Vascularized Bone Grafts from the Lateral Femoral Condyle for the Treatment of Avascular Lunate Necrosis (Kienböck's).

Background: Avascular necrosis of the lunate (Kienböck's disease) is rare and one of the main causes of progressive painful arthritis, requiring surgical intervention. Various approaches have shown benefits in treating Kienbock's disease but with limitations. The article aims to analyze the functional outcome using lateral femoral condyle free vascularized bone grafts (VBGs) as the first choice of treatment for Kienböck`s. Materials and methods: This was a retrospective analysis of 31 patients with Kienbock's who had microsurgical revascularization or reconstruction of the lunate between 2016 and 2021 using either corticocancellous or osteochondral VBGs from the lateral femoral condyle. The characteristics of lunate necrosis, choice of VBG and postoperative functional outcome were reviewed. Results: Corticocancellous VBGs were used in 20 patients (64.5%), while osteochondral VBGs in 11 patients (35.4%). The lunate was reconstructed in 11 patients, revascularized in 19 patients, and one patient received augmentation of a luno-capitate arthrodesis with a corticocancellous graft. We noted postoperative irritation of the median nerve (n = 3) and screw loosening requiring removal (n = 1) as minor complications. All patients had complete graft healing at eight-month follow-up and acceptable functional outcomes. Conclusions: Free VBG from the lateral femoral condyle represent a reliable method of lunate revascularisation or reconstruction in advanced Kienböck's. Their main advantages are the constant vascular anatomy, straightforward graft harvesting technique and possibility to harvest several graft types according to the requirements at the donor site. Postoperatively, the patients become pain-free and have an acceptable functional outcome.

Prefabrication and free transfer of a tissue engineered composite flap - An experimental model in the rat.

BACKGROUND: The technique of flap-prefabrication has been successfully established in tissue engineering: missing intrinsic vascularisation of engineered tissue can be generated in vivo by microsurgical vesselloop construction. It is possible to move engineered tissue into a defect with microsurgery. In the literature, the combination of engineered tissue covered with skin is not widely reported. OBJECTIVE: Aim of this study was to establish a model to investigate scaffold prefabrication with full thickness skin graft coverage with subsequent free tissue transfer. METHODS: 8 Wistar rats were operated in 2 separate steps: 1) after creating an arteriovenous loop with the femoral vessels, a porous scaffold was placed on the loop and covered with an inguinally based skin flap. A control was implanted without loop into the contralateral groin. 2) 6 weeks later the prefabricated composite flaps were microsurgically transferred to the cervical region. Skin-island monitoring was performed with Laser Doppler-scanner after the transfer. RESULTS: Continuous loss of the skin islands was observed within 72 hours. Complications included wound-dehiscence, thrombosis and death from anaesthesia; in spite of consistent loop viability. CONCLUSION: Evaluation showed that modifications are necessary to maintain the skin-island cove.

Optimal Solution Volume for Luminal Preservation: A Preclinical Study in Porcine Intestinal Preservation.

BACKGROUND: Rodent studies suggest that luminal solutions alleviate the mucosal injury and prolong intestinal preservation but concerns exist that excessive volumes of luminal fluid may promote tissue edema. Differences in size, structure, and metabolism between rats and humans require studies in large animals before clinical use. METHODS: Intestinal procurement was performed in 7 pigs. After perfusion with histidine-tryptophan-ketoglutarate (HTK), 40-cm-long segments were cut and filled with 13.5% polyethylene glycol (PEG) 3350 solution as follows: V0 (controls, none), V1 (0.5 mL/cm), V2 (1 mL/cm), V3 (1.5 mL/cm), and V4 (2 mL/cm). Tissue and luminal solutions were sampled after 8, 14, and 24 hours of cold storage (CS). Preservation injury (Chiu score), the apical membrane (ZO-1, brush-border maltase activity), and the electrolyte content in the luminal solution were studied. RESULTS: In control intestines, 8-hour CS in HTK solution resulted in minimal mucosal changes (grade 1) that progressed to significant subepithelial edema (grade 3) by 24 hours. During this time, a gradual loss in ZO-1 was recorded, whereas maltase activity remained unaltered. Moreover, variable degrees of submucosal edema were observed. Luminal introduction of high volumes (2 mL/mL) of PEG solution accelerated the development of the subepithelial edema and submucosal edema, leading to worse histology. However, ZO-1 was preserved better over time than in control intestines (no luminal solution). Maltase activity was reduced in intestines receiving luminal preservation. Luminal sodium content decreased in time and did not differ between groups. CONCLUSIONS: This PEG solution protects the apical membrane and the tight-junction proteins but may favor water absorption and tissue (submucosal) edema, and luminal volumes >2 mL/cm may result in worse intestinal morphology.

