CC BY-NC-ND 4.0 · Rev Bras Ortop (Sao Paulo) 2022; 57(05): 772-780
DOI: 10.1055/s-0041-1735946
Artigo Original
Mão

Microsurgical Reconstruction in an Orthopedic Hospital: Indications and Outcomes in Adults

Article in several languages: português | English
1   Grupo de Cirurgia da Mão e Microcirurgia Reconstrutiva, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
,
1   Grupo de Cirurgia da Mão e Microcirurgia Reconstrutiva, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
,
1   Grupo de Cirurgia da Mão e Microcirurgia Reconstrutiva, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
,
1   Grupo de Cirurgia da Mão e Microcirurgia Reconstrutiva, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
,
Rames Mattar  Júnior
1   Grupo de Cirurgia da Mão e Microcirurgia Reconstrutiva, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
,
1   Grupo de Cirurgia da Mão e Microcirurgia Reconstrutiva, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
› Author Affiliations

Abstract

Objective Advances in reconstructive microsurgery in orthopedic surgery provided better functional and aesthetic results and avoided many indications for amputation. In high-volume trauma and orthopedic hospitals, microsurgical reconstruction is essential to reduce costs and complications for these complex orthopedic defects. We describe a microsurgical approach to traumatic wounds, tumor resection, bone defects, and free muscle transfer, performed by an orthopedic microsurgery unit. The objective of the present study was to evaluate predictor factors for outcomes of microsurgical flaps for limb reconstruction, and to provide a descriptive analysis of microsurgical flaps for orthopedic indications.

Methods Cross-sectional prospective study that included all consecutive cases of microsurgical flaps for orthopedic indications from 2014 to 2020. Data were collected from personal medical history, intraoperative microsurgical procedure, and laboratory blood tests. Complications and free-flap outcomes were studied in a descriptive and statistical analysis.

Results We evaluated 171 flaps in 168 patients; the indications were traumatic in 66% of the patients. Type III complications of the Clavien-Dindo Classification were observed in 51 flaps. The overall success rate of the microsurgical flaps was 88.3%. In the multivariate analysis, the risk factors for complications were ischemia time ≥ 2 hours (p = 0.032) and obesity (p = 0.007). Partial flap loss was more common in patients with thrombocytosis in the preoperative platelet count (p = 0.001).

Conclusion The independent risk factors for complications of microsurgical flaps for limb reconstruction are obesity and flap ischemia time ≥ 2 hours, and presence of thrombocytosis is a risk factor for partial flap loss.

Financial Support

The present study received no financial support from public, commercial, or not-for-profit sources.


Work developed at the Hand Surgery and Reconstructive Microsurgery Group of the Instituto de Ortopedia e Traumatologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil.




Publication History

Received: 23 February 2021

Accepted: 18 May 2021

Article published online:
11 March 2022

© 2022. Sociedade Brasileira de Ortopedia e Traumatologia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commecial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

Thieme Revinter Publicações Ltda.
Rua do Matoso 170, Rio de Janeiro, RJ, CEP 20270-135, Brazil

