Journal of reconstructive microsurgery最新文献

Background: Lymphovenous anastomosis (LVA) is a microsurgical procedure that redirects stagnant lymph flow into the venous circulation, reducing fluid stasis in patients with secondary limb lymphedema. Although previous studies have reported that complex decongestive therapy redistributes fluid from the affected leg to other body segments, whether fluid reduction after LVA results from systemic elimination or intersegmental redistribution remains unclear. This study aimed to clarify the mechanism by analyzing the changes in segmental body water volume using bioelectrical impedance analysis.

Methods: We retrospectively analyzed the data of 40 Japanese women with unilateral stage II secondary leg lymphedema who underwent LVA from 2013 to 2021. Multifrequency segmental bioelectrical impedance analysis was used to assess extracellular, intracellular, and segmental body water in the legs, trunk, and arms. Measurements were performed preoperatively and at least 12 months postoperatively. Changes in segmental and total body water were statistically evaluated.

Results: Significant reductions were observed in segmental body water in the affected leg, and in the total body water (affected leg: 5.80 L to 5.20 L, p < 0.001; total body water: 25.6 L to 25.0 L, p = 0.002), with no significant changes in the unaffected leg, trunk, or arms. Extracellular and intracellular water in the affected leg decreased significantly (p = 0.001 and p < 0.001, respectively), whereas the percentage of extracellular water remained stable.

Conclusion: LVA achieved sustained reductions in segmental and total body water volumes, localized to the affected leg, without compensatory increases in other body segments. These findings support the efficacy of leg LVA in achieving long-term fluid homeostasis through systemic elimination of excess lymphatic fluid rather than redistribution.

Background: Lower extremity lymphedema (LEL) is a frequent, under recognized, and chronic condition. The prevalence of this condition in patients with lower limb trauma is unclear. A self-reported lower extremity lymphedema screening questionnaire (LELSQ) was recently validated for screening LEL. The primary aim of this study was to investigate the clinical and demographic characteristics of post-traumatic LEL (PTLEL) in patients with a history of severe lower extremity trauma using the LELSQ. Secondary objectives were to identify risk factors for PTLEL, to investigate the relationship between LELSQ scores, health related quality of life, and lower extremity functioning.

Methods: Patients treated for complex lower extremity trauma between January 1st 2009, and December 31st 2019, in two level one trauma centres who meet inclusion criteria were sent three questionnaires: LELSQ, EQ5D-5L, and the Lower Extremity Functional Scale (LEFS). Additionally baseline demographic and trauma data were collected.

Results: A total of 115 patients (46.0%) responded, of which 95 were included. LELSQ screened 59 patients (62.1%) positive for PTLEL. Those with PTLEL reported more problems with daily life, with a lower median EQ-VAS and EQ-index score (70.0 and 0.700, respectively) compared to non-PTLEL (90.0 and 0.874, respectively). A clinically reported difference was found in the LEFS median scores, with PTLEL 39.0 compared to 66.0 in non-PTLEL.

Conclusion: Among patients who participated in this study, 62.1% screened positive for PTLEL following complex lower limb trauma. PTLEL patients reported reduced health-related quality of life and lower extremity functioning compared with non-PTLEL patients, indicating that this a frequent and important issue following lower limb trauma.

Background: Wound failure after posterior spine surgery can lead to infection, hardware loss, and reoperation. Prophylactic paraspinous muscle flaps are used selectively, but criteria to select which patients benefit most have not been consistent.

Methods: We conducted a retrospective cohort study (2011-2022) of complex posterior spine operations closed by plastic surgery at a single center. The exposure was prophylactic paraspinous flap at the index operation versus standard primary closure. The primary outcome was a plastic surgery-managed wound complication requiring clinical intervention or return to the operating room. Using only routine pre and intraoperative variables, we created a five factor bedside score (obesity; lumbar/sacral level; albumin <35 g/L (3.5 g/dL); operative time >250 minutes; American Society of Anesthesiologists [ASA] class ≥3) and a parallel logistic model that excluded treatment to estimate baseline risk and support decision making.

