Role of Hyperbaric Oxygen Therapy in Maximizing Flap Survival in Compromised Free Flaps: A Case Report.

Background: Hyperbaric oxygen therapy (HBOT) has shown potential in salvaging compromised flaps, although its application has primarily been focused on local flaps rather than free flaps. Case: In this case report, we present the successful use of HBOT in a 76-year-old man who underwent free flap reconstruction for calcaneal osteomyelitis. Despite undergoing 2 reoperations on the second and third days post reconstruction, no thrombosis was observed at the anastomotic site. Following the second reoperation, HBOT was promptly initiated and continued for a total of 9 sessions. Notably, after the sixth HBOT session, fresh bleeding occurred upon flap puncture. Eventually, the flap developed epidermal necrosis, which was conservatively treated. Discussion: It is crucial to first rule out mechanical causes of compromised free flaps through surgical exploration, with HBOT serving as an adjunctive rather than a primary treatment option--even considered as the last resort. Nevertheless, in cases where mechanical causes have been ruled out, HBOT may significantly enhance flap survival rates in compromised free flaps.

Comparative study of conservative treatment and lymphaticovenular anastomosis with compression therapy for early-stage breast cancer-related lymphoedema.

This single-centre retrospective cohort study aimed to clarify the superiority of treatment by comparing the outcomes of lymphaticovenular anastomosis with compression therapy and conservative treatment centred on compression therapy in the early stage of breast cancer-related lymphoedema. Data were collected from all patients treated for breast cancer-related lymphoedema between January 2015 and December 2022. The patients were classified into conservative treatment and surgical treatment groups. The upper extremity lymphoedema index value was calculated, based on five circumference values of the upper extremity and body mass index, to compare the 6-, 12-, 18- and 24-month outcomes between the groups. Of 101 patients with breast cancer-related lymphoedema, 81 (conservative treatment: 52; surgical treatment: 29) were included in the analysis. The therapeutic effect was significantly higher in the surgical treatment group than in the conservative treatment group, when comparing the rate of change in oedema at 6 (-6.6% ± 7.3% vs. 0.9% ± 7.5%; p < 0.001), 12 (-7.3% ± 6.2% vs. 2.9% ± 8.6%; p < 0.001), 18 (-7.6% ± 8.0% vs. 3.9% ± 9.2%; p < 0.001) and 24 (-5.6% ± 6.0% vs. 4.4% ± 10.7%; p < 0.001) months. The incidence of cellulitis increased in the conservative treatment group (from 9.6% to 15.4%), whereas it was suppressed in the surgical treatment group (from 13.8% to 0%). Conservative treatment centred on compression therapy increased oedema over time; however, lymphaticovenular anastomosis with compression therapy effectively reduced oedema.

Conservative treatment versus lymphaticovenular anastomosis for early-stage lower extremity lymphedema.

OBJECTIVE: Several options for the treatment of lower extremity lymphedema (LEL) can be broadly classified into conservative treatment, such as compression garments and decongestive lymphatic therapy, and surgical treatment, such as lymphaticovenular anastomosis (LVA). The purpose of our study was to clarify the superiority of these treatments by comparing the outcomes of LVA with those of conservative treatment for early-stage LEL. METHODS: We performed a single-center, retrospective cohort study. The patients with LEL who presented to our department between January 2015 and December 2022 were identified and classified into two groups: conservative treatment and surgical treatment. The LEL indexes, calculated from the four lower extremity circumferences and the body mass index, were compared at the 6-, 12-, and 24-month follow-up between the two groups. RESULTS: Of the 101 patients with LEL, 53 with 72 affected limbs (conservative treatment, 39 patients and 53 affected limbs; surgical treatment, 15 patients and 19 affected limbs) were included in the present analysis. The therapeutic effect for reducing edema, as determined by comparing the corrected LEL index at 12 months (103.7 ± 12.7 vs 91.9 ± 10.7; P = .005) and 24 months (103.1 ± 12.9 vs 83.8 ± 7.2; P < .001), was significantly higher in the surgical treatment group than that in the conservative treatment group. The conservative treatment group showed little change in the corrected LEL index at ≤24 months of follow-up (+3.1%; P = .299). In contrast, the surgical treatment group showed a significant reduction in edema at 24 months according to the corrected LEL index (-16.2%; P = .019). CONCLUSIONS: In early-stage LEL, conservative treatment centered on compression therapy alone only maintained edema (ie, edema did not worsen or improve). In contrast, LVA with compression therapy reduced edema.

