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Background Posttraumatic lymphedema (PTL) is sparsely described in the literature. The aim of this study is to propose a comprehensive approach for prevention and treatment of PTL using lymphovenous anastomosis (LVA) and lymphatic vessels free flap, reporting our experience in the management of early-stage lymphedema. Methods A retrospective observational study was performed between October 2017 and July 2022. Functional assessment with magnetic resonance lymphangiography and indocyanine green lymphography was performed. Patients with lymphedema and functional lymphatic channels were included. Cases with limited soft tissue damage were proposed for LVA, and those with acute or prior soft tissue damage needing skin reconstruction were proposed for superficial circumflex iliac artery perforator lymphatic vessels free flap (SCIP-LV) to treat or prevent lymphedema. Primary and secondary outcomes were limb volume reduction and quality of life (QoL) improvement, respectively. Follow-up was at least 1 year. Results Twenty-eight patients were operated using this approach during the study period. LVA were performed in 12 patients; mean reduction of excess volume (REV) was 58.82% and the improvement in QoL was 49.25%. SCIP-LV was performed in seven patients with no flap failure; mean REV was 58.77% and the improvement QoL was 50.9%. Nine patients with acute injury in lymphatic critical areas were reconstructed with SCIP-LV as a preventive approach and no lymphedema was detected. Conclusion Our comprehensive approach provides an organized way to treat patients with PTL, or at risk of developing it, to have satisfactory results and improve their QoL.
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BACKGROUND: The superficial circumflex iliac artery perforator flap (SCIP) is a thin, pliable, and versatile flap used mainly for extremities and head and neck reconstruction. Different planning methods have been described, but these are not yet standardized like in other flaps. The aim of this study is to present a fast, effective, and reliable method for SCIP flap planning using computed tomography angiography (CTA). PATIENTS AND METHODS: Between October 2017 and September 2018, CTA was performed on 40 patients. Preoperative planning of SCIP flaps based on the medial branch was performed analyzing CTA images. The perforating sites of the medial branch on the deep (point D) and superficial fascia (point S) were identified. Distances to those points, from the center of the umbilicus in the "y-axis" and the midline perpendicularly in the "x-axis," were measured. These measurements were transferred to the patient's skin as a guide for dissection. RESULTS: Eighty areas were studied identifying points D and S in CTA. Forty-three SCIP flaps were performed using this planning method. In 100% of the flaps, points D and S matched perfectly with handheld Doppler and surgical findings. CONCLUSION: Points D and S method for medial branch based SCIP planning with CTA is an easy to learn, efficient, fast, and reliable technique for preoperative planning, allowing a safe and predictable elevation of the flap.
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Angiografia por Tomografia Computadorizada , Artéria Ilíaca/diagnóstico por imagem , Artéria Ilíaca/cirurgia , Planejamento de Assistência ao Paciente , Retalho Perfurante/irrigação sanguínea , Procedimentos de Cirurgia Plástica , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ultrassonografia DopplerRESUMO
Post-traumatic lymphedema is poorly understood. It is rarely considered in limb reconstruction decision-making approach. We report a case of a 41-year-old female who presented with right upper extremity lymphedema after degloving injury and split thickness skin graft, successfully treated with a superficial circumflex iliac artery perforator (SCIP) free flap restoring the lymphatic drainage. Right upper extremity had an excess of 258.7 mL or an excess volume of 27.86% compared to the healthy contralateral limb. A SCIP free flap including lymphatic vessels (SCIP-L) was performed to replace the skin graft in order to restore the lymphatic flow. Flap size was 19 × 8 cm and pedicle length was 4 cm. No lymph nodes were included and no lymphatic or lymphovenous anastomoses were performed. The surgery was uneventful, and there were no postoperative complications. Fourteen days after free tissue transfer, lymphedema showed clear improvement. At a 4-month follow-up, 55.6% reduction of excess volume was obtained. Indocyanine green lymphography performed at that time showed a restitution of lymph flow through the flap. Lymphedema improvements persisted at a 6-month follow-up. A successful treatment of post-traumatic lymphedema can be performed by using the SCIP-L free flap for soft tissue reconstruction of critical lymphatic drainage areas.
