Microsurgery最新文献

Background: In severe lower leg trauma requiring soft tissue transfer, a limited number of run-off vessels is a risk factor for reoperation and flap necrosis. We hypothesized that early reconstruction of injured major arteries (the anterior tibial artery (ATA) or posterior tibial artery (PTA)) to prepare two recipient arterial systems could reduce anastomotic complications. This study aimed to evaluate the effectiveness of arterial reconstruction in patients with severe lower extremity trauma.

Methods: This study included patients with Gustilo-Anderson type IIIB open lower leg fractures and arterial injuries who underwent free flap surgery. The patients were divided into two groups: group 1 comprised patients with ATA or PTA run-off at free-flap surgery, and group 2 comprised patients with both ATA and PTA run-off after early revascularization. Patient demographics, injury characteristics, and treatment details were recorded. Primary outcome was occurrence of flap necrosis, and secondary outcomes were occurrence of intraoperative anastomosis revision and unplanned return to operating room. Outcomes were statistically compared between the two groups.

Results: Groups 1 and 2 comprised 12 patients. Group 1 had a mean age of 38.7 years (nine males and three females), including nine ATA injuries and three PTA injuries: 11 latissimus dorsi (LD) and one anterolateral thigh (ALT) flaps were used. Group 2 had a mean age of 50.8 years (all males), with 2 ATA and 10 PTA injuries; 10 LD and 2 ALT flaps were used. Intraoperative revision and unplanned return were significantly more frequent in group 1 than in group 2 (both p = 0.029). Complete flap loss occurred in two patients in group 1 and none in group 2 (p = 0.333).

Conclusions: Early reconstruction of injured arteries to prepare two recipient systems significantly reduced vascular complications and may improve free-flap outcomes in patients with severe open lower leg fractures.

Background: Segmental mandibular reconstruction with osteocutaneous fibular free flaps commonly employs end-to-end (E-T-E) wedge osteotomies. However, excessive osteotomies or limited fibular length can compromise vascularity, bony union, available pedicle length. This study evaluates the outcomes of a modified end-to-side (E-T-S) fibular strut configuration in mandibular reconstruction.

Methods: A retrospective analysis was conducted on 11 patients who underwent mandibular reconstruction using fibular free flaps with at least one E-T-S osteotomy between 2017 and 2021. Bony union was assessed radiographically ≥ 12 months postoperatively and categorized as complete (CBU) or incomplete bony union (IBU). Complication rates were also analyzed.

Results: Among 33 junctions, 11 were reconstructed using the modified E-T-S approach. Of these, 7 achieved complete bony union. In the remaining 22 junctions reconstructed with E-T-E osteotomies, 15 achieved complete bony union.

Conclusion: Descriptively, the union rates observed in modified E-T-S osteotomies were similar to those seen in conventional E-T-E reconstructions. It offers a viable alternative in complex reconstructions where pedicle length, anatomy, or perfusion constraints preclude standard approaches.

Background: Pediatric cases of bone nonunion are rare and often a result of complex local vascular limitations. The periosteum plays a key role in bone healing through its regenerative properties. Vascularized periosteal grafts have previously been effective in treating complex cases. This study explores the vascular anatomy of the radial periosteum supplied by the anterior interosseous vessels and introduces the vascularized radial periosteal graft (VRPG), successfully implemented in a case of ulnar nonunion.

Material and methods: Cadaveric studies of ten upper limbs were conducted under ×2.5 loupe magnification following injection of colored natural latex through the brachial artery. Anterior interosseous vessels (AIOV) branches supplying the radial shaft periosteum were studied with regards to AIOV length, number of periosteal branches, and their respective distances from the distal radioulnar joint (DRUJ). As part of our case report, two pediatric cases of complex ulnar shaft nonunion underwent treatment with a VRPG: one a 15-year-old with a multioperated ulnar nonunion and the other a 5-year-old with congenital pseudoarthrosis.

Results: The mean AIOV length was 15.9 cm (range 14.2-17.8). They were found to have an average of 9.6 (range 8-13) periosteal branches with a mean distance to the DRUJ of 16 mm (range 11-23 mm) from the most distal branch and 111 mm (98-136) from the most proximal periosteal branch. Case report follow-up of both cases showed a very early initially ossified prominent callus and early bone union and callus remodeling with excellent function.

