ERAS for Head and Neck Tissue Transfer Reduces Opioid Usage, Peak Pain Scores, and Blood Utilization.

OBJECTIVES: We implement a novel enhanced recovery after surgery (ERAS) protocol with pre-operative non-opioid loading, total intravenous anesthesia, multimodal peri-operative analgesia, and restricted red blood cell (pRBC) transfusions. 1) Compare differences in mean postoperative peak pain scores, opioid usage, and pRBC transfusions. 2) Examine changes in overall length of stay (LOS), intensive care unit LOS, complications, and 30-day readmissions. METHODS: Retrospective cohort study comparing 132 ERAS vs. 66 non-ERAS patients after HNC tissue transfer reconstruction. Data was collected in a double-blind fashion by two teams. RESULTS: Mean postoperative peak pain scores were lower in the ERAS group up to postoperative day (POD) 2. POD0: 4.6 ± 3.6 vs. 6.5 ± 3.5; P = .004) (POD1: 5.2 ± 3.5 vs. 7.3 ± 2.3; P = .002) (POD2: 4.1 ± 3.5 vs. 6.6 ± 2.8; P = .000). Opioid utilization, converted into morphine milligram equivalents, was decreased in the ERAS group (POD0: 6.0 ± 9.8 vs. 10.3 ± 10.8; P = .010) (POD1: 14.1 ± 22.1 vs. 34.2 ± 23.2; P = .000) (POD2: 11.4 ± 19.7 vs. 37.6 ± 31.7; P = .000) (POD3: 13.7 ± 20.5 vs. 37.9 ± 42.3; P = .000) (POD4: 11.7 ± 17.9 vs. 36.2 ± 39.2; P = .000) (POD5: 10.3 ± 17.9 vs. 35.4 ± 45.6; P = .000). Mean pRBC transfusion rate was lower in ERAS patients (2.1 vs. 3.1 units, P = .017). There were no differences between ERAS and non-ERAS patients in hospital LOS, ICU LOS, complication rates, and 30-day readmissions. CONCLUSION: Our ERAS pathway reduced postoperative pain, opioid usage, and pRBC transfusions after HNC reconstruction. These benefits were obtained without an increase in hospital or ICU LOS, complications, or readmission rates. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:E792-E799, 2021.

A importância da gengiva ceratinizada e do volume tecidual para a saúde e estética peri-implantar / The importance of keratinized gengiva and tissue volume for periodontal health and aesthetics

A manipulação adequada dos tecidos moles peri-implantares é de essencial importância para se preservar a saúde em longo prazo, bem como para se obter uma estética favorável após a reabilitação protética dos implantes dentários. Defeitos peri-implantares, como ausência de tecido ceratinizado e perda de espessura tecidual prejudicam o resultado final e a previsibilidade do tratamento, logo o conhecimento sobre intervenções nos tecidos moles para a Implantodontia é fundamental. Este trabalho teve como objetivo realizar uma revisão da literatura abordando a necessidade de se ter volume tecidual e gengiva ceratinizada ao redor dos implantes, e a utilização de enxerto gengival livre e de tecido conjuntivo como as alternativas mais utilizadas para correção destas situações.

Adequate peri-implant soft tissue management is fundamental to preserve its long-term health as well as to obtain a favorable esthetics after dental implant prosthetic rehabilitation. Peri-implant defects, such as the lack of keratinized tissue and the loss of structural support compromise the final outcome and treatment predictability; thus, the knowledge regarding soft tissue intervention in implant dentistry is very important. This paper aims to report a literature review on the need of tissue volume and keratinized gingiva around implants, and the use of free gingival and connective tissue grafts as the most prevalent alternatives to correct those situations.