Venous end-to-side anastomosis for free-flap reconstruction in the extremities: A case series and meta-analysis.

This case series aimed to investigate the result of venous end-to-side (ETS) anastomosis in the extremities to contribute to a meta-analysis to evaluate the postoperative complications of venous ETS anastomosis in the extremities. This was a single-center case series and meta-analysis of patients who underwent venous ETS anastomosis for free-flap reconstruction of the extremities. We reviewed the records of 41 free flaps in 40 patients and performed a comprehensive search of PubMed, Scopus, and Web of Science for studies published from inception to December 2022. Primary outcomes were venous thrombosis, takebacks, and total and partial flap failures. Complication rates and confidence intervals were calculated using a random-effects model. In our case series, four (12.2%) patients with five flaps were taken back to the operating room, three (7.3%) flaps were due to venous thrombosis, and three (7.3%) flaps ultimately resulted in total flap failure. Our meta-analysis demonstrated the following complication rates: 4.0% (95% confidence interval [CI], 0-18.1%; I2 = 0%) for venous thrombosis, 8.5% (95% CI, 0-21.8%; I2 = 0%) for takebacks, 5.8% (95% CI, 0-18.3%; I2 = 0%) for total flap failure, and 8.8% (95% CI, 0-28.4%; I2 = 0%) for partial flap failure. Our case series and meta-analysis showed that the result of venous ETS anastomosis in the extremities was positive, and this technique was effective for addressing venous size discrepancy; although, its superiority to end-to-end anastomosis could not be established.

Methotrexate-associated lymphoproliferative disorder presenting as an ulcer with tendon exposure on the dorsum of the hand: a case report and literature review.

INTRODUCTION: MTX-LPD is a complication that occurs during MTX treatment. Skin lesions in MTX-LPD are often subcutaneous nodules with occasional necrosis and ulceration. Although MTX-LPD regression is frequently observed upon discontinuation of oral MTX treatment, delayed diagnosis of MTX-LPD with associated ulceration may lead to ulcer enlargement and the need for surgical procedures such as skin grafts. CASE REPORT: A 74-year-old female was diagnosed with RA and administered MTX for 3 years and 8 months. The patient presented with a 2-month-old ulcer on the dorsum of the hand. The ulcer size was 6.5 cm × 5 cm, and it was surrounded by an embankment tumor measuring 7 cm × 6 cm. Although a definitive diagnosis could not be made based on the biopsy specimen, excision of the ulcer-containing mass confirmed MTX-LPD diagnosis. MTX was discontinued, and free-flap reconstruction was performed 3 weeks after the first surgery. The postoperative period was uneventful, and MTX-LPD recurrence was not observed 10 months after the second surgery. CONCLUSION: Although MTX-LPD with ulceration is rare, it should be considered in cases of refractory ulcers in patients with RA. The discontinuation of MTX based on early MTX-LPD diagnosis is critical to avoid surgical procedures such as skin grafts and flap reconstruction.

Combined Revascularization and Free Flap Reconstruction for Chronic Limb-Threatening Ischemia: A Systematic Review and Meta-Analysis.

BACKGROUND: Combined revascularization and free flap reconstruction is one treatment method for chronic limb-threatening ischemia (CLTI) with complex wounds. The purpose of this systematic review and meta-analysis was to investigate the characteristics of this combined procedure and to assess postoperative outcomes. METHODS: A systematic search was performed across PubMed, Scopus, and the Web of Science for studies between January 2000 and February 2022. A random-effects meta-analysis for postoperative outcome was conducted. RESULTS: Fifteen articles encompassing 1,176 patients with 1,194 free flaps were ultimately included in the qualitative and quantitative assessment. Our meta-analysis showed the following complication rates for short-term postoperative outcomes: 37% (95% confidence interval [CI], 18-53%; I 2 = 74%) for reoperation, 13% (95% CI, 2-24%; I 2 = 0%) for vascular thrombosis, 9% (95% CI, 0-17%; I 2 = 0%) for total flap failure, 8% (95% CI, 0-17%; I 2 = 0%) for partial flap failure, 4% (95% CI, 0-10%; I 2 = 0%) for amputation, and 3% (95% CI, 0-9%; I 2 = 0%) for 30-day mortality. The 1-, 3-, and 5-year limb salvage rates were 86% (95% CI, 78-92%), 81% (95% CI, 68-88%), and 71% (95% CI, 53-83%), respectively. The 1-, 3-, and 5-year patient survival rates were 93% (95% CI, 90-96%), 92% (95% CI, 77-97%), and 75% (95% CI, 50-88%), respectively. CONCLUSION: Combined revascularization and free flap reconstruction for CLTI with complex wounds was clearly effective for the long-term outcomes. However, this combined procedure should be considered on the assumption that the reoperation rate is high and that flap-related complications rate may be higher than lower extremity reconstruction of other etiologies.