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Braço/cirurgia , Avulsões Cutâneas/cirurgia , Artéria Ilíaca/transplante , Vasos Linfáticos/transplante , Linfedema/cirurgia , Retalho Perfurante/irrigação sanguínea , Retalho Perfurante/cirurgia , Adulto , Feminino , Humanos , Complicações Pós-Operatórias/cirurgia , ReoperaçãoRESUMO
Design and preoperative planning of microsurgical flaps are fundamental steps for successful surgery. Currently, computed tomographic angiography is considered the gold standard, and new technologies such as thermography could complement its usefulness. The aim of this study was to determine the concordance between thermographic images obtained with a smartphone thermal camera and computed tomographic angiography for detecting perforators using the anterolateral thigh flap area as a model. A concordance study of diagnostic tests was performed in patients who underwent limb reconstruction in 2016. Perforators identified in thigh computed tomographic angiographic images and hotspots on thermographic images obtained by means of the FLIR ONE smartphone camera were compared based on the distance from the anterior superior iliac spine. The authors studied 20 patients, including 38 anterolateral thigh flap territories in total, and identified 117 perforators by computed tomographic angiography and 120 hotspots by thermography. The average mean distance from the anterior superior iliac spine using these methods was 193.14 mm, and the mean difference in distance was 2.37 mm, with both measurements being obtained within a radius of 20 mm, with a concordance kappa index of 0.975 (p < 0.001). Thermographic imaging presented a sensitivity of 100 percent and a specificity of 98 percent in detecting perforators. Thermographic images obtained with a smartphone thermal camera have a high concordance with the method considered the gold standard for perforator detection. In addition, its sensitivity and specificity are comparable to those of computed tomographic angiography, which makes it a very useful method for mapping perforators in free flap planning. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, II.
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Retalhos de Tecido Biológico/irrigação sanguínea , Retalho Perfurante/irrigação sanguínea , Smartphone , Termografia/instrumentação , Coxa da Perna/irrigação sanguínea , Angiografia por Tomografia Computadorizada/métodos , Humanos , Sensibilidade e Especificidade , Coxa da Perna/cirurgiaRESUMO
AIMS: To evaluate the effectiveness and safety of transdermal buprenorphine (BTDS) in the treatment of post-traumatic pain in a working population. PATIENTS & METHODS: Retrospective case series of patients with severe post-traumatic pain treated with BTDS between 2008 and 2012. RESULTS: 57 patients were evaluated: 38 men, 19 women (mean age 43 years); patients with burns (n = 22), skin degloving (14), open dislocations (eight), traumatic nerve lesions (six), spinal cord injury (four) and limb amputations (three). 25, 12 and 20 patients experienced neuropathic pain, nociceptive pain or neuropathic/nociceptive pain, respectively. The mean baseline DN4 questionnaire and pain intensity scores were 4.8±2.3 and 7.4±1.5, respectively. The mean duration of pain before BTDS use was 24.4 months (>3 months in 65% of patients). Total patient-years of BTDS treatment were 73. After 14.7±14.9 months of BTDS treatment, mean pain intensity was reduced by 4.2±2.2 points, 38 patients (66.7%) had ≥50% pain relief, 69% reported functional improvement, especially in gait ability (25) and activities of daily life (14), and 46 patients (80.7%) had improved sleep quality. The starting dose of BTDS was 4.4-17.5 µg/h; maintenance dose was 8.8-70 µg/h. At the start of BTDS treatment, all patients used a total of 187 concomitant analgesics daily, 72% of which were stopped during treatment with BTDS; the number of patients that could be managed exclusively with BTDS and rescue analgesia increased to 31%. 13 patients (22%) presented nausea, eight constipation, six local skin reactions, three vomiting and somnolence, and two patients experienced dizziness. Four patients (6.9%) stopped BTDS due to adverse reactions. CONCLUSIONS: BTDS is an effective and safe alternative for the treatment of patients with severe post-traumatic pain, reducing the intensity of pain and improving functional capacity and quality of sleep.
