Lower medial thigh perforator (LMTP) propeller flap for reconstruction of soft tissue defects around the knee.

BACKGROUND: Skin and soft-tissue defects around the knee are common and their reconstruction is still challenging and argued. Thin, pliable and well-vascularized tissues are required in order to restore the aesthetic appearance of the knee and facilitate joint function. Historically local muscle flaps were employed for the upper third of the lower limb reconstruction; however, since their introduction, different perforator flaps have been proposed for this purpose. The aim of this report is to share our clinical experience with the pedicled lower medial thigh perforator (p-LMT) flap for the reconstruction of skin and soft tissue defects around the knee. PATIENTS AND METHODS: Between August 2013 and July 20, 2018, patients underwent pedicled LMT propeller flap reconstruction for defects around the knee. The subunits of the defects were the suprapatellar, the infrapatellar and patellar area and in two cases a full around the knee defect was reported. Cause of defects included trauma (13), tumor (4) and infection after knee operation (3) and defect sizes ranged from 4 × 3 cm2 to 7 × 8 cm2 . RESULTS: Flap sizes ranged from 4 × 9 cm2 to 6 × 16 cm2 . One to two perforators based on the superficial femoral artery or descending genicular artery were found between the septum of satorius and vastus medialis, or piercing the vastus medialis during dissection. All flaps were rotated 180° in propeller fashion. All the donor sites were primarily closed and no complication at the donor site was detected. In the two cases of the total knee soft tissue defect, a double pedicled flaps reconstruction was required. After a 6 months follow-up, all the patients in the series achieved a full range of motion. CONCLUSIONS: Fasciocutaneous flaps are currently the first reconstructive option for the soft tissue defects around the knee. The p-LMT flap reconstruction in this case series achieved good aesthetic and functional outcomes and this flap may be a valuable option for the reconstruction of the small to medium soft tissue defects around the knee.

Intraoperatively Detected But Previously Indocyanine Green-Negative Lymphatic Vessels May Have Misprized Potentials and Should Not Be Neglected in Lymphaticovenous Bypass Surgery.

INTRODUCTION: Identification of patent lymphatic vessels without fibrosis and with high flow is difficult but crucial in the preoperative planning of lymphaticovenous anastomosis (LVA). Lymphatic vessels on the operating field cannot always be visualized preoperatively because of the anatomical and physiological characteristics of lymphedema tissue. The purposes of this study were to demonstrate our clinical experience in identifying indocyanine green (ICG)-negative lymphatics intraoperatively and to emphasize the therapeutic potential of performing anastomoses with ICG-negative lymphatics. METHODS: Indocyanine green-positive lymphatic ducts were marked preoperatively in 5 patients with lower extremity lymphedema; moreover, if ICG-negative lymphatics were identified during surgery, they were used for additional LVA thus implementing multiple anastomoses in one surgical setting. RESULTS: In total, 33 LVAs were performed in 5 patients with lower extremity lymphedema, of which 11 LVAs were implemented with ICG-negative lymphatics. Immediately after the anastomosis, a strong lymphatic drainage could be appreciated in all cases. Six months postoperatively patients reported a subjective decrease in limb circumference and pressure sensation. CONCLUSIONS: We believe that ICG-negative lymphatics found intraoperatively should be evaluated for additional LVAs in order to maximize drainage effect and might provide better outcomes.

Comprehensive review of vascularized lymph node transfers for lymphedema: Outcomes and complications.

INTRODUCTION: Lymphedema remains a challenging clinical problem. A new field of lymphatic surgery using micro and super microsurgery techniques is a rapidly advancing field aimed to treat recalcitrant cases. The objective of this study was to evaluate outcomes and complications of vascularized lymph node transfer (VLNT). Several early preliminary studies have reported promising outcomes, but they are limited by small numbers, short follow-up, and are inconsistent in addressing the origin and recipient site of the transferred lymph nodes as well as the donor site morbidity. METHODS: A review of literature was conducted using PubMed-MEDLINE, EMBASE for key words vascularized lymph node transfer (also autologous, lymph node transplant). Only human studies were included. RESULTS: A total 24 studies encompassing 271 vascularized lymph node transfers were included. The inguinal nodes were the most commonly used donor site followed by the lateral thoracic lymph nodes. The lateral thoracic lymph nodes were the least effective and had the highest complication rates (27.5%) compared to other lymph node donor sites (inguinal: 10.3% and supraclavicular: 5.6%). Upper extremity lymphedema responded better compared to lower extremity (74.2 vs. 53.2%), but there was no difference in placing the lymph nodes more proximally versus distally on the extremity (proximal: 76.9% vs. distal: 80.4%). CONCLUSION: Vascularized lymph node transfer for lymphedema treatment is a promising operative technique showing beneficial results in early but also in advanced stage lymphedema. This physiologic surgical procedure should be included in a modern reconstructive concept for lymphedema treatment. © 2016 Wiley Periodicals, Inc. Microsurgery 38:222-229, 2018.