Muscle/musculocutaneous versus fasciocutaneous free flap reconstruction in the lower extremity: A systematic review and meta-analysis.

BACKGROUND: Free flaps for soft tissue coverage of the lower extremity can be broadly divided into muscle/musculocutaneous and fasciocutaneous flaps. The purpose of this systematic review and meta-analysis was to assess their different post-operative outcomes. METHODS: A systematic search was performed in PubMed, Scopus, and the Web of Science from their inception to February 2022. Non-randomized comparative studies, which describe any post-operative outcome of muscle/musculocutaneous and fasciocutaneous free flaps reconstruction in the lower extremity were included. Articles with duplicate titles, editorials, review articles, case series, case reports, and publications lacking an abstract, those reporting pediatric patients, those describing only muscle/musculocutaneous or fasciocutaneous free flaps, those with incomplete or incomparable post-operative outcomes, and studies involving <10 muscle/musculocutaneous or fasciocutaneous free flaps were excluded. A comparative meta-analysis was conducted on muscle/musculocutaneous and fasciocutaneous free flaps outcomes, comprising vascular thrombosis, partial or complete flap necrosis, infection, donor-site complications, non-union, and primary or recurrent osteomyelitis. The fixed-effects meta-analysis model was used when low heterogeneity (I2 < 50%) was identified. RESULTS: Twenty-two articles with a total of 2711 flaps (1584 muscle/musculocutaneous flaps and 1127 fasciocutaneous flaps) were included in the qualitative and quantitative assessment. The rates of any flap necrosis (12.0% vs. 7.4%; p = 0.007) and donor-site complications (16.7% vs. 6.7%; p < 0.0001) were significantly higher for muscle/musculocutaneous flaps than for fasciocutaneous flaps. There were no significant differences in the rates of vascular thrombosis (10.5% vs. 10.7%; p = 0.98), complete flap necrosis (6.2% vs. 4.7%; p = 0.30), infection (19.4% vs. 14.7%; p = 0.18), non-union (18.9% vs. 14.8%; p = 0.33), and primary or recurrent osteomyelitis (14.7% vs. 12.4%; p = 0.69). CONCLUSION: This meta-analysis revealed no significant difference in long-term post-operative outcomes, but suggested that fasciocutaneous flaps should be preferred to avoid flap necrosis and donor-site complications.

Selection of deep or superficial recipient vein in lower extremity reconstruction using free flap: A systematic review and meta-analysis.

BACKGROUND: Free flap surgeries are useful procedures for lower-extremity reconstruction. Recipient vein selection for anastomosis is important to avoid venous congestion and thrombosis. Although deep or superficial venous system can be used as a recipient vein site, there is a lack of consensus on which system would be superior to avoid postoperative complications. This systematic review and meta-analysis aimed to assess the differences in outcomes between deep and superficial vein anastomosis for lower-extremity free flap reconstruction. METHODS: The PubMed, Scopus, Web of Science, and Cochrane Library medical databases were systematically searched from inception to April 2022, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. A comparative meta-analysis was conducted on studies of deep and superficial venous system anastomosis outcomes, comprising vascular thrombosis, reoperation, complete flap necrosis, and any flap necrosis. The fixed-effects meta-analysis model was used when low heterogeneity (I2 < 50%) was present. RESULTS: Six studies with 789 flaps were included in the analysis and qualitative and quantitative syntheses. The rate of vascular thrombosis (8.2% vs. 15.1%; p = .005) was significantly lower for flaps involving deep vein anastomosis than for those involving superficial vein anastomosis. The rate of reoperation after deep vein anastomosis was lower than that after superficial vein anastomosis, with no statistically significant difference (9.0% vs. 14.7%; p = .06). There were no significant differences in the rates of complete (2.5% vs. 2.0%; p = .90) or any flap necrosis (7.0% vs. 9.8%; p = .20). CONCLUSION: Deep vein anastomosis might be recommended for avoiding vascular thrombosis.

