Luciano Ruiz Torres

Extensor digitorum brevis flap on the treatment of lower limb injuries

OBJECTIVE: To describe our pioneer national experience with 11 patients with soft tissue defects in the distal 1/3 of the leg, ankle and forefoot treated with extensor digitorum brevis muscle flap (EDB). METHODS: Between November 2009 and July 2012 11 patients were operated with the flap technique. We operated nine men and two women aged between 10 and 66 years. The surgical indications were acute trauma in four patients and post-traumatic osteomyelitis in seven patients. The small defects were covered ranging from 3x3 to 6x3 cm. The patch was applied with proximal stalk in most cases. RESULTS: Complete healing and infectious cure were obtained in all cases, despite one loss. CONCLUSION: The EDB flap is a feasible and safe technique to repair foot, ankle and distal leg losses. Suffering, dehiscence and delayed healing of the EDB end flap donor area may, however, occur. L-shaped incisions should be avoided for muscle lifting. Level of Evidence IV, Case series.

Emprego do músculo gastrocnêmio no tratamento das lesões infectadas do joelho

OBJECTIVE: to prospectively evaluate the use of gastrocnemius muscle flap in the treatment of knee infected injuries. METHODS: twelve patients were operated on: eleven males with ages ranging from 19 to 78 years, mean: 55 years. Coverage of injuries with medial gastrocnemius muscle was accomplished in 11 patients and a lateral in 1. The mean number of preoperative surgical debridement procedures was 3.2, ranging from 1 to 9. RESULTS: all flaps survived. The most common etiological agent was S. aureus, in 54.5%. After a mean follow-up of 20.08 months (13 to 31), all patients show stable coverage without recurrence of infection signs or symptoms. CONCLUSION: gastrocnemius muscle use in knee infected injuries treatment presented good results and low morbity rates.

Avaliação artroscópica e macroscópica do complexo da fibrocartilagem triangular do punho. Estudo em cadáveres

O complexo da fibrocartilagem triangular tem importante papel na biomecânica do punho. O diagnostico preciso das lesoes e fundamental para se obter sucesso no tratamento. Ha controversias acerca da especificidade e sensibilidade dos metodos de imagem empregados atualmente. A artroscopia de punho e um metodo pouco empregado para o diagnostico das lesoes do CFCT em nosso meio, embora apresente grandes vantagens, como possibilidade de visao direta das lesoes e tratamento no mesmo tempo cirurgico. O objetivo deste estudo foi o de avaliar o papel da artroscopia de punho na inspecao do CFCT, bem como na deteccao de possiveis lesoes, comparando os dados com a disseccao macroscopica. Foram avaliados 15 punhos de cadaveres sexo masculino, media de idade de 56,1 anos. A artroscopia demonstrou presenca de lesoes em 33,3% dos punhos avaliados. Estes achados foram coincidentes apos estudo anatomico com ampla disseccao. Concluimos que houve absoluta correlacao entre o exame artroscopico e a disseccao macroscopica na deteccao de lesoes do CFCT.

Reimplantes nas amputações por mecanismo de avulsão: táticas e técnicas para o sucesso

OBJETIVOS: Avaliacao retrospectiva criteriosa de casos de reimplantes apos amputacao por avulsao. Avaliacao de tecnicas e taticas utilizadas que determinaram evolucao satisfatoria e bom resultado funcional. METODOS: Foram avaliados, retrospectivamente, prontuarios de 43 pacientes que tiveram membros amputados por mecanismo de avulsao e reimplantados nos ultimos 21 anos. RESULTADOS: A maior parte dos casos envolvia homens adultos jovens. A localizacao de amputacao mais frequente foi do polegar. As tecnicas e taticas cirurgicas utilizadas isoladas ou conjuntamente incluem: enxertos de nervo, enxertos vasculares (veia ou arteria), transposicao de feixe vascular digital, encurtamento do membro e reimplante heterotopico. A tecnica mais frequentemente utilizada foi o emprego de enxertos venosos. A taxa de sobrevida dos reimplantes foi alta (93%), assim como a satisfacao dos pacientes. CONCLUSAO: Os reimplantes por mecanismo de avulsao dependem do correto diagnostico de viabilidade anatomica e utilizacao de tecnicas e taticas cirurgicas apropriadas para cada caso. A experiencia da equipe cirurgica e estrutura hospitalar adequada sao fundamentais para obtencao de bons resultados. Existem poucos relatos na literatura sobre indicacao, tatica, tecnicas e resultados de procedimentos de reimplantes em amputacoes por avulsao. Acreditamos que a avaliacao retrospectiva desta serie de casos possa trazer novas informacoes e contribuicoes no atendimento desta situacao de alta complexidade. Nivel de evidencia IV, Serie de casos.

