Lower Limb Reconstruction - Fasciocutaneous Sural Flap / Reconstrução de membro inferior- retalho fasciocutâneo sural

Abstract Objective The present study aims to evaluate the use of the reverse-flow sural fasciocutaneous flap to cover lesions in the distal third of the lower limb. Methods A total of 24 cases were analyzed, including 20 traumatic injuries, 3 sports injuries, and 1 case of tumor resection. Results Among the 24 evaluated medical records, 16 patients were male, and 8 were female. Their age ranged from6 to 75 years old. Most of the patients evolved with total healing of the flap (n= 21). There was only one case of total necrosis of the flap in an insulin-dependent diabetic, high blood pressure patient, evolving to subsequent limb amputation. In two cases, there was partial necrosis and subsequent healing by secondary intention; one of these patients was a heavy smoker. Complications were associated with comorbidities and, unlike other studies, no correlation was observed with the learning curve. There was also no correlation with the site or size of the lesion to be covered. Conclusion It is clinically relevant that the success rate of the reverse-flow sural fasciocutaneous flap technique was of 87.5%. This is a viable and effective alternative in the therapeutic arsenal for complex lower limb lesions.

Resumo Objetivo Avaliar o uso do retalho fasciocutâneo sural de fluxo reverso na cobertura de lesões no terço distal dos membros inferiores. Métodos Foram analisados 24 casos, 20 de origem traumática, três por lesões esportivas e um por ressecção de lesão tumoral. Resultados Dos 24 prontuários avaliados, 16 eram homens e oito mulheres. A idade variou de seis a 75 anos. A maioria dos pacientes evoluiu com cicatrização total do retalho (21). Houve apenas um caso de necrose total do retalho em paciente diabético insulinodependente e hipertenso, evoluiu para posterior amputação do membro. Em dois casos, houve necrose parcial composterior cicatrização por segunda intenção, um desses pacientes era tabagista pesado. As complicações foram associadas às comorbidades e, ao contrário do evidenciado por outros estudos, não houve correlação com a curva de aprendizado. Também não houve correlação com o local ou o tamanho da lesão a ser coberta. Conclusão Tem-se como relevância clinica que a técnica de retalho fasciocutâneo sural de fluxo reverso usada obteve 87,5% de sucesso, é uma opção viável e eficaz no arsenal terapêutico das lesões complexas dos membros inferiores.

Experience with peripheral nerve injury in lower extremities

This study reports the results of 43 operations performed on nerves of lower extremities of 43 patients during a period of 7 years from 1999 - 2005 in Mansoura University Hospital and Mansoura Emergency Hospital. There were 15 patients with isolated sciatic nerve injury, 24 with isolated peroneal nerve injury and 4 with isolated tibial nerve injury. All patients were treated with nerve exploration within 1 hour to 7 months after injury and were followed-up for 6 months to 4 years. There were 22 nerve lesions not in continuity [9 needed suture repair and 13 needed sural nerve graft repair], while 21 nerve lesions were in continuity [16 partial lesions needed neurolysis and 5 complete lesions needed neuroma excision and suture repair]. Analysis of the outcome of surgical treatment was performed with respect to the following parameters: period between the injury and operation, patient age, type of injured nerve, mechanism of injury and type of surgical intervention. Overall significant outcome [>/= 3 Louisiana State University Health Science grade] was obtained in 53.5% [sciatic nerve 46%, peroneal nerve 54% and tibial nerve 75%]. According to the type of intervention and lesion categories; lesions not in continuity had a significant outcome 41% [suture repair 55.5% while graft repair 31%], and lesions in continuity had a significant outcome 67% [lesions underwent neurolysis 75%, while lesions underwent suture repair 40%]. Useful function was achieved in 3 [43%] of 7 patients with grafts less than 6 cm in length and in only 1 [16%] of 6 patients with grafts greater than 6 cm in length. The mean time to recovery in patients who underwent surgery was 18 months [range: 1- 32/ ]. In conclusion, the most favourable outcome was obtained with lesions that result in partial lesion in continuity. Considering the rate of spontaneous recovery of post-injection nerve injuries of the sciatic nerve and early onset of skeletal deformities, a closed nerve injury of the lower limb with no recovery within 3 months should always undergo surgery, even if complete functional outcome is not always guaranteed

A novel technique leading to complete sensory and motor recovery across a long peripheral nerve gap

Sensory nerve grafts are the [quot ]gold standard[quot ] for inducing neurological recovery in peripheral nerves with a gap. However, the effectiveness of sensory nerve grafts is variable, generally not leading to complete sensory and motor recovery, with good recovery limited to gaps shorter than 2 cm, and the extent of recovery decreasing with increasing graft length. An alternative technique using a conduit filled with pure fibrin to bridge a nerve gap leads to only limited neurological recovery. We tested the effectiveness of a novel nerve repair technique in which a 5-cm long radial nerve gap was repaired using two sural nerve graft surrounded by a collage tube filled with pure fibrin. By 1 1/2 years post surgery, the patient recovered complete sensory and motor function. In conclusion, this study suggests that the combination of pure fibrin surrounding sural nerve grafts is responsible for inducing the extensive neurological recovery induced by either pure fibrin or sural grafts alone. This technique is presently being tested in a clinical trial.