Procedimentos no atendimento para queimaduras nas mãos na fase aguda / Procedures in the care of hand burns in the acute phase

Introdução: A mão representa 3% da superfície corporal total, porém seu envolvimento em trauma grave, como uma queimadura, pode levar a sequelas funcionais graves. O presente estudo descreve os procedimentos no atendimento de pacientes na fase aguda com queimaduras envolvendo as mãos. Métodos: 122 pacientes com queimaduras térmicas envolvendo uma ou ambas as mãos foram incluídos no estudo, entre agosto de 2011 a julho de 2014. No exame físico inicial, determinou-se a extensão e a profundidade da lesão; as queimaduras profundas e circulares, com sinais e sintomas de perfusão inadequada, tiveram escarotomias realizadas para evitar perda de extremidade. As queimaduras de espessura parcial profunda ou de espessura total no dorso das mãos foram submetidas à excisão tangencial até 5 dias após o trauma; e o enxerto de pele parcial foi realizado em todos os pacientes antes do 15º dia do trauma. Resultados: Os homens representaram a maioria (58% da casuística). Em relação ao agente das queimaduras, os líquidos inflamáveis corresponderam a 46,7% das internações. Em 50,8% dos casos, as queimaduras eram de espessura parcial profunda ou de espessura total e necessitaram de procedimento operatório. Não foi identificada perda de enxerto no grupo. As escarotomias foram realizadas em 12,3% dos pacientes. Conclusão: A mão queimada necessita de atenção e cuidados locais adequados, juntamente com excisão precoce e enxertia de pele.

Introduction: The hand represents 3% of total body surface, but its involvement in severe trauma, such as burns, can lead to serious functional sequelae. The present study describes procedures in the care of patients in the acute phase with burns involving the hands. Methods: 122 patients with thermal burns involving one or both hands were included in the study between August 2011 and July 2014. On initial physical examination, the extent and depth of the lesions were determined; deep and circular burns, with signs and symptoms of inadequate perfusion, had escharotomies performed to avoid the loss of extremity. Burns of partial deep thickness or full thickness on the back of the hands received tangential excision within 5 days after the trauma; partial skin grafting was performed on all patients before the 15th day of the trauma. Results: Men represented the majority of cases (58%). In relation to the burn agent, flammable liquids caused 46.7% of admissions. In 50.8% of the cases, the burns were of partial deep thickness or of total thickness and required an operative procedure. No graft loss was identified in the group. Escharotomies were performed in 12.3% of the patients. Conclusion: The burned hand needs proper local attention and care, along with early excision and skin grafting.

Danish experience with free flaps in war wounds.

INTRODUCTION: To describe the lessons learned from treatment of war casualties at a public hospital in Denmark. METHODS: A retrospective review of soldiers who underwent free flap reconstruction at Rigshospitalet, Denmark, between January 2006 and December 2010. RESULTS: Nine patients were treated using free flaps. The age distribution was 21-34 years. Extremity fractures associated with considerable soft tissue loss were seen in all cases. The mean time from injury to reconstruction was 13.2 days. A total of 11 free flaps were used, the majority of which were latissimus dorsi flaps (seven out of 11). Flap-loss occurred in one patient, presumably due to leakage at the anastomotic site, which necessitated another free flap procedure. All patients received rehabilitation services following discharge from the inpatient unit, including prosthetic fitting. The mean follow-up time was 26 months. CONCLUSIONS: This report is the first to detail the reconstructive procedures in soldiers treated at a public hospital in Denmark. The treatment of war casualties has not only been a challenge to the surgeons tasked with managing these devastating injuries, but also to Danish healthcare in general. The outcome of multidisciplinary treatment, combining the expertise of various specialties, is highly encouraging. The rate of complications was low, and the aesthetic appearance of the reconstructed limbs and the functional recovery were satisfactory. We therefore recommend the use of free flaps to reconstruct defects resulting from battlefield trauma. FUNDING: none. TRIAL REGISTRATION: not relevant.

Esplenosis: diagnóstico no invasivo de un gran imitador / Splenosis: non-invasive diagnosis of a great mimicker

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Alteração do biótipo gengival na Implantodontia: relato de caso / Modification of gingival biotype on Implantology: case report

O presente artigo visa relatar um caso clínico, onde através de um procedimento cirúrgico, conseguiu-se a alteração do biótipo gengival fino para o biótipo gengival espesso com o aumento da gengiva queratinizada da região. Através da discussão e descrição detalhadas dos procedimentos cirúrgicos envolvidos conclui-se que a técnica de enxerto gengival livre é eficaz na alteração do biótipo gengival, permitindo o aumento da quantidade de gengiva queratinizada ao redor dos implantes.