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Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/uso terapêutico , Buprenorfina/administração & dosagem , Buprenorfina/uso terapêutico , Dor Crônica/tratamento farmacológico , Dor Crônica/etiologia , Ferimentos e Lesões/complicações , Acidentes de Trabalho , Administração Cutânea , Adulto , Idoso , Idoso de 80 Anos ou mais , Analgésicos Opioides/efeitos adversos , Buprenorfina/efeitos adversos , Quimioterapia Combinada , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor/efeitos dos fármacos , Cooperação do Paciente , Estudos Retrospectivos , Retorno ao Trabalho , Adulto JovemRESUMO
OBJECTIVE: The efficacy of 5% lidocaine medicated plaster (LMP) has previously been demonstrated in post-traumatic localized neuropathic pain. This study evaluated the use of LMP in localized neuropathic pain secondary to traumatic peripheral nerve injury. PATIENTS AND METHODS: This prospective observational study enrolled patients with traumatic injuries to peripheral nerves that were accompanied by localized neuropathic pain of more than 3 months duration. Demographic variables, pain intensity (measured using the numeric rating scale; NRS), answers to the Douleur Neuropathique 4 (DN4) questionnaire, and the size of the painful area were recorded. RESULTS: Nineteen patients were included, aged (mean ± standard deviation) 41.4 ± 15.7 years. Nerve injuries affected the upper (eight patients) or lower (11 patients) limbs. The mean duration of pain before starting treatment with LMP was 22.6 ± 43.5 months (median 8 months). Mean baseline values included: NRS 6.7 ± 1.6, painful area 17.8 ± 10.4 cm(2) (median 18 cm(2)), and DN4 score 6.7 ± 1.4. The mean duration of treatment with LMP was 19.5 ± 10.0 weeks (median 17.4 weeks). Mean values after treatment were: NRS 2.8 ± 1.5 (≥3 point reduction in 79% of patients, ≥50% reduction in 57.9% of patients) and painful area 2.1 ± 2.3 cm(2) (median 1 cm(2), ≥50% reduction in 94.7% of patients). Functional improvement after treatment was observed in 14/19 patients (73.7%). CONCLUSION: LMP effectively treated traumatic injuries of peripheral nerves which presented with chronic localized neuropathic pain, reducing both pain intensity and the size of the painful area.
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INTRODUCTION: Dermal substitutes, such as Integra(®) introduced as a new alternative to our surgical arsenal and its use in burn treatment, in both acute and chronic phases, have gained great importance. OBJECTIVE: The aim of the experiment is to describe the results of the functional evaluation of patients with burned hands treated with Integra(®) in both acute and chronic phases. MATERIAL AND METHODS: A retrospective review of a transversal cohort. Patient characteristics evaluated were sociodemographic characteristics, burn mechanism, burn extension and depth, treatments received previous to Integra(®) and complications related to its use. Clinical and photographic evaluations were performed evaluating skin elasticity, range of articular movement, prehensile strength, pain and functional evaluation using the validated 400 Point Evaluation Test. RESULTS: A total of 17 burned hands in 14 right-handed patients, were treated with Integra(®), three being bilateral hand burns. Eleven were treated in the acute phase and in nine in the scar reconstruction phase. Range of articular motion was complete in 15 of 17 hands. In 88% of the hands, flexible skin coverage was achieved. No statistically significant difference was observed in prehension strength of the burned hand versus the contralateral non-burned hand. Sixteen hands had a painless evolution. The 400 Point Evaluation score was 92.8 ± 6.3% (80 - 100%). Nearly four-fifths (79%) of the patients returned to normal active working activities.