The versatile Adani's flap for fingertip coverage: indications and case reports.

Heterodigital pedicle flaps have 2 possible patters of vascularization: anterograde flow (Littler) or reverse flow (Adani). The Adanis flap uses the Y-V pedicle lengthening principle. The flap is raised from the adjacent uninjured finger based on the digital artery. The common digital artery is ligated and a long pedicle is formed from the 2 converging digital arteries to supply a reverse flow flap. Four patients with severe fingertips injuries were submitted to surgical treatment with the Adanis flap. All flaps integrated and provided skin coverage. The Adanis flap has a long vascular pedicle that allows a wide arch of transposition. An easier vascular dissection in a site distant from the trauma which evolves a higher diameter digital artery and proximal interphalangeal arterial system promotes a high survival rate and good functional results. Adani′s flap is a reliable technique for severe fingertip injuries.

Estudo clínico do retalho lateral do braço ampliado

OBJETIVO: Avaliar prospectivamente os resultados obtidos no tratamento de pacientes portadores de lesoes do revestimento cutâneo de dimensoes menores ou iguais a 20cm de comprimento por 10cm de largura com a utilizacao do retalho microcirurgico lateral do braco ampliado distalmente ao epicondilo lateral do cotovelo. METODOS: Foram operados 23 pacientes, 69,5% do sexo masculino, 73,9% de origem traumatica e a regiao receptora foi o membro inferior em 65.2% dos casos. A idade variou de 6 a 62 anos, com media de 32 anos. O seguimento minimo foi de 5 meses. RESULTADOS: Obtivemos sucesso na realizacao em 100% dos casos. As dimensoes dos retalhos variaram de 9 a 20cm em comprimento, com media de 14cm e em largura, de 3 a 8 cm, com media de 5.5cm. A maior distância entre o epicondilo lateral e a extremidade distal do retalho foi de 8 cm, variando de 2 cm ate 8 cm, com media de 4.9cm. CONCLUSAO: O retalho microcirurgico lateral do braco ampliado distalmente ao epicondilo lateral do cotovelo mostrou-se seguro para a cobertura cutânea de lesoes de dimensoes iguais ou menores a 20cm de comprimento por 10 cm de largura, com o prolongamento do retalho ate 8cm distal ao epicondilo lateral.

ROLE OF ARTERIOVENOUS VASCULAR LOOPS IN MICROSURGICAL RECONSTRUCTION OF THE EXTREMITIES

ABSTRACT Objective: To analyze 10 consecutive cases of microsurgical arteriovenous loops created to reconstruct complex injuries from March 2011 to May 2012. Methods: This observational cohort-type study conducted by the Hand and Microsurgery Group at the HC-FMUSP included patients who were candidates for microsurgical reconstruction as a last alternative to amputation of the limb with proven absence of adequate recipient vessels for primary microsurgical anastomosis, in a prospective and consecutive manner. We analyzed 14 variables (epidemiological, clinical, procedure-related, and outcome) in patients who underwent reconstruction using an arteriovenous loop utilizing a single-stage or two-stage procedure. Results: The injuries were mostly traumatic (80%). The success rate of the single-stage procedure was 75%, and 17% for the two-stage procedure. The rate of preservation for the injured limb was 44%. Conclusion: This study reinforces the more recent understanding that the indication for single-stage or two-stage reconstruction should be individualized; our findings favor the single-stage reconstruction. This technique should be used in selected cases, as a last reconstructive alternative before amputation, and further studies are necessary to confirm its safety and efficacy in our practice. Level of Evidence IV; Case series.