This paper aimed to report a case where, through surgical procedure, it was possible to convert thin gingival biotype into thick gingival biotype, with an augment of keratinized gingiva in the region. Through detailed description and discussion of the surgical procedures utilized, it was concluded that the free gingival graft technique is effective in altering the gingival biotype allowing an augment of the quantity of keratinized gingival around the implant.

Methods of assessment of cortical plasticity in patients following amputation, replantation, and composite tissue allograft transplantation.

The brain is always adapting to new inputs from the environment. New noninvasive techniques are available to scrupulously study cortical plasticity. Several studies have proven that these modifications of neural pathways occur because of denervation from injury such as amputation. Changes that occur rapidly are likely because of unmasking of established synapses that are latent, whereas changes that occur over long periods of time are more likely because of establishment of new neural connections. Cortical reorganization that occurs from traumatic amputation has been shown to be reversible with replantation and transplantation. With the new field of composite tissue transplantation, such as hand or face, it is critical to be aware of these changes to choose potential patients and to modify their rehabilitation, on the basis of our understanding of the cortical reorganization that occurs over time.

Composite tissue allotransplantation: a proposed classification system based on relative complexity.

Numerous achievements have been made encompassing a wide array of composite tissue allograft (CTA) subtypes. We sought to develop a simple, reproducible CTA classification system for the purpose of comparing clinical investigation. Each CTA subtype differs in relative complexity and can therefore be theoretically classified based on its unique combination of multiple factors. Eight complexity factors (CFs) are hypothesized: anatomic detail, psychological obstacles, rejection risk, required rehabilitation, relative antigenicity, functionality/cosmesis, skin ratio, and salvageability. A distribution of total complexity scores, ranging from 8 to 24, is classified into 3 ordered categories representing varying degrees of complexity. In conclusion, we have created a new classification system so that ongoing research and future data may be compared in a type-specific fashion.

Meniscus transplantation: indications, techniques, clinical outcomes.

Although many meniscus tears can be successfully repaired, not all are salvageable, especially if considerable tissue damage has occurred. Meniscus transplantation has been shown to be an acceptable procedure for younger patients. The primary candidate is a patient younger than age 50 years who has had a total meniscectomy and who either has pain in the tibiofemoral compartment, arthroscopic evidence of articular cartilage deterioration, or both. Contraindications are advanced knee joint arthrosis with flattening of the femoral condyle, concavity of the tibial plateau, and osteophytes that prevent anatomic seating of the meniscus allograft; axial malalignment; knee joint instability; knee arthrofibrosis; muscular atrophy; and prior joint infection. Prophylactic meniscus transplantation after total meniscectomy is not recommended in asymptomatic patients who do not demonstrate articular cartilage deterioration because long-term predictable success rates are not available. Most clinical studies on meniscus transplantation have reported improvements in knee function and pain, especially in patients who have symptoms affecting daily activities, as there are few if any other available treatment options.

Meniscal allografts--where do we stand?

Meniscal transplantation has been recommended for selected meniscus-deficient patients in an effort to forestall progressive joint degeneration. Meniscal allograft transplantation may be considered for patients with symptoms (pain and swelling) due to meniscal deficiency in an effort to prevent progressive articular cartilage degeneration. Medial meniscal transplantation may also be considered during concomitant anterior cruciate ligament reconstruction, since absence of the medial meniscus results in increased forces in the anterior cruciate ligament graft. Contraindications for meniscal transplantation include advanced articular cartilage degeneration (especially on the flexion weightbearing zone of the condyle), axial malalignment, and flattening of the femoral condyle. Patient evaluation should include standing, long-leg radiographs for assessment of the mechanical axis and magnetic resonance imaging with appropriate pulse sequences for evaluation of hyaline cartilage thickness. Fresh-frozen and cryopreserved allografts are currently the most commonly used transplantation materials. Appropriate graft sizing is critical; most tissue banks size the meniscus based on radiographic tibial plateau measurements. Early results of meniscal transplantation indicate predictable improvements in pain, swelling, and knee function; however, no long-term results are available. Poor results have been reported in patients with advanced cartilage degeneration. Objective evaluations often demonstrate some degree of degeneration of the posterior horn of the transplant. Earlier transplantation should be considered for patients with known meniscal deficiency.