Results: Among 281 operations, 150/281 (53%) received prophylactic paraspinous closure. Plastic-surgery-managed wound complications occurred in 35/281 (12.5%). A simple baseline-risk model separated patients into Low, Intermediate, and High-risk groups with observed complication rates of 7.9%, 11.7%, and 23.2%, respectively. Model performance was modest (area under the ROC curve [AUC] 0.66; optimism-corrected AUC 0.56; Brier 0.106). In adjusted analyses, ASA ≥3 was associated with higher odds of a wound complication (adjusted OR 9.35; 95% CI, 1.20-73.02). In the High-risk (4-5 points) group of the five-factor score, prophylactic closure reduced reoperations from 20.0% (4/20) to 0% (0/27) (absolute risk reduction [ARR] 20%; number needed to treat [NNT] 5; p=0.027). No significant differences were seen in the lower-risk groups.

Conclusion: A simple five factor score stratifies baseline wound risk after posterior spine surgery and identifies patients most likely to benefit from prophylactic paraspinous flap closure. Selective, preoperative use in high risk patients may reduce returns to the operating room.

Background: Head and neck squamous cell carcinoma is widespread and projected to increase in prevalence by ~30% by 2030. This study evaluates the association between body mass index (BMI), perioperative frailty, and postoperative outcomes, including hospital length-of-stay and perioperative complications for patients undergoing fibular free-tissue reconstruction for head and neck defects.  Methods: We conducted a retrospective, multi-institutional cohort study using the American College of Surgeons National Surgical Quality Improvement Program database, encompassing subjects of mandibular malignancy radical excision with free myocutaneous and fibular flap reconstruction between 2012 and 2022. Primary independent variables were BMI and modified frailty index-11 (mFI-11) scores. Descriptive statistics and logistic regression analyses were employed to explore the relationship between BMI, frailty, hospital stay, and perioperative complications.   Results: 4,808 patients were included (3,082 males, 1,723 females). Within this cohort, 36.5% were normal BMI (18.5-25.0; n=1,755), 5.3% were underweight (BMI<18.5; n=255), and 58.2% were overweight or obese (BMI>25.0; n=2,798). 2,288 (47.6%) were robust (mFI=0), 1,624 (33.8%) pre-frail (mFI=1), and 896 (18.6%) frail (mFI≥2). Perioperative complication risk was 38.4% for normal-weight patients, 55.3% for underweight patients (P<0.001), and 28.8% for overweight/obese patients (P<0.001). Multivariate analysis revealed overweight/obese patients had shorter hospital stays (β -1.0 days, 95% [CI] -1.5 to -0.5, P<0.001) compared to normal-weight patients. Normal-weight patient complication rates increased from 26.9% (robust) to 39.0% (frail, p=0.0003). Conversely, robust patient complication rates were lower in overweight (23.2%) and obese (23.1%) compared to underweight (42.4%). The highest-risk group consisted of underweight frail patients (56.2%).

Conclusions: Underweight BMI and physiologic frailty function as independent yet synergistic risk factors for poor outcomes after free myocutaneous and fibular flap reconstruction following radical mandibular tumor excision. Notably, decreased BMI confers a greater risk than frailty. These findings challenge the obesity paradox and mandate assessing both nutritional status and physiologic reserve for optimal risk stratification.

Free tissue transfer (FTT) is determined by a multitude of patient and surgeon factors. However, no tool exists to quantify patient risk for complications following FTT. This study developed the microsurgical index for complication risk and outcomes (MICRO) to address this.Patients were queried from the 2007 to 2015 MarketScan Databases with CPT codes for FTT requiring microsurgical anastomosis. ICD-9 codes were used to query comorbidity and 90-day postoperative complication data for each patient. The Charlson and Elixhauser Comorbidity Indexes were constructed for each patient. The MICRO was then constructed with a forward stepwise selection from Elixhauser comorbidities and domain expert input. Indexes were used as covariates in multivariate logistic regression models with patient age, sex, and flap tissue type to predict complications following FTT. The area under the receiver operating characteristic curve and fivefold cross-validation classification accuracy was determined.A total of 5,595 patients were included. The final MICRO consists of seven variables (Charlson: 19; Elixhauser: 30). It had the highest area under the receiver operating characteristic curve (0.60) and accuracy (60.4%) of all indexes when predicting complications.The MICRO outperforms available patient comorbidity indexes at predicting complications following FTT with far fewer variables. Future studies could augment the MICRO with more granular or institutional data consisting of surgeon, donor-site, and recipient-site data to create a sharper risk-stratification tool for the plastic surgeon.