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Queimaduras/cirurgia , Sulfatos de Condroitina , Colágeno , Traumatismos da Mão/cirurgia , Mãos/fisiologia , Procedimentos de Cirurgia Plástica/métodos , Recuperação de Função Fisiológica , Adulto , Idoso , Queimaduras/fisiopatologia , Feminino , Seguimentos , Traumatismos da Mão/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Pele Artificial , Resultado do Tratamento , Cicatrização , Adulto JovemRESUMO
OBJECTIVE: To evaluate the use of 5% lidocaine medicated plaster (LMP) for treating painful scars resulting from burns or skin degloving. PATIENTS AND METHODS: This was a prospective, observational case series study in individuals with painful scars <70 cm(2) in area, caused by burns or skin degloving. The study included a structured questionnaire incorporating demographic variables, pain evaluation using the numeric rating scale (NRS), the DN4 questionnaire, and measurement of the painful surface area. Patients with open wounds in the painful skin or with severe psychiatric disease were excluded. RESULTS: Twenty-one men and eight women were studied, aged (mean + standard deviation) 41.4 ± 11.0 years, with painful scars located in the upper extremity (n = 9), lower extremity (n = 19), or trunk (n = 1). Eleven patients (37.9%) had an associated peripheral nerve lesion. The scars were caused by burns (n = 13), degloving (n = 7), and/or orthopedic surgery (n = 9). The duration of pain before starting treatment with lidocaine plaster was 9.7 ± 10.0 (median 6) months. The initial NRS was 6.66 ± 1.84 points, average painful area 23.0 ± 18.6 (median 15) cm(2), and DN4 score 4.7 ± 2.3 points. The duration of treatment with LMP was 13.9 ± 10.2 (median 11) weeks. After treatment, the NRS was reduced by 58.2% ± 27.8% to 2.72 ± 1.65. The average painful area was reduced by 72.4% ± 24.7% to 6.5 ± 8.6 (median 5) cm(2). Nineteen patients (69%) showed functional improvement following treatment. CONCLUSION: LMP was useful for treating painful scars with a neuropathic component, producing meaningful reductions in the intensity of pain and painful surface area. This is the first time that a decrease in the painful area has been demonstrated in neuropathic pain using topical therapy, and may reflect the disease-modifying potential of LMP.
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OBJECTIVE: To determine the concordance between superficial cultures (SC) and quantitative cultures (QC) in the diagnosis of wound infection in burn patients. SAMPLE: All SC and QC taken from the same patient, site and during the same surgery were analysed. VARIABLES: On the SC, the microorganism (MO) and its amount defined subjectively by the microbiologist was recorded (negative, very low, low, regular and abundant). On the QC, the MO and its amount were expressed as colony forming units per gram of tissue (CFUs/g). STATISTICS: Kappa index of agreement beyond chance; Wilcoxon and Kruskall-Wallis for continuous variables and chi(2) for categorical variables were used with a p<0.05 indicating statistical significance. RESULTS: One thousand four hundred and forty three pairs of cultures were analyzed. The concordance between SC and QC (Kappa index) was 52%. On the SC, only when the microbiologist subjectively informed "abundant" MOs there was a significant difference (p<0.0001). There were 6.1% of QCs with more than 10(5) CFUs/g and the most frequent MOs isolated were: S. aureus (27.9%), E. coli (11.6%), P. aeruginosa (11.6%), E. faecalis (11.6%) and S. epidermidis (7.0%). CONCLUSIONS: SC has a moderate concordance with the QC showing a low reliability between the two methods. The subjective information given by the microbiology technician in the SC is not precise. A study in which the two methods be compared blindly against the reference standard, in a prospective cohort of patients, it is needed to discriminate which of two methods it is the most accurate one determining sensitivity and specificity.