Arterio-venous fistula using nonpenetrating titanium clips (VCS).

UNLABELLED: Vascular access in haemodialysis is still accompanied by a high morbidity rate. Neointimal hyperplasia due to thrombosis is one of the main causes of vascular access failure. The purpose of this paper is to present the use of non-penetrating titanium clips (VCS) for the creation of an arteriovenous fistula and its outcome. MATERIALS AND METHODS: A male patient, 47 years old, with end-stage renal disease - ESRD - (2005) was addressed to our service, for a vascular access reintervention, after a failed forearm radio-cephalic fistula performed 3 months before. In January 2007, an arteriovenous fistula between the brachial artery and the median cubital vein using non-penetrating titanium clips (Anastoclip VCS) was created. RESULTS: The vascular anastomosis was performed in 17 min. After unclamping the artery, a solid pulse and consistent thrill were obtained at the level of the cubital fossa. The postoperative course was uneventful. The arteriovenous fistula remains functional 60 months post-surgery. CONCLUSIONS: The Anastoclip VCS system is versatile, safe to manipulate and enables fast anastomosis. Arteriovenous anastomosis performed with non-penetrating clips may be a solution with the potential to reduce postoperative complications and extend arteriovenous fistula patency in ESRD.

Breast reconstruction with autologous tissue--our clinical experience.

INTRODUCTION: Breast reconstruction after mastectomy gained new grounds since the introduction of autologous tissue and oncoplastic surgery techniques. Nowadays large postoperative breast defects can be treated with high quality tissues obtained by autogenous flap surgery, to achieve the best functional and physical results. OBJECTIVES: The purpose of this study is to analyze our results in breast reconstruction using autologous tissue and to emphasize the importance of a multidisciplinary team. MATERIAL AND METHODS: During a five year period (2005-2009) we performed 28 breast reconstructions after cancer surgery, 15 in delayed and 13 in primary reconstruction, using three types of flaps: latissiumus dorsi flap, transverse rectus abdominis myocutaneous flap and deep inferior epigastric artery perforator flap. RESULTS: Functional and cosmetic results were very good, only minor complications such as seroma and hematoma of the donor site and partial/marginal flap necrosis occurred after the surgical procedure. There were no major complications like total flap loss. CONCLUSIONS: Breast reconstruction with autologous tissue is a safe, well proved, although not easy procedure that confers best functional and cosmetic results and is at the same time oncologically safe.

Infrarenal abdominal aorta approach through median minilaparotomy.

Classically, infrarenal aortic exposure is achieved by xyphopubic or xypho-infraumbilical laparotomy, in transperitoneal approach, or through a left abdominal incision, in retroperitoneal approach. The transperitoneal approach is associated with longer intestinal activity resumption time and incisional hernias on long term, due to intestinal extracavitary mobilization and long incision. These disadvantages disappear in laparoscopic approach, but this method is extremely laborious, requires an extended period for dissection, and elicits increased difficulty in performing the anastomosis on the aorta. The purpose of the study is to evaluate the infrarenal abdominal aorta approach through median minilaparotomy, a method that combines the excellent exposure of xypho-pubic incision with the low morbidity of laparoscopic approach. Between 07.01.2010 - 07.01.2011, we performed 37 revascularization surgeries in 36 patients with aorto-iliac occlusive disease (one patient required reintervention due to graft thrombosis), approaching the infrarenal aorta through median minilaparotomy. The sex distribution was 35 men and one woman. The average age was 61.1 years. There have been 25 aorto-bifemoral bypasses, 11 aorto-unifemoral bypasses, and one aorto-biiliac bypass. The mean aorta clamping time was 15 minutes. Average operating time was 150 minutes. We used 26 bifurcated Dacron prostheses and 11 linear ePTFEprostheses. The average intestinal activity resumption time was 32 hours. All patients included in the study were mobilized 24 hours after surgery. The average length of hospitalization was 7.7 days. 5 patients experienced complications during hospitalization and 3 patients suffered long term complications. Infrarenal abdominal aorta approach through median minilaparotomy is a viable alternative to conventional surgical techniques used in aortoiliac occlusive disease.

[Accessory renal allotransplantation with internal or external urinary drainage. An experimental model in pig]. / Allotransplantarea renala accesorie cu drenaj urinar intern sau extern. Model experimental la porc.