Rectus Abdominis Musculocutaneous Flap With Supercharging for Reconstruction of Extensive Thoracic Defect Due to Deep Sternal Wound Infection: A Case Report.

Deep sternal wound infection is a serious postoperative complication of cardiac surgery and often requires flap reconstruction. Herein, we report a case of deep sternal wound infection with an extensive thoracic defect that was successfully treated using a modified technique. This technique, defined as "supercharging," anastomoses the deep inferior epigastric artery and vein of pedicled rectus abdominis musculocutaneous flap to the transverse cervical artery and external jugular vein, respectively. The transverse cervical artery is an easily accessible and reliable recipient vessel. Therefore, we recommend that our technique be used, especially in cases of deep sternal wound infection with extensive thoracic defects.

Implant salvage in patients with severe post-fracture fixation surgical site infection using negative pressure wound therapy with intramedullary and subcutaneous antibiotic perfusion.

INTRODUCTION: Post-fracture fixation surgical site infection (SSI) is a devastating complication, and the standard-of-care therapeutic regimen is ineffective in managing it. Negative pressure wound therapy with instillation and dwell time (NPWTi-d) can be used to salvage orthopedic fixation hardware in the setting of infection; moreover, NPWTi-d can be used effectively in the management of superficial post-fracture fixation SSI. CASE REPORT: Two cases were treated with NPWTi-d. Because of difficulties disrupting the deep dead space biofilm in a deep post-fracture fixation SSI (and because of the risk for bone infection), a double-lumen tube was used for subcutaneous antibiotic perfusion and dead space suction drainage, and bone marrow needles were used for intramedullary antibiotic perfusion to manage or prevent early osteomyelitis. The 2 patients with severe SSI after below-knee fracture fixation were treated with continuous intramedullary and subcutaneous antibiotic perfusion with NPWT to salvage the orthopedic implant. The debrided wounds of the lower leg and heel were reconstructed with free flaps and incisional NPWT, followed by administration of continuous intramedullary and subcutaneous antibiotic perfusion to preserve the titanium plates. In both patients, the wounds healed without complications and remained healed after more than 7 months. CONCLUSIONS: Continuous local antibiotic perfusion around infected orthopedic fixation hardware can be an ideal treatment for patients with SSI after fracture fixation. Although this technique can be improved further, it is more effective than conventional therapy in the management of severe post-fracture fixation SSI with a dead space.

Finger Reconstruction With Distally Based Dorsal Metacarpal Flaps: A Systematic Review.

BACKGROUND: Distally based dorsal metacarpal flaps for the reconstruction of finger soft-tissue defects are classified into 3 categories: dorsal metacarpal artery perforator flap, reverse dorsal metacarpal artery (RDMA) flap, and extended reverse dorsal metacarpal artery (ERDMA) flap. The present systematic review aimed to evaluate differences in the outcomes of commonly encountered defects and postoperative complications among these three flaps. METHODS: PubMed, Scopus, and Web of Science were systematically searched from when the flats were first reported to May 2021. Random-effects meta-analysis for each outcome was performed, and 24 studies were included in the analysis. RESULTS: Dorsal metacarpal artery perforator flaps were mainly used for defects extending to the proximal interphalangeal joint (n = 62 [29.1%]) and proximal phalanx (n = 85 [39.9%]). Conversely, defects extending to the distal phalanx (n = 24 [43.6%]) were mostly reconstructed using the ERDMA flap. The rate of venous congestion was highest for the ERDMA flap (29.3%; 95% confidence interval [CI], -17.2% to 65.1%; I2 = 0%) and lowest for RDMA flap (8.1%; 95% CI, -5.9% to 21.7%; I2 = 0%). The RDMA flap showed the lowest rate of any short-term complications, including partial and total necrosis (6.6%; 95% CI, -6.8% to 19.8%; I2 = 0%). CONCLUSIONS: This systematic review demonstrated that the dorsal metacarpal artery perforator flap was suitable for reconstruction proximal to the middle phalanx, and the ERDMA flap was suitable for reconstruction distal to the distal interphalangeal joint. Although the RDMA flap showed the lowest rate of short-term complications and limited analysis was secondary to limited data available, these occurred in 6.6% to 10.9% of distally based dorsal metacarpal flaps.