Systematic review of lymphovenous anastomosis (LVA) for the treatment of lymphedema.

INTRODUCTION: Lymphedema is a chronic condition caused by the obstruction or impairment of lymphatic fluid transport resulting in irreversible skin fibrosis. Besides conservative therapy, surgical techniques for lymphedema including liposuction, lymphatico-lymphatic bypass, lymphovenous anastomosis (LVA), and vascularized lymph node transfer (VLNT) are options with increasing popularity in the recent past. In our review, we investigated the efficacy of LVA for the treatment of lymphedema. Both objective and subjective outcomes of surgical treatment were evaluated. METHODS: Studies were identified through systematic review in PubMed database up to September 2016. Only original Articles which exclusively performed LVA for lymphedema treatment were included. Our primary endpoint was the objective of a subjective postoperative lymphedema reduction. RESULTS: A total of 293 titles were identified, out of which 18 studies including 939 patients were deemed eligible. The studies included in this review describe significant variations in surgical techniques, number of anastomoses and supplementary interventions. All studies reported objective reductions in circumference measurements. Subjective symptom relief was found in 50-100% of the patients as well as a reduction in the number of cellulitis episodes in all investigated cases. CONCLUSION: Although the studies included in this review showed great heterogeneity, LVA surgery revealed both objective and subjective improvements in most patients.

Changes in coagulation and temperature management in burn patients - A survey of burn centers in Switzerland, Austria and Germany.

BACKGROUND: Severely burned patients suffer from both coagulopathy and hypothermia, with a lack of international consensus and appropriate treatment guidelines. This study examines recent developments and trends in coagulation and temperature management in European burn centers. METHODS: A survey was sent to burn centers in Switzerland, Austria and Germany in 2016 and again in 2021. The analysis was performed using descriptive statistics, with categorical data reported in absolute numbers (n) and percentages (%) and numerical data reported as mean and standard deviation. RESULTS: The rate of completed questionnaires was 84 % (16 of 19 questionnaires) in 2016 and 91 % (21 of 22 questionnaires) in 2021. The number of global coagulation tests performed has decreased over the observation period in favor of single factor determination and bed-side point-of-care coagulation tests. This has also led to increased administration of single factor concentrates in therapy. Although many centers had a defined treatment protocol for hypothermia in 2016, coverage increased such that in 2021 all centers surveyed had such a protocol. The body temperature was measured more consistently in 2021; thus, hypothermia was more actively sought, detected and treated. CONCLUSION: A point-of-care guided, factor-based coagulation management and the maintenance of normothermia have gained importance in the care of burn patients in recent years.

Impact of allogeneic blood transfusions on clinical outcomes in severely burned patients.

BACKGROUND: Allogeneic blood transfusions are common in the treatment of severely burned patients as surgery may lead to major blood loss. However, transfusions are associated with a number of adverse events. Therefore, the purpose of our study was to investigate the impact of allogeneic blood transfusions on clinical outcomes in severely burned patients. METHODS: This retrospective study included all adult patients admitted to the burn center of the University Hospital Zurich between January 2004 and December 2014, with burn injuries greater than 10% of total body surface area and receiving both surgical and intensive care treatment. Primary Endpoints were infectious or thromboembolic complications and mortality and secondary endpoints were length of hospital and ICU stay. Simple and multivariable logistic and linear regression models, adjusted for injury severity and confounders, were applied. RESULTS: 413 patients met inclusion criteria of which 212 patients (51%) received allogenic blood products. After adjustment for injury severity and confounders, red blood cell transfusion was independently associated with wound infection (OR 13.5, 95% CI 1.7-107, p = 0.014), sepsis (OR 8.3, 4.2-16.3; p < 0.001), pneumonia (OR 4.7, 2.2-10.0; p < 0.001), thrombosis (OR 3.0, 1.2-7.4; p = 0.015), central line infection (OR 34.7, 4.6-260; p = 0.001) and a longer ICU and hospital stay (difference 17.7, CI 12.1-23.4, p < 0.001 and 22.0, 15.8-28.2, p < 0.001, respectively). Fresh frozen plasma transfusion was independently associated with a longer ICU and hospital stay (difference 13.7, 95% CI 5.5-21.8, p = 0.001 and 13.5, 4.6-22.5, p = 0.003, respectively). Platelet transfusion was independently associated with systemic inflammatory response syndrome (OR 4.5, 1.3-15.5; p = 0.018) and mortality (OR 5.8, 2.1-16.0; p = 0.001). CONCLUSION: Transfusion of allogeneic blood products is associated with an increased infection rate and thromboembolic morbidity and a longer hospital stay in severely burned patients.