Conclusions: The AIOV reliably supplies the radial periosteal shaft, allowing for successful harvest of a pedicled periosteal flap. This flap has proven effective in treating 2 cases of pediatric ulnar nonunion and warrants further evaluation and consideration in similar cases in the future.

Background: The treatment of tongue malignancies frequently produces deficits in feeding, swallowing, and speech intelligibility. These have a significant impact on patients' quality-of-life. Free tissue transfer is the preferred method for reconstructing larger, complex defects, and aims to restore both mechanical and sensory function while protecting the airway. The role of dynamic free flap designs incorporating motor reinnervation remains unclear, particularly in cases with more extensive glossectomy defects. The objective of this systematic review is to evaluate the speech and swallow outcomes of patients undergoing dynamic free flap reconstruction following ablative tongue surgery.

Methods: A systematic review was performed to determine the role of dynamic free flap surgery for functional tongue reconstruction. Searches were conducted in MEDLINE (PubMed), EMBASE, the Cochrane Library, Google Scholar, and included English-language studies from 1980 onward. Search terms included: glossectomy in combination with functional reconstruction and related outcomes. Primary outcome measures were flap compromise, competent swallow, and intelligible speech. A meta-analysis was performed using pooled data from comparative studies. Key data analysis was undertaken to calculate weighted effect sizes using random-effects models.

Results: Thirteen studies reported on the use of dynamic free flaps for tongue reconstruction. A total of 168 innervated flaps were available for comparison after pooling data. The non-weighted flap failure rate was 1.2% within this cohort. Competent swallow varied from 43% to 100% with a mean value of 80.2%. Rates of satisfactory speech were between 73% and 100% with a mean value of 91.7%. The mean follow-up duration was 21.8 months and ranged between 9.5 and 47.6 months. With further analyses of comparative sub-groups, there was a marked improvement in swallow competency with dynamic flap types over static designs (OR = 4.09, 95% CI: 1.75, 9.58, p = < 0.01).

Conclusion: Current evidence indicates that dynamic free flap designs enhance functional recovery and may benefit both swallow and speech outcomes postoperatively.

Introduction: Minimally invasive techniques for DIEP flap harvest, including transabdominal (TAPP) and totally extraperitoneal (TEP) approaches, have been reported to be beneficial in reducing morbidity; however, direct comparative synthesis between these methods remains scarce, limiting consensus on the optimal approach.

Method: Following PRISMA guidelines, we searched MEDLINE, Embase, and Cochrane Central for prospective and retrospective studies on robotic or laparoscopic DIEP harvest in breast reconstruction. Cadaveric studies and non-DIEP procedures were excluded. Primary operative outcomes included harvest time, type of robot, fascial incision length, intramuscular length, and intraoperative complications, while secondary clinical outcomes were postoperative complications, length of stay, and pain. A structured narrative synthesis was conducted using pooled descriptive data, without inferential statistical analysis.

Results: Ten studies were included, including six describing TAPP harvest, two robotic TEP, and two laparoscopic TEP. Reported unilateral reconstruction times averaged 442.6 ± 63.4 min for TAPP and 460.3 ± 90.4 min for TEP, while bilateral procedures averaged 682.6 ± 115.1 min for TAPP compared with 453.0 ± 81.5 min for TEP. Fascial incisions were longer with TAPP (3.75 ± 1.34 cm) compared to TEP (2.59 ± 0.49 cm), and intramuscular pedicle dissection length was greater in TAPP (4.1 ± 0.7 vs. 2.25 ± 0.27 cm). No study reported bowel injury or postoperative ileus, and overall complication rates-including vessel avulsion, flap loss, infection, and seroma-were similar. Postoperative pain scores were 1.9 ± 0.9 in TAPP versus 2.3 ± 0.9 in TEP, while hospital stay averaged 3.9 ± 1.3 days for TAPP and 4.5 ± 0.9 days for TEP.

Conclusion: Both TAPP and TEP appear safe and effective for minimally invasive DIEP flap harvest. Trends suggest bilateral TAPP requires longer operative times, while TEP results in shorter fascial incisions and had shorter intramuscular pedicle lengths. Pain and complication rates were comparable, although study heterogeneity and small sample sizes limit generalizability. Larger, prospective comparative studies are essential to better define technique selection.