Which Nerve to Use? Comparison Between Donor Nerves to Motorize the Free Functional Gracilis Muscle Transfer for Elbow Flexion in Traumatic Brachial Plexus Injuries

Introduction: Elbow flexion deficit is a frequent problem in traumatic brachial plexus injuries and reestablishment of this function is the primary treatment goal. When management is delayed or the initial acute approach fails, free functional transfer of the gracilis muscle for elbow flexion is the treatment of choice: the authors seek to determine which donor nerve (spinal accessory, intercostal, median, or ulnar) results in better elbow flexion after microsurgical reconstruction. Methods: Retrospective analysis of patients with traumatic brachial plexus injuries who underwent functional free gracilis muscle flap for elbow flexion between February 2003 and October 2014 was carried out. Postoperative function of the gracilis functional flap was recorded and patients were divided into 4 groups according to donor nerve: spinal accessory nerve (SAN), intercostal nerves (ICN), motor fascicles of the median (MED), and ulnar nerve (ULNAR). Cases in which a primary neurorrhaphy was not possible were further subdivided into 2 groups: SAN with graft interposition (SAN graft) and ICN with graft interposition (ICN graft). The final elbow flexion strength was evaluated by the British Medical Research Council (BMRC) scale and time in months when the authors first observed M3 muscle power was also of note. Results: Fifty-nine patients met inclusion criteria for this retrospective study. Two cases were excluded due to flap loss (3%) and 3 were lost to follow up (5%). Of the 54 patients enrolled, 53 were males (98.2%) with a mean age of 29 years. The mean follow-up period was 28 months. Thirty-four cases obtained muscle strength of ≥ M3 (62.9%), 6 M0 (11.1%), 4 M1 (7.5%), 10 M2 (18.5%), 13 M3 (24%), and 21 M4 (38.9%). The mean interval to first recorded M3 muscular strength was 16 months. Patients stratified by donor nerve achieving ≥ M3 had the following distribution: SAN 83.3% (15/18), SAN graft 50% (2/4), ICN 50% (2/4), ICN graft 33.3% (1/3), MED 40% (2/5), and ULNAR 60% (12/20). No statistical difference for final muscle strength was found between donor nerve groups. SAN transfer with graft interposition took longer to reach muscle strength of M3 or greater (P < .05). Conclusion: Free functional gracilis muscle flap for traumatic brachial plexus injuries is a viable option for elbow flexion recovery. Comparison between 4 different nerve transfers—SAN, ICN, MED, and ULNAR—did not clearly indicate a better alternative over the others.

Microsurgical transfer of the gracilis muscle for elbow flexion in brachial plexus injury in adults: retrospective study of eight cases

Objective: Treating brachial plexus injuries is a major challenge, especially lesions that are presented late, with more than 12 months of evolution. We retrospectively analyzed patients who underwent one of the possibilities for attempting to restore the function of upper limbs affected under such conditions: microsurgical transfer of the gracilis muscle for elbow flexion. Methods: Eight patients were included, divided into two groups: one in which the procedure consisted of neurorrhaphy of the muscle flap with sural nerve grafting and anastomosis more distally; and the other, in which the neurorrhaphy was performed directly on the spinal accessory nerve, with anastomosis in thoracoacromial vessels. Results: We found a significant difference between the groups. A greater number of satisfactory results (75% M4) were found among patients who underwent direct neurorrhaphy, whereas the procedure using grafts for neurorrhaphy was less successful (25% M4). Conclusion: Patients who underwent microsurgical functional transfer of the gracilis muscle in which vascular anastomoses were performed in thoracoacromial vessels presented better functional outcomes than shown by those whose anastomoses were in the brachial artery with subsequent use of a nerve graft.

Transferências microcirúrgicas do músculo grácil para flexão do cotovelo na lesão do plexo braquial do adulto: estudo retrospectivo de oito casos

OBJECTIVE: Treating brachial plexus injuries is a major challenge, especially lesions that are presented late, with more than 12 months of evolution. We retrospectively analyzed patients who underwent one of the possibilities for attempting to restore the function of upper limbs affected under such conditions: microsurgical transfer of the gracilis muscle for elbow flexion. METHODS: Eight patients were included, divided into two groups: one in which the procedure consisted of neurorrhaphy of the muscle flap with sural nerve grafting and anastomosis more distally; and the other, in which the neurorrhaphy was performed directly on the spinal accessory nerve, with anastomosis in thoracoacromial vessels. RESULTS: We found a significant difference between the groups. A greater number of satisfactory results (75% M4) were found among patients who underwent direct neurorrhaphy, whereas the procedure using grafts for neurorrhaphy was less successful (25% M4). CONCLUSION: Patients who underwent microsurgical functional transfer of the gracilis muscle in which vascular anastomoses were performed in thoracoacromial vessels presented better functional outcomes than shown by those whose anastomoses were in the brachial artery with subsequent use of a nerve graft.