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Humnekar A, Kala PC, Dixit PK, Katrolia D, Karmakar S, Singla P, Singh AP. Propeller vs. free fasciocutaneous flap in reconstruction of complex lower limb defects-A prospective study. J Plast Reconstr Aesthet Surg 2024; 93:235-241. [PMID: 38723508 DOI: 10.1016/j.bjps.2024.04.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 03/05/2024] [Accepted: 04/05/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND Of all body regions, lower extremity wounds have been and remain the greatest challenge. Free flaps have been accepted as a reasonable option to solve this dilemma, but they require the complexity of microsurgery. This study aimed to compare the postoperative and clinical outcomes of propeller flap and fasciocutaneous free flap in the reconstruction of complex lower limb defects. MATERIALS AND METHODS This randomized controlled trial was conducted from July 2021 to June 2023. Selected patients were randomized into two groups: the propeller flap group and fasciocutaneous free flap group. Demographic data, preoperative parameters, and postoperative parameter, including esthetic analysis, scar assessment, neurosensory analysis, psychosocial analysis, and lower extremity function, were estimated and statistically significant compared between the two study groups. RESULTS Road traffic accident (73.3%) was the most common etiology for lower limb defects in both groups. The foot and lower third of the leg were the most common site of defect, constituting 79.99%. The duration of surgery was significantly shorter in propeller flap as compared to fasciocutaneous free flaps. Flap size was smaller, with better neurosensory improvements in propeller flap group. Esthetic analysis, scar assessment, psychosocial analysis, and lower extremity functional analysis yielded similar results in both study groups. CONCLUSION Propeller flap has better outcomes compared to free flap in terms of smaller size of flap, shorter duration of surgery, and reduced length of hospital stay. Comparable results were obtained with respect to esthetic score, scar assessment score, psychosocial analysis, and neurosensory recovery and lower extremity functional score.
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Affiliation(s)
- Akhilesh Humnekar
- Department of Burns and plastic surgery, All India Institute of Medical Science, Jodhpur, Rajasthan, India.
| | - Prakash C Kala
- Department of Burns and plastic surgery, All India Institute of Medical Science, Jodhpur, Rajasthan, India
| | - Pawan K Dixit
- Department of Burns and plastic surgery, All India Institute of Medical Science, Jodhpur, Rajasthan, India
| | - Deepti Katrolia
- Department of Burns and plastic surgery, All India Institute of Medical Science, Jodhpur, Rajasthan, India
| | - Shilpi Karmakar
- Department of Burns and plastic surgery, All India Institute of Medical Science, Jodhpur, Rajasthan, India
| | - Priyanka Singla
- Department of Burns and plastic surgery, All India Institute of Medical Science, Jodhpur, Rajasthan, India
| | - Apoorva P Singh
- Department of Burns and plastic surgery, All India Institute of Medical Science, Jodhpur, Rajasthan, India
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Renom M, Feuvrier D, Obert L, Sergent AP, Loisel F, Pluvy I. [Emergency free flap in reconstruction of the lower limb: About 23 cases over 11 years]. ANN CHIR PLAST ESTH 2023; 68:326-332. [PMID: 36463023 DOI: 10.1016/j.anplas.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 10/30/2022] [Accepted: 11/07/2022] [Indexed: 12/05/2022]
Abstract
OBJECTIVES To study the coverage period influence and various parameters concerning the microsurgical act on the patient clinical outcomes. METHODS We report 23 cases of reconstruction of lower limb loss of substance by free flap operated from 2010 to 2021. Among them, 9 patients were operated on as an emergency versus 14 in the secondary or late phase of the trauma. RESULTS The average age of injured patients operated on emergency was 42 years (17-68 years) and 34 years for the patients who undergo deferred surgery (17-57 years). The sex ratio (female/male) was 22% in patients operated on urgently and 7% in patients operated on later. Regarding the type of free flap, it was Serratus anterior muscle flap in 10 cases, Latissismus dorsi flap in 9 cases, ALT flap in 3 cases and Gracilis muscle flap in 1 case. There were 2 failures of vascularized free transfer (8.7%) with complete necrosis of the flap and 3 revision surgeries on venous thrombosis which finally made it possible to obtain 3 flap successes. We analyze the results (complications/osteitis) according to the time to coverage. CONCLUSIONS In our study, we did not find any significant difference between the groups operated in emergency and at a distance concerning the rate of infection and failure of the flaps.
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Affiliation(s)
- M Renom
- Service de chirurgie orthopédique, traumatologique, chirurgie plastique et assistance main, CHU Besançon, 25000 Besançon, France.
| | - D Feuvrier
- Service de chirurgie orthopédique, traumatologique, chirurgie plastique et assistance main, CHU Besançon, 25000 Besançon, France
| | - L Obert
- Service de chirurgie orthopédique, traumatologique, chirurgie plastique et assistance main, CHU Besançon, 25000 Besançon, France
| | - A-P Sergent
- Service de chirurgie orthopédique, traumatologique, chirurgie plastique et assistance main, CHU Besançon, 25000 Besançon, France
| | - F Loisel
- Service de chirurgie orthopédique, traumatologique, chirurgie plastique et assistance main, CHU Besançon, 25000 Besançon, France
| | - I Pluvy
- Service de chirurgie orthopédique, traumatologique, chirurgie plastique et assistance main, CHU Besançon, 25000 Besançon, France
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Jeong SH, Namgoong S, Dhong ES, Han SK. Deep vein thrombosis in donor or recipient veins encountered during lower extremity reconstruction with a free anterolateral thigh perforator flap: How do we deal with it? Front Surg 2022; 9:985245. [PMID: 36248374 PMCID: PMC9557242 DOI: 10.3389/fsurg.2022.985245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 09/12/2022] [Indexed: 11/13/2022] Open
Abstract
Background The free anterolateral thigh perforator (ALTP) flap has been successfully adopted to reconstruct traumatic soft tissue defects in the lower extremities. However, the occurrence of deep vein thrombosis (DVT) in donor or recipient veins has been overlooked, and there has been no reliable guideline to manage it. Therefore, in this study, we review our cases where the ALTP flaps were transferred to traumatic lower limbs even though DVT was found in the pedicle or recipient veins. Furthermore, based on our experiences, we suggest an algorithmic approach for dealing with DVT. Patients and methods This study included 108 patients who underwent lower extremity reconstruction using a free ALTP flap between January 2014 and January 2021. All medical records were reviewed, including preoperative assessment data, intraoperative findings, and postoperative complications. Notably, when DVT was found in both the donor and recipient veins, we thoroughly assessed operative findings, surgical solutions, and final outcomes. Results Sixty-one of 108 (56.4%) patients underwent computed tomographic venography (CTV) preoperatively, revealing DVT in 11 of these 61 (18%) patients. Three of these 11 patients had iliofemoral DVT, and surgery was delayed more than two weeks after detection. The remaining eight patients had calf DVT and underwent free ALTP flap transfer as scheduled. Conversely, 47 of 108 (43.6%) patients did not undergo CTV, and an occult DVT was found in five of these 47 (10.6%) patients. In two of these five patients, free flap surgery was replaced with amputation and local flap coverage. In the remaining three patients and one patient with an occult DVT that was not found on CTV, the free ALTP flap transfer was carried out. In 15 patients with DVT, free ALTP flap transfer was performed using various alternative methods for venorrhaphy. Consequently, all flaps survived, with partial necrosis occurring in two patients. Conclusion If DVT-affected veins are appropriately managed, the free ALTP flap can be successfully transferred to the traumatic lower limb even when DVT occurs in donor or recipient veins. The author's algorithm can help surgeons overcome the insufficiency of veins for pedicle anastomosis due to DVT and avoid postoperative thromboembolic complications.
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Pedicled Omental Transposition for Recurrent Skin Erosion Following Deep Brain Stimulation Without Hardware Removal. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03354-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Extensor digitorum brevis muscle flap for lower extremity coverage in a context of posttraumatic sepsis. Orthop Traumatol Surg Res 2021; 107:102901. [PMID: 33766678 DOI: 10.1016/j.otsr.2021.102901] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 07/20/2020] [Accepted: 09/14/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Traumatic injuries to the distal quarter of the leg present a significant risk of skin necrosis and exposure of the underlying fracture site or the osteosynthesis material that often result in bone and joint infection. In the case of small or medium-sized bone exposure, local muscles may be one of the best options for lower extremity coverage. We describe our experience using the extensor digitorum brevis muscle flap in a context of posttraumatic bone and joint infection in fourteen patients. Our main objective was to assess the outcomes and the donor-site morbidity of the extensor digitorum brevis muscle flap. MATERIALS AND METHODS A single-center retrospective study in a French reference center for bone and joint infection from 2014 to 2018 reviewed cases of traumatic injuries with skin complications and bone and joint infection that required an extensor digitorum brevis muscle flap coverage. Fourteen patients were evaluated for early and late complications, 11 men and three women with a mean age of 51.4±17.72 (19-71) years. Seven of these were open fractures and nine cases were pilon fractures. Donor-site morbidity was assessed in nine patients. RESULTS Early flap complications included two cases (14.2%) of hematoma, one case (7.1%) of partial necrosis and four cases (28.5%) of donor-site dehiscence. Late complications caused by persistent infection were found in two patients (14.2%), with one case (7.1%) of chronic osteoarthritis and one case (7.1%) of septic pseudarthrosis. From a functional and cosmetic point of view, eight patients (89%) were satisfied, to very satisfied. CONCLUSION Experience and a multidisciplinary approach are keys in providing an optimal treatment strategy for complex cases of bone and joint infection. The extensor digitorum brevis muscle is a reliable flap for small defects with underlying infection. Being made up of muscle tissue, this flap offers good resistance to infection and enables satisfactory distribution of antibiotics. LEVEL OF EVIDENCE IV.
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Baus A, Bich CS, Grosset A, de Rousiers A, Duhoux A, Brachet M, Duhamel P, Thomas M, Rogez D, Mathieu L, Bey E. Medical and surgical management of lower extremity war-related injuries. Experience of the French Military Health Service (FMHS). ANN CHIR PLAST ESTH 2020; 65:447-478. [DOI: 10.1016/j.anplas.2020.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 05/13/2020] [Indexed: 01/27/2023]
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Multidisciplinary management of the bone and joint infection complicating treatment of an open fracture of the lower limb. ANN CHIR PLAST ESTH 2020; 65:380-393. [PMID: 32800464 DOI: 10.1016/j.anplas.2020.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 05/21/2020] [Indexed: 11/24/2022]
Abstract
Bone and joint infections (BJI) of the lower limb can cause functional sequelae and in some cases have an impact on patient's life prognostic. One of the main objectives of multidisciplinary consultation team meetings (MTM) in the treatment of bone and joint infections is to provide an appropriate medical-surgical care, pooling skills of different organ specialists: infectious disease physicians, microbiologists, orthopedic surgeons and plastic surgeons. Treatment is based on aggressive debridement, bone stabilization, adequate antibiotic therapy, long-term coverage of the loss of skin substance and close clinical monitoring. The authors present their multidisciplinary diagnostic and therapeutic approaches to BJI complicating an open fracture at a referent center in the management of complex bone and joint infections.
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Pasquesoone L, Barry L, Sturbois-Nachef N, Duquennoy-Martinot V, Chantelot C, Guerre E. The interest of "ortho-plastic" collaboration in management of complex limb injury. ANN CHIR PLAST ESTH 2020; 65:423-446. [PMID: 32654841 DOI: 10.1016/j.anplas.2020.05.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 05/21/2020] [Indexed: 01/26/2023]
Abstract
Constantly evolving knowledge on fracture management, soft tissue coverage, microsurgery and vasculo-nervous repair now permits salvage of limbs that previously would have had to be amputated. Management of complex limb injuries of which the severity inevitably entails functional and esthetic sequelae calls for mastery of the full spectrum of bone and soft tissue reconstruction. Such mastery is rarely attainable by a single surgical specialty; individually and isolatedly, an orthopedic or plastic surgeon cannot ensure optimal management of the above-mentioned patients. While the orthopedist performs a key function in provisional or definitive fixation, the plastic surgeon's expertise is essential to restoration of the cutaneous envelope. Collaboration between the two specialties from the outset and throughout treatment characterizes the modern-day concept of "ortho-plastic" surgery. Through unification of the theoretical competence and practical skills of orthopedists and plastic surgeons, it provides a patient with the best possible functional and esthetic results in a wide range of clinical situations. In this article, we present a review of the literature illustrating the interest of "ortho-plastic" collaboration in management of complex limb injury; concrete examples will be given through evocation of clinical cases encountered by the team that was put together in August 2015 at the university hospital (CHU) of Lille.
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Affiliation(s)
- L Pasquesoone
- Service de chirurgie plastique, reconstructrice et esthétique, Centre de traitement des brûlés, CHU, Hôpital Roger-Salengro, avenue Emile-Laine, 59037 Lille, France.
| | - L Barry
- Service de chirurgie plastique, reconstructrice et esthétique, Centre de traitement des brûlés, CHU, Hôpital Roger-Salengro, avenue Emile-Laine, 59037 Lille, France
| | - N Sturbois-Nachef
- Service d'orthopédie B, CHU Lille, Hôpital Roger-Salengro, avenue Emile-Laine, 59037 Lille, France
| | - V Duquennoy-Martinot
- Service de chirurgie plastique, reconstructrice et esthétique, Centre de traitement des brûlés, CHU, Hôpital Roger-Salengro, avenue Emile-Laine, 59037 Lille, France
| | - C Chantelot
- Service de traumatologie, CHU Lille, Hôpital Roger-Salengro, avenue Emile-Laine, 59037 Lille, France
| | - E Guerre
- Service d'orthopédie B, CHU Lille, Hôpital Roger-Salengro, avenue Emile-Laine, 59037 Lille, France
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Innocenti M, Dell'Acqua I, Famiglietti M, Vignini L, Menichini G, Ghezzi S. Free perforator flaps vs propeller flaps in lower limb reconstruction: A cost/effectiveness analysis on a series of 179 cases. Injury 2019; 50 Suppl 5:S11-S16. [PMID: 31706586 DOI: 10.1016/j.injury.2019.10.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE The aim of this report is to compare free perforator flaps and propeller flaps in the coverage of lower limb soft tissue defects. PATIENTS AND METHODS 179 patients (age between 5 and 92 years old), underwent soft tissue reconstruction of the lower limb between January 2009 and January 2015, either by free flap or propeller flap. The two groups were retrospectively evaluated in order to assess the outcome, complications and potential risk factors. Correlations between risk factors and presence/absence of failure or complications have been evaluated with descriptive statistical analysis and a set of logistic regression models. Finally, an economic analysis was conducted to evaluate the different tecniques. RESULTS In a simple descriptive statistical analysis, the overall failure rate is 6% for free flaps and 3.7% for propeller flaps; the complication rates are 14% vs 21.5% and it increases as dimension increases. The logistic models relating failure and complications with potential risk factors do not show significant differences, whereas the economic analysis show that the average expense of free flaps is 5077.5€ per patient, 1595.6€ per patient for propeller flaps. CONCLUSIONS Our results do not demonstrate significant differences between the two groups about correlation of risk factors or flap size with complication or failure. The surgical option choice should be taken only after accurate evaluation of the soft tissue surrounding the defect. Propeller flaps should be preferred in case of small/medium size defects in otherwise healthy extremities. Free perforator flaps should be the choice in large defects due to trauma or vascular diseases. The economic analysis suggests that propeller flap should be considered when possible.
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Affiliation(s)
- Marco Innocenti
- Department of Plastic and Reconstructive Surgery and Microsurgery, Careggi University Hospital, Largo Palagi 1, 50139 Florence, Italy.
| | - Irene Dell'Acqua
- Department of Plastic and Reconstructive Surgery and Microsurgery, Careggi University Hospital, Largo Palagi 1, 50139 Florence, Italy
| | - Matteo Famiglietti
- Department of Plastic and Reconstructive Surgery and Microsurgery, Careggi University Hospital, Largo Palagi 1, 50139 Florence, Italy
| | - Livia Vignini
- Department of Plastic and Reconstructive Surgery and Microsurgery, Careggi University Hospital, Largo Palagi 1, 50139 Florence, Italy
| | - Giulio Menichini
- Department of Plastic and Reconstructive Surgery and Microsurgery, Careggi University Hospital, Largo Palagi 1, 50139 Florence, Italy
| | - Serena Ghezzi
- Department of Plastic and Reconstructive Surgery and Microsurgery, Careggi University Hospital, Largo Palagi 1, 50139 Florence, Italy.
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Kopp Q, Montoya D, Brix M, Dautel G, Simon E. [Analysis of microsurgical reconstruction activity in a university hospital: A 14-year historical cohort]. ANN CHIR PLAST ESTH 2019; 64:311-319. [PMID: 31047765 DOI: 10.1016/j.anplas.2019.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Accepted: 03/14/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Each university hospital has its own specificities in microsurgical reconstructions. Activities may focus on breast reconstruction, ENT reconstruction or traumatic substance loss. This study analyzes the specificities at the University Hospital of Nancy, studies the indications, the operating data and the failure rates. METHOD We realized a historical cohort of microsurgical reconstructions at Nancy University Hospital from January 1, 2004 to December 31, 2017. All free flaps were included and analyzed. RESULTS A total of 359 free flaps were made. The failure rate was 9.47%. Forty eight different operators have been identified. Substance losses were essentially traumatic (56.8%). A total of 20 different flaps were use with 49% bone reconstruction. The fibula flap was the first flap used (26.5%). Arterial anastomoses were performed in termino-lateral in 44% and venous anastomoses were single in 70.5%. High BMI, diabetes, high blood pressure, atherosclerosis, and arterial or venous graft were identified as risk factors for failure (P<0.05). The smoking and the realisation of the intervention by a young operator have no impact on the success rate. CONCLUSION Our specificity is the bone reconstruction which represents a significant part of our activity. In the university center, the number of etiology of substance losses, operator and flap used is important but it still allows to obtain results in adequacy with the literature.
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Affiliation(s)
- Q Kopp
- Service de chirurgie maxillofaciale, plastique, reconstructrice et esthétique, CHRU de Nancy, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54000 Nancy, France; Université de Lorraine, 54000 Nancy, France; Service de chirurgie reconstructrice de l'appareil locomoteur et chirurgie de la main, CHRU de Nancy, centre chirurgical Émile-Gale, 54000 Nancy, France.
| | - D Montoya
- Université de Lorraine, 54000 Nancy, France; Service de chirurgie reconstructrice de l'appareil locomoteur et chirurgie de la main, CHRU de Nancy, centre chirurgical Émile-Gale, 54000 Nancy, France
| | - M Brix
- Service de chirurgie maxillofaciale, plastique, reconstructrice et esthétique, CHRU de Nancy, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54000 Nancy, France; Université de Lorraine, 54000 Nancy, France
| | - G Dautel
- Université de Lorraine, 54000 Nancy, France; Service de chirurgie reconstructrice de l'appareil locomoteur et chirurgie de la main, CHRU de Nancy, centre chirurgical Émile-Gale, 54000 Nancy, France
| | - E Simon
- Service de chirurgie maxillofaciale, plastique, reconstructrice et esthétique, CHRU de Nancy, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54000 Nancy, France; Université de Lorraine, 54000 Nancy, France
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Wain RAJ, Gaskell NJ, Fsadni AM, Francis J, Whitty JPM. Finite Element Predictions of Sutured and Coupled Microarterial Anastomoses. ADVANCED BIOMEDICAL ENGINEERING 2019. [DOI: 10.14326/abe.8.63] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Richard AJ Wain
- John Tyndall Institute, School of Engineering, University of Central Lancashire
- School of Medicine and Dentistry, University of Central Lancashire
- Department of Plastic & Reconstructive Surgery, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust
| | - Nicolas J Gaskell
- John Tyndall Institute, School of Engineering, University of Central Lancashire
| | - Andrew M Fsadni
- John Tyndall Institute, School of Engineering, University of Central Lancashire
| | - Jonathan Francis
- John Tyndall Institute, School of Engineering, University of Central Lancashire
| | - Justin PM Whitty
- John Tyndall Institute, School of Engineering, University of Central Lancashire
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Wain RAJ, Smith DJ, Hammond DR, Whitty JPM. Influence of microvascular sutures on shear strain rate in realistic pulsatile flow. Microvasc Res 2018. [PMID: 29522755 DOI: 10.1016/j.mvr.2018.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Arterial thrombus formation is directly related to the mechanical shear experienced by platelets within flow. High shear strain rates (SSRs) and large shear gradients cause platelet activation, aggregation and production of thrombus. This study, for the first time, investigates the influence of pulsatile flow on local haemodynamics within sutured microarterial anastomoses. We measured physiological arterial waveform velocities experimentally using Doppler ultrasound velocimetry, and a representative example was applied to a realistic sutured microarterial geometry. Computational geometries were created using measurements taken from sutured chicken femoral arteries. Arterial SSRs were predicted using computational fluid dynamics (CFD) software, to indicate the potential for platelet activation, deposition and thrombus formation. Predictions of steady and sinusoidal inputs were compared to analyse whether the addition of physiological pulse characteristics affects local intravascular flow characteristics. Simulations were designed to evaluate flow in pristine and hand-sutured microarterial anastomoses, each with a steady-state and sinusoidal pulse component. The presence of sutures increased SSRmax in the anastomotic region by factors of 2.1 and 2.3 in steady-state and pulsatile flows respectively, when compared to a pristine vessel. SSR values seen in these simulations are analogous to the presence of moderate arterial stenosis. Steady-state simulations, driven by a constant inflow velocity equal to the peak systolic velocity (PSV) of the measured pulsatile flow, underestimated SSRs by ∼ 9% in pristine, and ∼ 19% in sutured vessels compared with a realistic pulse. Sinusoidal flows, with equivalent frequency and amplitude to a measured arterial waveform, represent a slight improvement on steady-state simulations, but still SSRs are underestimated by 1-2%. We recommend using a measured arterial waveform, of the form presented here, for simulating pulsatile flows in vessels of this nature. Under realistic pulsatile flow, shear gradients across microvascular sutures are high, of the order ∼ 7.9 × 106 m-1 s-1, which may also be associated with activation of platelets and formation of aggregates.
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Affiliation(s)
- R A J Wain
- School of Mathematics, University of Birmingham, B15 2TT, UK; Institute of Translational Medicine, University of Birmingham, B15 2TT, UK; School of Medicine and Dentistry, University of Central Lancashire, Preston PR1 2HE, UK; Computational Mechanics Research Group, School of Engineering, University of Central Lancashire, Preston PR1 2HE, UK.
| | - D J Smith
- School of Mathematics, University of Birmingham, B15 2TT, UK; Institute for Metabolism and Systems Research, University of Birmingham, B15 2TT, UK
| | - D R Hammond
- School of Medicine and Dentistry, University of Central Lancashire, Preston PR1 2HE, UK
| | - J P M Whitty
- Computational Mechanics Research Group, School of Engineering, University of Central Lancashire, Preston PR1 2HE, UK
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Bekara F, Herlin C, Somda S, de Runz A, Grolleau JL, Chaput B. Free versus perforator-pedicled propeller flaps in lower extremity reconstruction: What is the safest coverage? A meta-analysis. Microsurgery 2016; 38:109-119. [PMID: 27018650 DOI: 10.1002/micr.30047] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 02/22/2016] [Accepted: 02/25/2016] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Currently, increasingly reconstructive surgeon consider the failure rates of perforator propeller flaps especially in the distal third of the lower leg are too important and prefer to return to the use of free flap at first line option with failure rates frequently lower than 5%. So, we performed a systematic review with meta-analysis comparing free flaps (perforator-based or not) and pedicled-propeller flaps to respond to the question "what is the safest coverage for distal third of the lower limb?" METHODS This review was conducted according to PRISMA criteria. From 1991 to 2015, MEDLINE®, Pubmed central, Embase and Cochrane Library were searched. The pooled estimations were performed by meta-analysis. The homogeneity Q statistic and the I2 index were computed. RESULTS We included 36 articles for free flaps (1,226 flaps) and 19 articles for pedicled-propeller flaps (302 flaps). The overall failure rate was 3.9% [95%CI:2.6-5.3] for free flaps and 2.77% [95%CI:0.0-5.6] for pedicled-propeller flaps (P = 0.36). The complication rates were 19.0% for free flaps and 21.4% for pedicled-propeller flaps (P = 0.37). In more detail, we noted for free flaps versus pedicled-propeller flaps: partial necrosis (2.70 vs. 6.88%, P = 0.001%), wound dehiscence (2.38 vs. 0.26%, P = 0.018), infection (4.45 vs. 1.22%, P = 0.009). The coverage failure rate was 5.24% [95%CI:3.68-6.81] versus 2.99% [95%CI:0.38-5.60] without significant difference (P = 0.016). CONCLUSION In the lower limb the complications are not rare and many teams consider the free flaps to be safer. In this meta-analysis we provide evidence that failure and overall complications rate of perforator propeller flaps are comparable with free flaps. Although, partial necrosis is significantly higher for pedicled-propeller flaps than free flaps, in reality the success of coverage appears similar. © 2016 Wiley Periodicals, Inc. Microsurgery, 38:109-119, 2018.
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Affiliation(s)
- Farid Bekara
- Department of Plastic and Reconstructive Surgery, Lapeyronie University Hospital, Montpellier, France
| | - Christian Herlin
- Department of Plastic and Reconstructive Surgery, Lapeyronie University Hospital, Montpellier, France
| | - Serge Somda
- Biostatistic Unit, Institut Universitaire du Cancer Toulouse, Toulouse, France
| | - Antoine de Runz
- Department of Plastic and Reconstructive Surgery, Nancy University Hospital, Nancy, France
| | - Jean Louis Grolleau
- Department of Plastic and Reconstructive Surgery, Rangueil University Hospital, Toulouse, France
| | - Benoit Chaput
- Department of Plastic and Reconstructive Surgery, Rangueil University Hospital, Toulouse, France
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Heterotopic Ossification following Tissue Transfer for Combat-Casualty Complex Periarticular Injuries. Plast Reconstr Surg 2015; 136:808e-814e. [DOI: 10.1097/prs.0000000000001796] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Verbelen J, Hoeksema H, Pirayesh A, Van Landuyt K, Monstrey S. Exposed tibial bone after burns: Flap reconstruction versus dermal substitute. Burns 2015; 42:e31-7. [PMID: 26376411 DOI: 10.1016/j.burns.2015.08.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 08/03/2015] [Indexed: 11/26/2022]
Abstract
A 44 years old male patient had suffered extensive 3rd degree burns on both legs, undergoing thorough surgical debridement, resulting in both tibias being exposed. Approximately 5 months after the incident he was referred to the Department of Plastic and Reconstructive Surgery of the University Hospital Gent, Belgium, to undergo flap reconstruction. Free flap surgery was performed twice on both lower legs but failed on all four occasions. In between flap surgery, a dermal substitute (Integra(®)) was applied, attempting to cover the exposed tibias with a layer of soft tissue, but also without success. In order to promote the development of granulation tissue over the exposed bone, small holes were drilled in both tibias with removal of the outer layer of the anterior cortex causing the bone to bleed and subsequently negative pressure wound therapy (NPWT) was applied. The limited granulation tissue resulting from this procedure was then covered with a dermal substitute (Glyaderm(®)), consisting of acellular human dermis with an average thickness of 0.25mm. This dermal substitute was combined with a NPWT-dressing, and then served as an extracellular matrix (ECM), guiding the distribution of granulation tissue over the remaining areas of exposed tibial bone. Four days after initial application of Glyaderm(®) combined with NPWT both tibias were almost completely covered with a thin coating of soft tissue. In order to increase the thickness of this soft tissue cover two additional layers of Glyaderm(®) were applied at intervals of approximately 1 week. One week after the last Glyaderm(®) application both wounds were autografted. The combination of an acellular dermal substitute (Glyaderm(®)) with negative pressure wound therapy and skin grafting proved to be an efficient technique to cover a wider area of exposed tibial bone in a patient who was not a candidate for free flap surgery. An overview is also provided of newer and simpler techniques for coverage of exposed bone that could question the universal plastic surgery paradigm that flap surgery is the only way to cover these defects.
