Microsurgery
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Much has been learned over the past several decades regarding thrombophilic conditions. Thrombotic complications, such as deep venous thrombosis, pulmonary embolus, myocardial infarction, and stroke, are sometimes attributed to a diagnosable thrombophilia. Less has been written with regard to their effect on reconstructive outcomes. ⋯ When this does occur, salvage can be difficult and outcome can be compromised. It is imperative that microsurgeons be knowledgeable of both major and minor thrombogenic conditions to optimize intraoperative outcome and postoperative care. We present a case of a failed free flap for lower extremity reconstruction associated with hyperhomocysteinemia in conjunction with markedly elevated Factor VIII levels.
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Traumatic dislocation of the hip results in osteonecrosis of the femoral head (ONFH) or avascular necrosis (AVN) in approximately 40% of patients. This high-energy event causes an ischemic insult to the femoral head that may lead to ONFH. Here, we investigate use of Free-Vascularized Fibular Grafting (FVFG) in patients with ONFH after traumatic hip dislocation. ⋯ The average preoperative Harris Hip score was 64.9 which improved by over 10 points to 76.1 at 1-year follow-up. Seven of 35 patients required conversion to THA at an average of 45 (13-86) months postoperation. After a maximum follow up of 21 years, the remainder of the patients retained their native hips and Harris Hip scores tended to show improved hip function.
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Exposure of a knee endoprosthesis represents a limb-threatening condition, requiring long-term antibiosis, irrigation, and serial debridement to avoid knee arthrodesis or amputation. Although traditional orthopedic surgical doctrine mandates removal of exposed hardware under a dehisced wound, salvage of exposed prostheses using local muscle flap coverage has been reported. However, the complex three-dimensional geometry of the soft tissue surrounding the knee as well as the requirement for sustained local tissue levels of antibiotics to re-sterilize the hardware suggest that microvascular tissue transfer may constitute an advantageous means of wound coverage, increasing both limb and prosthesis salvage rates. We report our experience with free tissue transfer reconstruction of these complex wounds. ⋯ The advantages of microvascular tissue transfer are well suited to the treatment of exposed knee endoprostheses. The reliable rectus and latissimus flaps provide robust local perfusion to the wound, fill complex three-dimensional contour defects around knee implants, and lead to a high rate of salvage of both limbs and prostheses.
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Comparative Study
The timing of microsurgical reconstruction in lower extremity trauma.
The timing of post traumatic microsurgical lower extremity reconstruction was defined by Godina in 1986, with recommendations for flap coverage of Gustillo grade IIIb/c fractures within 72 hours of injury. Godina's study showed the highest risk of infection and flap loss in the delayed period (72 hours-90 days). Subsequent authors have also cited lower rates of flap loss and infection when repair was performed "early". ⋯ All patients underwent reconstruction in the delayed (>72 hours) period. There were no flap losses and one case of late osteomyelitis. We conclude that lower extremity reconstruction can be performed safely and effectively in the "delayed" period to allow for wound debridement, stabilization of other injuries, and transfer to a microsurgical facility.
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Although direct exposure to procedures in the operating theater environment, together with practice on laboratory animals, is still seen as the gold standard of teaching in microsurgery, practice on nonliving simulators is currently being validated as an important educational tool. We reviewed the widely used nonliving training models, together with currently accepted innovations, which are parts of curricula of training courses in microsurgery. Using the experience accumulated in training programs at the Centre for Simulation and Training in Surgery, we identified which particular skills can be reliably targeted by each nonliving tissue exercise. ⋯ The training program can comprise a series of increasingly difficult exercises, which mirror the real life situations. Performance on nonliving models in each progressively more challenging exercise can be assessed via direct observation, assisted by clear and objective criteria. Finally, focused training will help both the transition to human surgery and replication of the favorable results to large series of subjects.