Reconstrucción de lesiones de extremidad inferior con Colgajo de Arteria Sural Superficial, experiencia de 10 años / Reconstruction of lower extremity lesions with superficial sural artery flap: a ten-year experience

La cobertura de heridas complejas en extremidades inferiores es un desafío de difícil manejo. Se realizó un estudio retrospectivo, analizando el resultado y las complicaciones en el uso del colgajo sural a pedículo distal para cobertura de defectos de extremidad inferior. Material y Método: Revisión de fichas clínicas de todos los pacientes sometidos a colgajo sural en los Hospitales Militar y Trabajador de Santiago entre los años 1995 y 2005, analizando características epidemiológicas, técnica quirúrgica y complicaciones del procedimiento. Resultados: Colgajos surales totales: 40 casos. Etiología de lesión: Fracturas: 33 casos (82,5%), heridas complejas (infectadas, inestables) 4 casos (10%), desforrramiento: 2 casos (5%) y quemadura: 1 caso (2,5%). En 20 casos no hubo complicación, y dentro de las complicaciones se encontraron necrosis parcial: 8 casos (20%), infección: 5 casos (12,5%), epidermolísis: 4 casos (10%) y seroma en 3 casos (7,5%). No se reportaron casos de necrosis total. Conclusión: El colgajo sural a pedículo distal es una alternativa válida de cobertura en lesiones complejas de extremo distal de extremidad inferior, con complicaciones de manejo aceptables, y con buen resultado a largo plazo.

Background: The covering of complex wounds of lower extremities is a difficult challenge. Aim: To analyze the results and complications on the use of sural flaps with distal pedicle for the covering of lower extremity defects. Material and Methods: We reviewed the clinical records of all the patients that had sural flaps between 1995 and 2005 at the Military Hospital and Workers Hospital of Santiago, Chile. We analyzed the epidemiologic characteristics, surgical techniques and complications of the procedure. Results: We found 40 cases of sural flaps. The etiology of the lesions were fractures in 33 cases (82.5%), complex wounds: four cases (10%), skin tearing and muscle laceration in 2 cases (5%) and burns 1 case (2.5%). In 20 cases there were no complications. Eight cases had partial necrosis (20%), five had infections (12.5%), four had epidermolysis and three had a seroma (7.5%). There were no reports of total necrosis. Conclusions: Sural flaps with a distal pedicle are a valid alternative for the covering of complex wounds of the distal portion of lower extremities, with a low rate of complications and good long term results.

Bilateral high radial nerve compressions: a case report.

A 40-year-old woman with bilateral high radial nerve compressions by non-traumatic cause was reported. It occurred first at the right radial nerve which was explored after a period of investigation and conservative treatment. Two constricted sites 2.0 cm apart of the right radial nerve crossed by branches of the radial collateral artery beneath the lateral head of the triceps were found. The constricted sites including tissue in between was resected and replaced with a sural nerve graft. One year later the patient had the same episode on the left side. The operative finding was the same as the previous one. Sural nerve graft was performed after neurolysis had failed. The patient's normal radial nerve function returned in one year. This is the first reported case in the literature of bilateral high radial nerve compressions by branches of the radial collateral artery.

Estudos microscópico e eletromiográfico após neurorrafia do nervo ciático de rato e sepultamento epineural de nervos surais, próximos ou distantes da sutura e com tamanhos diferentes / Microscopic and eletromyographic study after neurorraphy in rat sciatic nerve and concealed of epineural nerves near or distant of the suture with different sizes

Objetiva-se avaliar microscópica e eletromiograficamente os efeitos do sepultamento epineural de segmentos de nervo sural em nervos ciáticos seccionados e suturados, no mesmo tempo operatório. Foram utilizados 60 ratos, machos, da linhagem Wistar, operados em 3 grupos: Grupo 1, enxertia de nervo sural, com 9 mm, próximo à neurorrafia; Grupo 2, enxertia de nervo sural, com 9 mm, distante 10 mm da neurorrafia e Grupo 3, enxertia de nervo sural com, 18 mm, próximo da neurorrafia. Após 3 meses realizou-se o estudo morfológico onde os parâmetros avaliados foram: vascularizaçäo, vacuolizaçäo nas fibras nervosas, presença de mastócitos e de infiltrado inflamatório. O estudo morfométrico foi efetuado após 6 meses, medindo-se o diâmetro externo das fibras nervosas e a densidade de fibras nervosas por mm². Procedeu-se ao estudo eletromiográfico, avaliando a amplitude máxima e a frequência dos potenciais eletromiográficos, em repouso. Os ratos do Grupo 3, apresentaram nervos ciáticos morfologicamente melhor conservados e fibras com diâmetros externos significantemente maiores do que os dos Grupos 1 e 2. Os ratos do Grupo 1 demonstraram pormenores histológicos e fibras com diâmetros maiores do que os do Grupo 2. Näo houve diferenças significantes quanto à densidade de fibras por mm² e a amplitude máxima e à frequência dos potenciais EMG, nos Grupos 1,2 e 3. O sepultamento epineural de enxertos de nervo sural com mais extensäo e próximos à incisäo foram significantemente melhores do que os enxertos menores e distantes da neurorrafia. Os enxertos com mesma extensäo colocados próximos à neurorrafia foram significantemente melhores do que os distantes, embora näo se tenham verificado diferenças no estudo eletromiográfico...

Recovery of congenital facial palsy in patients with hemifacial microsomia subjected to sural to facial nerve grafts is enhanced by electric field stimulation

The effect of electric field stimulation for promoting axonal growth between sural to facial nerve graft in cases of congenital permanent facial palsy associated with hemifacial microsomia was studied pre- and postoperatively. A sural to facial nerve graft was performed in all cases and long term postoperative electric field stimulation was randomly applied to half to the patients. Although improvement occurred in both groups, the results indicated that clinical and elctrophysiological recovery was significantly better in patients receiving post-operative electric field stimulation. The results, therefore, suggest that electric stimulation of the grafted area induces improvements of facial palsy over and above those observed in the non-stimulated patients