Many microsurgeons recommend that their patients avoid all compounds containing caffeine after free tissue transfer, however, there is little in the literature to implicate caffeine as a contributor to flap loss. While caffeine has historically been viewed as a vasoconstrictor that could theoretically impair flap perfusion, its physiological effects are complex, involving both vasoconstrictive and vasodilatory mechanisms. This review aims to determine whether caffeine consumption may increase flap-related complications including ultimate failure.A narrative review was conducted through PubMed and Google Scholar to evaluate the mechanism of action of caffeine. Articles were included if they provided insights into caffeine's mechanisms of action in the central nervous system, cardiovascular system, endothelium, and microcirculation.Caffeine causes the release of neurotransmitters in the CNS promoting wakefulness through the antagonism of adenosine receptors. In both smooth muscle and vascular endothelium, caffeine promotes vasodilation through the activation or inhibition of different types of receptors including adenosine, inositol triphosphate, and nitrous oxide. Studies in both human and animal models suggest that caffeine does not significantly affect microvascular perfusion or anastomotic patency. Data suggest that habitual caffeine consumers show blunted vascular responses, further mitigating concerns in flap outcomes.Despite current recommendations for caffeine restriction following free tissue transfer, the existing evidence does not support caffeine as a major risk factor for flap failure. Postoperative caffeine avoidance may be unnecessary, particularly for habitual users. Larger prospective studies are needed to further elucidate caffeine's role in microsurgical outcomes and to explore the effects of other stimulants, such as ADHD medications, on microvascular circulation.

Shorter delays from presentation to soft tissue coverage in patients with lower extremity open fractures are associated with fewer infections. Orthoplastic teams should know how long flaps can be safely delayed after internal fixation (IF), rather than presentation, because concurrent life-threatening injuries delay limb salvation. We compared infection rates (IRs) of flap coverage delays within 24, 24 to 72, and over 72 hours of IF.This is a retrospective cohort study of adult patients in a Level I trauma center from 2011 to 2021. Patients sustained Gustilo III lower extremity fractures and received flap coverage after fixation. IRs between various delays of flap coverage were compared. A multivariate logistic regression model (including patient demographics, flap composition, bone fixation technique, perioperative antibiotics, three aforementioned time intervals, time from presentation to flap coverage, and time from fixation to flap coverage) was used to determine significant predictors of infections.Of 274 patients, 76 (27.7%) developed an infection. The average time between fixation and flap coverage was 84.9 hours and 106.6 hours in non-infected and infected patients (p = 0.074). IRs among the time intervals were 23.2%, 25.0%, and 31.5% (p = 0.40). Time from fixation to flap coverage was the only significant predictor of infection (p = 0.04).Time from fixation to flap placement is an effective predictor of wound infection. Although the IRs of the >72-hour group did not reach significance, we believe larger cohorts would yield statistical significance. We recommend soft tissue coverage within 72 hours of IF to mitigate infections.

Popliteal artery variants (PAVs) are anatomical deviations of the popliteal artery's branching pattern and should be considered in microsurgical planning for patients undergoing lower extremity (LE) free tissue transfer (FTT). However, there is a significant lack of FTT literature in this patient population. Thus, this study presents our 12-year experience with LE FTT in patients with PAV.Patients receiving LE FTT reconstruction from July 2011 to March 2024 were reviewed. Preoperative angiograms were reviewed by a single vascular surgeon, and the presence of PAV was identified and classified as IIIA, IIIB, or IIIC. Primary outcomes were flap success and limb salvage.A total of 339 LE FTT were performed in 331 patients. A total of 32 patients (9.4%) had PAV, accounting for a total of 34 LE FTT. Class IIIA was the most common category (n = 20, 58.8%) followed by IIIB (n = 8, 23.5%) and IIIC (n = 6, 11.7%). Median age and body mass index were 63.5 (interquartile range [IQR]: 22.5) years and 27.4 (IQR: 10.3) kg/m². The median Charlson Comorbidity Index was 5 (IQR: 2.5), with prevalent rates of diabetes (n = 18/32, 56.3%) and peripheral artery disease (n = 16/32, 50.0%). Median wound area was 71.0 (IQR: 80.0) cm². Flap success rate was 100% (n = 34/34). At a median follow-up of 12.8 (IQR: 22.6) months, limb salvage was 97.1% (n = 33/34) and mortality was 6.3% (n = 2/32).In this large population of LE FTT, PAV occurs in almost 1 out of 10 patients. Essential to flap success and limb salvage is appropriate preoperative vascular imaging with arteriography, as the presence of PAV changes microsurgical intraoperative planning and technical considerations.