 
  • Referências

  • 1 Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986; 78 (03) 285-292
  • 2 Gottlieb LJ, Krieger LM. From the reconstructive ladder to the reconstructive elevator. Plast Reconstr Surg 1994; 93 (07) 1503-1504
  • 3 Wagels M, Rowe D, Senewiratne S, Read T, Theile DR. Soft tissue reconstruction after compound tibial fracture: 235 cases over 12 years. J Plast Reconstr Aesthet Surg 2015; 68 (09) 1276-1285
  • 4 Heitmann C, Levin LS. The orthoplastic approach for management of the severely traumatized foot and ankle. J Trauma 2003; 54 (02) 379-390
  • 5 Dos Anjos KC, de Rezende MR, Mattar Jr R. Social and hospital costs of patients admitted to a university hospital in Brazil due to motorcycle crashes. Traffic Inj Prev 2017; 18 (06) 585-592
  • 6 Clavien PA, Barkun J, de Oliveira ML. et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 2009; 250 (02) 187-196
  • 7 World Health Organization WHO. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity vitamin and mineral nutrition information system. Geneva: World Health Organization. 2011 . Available from: https://www.who.int/vmnis/indicators/haemoglobin/en/
  • 8 Harrison CN, Bareford D, Butt N. et al. British Committee for Standards in Haematology. Guideline for investigation and management of adults and children presenting with a thrombocytosis. Br J Haematol 2010; 149 (03) 352-375
  • 9 Al-Dam A, Zrnc TA, Hanken H. et al. Outcome of microvascular free flaps in a high-volume training centre. J Craniomaxillofac Surg 2014; 42 (07) 1178-1183
  • 10 Pohlenz P, Blessmann M, Blake F, Li L, Schmelzle R, Heiland M. Outcome and complications of 540 microvascular free flaps: the Hamburg experience. Clin Oral Investig 2007; 11 (01) 89-92
  • 11 Fischer JP, Wink JD, Nelson JA. et al. A retrospective review of outcomes and flap selection in free tissue transfers for complex lower extremity reconstruction. J Reconstr Microsurg 2013; 29 (06) 407-416
  • 12 Lazo DAA, Zatit SCA, Colicchio O, Nishimura MT, Mazzer N, Barbieri CH. Reconstrução dos membros com retalhos microcirùrgicos na urgência: experiência de 10 anos com 154 casos consecutivos. Rev Soc Bras Cir Plást 2005; 20 (02) 88-94
  • 13 Severo AL, Scorsatto C, Valente EB, Lech OLC. Retalhos para reconstrução de perdas musculocutâneos em membros inferiores: análise de 18 casos. Rev Bras Ortop 2004; 39 (10) 578-589
  • 14 Mathews JA, Ward J, Chapman TW, Khan UM, Kelly MB. Single-stage orthoplastic reconstruction of Gustilo-Anderson Grade III open tibial fractures greatly reduces infection rates. Injury 2015; 46 (11) 2263-2266
  • 15 Chang EI, Chang EI, Soto-Miranda MA. et al. Comprehensive evaluation of risk factors and management of impending flap loss in 2138 breast free flaps. Ann Plast Surg 2016; 77 (01) 67-71
  • 16 Jubbal KT, Zavlin D, Suliman A. The effect of age on microsurgical free flap outcomes: An analysis of 5,951 cases. Microsurgery 2017; 37 (08) 858-864
  • 17 Malata CM, Cooter RD, Batchelor AG, Simpson KH, Browning FS, Kay SP. Microvascular free-tissue transfers in elderly patients: the leeds experience. Plast Reconstr Surg 1996; 98 (07) 1234-1241
  • 18 Cleveland EC, Fischer JP, Nelson JA, Wink JD, Levin LS, Kovach 3rd SJ. Free flap lower extremity reconstruction in the obese population: does weight matter?. J Reconstr Microsurg 2014; 30 (04) 263-270
  • 19 Hill JB, Patel A, Del Corral GA. et al. Preoperative anemia predicts thrombosis and free flap failure in microvascular reconstruction. Ann Plast Surg 2012; 69 (04) 364-367
  • 20 Ross GL, Ang ES, Lannon D. et al. Ten-year experience of free flaps in head and neck surgery. How necessary is a second venous anastomosis?. Head Neck 2008; 30 (08) 1086-1089
  • 21 Dornseifer U, Kleeberger C, Kimelman M. et al. Less is more? Impact of single venous anastomosis on the intrinsic transit time of free flaps. J Reconstr Microsurg 2017; 33 (02) 137-142
  • 22 Tsai YT, Lin TS. The suitability of end-to-side microvascular anastomosis in free flap transfer for limb reconstruction. Ann Plast Surg 2012; 68 (02) 171-174
  • 23 Cho EH, Garcia RM, Blau J. et al. Microvascular anastomoses using end-to-end versus end-to-side technique in lower extremity free tissue transfer. J Reconstr Microsurg 2016; 32 (02) 114-120
  • 24 Heidekrueger PI, Ninkovic M, Heine-Geldern A, Herter F, Broer PN. End-to-end versus end-to-side anastomoses in free flap reconstruction: single centre experiences. J Plast Surg Hand Surg 2017; 51 (05) 362-365
  • 25 le Nobel GJ, Higgins KM, Enepekides DJ. Predictors of complications of free flap reconstruction in head and neck surgery: Analysis of 304 free flap reconstruction procedures. Laryngoscope 2012; 122 (05) 1014-1019
  • 26 Raval MV, Wang X, Cohen ME. et al. The influence of resident involvement on surgical outcomes. J Am Coll Surg 2011; 212 (05) 889-898
  • 27 Hirche C, Kneser U, Xiong L. et al. Microvascular free flaps are a safe and suitable training procedure during structured plastic surgery residency: A comparative cohort study with 391 patients. J Plast Reconstr Aesthet Surg 2016; 69 (05) 715-721
  • 28 Hill JB, Vogel JE, Sexton KW, Guillamondegui OD, Corral GAD, Shack RB. Re-evaluating the paradigm of early free flap coverage in lower extremity trauma. Microsurgery 2013; 33 (01) 9-13
  • 29 Rinker B, Amspacher JC, Wilson PC, Vasconez HC. Subatmospheric pressure dressing as a bridge to free tissue transfer in the treatment of open tibia fractures. Plast Reconstr Surg 2008; 121 (05) 1664-1673
  • 30 Xiong L, Gazyakan E, Kremer T. et al. Free flaps for reconstruction of soft tissue defects in lower extremity: A meta-analysis on microsurgical outcome and safety. Microsurgery 2016; 36 (06) 511-524