Use of Muscle Flaps for Salvage of Groin Wound Infection Following Vascular Surgery: A Systematic Review and Meta-Analysis.

BACKGROUND: Groin wound infections in vascular surgery are still a common complication and challenging problem. This systematic review aimed to establish a complete view of patient characteristics and clinical outcomes for infected groin wounds following vascular surgery reconstruction using muscle flaps and to evaluate the differences in outcomes between the sartorius muscle flap (SMF), rectus femoris muscle flap (RFF), and gracilis muscle flap (GMF). METHODS: PubMed, Scopus, and Web of Science were systematically searched from inception to April 2021. Random-effects meta-analysis for comorbidities and outcomes and subgroup analyses for outcomes were performed. RESULTS: Thirty studies were included in qualitative and quantitative syntheses. Overall pooled data showed the following outcome rates: 4.5% muscle flap necrosis (95% confidence interval [CI], -3.4-12.3%; I2 = 0%), 21.8% overall complications (95% CI, 15.8-27.7%; I2 = 0%), 8.0% limb loss (95% CI, 1.9-14.1%; I2 = 0%), 15.4% graft loss (95% CI, 5.0-25.3%; I2 = 37.9%), and 7.4% 30-day mortality (95% CI, -.9-15.6%; I2 = 0%). The rates of overall complications were 20.3% (95% CI, 12.1-28.2%; I2 = 0%), 23.2% (95% CI, 11.2-34.5%; I2 = 10.2%), and 18.0% (95% CI, -3.537.8%; I2 = 0%) for the SMF, RFF, and GMF, respectively. The rate of limb loss was highest for the GMF (17.2%; 95% CI, -4.237.2%; I2 = 0%). The rate of graft loss for the RFF was the highest (20.7%; 95% CI, .6-39.1%; I2 = 53.9%). The rate of 30-day mortality was the lowest for the SMF (5.3%; 95% CI, -6.1-16.6%; I2 = 0%). CONCLUSIONS: The effectiveness and safety of muscle flap reconstruction for infected groin wounds following vascular surgery are clearly positive. This review indicated a tendency for lower complication rates with the SMF than with other muscle flaps.

A Simple, Versatile Device for Multiplanar Photography.

BACKGROUND: Taking pictures of protruding body parts (such as fingertips, toes, nipples, auricles, hands, and feet) from multiple directions is difficult. To solve this problem, we developed a simple and easy-to-use device, using mirrors. METHODS: The device is composed of 4 trapezoidal plane plastic mirrors firmly connected to each other. It is possible to photograph the object from 5 directions at once, including the real image of the object at the center, and 4 images that are reflected in the mirrors around the sides. RESULTS: The device allowed photographing various body parts from multiple directions at once. CONCLUSION: This simple and easy-to-use device helps us to take additional photographs in a single shot, which previously took more time and effort.

Conformational Change and Epimerization of Diketopiperazines Containing Proline Residue in Water.

In water, diketopiperazines cyclo(L-Pro-L-Xxx) and cyclo(L-Pro-D-Xxx) (Xxx=Phe, Tyr) formed an intramolecular hydrophobic interaction between the main skeleton part and their benzene ring, and both cyclo(L-Pro-L-Xxx) and cyclo(L-Pro-D-Xxx) took a folded conformation. The conformational changes from folded to extended conformation by addition of several deuterated organic solvents (acetone-d6, metanol-d4, dimethyl sulfoxide-d6 (DMSO-d6)) and the temperature rise were investigated using 1H-NMR spectra. The results suggested that the intrarmolecular hydrophobic interaction of cyclo(L-Pro-D-Xxx) formed more strongtly than that of cyclo(L-Pro-L-Xxx). Under a basic condition of 1.0×10-1 mol/L potassium deuteroxide, enolization of O1-C1-C9-H9 moiety of cyclo(L-Pro-L-Xxx) occurred, while that of the O4-C4-C3-H3 moiety did not. Cyclo(L-Pro-L-Xxx) epimerized to cyclo(D-Pro-L-Xxx), while cyclo(L-Pro-D-Xxx) did not change.