Groin defect reconstruction with perforator flaps: Considerations after a retrospective single-center analysis of 54 consecutive cases.

INTRODUCTION: Groin defects with exposed complex structures are challenging to treat. Perforator flaps provide a contemporary alternative to established muscle flaps to cover all varieties of groin defects, with minimum donor site morbidity, less postoperative pain, and faster rehabilitation. In this retrospective single-center analysis, we aimed to show that pedicled perforator flaps are a valid option for groin defect reconstruction. We present three different pedicled perforator flaps and discuss the flap selection process and their distinct advantages and disadvantages. METHODS: A series of 54 consecutive cases of patients with groin defects were allocated into three different treatment groups. Reconstruction was performed utilizing the anterolateral thigh (ALT) flap, the pedicled posteromedial thigh (PMT) perforator flap, and the vertical deep inferior epigastric artery perforator (vDIEP) flap. RESULTS: All 54 flaps survived. Early complications included one hematoma (vDIEP) and two infections (ALT and PMT). Delayed complications occurred in three recipient-site seromas (ALT, PMT, and vDIEP), one donor-site seroma (vDIEP), and one flap dehiscence (ALT). All flaps provided stable coverage during 3-12 months of follow-up. CONCLUSION: We propose pedicled perforator flaps to be a safe and reliable option for groin defect reconstruction. The pedicled PMT flap should be the first choice if the profunda femoris artery and its perforators are available. The ALT flap can be applied as a second choice, especially if complex groin defect with exposed vascular prosthesis reconstruction is needed because of its versatile expansion options, for example, as a chimeric flap using a portion of the vastus lateralis muscle. In cases where the profunda femoris artery is not available, the vDIEP flap should be the preferred method.

Closed mallet thumb injury treated surgically: a case report.

In this report a case of closed mallet thumb injury is described, which was diagnosed clinically and indication for surgical treatment was confirmed with ultrasound examination. The EPL-tendon was successfully reconstructed with an excellent result. We propose a mandatory ultrasound examination of all closed mallet thumb injuries.

Analysis of Prognostic Values of Various PET Metrics in Preoperative 18F-FDG PET for Early-Stage Bronchial Carcinoma for Progression-Free and Overall Survival: Significantly Increased Glycolysis Is a Predictive Factor.

The purpose of this study was to assess various volume-based PET quantification metrics, including metabolic tumor volume and total lesion glycolysis (TLG) with different thresholds, as well as background activity-based PET metrics (background-subtracted lesion activity [BSL] and background-subtracted volume) as prognostic markers for progression-free and overall survival (PFS and OS, respectively) in early-stage I and II non-small cell lung cancer (NSCLC) after resection. Methods: Patients (n = 133) underwent an adequate 18F-FDG PET/CT scan before surgery between January 2003 and December 2010. All PET activity metrics showed a skewed distribution and were log-transformed before calculation of the Pearson correlation coefficients. Survival tree analysis was used to discriminate between high- and low-risk patients and to select the most important prognostic markers. The Akaike information criterion was used to compare 2 univariate models. Results: Within the study time, 36 patients died from NSCLC and 26 patients from other causes. At the end of follow-up, 70 patients were alive, with 67 patients being free of disease. All log-transformed PET metrics showed a strong linear association, with a Pearson correlation coefficient between 0.703 and 0.962. After multiple testing corrections, only 1 prognostic marker contributed a significant split point in the survival tree analysis. Of 10 potential predictors including 7 PET metrics, a BSL greater than 6,852 (P = 0.017) was chosen as split point, assigning 13 patients into a high-risk group. If BSL was removed from the set of predictors, a 42% TLG (TLG42%) of greater than 4,204 (P = 0.023) was chosen as split point. When a dichotomized BSL or TLG42% variable was used for a univariate Cox model, the Akaike information criterion difference of both models was smaller than 2; therefore, the data do not provide evidence that 1 of the 2 prognostic factors is superior. Conclusion: Volume-based PET metrics correlate with PFS and OS and could be used for risk assessment in stage I-II NSCLC. The different PET metrics assessed in this study showed a high correlation; therefore, it is not surprising that there was no significant difference to predict PFS or OS within this study. Overall, patients with large and metabolically active tumors should be considered high risk and might need further treatment after resection. Because all analysis steps were done with the same data, these results should be validated on new patient data.