Rinoplastias secundárias / Revision rhinoplasty

Um número crescente de reintervençöes após uma rinoplastia primária vem sendo observado nos últimos anos. Pacientes insatisfeitos e com queixas diversas, desde pequenas alteraçöes de relevo nasal até alteraçöes graves da forma e prejuízo funcional, têm chegado ao Serviço, provenientes de diversos outros serviços. Uma análise de cada caso torna-se fundamental para chegar-se a uma determinaçäo diagnóstica precisa e um planejamento tático-cirúrgico individualizado. Enfatiza-se a importância do conhecimento anatômico e funcional do nariz pelo cirurgiäo que deve estar familiarizado com as diversas técnicas e estar apto a desempenhá-las. Em virtude da maior incidência de deformidades pós-cirúrgicas deverem-se à retirada excessiva de tecidos, comenta-se o uso de enxertos autógenos, sua modelagem, posicionamento e vias de acesso, de acordo com a filosofia e a experiência do autor sênior, assim como suas implicaçöes estéticas e funcionais. O aspecto psicológico do paciente é relevante já que o cirurgiäo, em alguns casos, deverá postergar a reintervençäo ao momento adequado, quando os tecidos oferecerem condiçöes desejadas

La movilización sinérgica en la rehabilitación inmediata de los injertos tendinosos / Synergic movilization in the inmediate rehabilitation of tendinous grafs

Se presenta una serie de 27 injertos tendinosos en lesionados no recientes, de los tendones flexores de la mano, a los cuales se les practicó la rehabilitación precoz mediante la movilización sinérgica de los injertos, utilizando la férula sinérgica asociada a una terapia medicamentosa esteroidea enérgica. La evaluación se realizó con el uso de la escala de Buck Grameko. De los injertos realizados, el 92 por ciento obtovo resultados satisfactorios (excelentes y buenos) y sólo el 8 por ciento tuvo malos resultados. El tiempo promedio de incapacidad fue de 74 días

Aggressive rehabilitation following anterior cruciate reconstruction: an update and protocol.

Dramatic changes in anterior cruciate ligament (ACL) reconstruction surgery and rehabilitation methods have occurred during the past few years. These developments are reviewed briefly, and a rapid rehabilitation protocol is presented which facilitates the safe return of the patient to his or her pre-operative functional level in sports and activities of daily living.

Results of knee manipulations after anterior cruciate ligament reconstructions.

We analyzed the results of knee manipulations in 42 knees that had persistent flexion or extension deficits after intraarticular ACL reconstructions. All manipulations were done under a spinal or general anesthetic and, in 10 cases, arthroscopic debridement of adhesions also was performed. The average time from reconstruction to manipulation was 7 months (range, 3 to 14 months) and the average followup was 26 months (range, 6 to 56 months). At manipulation, average flexion was increased from 95 degrees to 136 degrees and average extension from 11 degrees to 3 degrees. In no case was motion gained at the expense of joint stability and, at final followup, average flexion and extension were 127 degrees and 4 degrees, respectively. The final range of motion achieved was not affected by the time to manipulation, severity of premanipulation flexion deficit, or concomitant arthroscopic debridement of adhesions. However, knees with premanipulation extension deficits of greater than or equal to 15 degrees achieved significantly less final extension than knees with lesser premanipulation deficits. Overall, manipulations were a safe and effective method for improving both flexion and extension in 86% of the knees that had restricted motion after ACL reconstructions.