This study describes an experimental model of accessory renal allotransplantation in the big laboratory animal (pig). A total of 24 common-breed pigs were used. All allografts were transplanted in an accessory manner and revascularized at the level of the infrarenal abdominal aorta and inferior vena cava. The urinary drainage was performed either through a nexternal uretheroneostomy at the ipsilateral lumbar region (Group A--n=8) or by internal uretheroneocystostomy (Group B--n=8). All transplants were monitored for 8 days postoperatively using translumbar ultrasound-guided biopsies at 1, 4, 7 days. A total of 16 transplants were performed. 1 ectopic donor kidney was found and transplanted in the same fashion. Mean operative time was 125 minutes, immediate postoperative survival was 100% and at 72 hours, 87.5%. The onset of acute rejection was at day 4, by massive lymphocyte infiltration and was directly correlated with the abrupt decrease of the allograft diuresis in Group A, at day 3. At day 7, the rejection was complete. Both methods of urinary drainage are functional and can be employed. This experimental model is a useful tool for training of the transplant surgeons or for transplantation research. The surgical technique for accessory renal allotransplantation in pig is easy to learn and offers the possibility for allograft monitoring until complete rejection without influencing the receptor health condition.

[The first NOTE (Natural Orifice Translumenal Endoscopic) cholecystectomy in Romania: an experimental model in pig]. / Prima colecistectomie NOTES din România: model experimental.

NOTES (Natural Orifice Translumenal Endoscopic Surgery) represents a very new acquisition in the field of gastrointestinal endoscopy, which uses common flexible endoscopes in order to perform intraperitoneal surgical procedures. This procedure offers a very good visualisation of the peritoneal cavity, as well as the possibility of performing surgical procedures. The aim of the study is to report our experience--the first of its kind in Romania--in performing per os, transgastric procedures, emphasizing the technical challenges and the possible complications associated with this method. This is an experimental study, using pigs (tri-hybrid PIC strain), in which peritoneoscopy and cholecystectomy were performed via a hybrid-NOTES approach (a 5 mm laparoscopic port has been used, placed in the right upper quadrant). The transgastric approach of the peritoneal cavity proved to be easy, allowing simple surgical procedures. The results of the study show the feasibility of the method. During surgery, no serious complications occurred, the minor incidents being managed without conversion to classical or laparoscopic surgery.

[Endoscopy-assisted harvesting and free latissimus dorsi muscle flap transfer in reconstructive microsurgery]. / Recoltarea asistata-endoscopic si transferul liber a lamboului muscular de latissimus dorsi în microchirurgia reconstructiva.

Because of their generous dimensions, constant anatomy, great plasticity and well defined vascularization, muscles remain the preferred choice when approaching reconstruction of complex tissue defects resulting after trauma or oncological resections. The latissimus dorsi, represents a widely used flap when performing reconstructive microsurgery using free tissue transfer, but with important postoperative complications like seroma, donor-site hematoma and large scars. Along with the development of video assisted harvesting of muscular free flaps, the minimal invasive approach brings an important decrease of the donor site morbidity, followed by a faster healing. This article presents the case of a patient diagnosed with chronic osteomyelitis fistula, on the site of an older posttraumatic fracture at the level of the tibial diaphysis, where a large debridement of soft tissues and the involved bone was performed, followed by microsurgical reconstruction of the left over defect, using a free latissimus dorsi muscular flap harvested by endoscopic-assisted technique.

[Experimental model of pancreas transplantation with portal or systemic drainage in laboratory rats]. / Model experimental de transplant pancreatic cu drenaj portal sau sistemic la sobolanul de laborator.

The aim of this study was to develop an experimental model of pancreas transplantation in rats as a standardized tool for research in transplant immunobiology. Brown Norway (donors) and Lewis (receptors) rats, males, with an average weight of 220 grams, were used. The diabetes was induced in recipients using streptozocin. The pancreas was harvested with a duodenal stump, a segment of aorta containing the celiac and superior mesenteric artery and the portal vein and transplanted as follows: Group A (n=8) - systemic venous drainage; Group B (n=8) - portal venous drainage. The exocrine drainage of the pancreatic graft was established by para-topic reintegration of the graft duodenal stump in the recipient. Postoperative follow-up consisted of daily measurement of glycemia and macroscopic evaluation of the proximal duodenal stump mounted as a cutaneous stoma. Overall postoperative survival at 8 days was 87,5% for Group A and 75% for Group B. Glycemia levels started to regain normal values in both groups, at 2 days postoperatively. Rejection started at 9 and 10 days postoperatively for Group A and B respectively, being expressed by the gradual re-appraisal of hyperglycemia that followed necrosis of the proximal duodenal stump. The experimental model described is functional and has the advantage of being used either with portal or systemic drainage of the pancreatic graft. The results obtained show no significant difference between the time-points of normal postoperative glycemia when either systemic or portal venous drainage were used.

[Infected wound treatment using negative pressure atmosphere]. / Tratamentul plagilor supurate în atmosfera cu presiune negativa.