Neuromas can cause severe neuropathic pain, leading to functional decline and psychosocial distress. For pain relief, patients refractory to medications for neuropathic pain may be prescribed opioids; however, such use has been shown to have unfortunate adverse effects. With increasing awareness and diagnostic capabilities for neuroma formation, this study evaluates whether upper extremity neuroma excision may reduce opioid use and if adjunctive nerve procedures further reduce opioid use.The PearlDiver database was queried for patients undergoing upper extremity neuroma excision surgery from 2010 to 2020. Patients with opioid prescription fill records preoperatively were extracted and stratified by an operative technique involving either (1) excision alone, (2) nerve implantation into bone or muscle, or (3) nerve reconstruction. Records were then assessed at 1, 3, and 6 months postoperatively to assess for opioid use. Prescription fill rates at 1, 3, and 6 months postoperatively were then assessed across techniques.Of the 14,330 patients that underwent upper extremity neuroma excision, 4,156 filled opioids preoperatively. Excision led to significant reductions in opioid prescription fill rates postoperatively, decreasing to 67.4% at 1 month and to 57.5% by 6 months (p < 0.001). Excision alone resulted in lower opioid use compared with excision with implantation at all postoperative time points (p < 0.05). At 6 months, opioid use was also significantly less following excision with nerve reconstruction compared with implantation (56.4% vs. 65.6%, p = 0.0096). There were no differences between excision alone and excision with nerve reconstruction.Neuroma excision significantly reduces opioid use in patients with preoperative opioid use while adjunctive operative techniques did not potentiate opioid reduction. This highlights the importance of understanding patient complaints, neuroma localization, and candidacy for excision as an effective measure for addressing opioid use in patients with preoperative opioid dependence.

Ischemic myopathy in the upper limb may develop progressively in cases of peripheral arterial disease or acutely following traumatic vascular injuries. Prolonged ischemia can lead to catastrophic damage to distal muscles, with a significant risk of irreversible motor function loss. It is hypothesized that the neuromuscular junction (NMJ) sustains substantial damage beyond a critical threshold of arterial ischemia. Furthermore, concomitant upstream nerve injuries may exacerbate NMJ degeneration, potentially resulting in permanent dysfunction. This study aims to evaluate the NMJ-level changes in target muscles and investigate the impact of nerve injury and repair, with a particular focus on the potential benefits of the supercharge end-to-side (SETS) nerve transfer technique.A mouse forelimb ischemia model was created by clamping the brachial artery and ablating collateral vessels. The first aim assessed NMJ changes with increasing ischemia time. The second investigated the impact of ischemia on muscle reinnervation after transection and repair of the median nerve. Lastly, the ulnar nerve was used for SETS to the distal median nerve following nerve repair to evaluate its effect on muscle recovery. Functional grip tests, electrophysiological assessments, and immunohistochemical analyses were performed.Prolonged ischemia significantly decreased CMAP and grip strength, with markedly declined after 8 hours of prolonged arterial ischemia. When the upstream median nerve was cut and repaired, NMJ innervation of the target muscle dropped significantly at 12 hours, with fully innervated NMJs reduced to 27 to 39% compared with 67 to 72% at 4 to 8 hours (control = 81%). SETS transfers significantly improved CMAP, grip strength, and NMJ innervation, particularly in the 12-hour ischemia group.Prolonged ischemia leads to severe NMJ degeneration within the target muscle, with 8 hours being the critical time point at limb ischemia, and 12 hours being the time point after ischemia and nerve injury. As an alternative to limb amputation or muscle loss, SETS nerve transfer to augment the innervating median nerve can initiate partial NMJ innervation within the remaining target muscles to attempt to restore functional capacity.