Alfonso Oliva

A clinical study of end-to-end versus end-to-side techniques for microvascular anastomosis

&NA; The choice of microvascular anastomotic technique, end‐to‐end versus end‐to‐side, is still an item of debate. A review of the literature reveals no difference in patency rates in animal models where there is no size discrepancy. The available clinical evidence stems from Godinas early experience, proclaiming a higher failure rate with end‐to‐end anastomoses. Factors such as size mismatch and use of injured vessels, rather than anastomotic technique, may have been responsible. This clinical study examines the fate of over 2000 microvascular anastomoses performed in more than 900 tissue transplants. Complications attributable to the anastomosis were considered failures of the anastomosis, were tabulated, and were compared between the two techniques. The end‐to‐end and end‐to‐side microvascular techniques were found to be equally effective when properly applied. The choice of technique therefore should be secondary to factors influencing the choice of recipient vessel, such as the condition of the vessel, its accessibility, and the preservation or augmentation of maximal distal flow to an extremity.

Improved salvage of complicated microvascular transplants monitored with quantitative fluorometry.

Quantitative fluorometry has been used to monitor circulation in transplanted toes and cutaneous flaps in our unit since 1982. Analysis of 177 uncomplicated transplants monitored by quantitative fluorometry shows that this technique has low false indication rates for arterial occlusion (0.6 percent of patients) and venous occlusion (6.2 percent of patients). None of these patients was reexplored because of a false monitor reading, and except for single abnormal sequences, monitoring appropriately indicated intact circulation throughout the postoperative period. Quantitative fluorometry has correctly indicated vascular complications in 21 (91.3 percent) of 23 transplants over an 8-year period. The salvage rate (85.7 percent) of the fluorescein-monitored reexplored transplants was significantly higher than the salvage rates of similar reexplored transplants not monitored with fluorescein and of reexplored muscle flaps (which cannot be monitored with the fluorometer used at this unit). These clinical data indicate that quantitative fluorometry is a valid and useful postoperative monitor for transplanted toes and cutaneous flaps.

Calcific myonecrosis following compartment syndrome : report of two cases, review of the literature, and recommendations for treatment

Calcific myonecrosis of lower extremity muscles has been identified as an uncommon late sequela of posttraumatic compartment syndromes or ischemic myonecrosis. Previous reports have detailed a small number of cases with similar clinical and radiographic features. Two cases of calcific myonecrosis diagnosed more than 30 years following trauma to an extremity are presented. Treatment consisted of serial debridement of all infected and necrotic tissue followed by wound closure using a rectus abdominis muscle microvascular transplant in one patient and delayed primary closure in the other. Both patients have resumed active lifestyles with no recurrence of drainage or infection. Aggressive debridement and definitive soft tissue coverage are the mainstay of effective treatment for this entity.

Simultaneous free-tissue transfer and Ilizarov distraction osteosynthesis in lower extremity salvage : case report and review of the literature

The last decade has witnessed the refinement of microvascular tissue transplantation and its application in treating difficult open wounds. Nonetheless, severe type III tibial injuries continue to challenge reconstructive surgeons. The clinical presentation and surgical treatment of a type IIIB tibial fracture, complicated by long-standing chronic osteomyelitis, angulation deformity, and bone shortening, is presented. This case illustrates the benefit of combining microvascular transplantation of distant tissues with the Ilizarov technique of distraction osteosynthesis in the treatment of complicated lower extremity injuries.

Unrecognized Injuries In Patients Referred For Emergency Microsurgery

Replantation of amputated parts and emergency microvascular repair of injured extremities are the two most common applications of clinical microsurgery. A major complication of emergency referral of such cases is the existence of the other injuries unrecognized at the time of initial evaluation. We have reviewed this complication within a series of emergency microsurgical cases referred to this unit. Several reports examining this problem of missed injuries exist in the general trauma literature. To our knowledge this study is the first to look at this important problem in the context of acutely injured patients referred for emergency microsurgery. A retrospective analysis of patients referred to Davies Medical Center over a 7-year period was performed. Nine of 1100 patients (0.8%) transferred to our unit for microsurgical evaluation and treatment had unrecognized coexisting injuries that put those patients at high risk for injury-specific morbidity and demanded immediate changes in the original care planned at the time of referral. Brief case histories of these patients are outlined. We review the trauma literature of such injuries. A concise protocol elucidating the guidelines and pitfalls of emergency microsurgical referral is offered.