Timing Of Microsurgical Reconstruction Research Articles

Discussion: Timing of Microsurgical Reconstruction in Lower Extremity Trauma: An Update of the Godina Paradigm

Discussion: Timing of Microsurgical Reconstruction in Lower Extremity Trauma: An Update of the Godina Paradigm

The timing of microsurgical reconstruction in lower extremity trauma

The timing of post traumatic microsurgical lower extremity reconstruction was defined by Godina in 1986, with recommendations for flap coverage of Gustillo grade IIIb/c fractures within 72 hours of injury. Godina's study showed the highest risk of infection and flap loss in the delayed period (72 hours-90 days). Subsequent authors have also cited lower rates of flap loss and infection when repair was performed "early". However, the definition of "early" remains ambiguous. We hypothesized that definitive debridement with optimal dressing care, meticulous microsurgical treatment planning, and vessel anastomoses outside of the zone of injury would allow for delayed reconstruction with high success rates. A retrospective review of 14 lower extremity reconstructions with free flaps was undertaken over a 4-year period. All patients underwent reconstruction in the delayed (>72 hours) period. There were no flap losses and one case of late osteomyelitis. We conclude that lower extremity reconstruction can be performed safely and effectively in the "delayed" period to allow for wound debridement, stabilization of other injuries, and transfer to a microsurgical facility.

An Economic Analysis of the Timing of Microsurgical Reconstruction in Brachial Plexus Birth Palsy

An Economic Analysis of the Timing of Microsurgical Reconstruction in Brachial Plexus Birth Palsy

An Economic Analysis of the Timing of Microsurgical Reconstruction in Brachial Plexus Birth Palsy

Background: The role and timing of microsurgical reconstruction of the brachial plexus in infants who have no signs of biceps recovery within the first six months of life is controversial. The purpose of the present study was to create an economic model to compare microsurgical treatment at three as opposed to six months in patients with brachial plexus birth palsy who had no return of biceps function at three months. