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Eseme EA, Remy K, Mené BL, Walz SN, Madduri S, Oranges CM, Kalbermatten DF. Sensory and pain outcomes of neurotized skin-grafted free gracilis muscle flaps for lower extremity reconstruction. J Plast Reconstr Aesthet Surg 2024; 92:216-224. [PMID: 38574568 DOI: 10.1016/j.bjps.2024.02.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 02/24/2024] [Accepted: 02/29/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Skin-grafted free gracilis muscle flaps are commonly used for lower extremity reconstruction. However, the loss of sensory function may lead to increased patient morbidity. This study prospectively analyzed the sensory and neuropathic pain outcomes of neurotized skin-grafted free gracilis muscle flaps used for the reconstruction of lower extremity defects. METHODS Patients undergoing lower extremity reconstructions between 2020 and 2022 with neurotized skin-grafted free gracilis muscle flaps were prospectively enrolled. Sensation was assessed at 3, 6 and 12 months postoperatively using monofilaments, two-point discrimination, a vibration device, and cold and warm metal rods. Sensations were tested in the center and periphery of the flaps, as well as in the surrounding skin. The contralateral side served as the control. Patients completed the McGill pain questionnaire to evaluate patient-reported neuropathic pain. RESULTS Ten patients were included. At 12 months postoperatively, monofilament values improved by 44.5% compared to that of the control site, two-point discrimination, cold detection, warmth detection, and vibration detection improved by 36.2%, 48%, 50%, and 88.2%, respectively, at the reconstructed site compared to those at the control site. All sensory tests were significantly better than 3 and 6 months values (p < 0.05), but remained significantly poorer than the control site (p < 0.05). Sensation in the central flap areas were similar to peripheral flap areas throughout the follow-up period (p > 0.05). The surrounding skin reached values similar to the control site at 12 months (p > 0.05). Moreover, 50% of patients reported neuropathic pain at 3 months postoperatively, 40% at 6 months, and 0% at 12 months (p < 0.05). CONCLUSION Mechanical detection, vibration detection, temperature detection, and two-point discrimination significantly improved over time but without reaching normal sensory function at 12 months postoperatively. Neuropathic pain resolved at 12 months.
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Affiliation(s)
- Ebai A Eseme
- Department of Plastic, Reconstructive and Aesthetic Surgery, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Katya Remy
- Department of Plastic, Reconstructive and Aesthetic Surgery, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Blandine L Mené
- Department of Occupational Therapy, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Solange N Walz
- Department of Plastic, Reconstructive and Aesthetic Surgery, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Srinivas Madduri
- Department of Plastic, Reconstructive and Aesthetic Surgery, Geneva University Hospitals, University of Geneva, Geneva, Switzerland; Bioengineering and Neuroregeneration Laboratory, Department of Surgery, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Carlo M Oranges
- Department of Plastic, Reconstructive and Aesthetic Surgery, Geneva University Hospitals, University of Geneva, Geneva, Switzerland.
| | - Daniel F Kalbermatten
- Department of Plastic, Reconstructive and Aesthetic Surgery, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
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Huang QQ, He ZL, Wu YY, Liu ZJ. Limited thoracoplasty and free musculocutaneous flap transposition for postpneumonectomy empyema: A case report. World J Clin Cases 2021; 9:8114-8119. [PMID: 34621869 PMCID: PMC8462213 DOI: 10.12998/wjcc.v9.i27.8114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 05/24/2021] [Accepted: 08/12/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Empyema is a severe complication following pneumonectomy that is associated with high morbidity and mortality rates. Although there are a wide variety of treatment options, successful management remains challenging when this condition is combined with a large cavity in very thin patients who had previously undergone a posterolateral thoracotomy.
CASE SUMMARY We reported the case of a thin, 63-year-old man with a progressive pulmonary cyst who underwent left pneumonectomy via posterolateral thoracotomy 23 years ago. After an initially uneventful postoperative course, he was readmitted with empyema and a large cavity 21 years after surgery. He was successfully treated with limited thoracoplasty, followed by free vastus lateralis musculocutaneous flap transposition.
CONCLUSION This case highlights that the treatment mode of limited thoracoplasty and free vastus lateralis musculocutaneous flap transposition is safe and effective for the management of postpneumonectomy empyema with a large cavity in thin patients who had previously undergone a posterolateral thoracotomy.
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Affiliation(s)
- Qian-Qian Huang
- Operating Room, Tongde Hospital of Zhejiang Province, Hangzhou 310012, Zhejiang Province, China
| | - Zhong-Liang He
- Department of Cardiothoracic Surgery, Tongde Hospital of Zhejiang Province, Hangzhou 310012, Zhejiang Province, China
| | - Yong-Yong Wu
- Department of Cardiothoracic Surgery, Tongde Hospital of Zhejiang Province, Hangzhou 310012, Zhejiang Province, China
| | - Zhi-Jun Liu
- Department of Cardiothoracic Surgery, Tongde Hospital of Zhejiang Province, Hangzhou 310012, Zhejiang Province, China
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Galitzine S, Wilson K, Edington M, Burumdayal A, McNally M. Patients' reported experiences and outcomes following surgical excision of lower limb osteomyelitis and microvascular free tissue reconstruction under 'awake' epidural anaesthesia and sedation. Surgeon 2021; 19:193-199. [PMID: 32616367 PMCID: PMC7323658 DOI: 10.1016/j.surge.2020.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 04/29/2020] [Accepted: 05/07/2020] [Indexed: 11/13/2022]
Abstract
BACKGROUND Orthoplastic operations for lower limb osteomyelitis (LLOM) involving microvascular free tissue reconstructions ("free-flaps") are usually performed under general anaesthesia (GA), with or without epidural anaesthesia (EA) due to concerns about the discomfort associated with prolonged surgery. However, our clinical experience supports "awake" epidural anaesthesia with sedation (EA + Sed) rather than EA + GA as a technique of choice for this type of surgery. METHODS We used a standardised postoperative questionnaire to formally assess the experiences and outcomes for 50 patients who underwent free-flaps for LLOM under EA + Sed. FINDINGS The mean duration of surgery was 522 min (8.7 h), range 240-875 min. There were no ITU admissions or flap failures. Postoperatively, fifty patients completed a standardised questionnaire about their experiences before the operation, in the anaesthetic room and theatre. 80% were aware of the procedure at least "some of the time". 72.5% patients and 75% respectively, did not have any concerns in the anaesthetic room and theatre. Concerns expressed by the remaining patients were manageable. 97.5% of those patients who recalled their operation reported their overall experience as "comfortable" or "very comfortable". 92% of respondents had undergone previous lower limb surgery under GA ± EA. In this subgroup, 91.3% reported the recovery after EA + Sed as "quicker" than GA, and 89.4% reported their experience with EA + Sed as "better". All fifty patients (100%) were "satisfied" or "very satisfied" with their experience and all but one (98%) would recommend this technique to others. CONCLUSIONS Our study showed that despite prolonged duration, the patients' reported experiences and outcomes were excellent when EA + Sed was used for orthoplastic operations involving free-flaps for LLOM. We recommend EA + Sed as the anaesthetic technique of choice for such patients.
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Affiliation(s)
- Svetlana Galitzine
- Nuffield Department of Anaesthetics, Oxford University Hospitals, Oxford, UK.
| | - Katy Wilson
- Anaesthetic ST6, Nuffield Department of Anaesthetics, Oxford University Hospitals, Oxford, UK.
| | | | - Amisha Burumdayal
- Nuffield Department of Anaesthetics, Oxford University Hospitals, Oxford, UK.
| | - Martin McNally
- Oxford Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK.
