For elbow flexion, best outcome was seen in the ipsilateral C5 to MCN and MN. CONCLUSION: In acute total BPI, the priority is to identify the ipsilateral C5 root to innervate MN, with concomitant innervation of MCN to establish the best outcomes for finger and elbow flexion. CC7 is more reliable when used to innervate one target (MN). LEVEL OF EVIDENCE: III.

Vascularized lymph node transplantation successfully reverses lymphedema and maintains immunity in a rat lymphedema model.

Vascularized lymph node transplantation (VLNT) has shown inspiring results for the treatment of lymphedema. Nevertheless, it remains unclear how VLNT restores lymphatic drainage and whether or not immunity recovers after surgery. Hindlimb lymphedema model was created using rats with extensive groin and popliteal lymph node removable following with radiotherapy, and the lymphedema was confirmed using indocyanine green (ICG) lymphangiography and micro-computer tomography for volume measurement. VLNT was performed 1 month later. Volume measurement, ICG lymphangiography, histology, and immune reaction were done 1 month after surgery. VLNT successfully reduced the volume of the lymphedema hindlimb, restored lymphatic drainage function with proven lymphatic channel, and reduced lymphedema-related inflammation and fibrosis. It promotes lymphangiogenesis shown from ICG lymphangiography, histology, and enhanced lymphangiogenesis gene expression. Dendritic cell trafficking via the regenerated lymphatic channels was successfully restored, and maintained systemic immune response was proved using dinitrofluorobenzene sensitization and challenge. VLNT effectively reduces lymphedema and promotes lymphatic regeneration in the capillary lymphatic but not the collecting lymphatic vessels. Along with the re-established lymphatic system was the restoration of immune function locally and systemically. This correlated to clinical experience regarding the reduction of swelling and infection episodes after VLNT in lymphedema patients.

Oberg-Manske-Tonkin Classification of Congenital Upper Extremity Anomalies: The First Report From Turkey.

PURPOSE: Although the Oberg-Manske-Tonkin (OMT) classification has been recommended by the International Federation of Societies for Surgery of the Hand owing to some insufficiencies of the Swanson classification system, it has not achieved a universal adoption by hand surgeons. In this study, we hypothesize that the OMT classification can be used easily to classify congenital upper extremity anomalies. We also aim to make epidemiological analysis of congenital upper extremity anomalies with the OMT classification and to compare the applicability of the OMT and the Swanson classifications. METHODS: We retrospectively analyzed 711 patients and 833 extremities operated on between 2012 and 2017. Photographs, plain x-rays, and brief medical histories of the patients were evaluated by 4 plastic surgeons. Two independent evaluations were made by each surgeon in 1-month interval using these classification systems. RESULTS: Total number of upper extremity anomalies recorded was 1050. Of the 711 patients operated on, 122 had bilateral anomalies. The anomalies were identified in 833 extremities because many extremities had more than a single diagnosis. We were able to classify all of the anomalies within the OMT classification. The OMT classification gives better reliability results compared with the Swanson classification according to intrarater and interrater reliabilities. CONCLUSIONS: Compared with the Swanson classification system based on phenotypic evaluation of the extremity, the OMT classification system is easier to apply and the association of the anomaly with the embryologic origin during evaluation is possible. We believe that multiple studies from different centers will boost the international acceptance of the OMT classification.

Effect of Degree of Arterial Inflow on a Functioning Free Muscle Transplantation in a Rat Gracilis Model.

BACKGROUND: Various surgical effects have previously been studied in an attempt to improve the functional outcome of the functioning free muscle transplantation (FFMT). However, the effect of the recipient arterial inflow on the FFMT has remained uninvestigated. This study was to investigate whether or not high flow versus low flow will affect the functional outcome of FFMT. METHODS: Rat's left gracilis FFMT model was devised and the nutrient arterial inflow was modified. Twenty-four Lewis rats were divided evenly into relatively high (0.071 mL/min) and relatively low (0.031 mL/min) blood flow groups (p < 0.001). The unoperated right sides served as the controls. Cases resulting in poor function were additionally grouped as functional failure group for comparison. Regular swimming exercise was implemented at 1 month postoperatively for 3 months. Gracilis muscle functions were then evaluated. RESULTS: Compared groups were: control (n = 13), low blood flow (n = 10), high blood flow (n = 8), and functional failure (n = 5). The control group showed superior functional results over the experimental groups (p < 0.0001). In the experimental group, successful group showed superior over the poor function group (p < 0.01). However, there was no significant difference between the high- and low-flow groups. CONCLUSION: This is the first study to evaluate the effect of arterial inflow on the FFMT. The rate of blood flow (relatively high vs. low) has little effect on the functional outcome of transferred muscle. Survival of FFMT is the major concern while performing FFMT surgery. Arterial inflow while choosing the recipient artery is not the factor for consideration.

Effects of Systemic and Local Caffeine on Vessel Diameter, Anastomosis Patency, and Intimal Hyperplasia in the Rat.