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Affiliation(s)
- Jozef Verbelen
- Department of Plastic and Reconstructive Surgery - Burn Center Gent University Hospital, Gent, Belgium
| | - Henk Hoeksema
- Department of Plastic and Reconstructive Surgery - Burn Center Gent University Hospital, Gent, Belgium
| | | | - Koenraad Van Landuyt
- Department of Plastic and Reconstructive Surgery - Burn Center Gent University Hospital, Gent, Belgium
| | - Stan Monstrey
- Department of Plastic and Reconstructive Surgery - Burn Center Gent University Hospital, Gent, Belgium.
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Chan JK, Gardiner MD, Pearse M, Nanchahal J. Lower limb reconstruction. Plast Reconstr Surg 2015. [DOI: 10.1002/9781118655412.ch46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Cashion AT, Caballero M, Halevi A, Pappa A, Dennis RG, van Aalst JA. Programmable mechanobioreactor for exploration of the effects of periodic vibratory stimulus on mesenchymal stem cell differentiation. Biores Open Access 2014; 3:19-28. [PMID: 24570842 PMCID: PMC3931438 DOI: 10.1089/biores.2013.0048] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
A programmable bioreactor using a voice-coil actuator was developed to enable research on the effects of periodic vibratory stimulus on human and porcine mesenchymal stem cells (MSCs). We hypothesized that low frequency vibrations would result in a cartilage phenotype and higher frequency vibrations would result in a bone phenotype. The mechanical stimulation protocol is adjusted from a computer external to the incubator via a USB cable. Once programmed, the embedded microprocessor and sensor system on the bioreactor execute the protocol independent of the computer. In each test, a sinusoidal stimulus was applied to a culture plate in 1-min intervals with a 15-min rest following each, for a total of 15 h per day for 10 days. Frequencies of 1 and 100 Hz were applied to cultures of both human and porcine umbilical cord–derived MSCs. Chondrogenesis was determined by Alcian blue staining for glycosaminoglycans and an increased differentiation index (ratio of mRNA for collagen II and collagen I). Osteogenic differentiation was indicated with Alizarin red for calcium staining and increased bone morphogenetic protein 2 mRNA. One-hertz stimulation resulted in a cartilage phenotype for both human and porcine MSCs, while 100-Hz stimulation resulted in a bone phenotype.
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Affiliation(s)
- Avery T Cashion
- Joint Department of Biomedical Engineering, University of North Carolina and North Carolina State University , Chapel Hill, North Carolina
| | - Montserrat Caballero
- Division of Plastic Surgery, Department of Surgery, University of North Carolina , Chapel Hill, North Carolina
| | - Alexandra Halevi
- Division of Plastic Surgery, Department of Surgery, University of North Carolina , Chapel Hill, North Carolina
| | - Andrew Pappa
- Division of Plastic Surgery, Department of Surgery, University of North Carolina , Chapel Hill, North Carolina
| | - Robert G Dennis
- Joint Department of Biomedical Engineering, University of North Carolina and North Carolina State University , Chapel Hill, North Carolina
| | - John A van Aalst
- Division of Plastic Surgery, Department of Surgery, University of North Carolina , Chapel Hill, North Carolina
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