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Nagel SS, Thomas B, Fischer S, Diehm Y, Ziegler B, Bigdeli AK, Schmidt VJ, Kneser U, Radu CA. Random-pattern versus perforator-based adipocutaneous skin paddles for postoperative monitoring of free muscle flaps-a comparative retrospective cohort study. J Plast Reconstr Aesthet Surg 2020; 74:747-754. [PMID: 33189621 DOI: 10.1016/j.bjps.2020.10.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 05/31/2020] [Accepted: 10/10/2020] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Free microvascular muscle flaps represent well-established reconstructive options for complex soft tissue defects. However, due to their lack of cutaneous capillary beds, they are difficult to monitor postoperatively. To this end, random and axial-pattern adipocutaneous skin paddles are often included. The objective of the study was to compare the impact of random-pattern versus perforator-based adipocutaneous skin paddles on operative efficacy and muscle flap safety. METHODS Between August 2014 and July 2016, a total of 120 free muscle flaps were included in this retrospective monocentric cohort study. Based on their skin-paddle type, they were either grouped into a 'perforator-based' (group Pb) or 'random-pattern' (group Rp) cohort. The electronic medical records and operative reports of all patients were subsequently reviewed and patient, defect, and flap characteristics of both groups were compared. The effect of the competing skin paddle types on the overall operative time, incidences of flap loss or microvascular complications, and total length of hospital stay were then assessed. RESULTS Group Pb comprised 72 flaps, whereas 48 flaps constituted group Rp. Patient, defect, and flap characteristics were similar between both groups. Groups Pb and Rp were comparable regarding patient age (group Pb: 61 (10-90) vs. Rp: 59 (13-81), p = 0.556), ASA (American Society of Anesthesiologists) class (group Pb: 3 (1-4) vs. Rp 3 (1-3), p = 0.977), and comorbidities, summarized by the Charlson comorbidity index (CCI; group Pb: 1 (0-4 vs. Rp: 1 (0-5), p = 0.295). Both types of monitoring skin paddles were equally reliable. There was no significant difference in the mean operation time between both groups (group Pb: 373 ± 122 min vs. Rp: 342 ± 84 min, p = 0.124). In-patient treatment after flap surgery and total length of hospital stay were significantly shorter in group Pb (group Pb: 24 ± 10 days vs. Rp: 32 ± 17 days, p = 0.002 and group Pb: 39 ± 15 vs. Rp: 48 ± 24, p = 0.022). CONCLUSION Perforator-based skin paddles are a reliable tool for postoperative perfusion monitoring of free muscle flaps and help avoid additional surgical interventions as opposed to their random-pattern counterparts. Thus, the overall and postoperative length of hospital stay is significantly reduced.
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Affiliation(s)
- S S Nagel
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic- and Hand Surgery, University of Heidelberg, Germany
| | - B Thomas
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic- and Hand Surgery, University of Heidelberg, Germany
| | - S Fischer
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic- and Hand Surgery, University of Heidelberg, Germany
| | - Y Diehm
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic- and Hand Surgery, University of Heidelberg, Germany
| | - B Ziegler
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic- and Hand Surgery, University of Heidelberg, Germany
| | - A K Bigdeli
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic- and Hand Surgery, University of Heidelberg, Germany
| | - V J Schmidt
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic- and Hand Surgery, University of Heidelberg, Germany
| | - U Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic- and Hand Surgery, University of Heidelberg, Germany
| | - C A Radu
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic- and Hand Surgery, University of Heidelberg, Germany.
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Spindler N, Hanske S, Schierle K, Aydogan E, Böhme J, Langer S, Josten C. [Glomuvenous malformations]. Orthopade 2015; 44:716-9. [PMID: 26201945 DOI: 10.1007/s00132-015-3142-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
SYMPTOMS A patient presented suffering from neural pain in the medial foot for a period of over 20 years. DIAGNOSIS Diagnostic showed a widely spread soft-tissue tumor consisting of confluent glomuvenous malformations that was responsible for the immense pain syndrome.The solitary or multiform-appearing knots are not compressible and manifest as the characteristic syndromes of regional pain, sensitivity to coldness, or local pressure pain. Alternatively, the patient could also be completely symptom-free. TREATMENT Because of the dimension of the tumor and the degree of suffering, a radical resection with simultaneous microsurgical reconstruction was carried out. Twelve weeks postoperatively, healing of the flap stabilized, the foot is fully weight-bearing, and the patient is pain-free.
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