BACKGROUND: The use of caffeine is not recommended prior to elective microsurgery due to its demonstrated negative effects on vessel anastomosis by the presumed sympathomimetic induction of vasoconstriction. In this study, we aimed to elucidate the systemic and local effects of caffeine on vessel diameter, anastomosis patency, and degree of intimal hyperplasia during the healing process. METHODS: Twenty-five rats were randomly assigned to five groups: (1) negative control, (2) preoperative systemic caffeine, (3) postoperative systemic caffeine, (4) perioperative systemic caffeine, and (5) a local caffeine group. Both the right and left femoral arteries were used. Ten anastomoses were performed per group. The arterial diameter was measured by micrometer, anastomosis patency was assessed surgically and histologically, and the histological examination was conducted 3 weeks postoperatively to determine intimal hyperplasia. RESULTS: The overall patency rate was 96%. Mild vasoconstriction was observed in the systemic caffeine groups (statistically insignificant); however, there were no negative effects on anastomosis patency. Local caffeine irrigation resulted in significant vasodilatation in the local caffeine group (p = 0.001); a similar effect was not observed in the other groups. There was a significant decrease in the intima/media ratio in the local caffeine group (p < 0.01), when compared with the control and systemic caffeine groups. No other intima/media ratio differences were observed among other comparison groups. CONCLUSION: The systemic administration of caffeine, although statistically insignificant, has an observable effect on vasoconstriction. However, it does not appear to have negative effects on anastomosis patency regardless of its application period (pre-, post-, or perioperatively). The local application of caffeine resulted in considerable vasodilatation as opposed to the vasoconstriction effect in the systemic caffeine groups. Decreased intimal hyperplasia at the anastomosis edge, and antifibrotic properties in the surgical field were also observed in this group. Histologically, the local caffeine group demonstrated an additional beneficial effect on anastomosis remodeling.

A Biomimetic Alternative to Synthetic Hydroxyapatite: "Boron-Containing Bone-Like Hydroxyapatite" Precipitated From Simulated Body Fluid.

BACKGROUND: Biological hydroxyapatite (HA), has several mechanical and physical advantages over the commercially available synthetic apatite (CAP-HA). The aim of this in vivo study was to investigate the effect of osteoinductive "bone-like hydroxyapatite" obtained from simulated body fluid (SBF) combined with osteoinductive "boron" (B) on bone healing. MATERIALS: Bone like nanohydroxyapatite (SBF-HA) was precipitated from 10× simulated body fluid (10×SBF). Thirty Sprague-Dawley rats were randomly divided into 5 experimental groups (n = 6 each). The groups were involving blank defect, chitosan, SBF-HA, SBF-HA/B, and CAP-HA. Two biparietal round critical sized bone defect was created using a dental burr. The rats were sacrificed respectively at the end of second and fourth months after surgery and their calvarium were harvested for further macroscopic, microtomographic, and histologic evaluation. RESULTS: The SBF-HA/B group demonstrated the highest mineralized matrix formation rates (30.69 ± 3.73 for the second month, 62.68 ± 7.03 for the fourth month) and was significantly higher than SBF-HA and the CAP-HA groups. The SBF-HA/B group demonstrated the highest mineralized matrix formation rates (30.69 ± 3.73 for the second month, 62.68 ± 7.03 for the fourth month) and was significantly higher than SBF-HA and the CAP-HA groups. In means of bone defect repair histologically, the highest result was observed in the SBF-HA/B group (P < 0.001). CONCLUSIONS: The "bone-like hydroxapatite" obtained from simulated body fluid is worth attention when both its beneficial effects on bone healing and its biological behavior is taken in consideration for further bone tissue engineering studies. It appears to be a potential alternative to the commercially available hydroxyapatite samples.

Microvascular tissue transfers in the elderly: safety analysis for a challenging area.

BACKGROUND/AIM: Due to increased average life expectancy, the number of elderly patients requiring complex reconstructive microsurgical procedures is rising. Age, comorbid conditions, and location of operation are all possible risk factors. The aim of this study is to evaluate surgical outcomes to set the right criteria. MATERIALS AND METHODS: Between 1996 and 2014, the data of 30 patients over the age of 70, who were treated with microsurgical techniques in our clinic, were extracted from patient records and analyzed retrospectively. RESULTS: In this patient population, flap success rate was 94%. Systemic and surgical complication rates were 40% and 48%, respectively. Complication rates were higher in head and neck cases but there was no statistically significant difference compared to reconstructions in other areas. Loss of oral lining, as a serious complication, had no effect on complications in head and neck reconstruction patients in our series. Conclusions: Flap success is comparable to younger age groups but procedures are associated with a high rate of complications Evaluating and controlling comorbid conditions is important. The American Society of Anesthesiologists scoring system is reliable in this patient population. Although complications are more common, these procedures can be performed safely in elderly populations with careful patient selection.