The aim of this clinical study is the presentation of a adjuvant therapy for chronic or infected wounds. Unwanted complication in any surgical branch the infected wound benefits primarily of surgical debridement. The treatment in negative pressure atmosphere of the complicated wound is a valuable adjuvant treatment due to volume reduction of the soft tissue defect, stimulation of the granulation tissue formation, decreasing of the bacterial contamination, permanent secretion drainage in a closed system with local continuous or intermittent lavage possibility. The patented V.A.C. system is the ideal but expensive option for this therapy. However good results were obtained in the treatment of difficult infected wounds by building a system using a auto adhesive incision drape and Redon drainage.

[Complex microsurgical reconstruction of diabetic foot]. / Reconstructie complexa microchirurgicala a piciorului diabetic.

Microsurgical techniques increased the operability of patients with critical limb ischemia to more than 95%. However, the percentage of ischemic limb salvage remains limited, especially in diabetic patients with associated tissue gangrene and neuropathy. The study presents a 67 years old female patient with type II diabetes mellitus and critical limb ischemia, complicated with progressive gangrene of the pre-calcaneal region and thus representing a classical indication for thigh amputation. A sequential femur-popliteal-tibial anterior by-pass was performed, followed by soft tissue reconstruction using a latissimus-dorsi musculo-cutaneous free flap. Two years postoperatively, the patient developed clinical signs of symmetrical peripheral distal neuropathy, managed by bilateral posterior tibial nerve decompression. The patient follow-up was of 3 years. Through the entire period, distal pulse (ram of posterior tibial artery) remained present with a good integration of the flap and with absent clinical and paraclinical signs of neuropathy. The patient regained full ambulation. Morphologically and functionally the affected limb is entirely salvaged. Using microsurgical techniques, a more complex and complete approach of the diabetic patient with ischemic-neuropathic syndrome can be considered. This includes revascularization, soft tissue reconstruction and nerve decompression. In selected patients with indication of major amputation these methods offer a salvage option, with excellent long-term results.

Preliminary results of orthotopic en bloc uterus and ovary transplantation in the laboratory rat.

A new experimental model of whole uterus and ovary transplantation in the laboratory rat was achieved. The main goals of this study were concerned with developing and standardizing the microsurgical technique of uterus transplantation in rats and observing the particular cellular patterns of acute allograft rejection at the level of the transplanted graft. Thirty-five orthotopic uterus transplantations were performed. An additional 20 female rats were used for dissection training sessions. Recipients were euthanasied at 24 hours, 48 hours and 72 hours. Immediate postoperative survival was 100%. Patency of the microsurgical anastomoses, checked at 24 hours, was 100%. At 72 hours thrombosis occurred in all anastomoses. The explanted uterine grafts were fixed in formaline and analyzed under light microscopy and specific imunohistochemical analysis. The acute allograft rejection has a particular cellular reaction pattern, probably due to the unique diversity of the tissues that compose it. Inflammatory cells like LTCD8+, LBCD20+ and mastocytes tend to agglomerate in the vicinity of nervous and vascular structures, showing no signs of lymphoid tissue disposition like in typical acute rejection. Uterus transplantation in rats has proven to be a valid experiment that allows us to express hope that by further research on transplantation of the uterus gynecologists will be able to introduce an adapted technique in the treatment of specific cases of human female infertility.

[Experimental model of orthotopic uterus transplantation in the laboratory rat]. / Model experimental de transplant uterin ortotopic la sobolanul de laborator.

This study develops and standardizes an experimental model of uterus transplantation in the laboratory rat. Twelve orthotropic uterus transplantation were done. Animals were randomized in three groups. Postoperative survival was 100% and 75% at 72 hours. Recipients were euthanased at 24 hours, 48 hours and 72 hours and the grafts were harvested. Patency of the microsurgical anastomoses was 100% at 24 hours, 63% at 48 hours and 0% at 72 hours. The explanted uterine grafts were fixed in formalize and analyzed under light microscopy. The acute allograft rejection starts during the second day after transplantation. In additional dissection, anatomy of the pelvic region with regard to the topography of the uterus, tube and ovarian vessels was studied. This model of uterus transplantation in rats proposes a standardized tool for further research regarding cellular mechanisms of the acute allograft rejection and, for future, pregnancy of the transplanted uterus.

[Experimental model of heterotopic renal transplantation in rat]. / Model experimental de transplant renal heterotopic la sobolan.

This study describes the experience with a new technique for heterotopic kidney transplantation in the laboratory rat. This technique combines already known aspects in renal experimental transplantation, with technical improvements added to each surgical step. Ten heterotopic kidney transplantation were performed. Immediate postoperative survival was 100% and at 48 hours was 90%. The patency of the vascular anastomosis checked at 72 hours in survivors was 100%. As a preliminary study, 20 renal hilum dissections were done, noting the topographical aspects of the renal vessels. Representing a standardized and easy to use model, this solid organ transplantation technique is a valuable tool for studying the immunological and physiopathological aspects of transplantation and for refining the microsurgical skills.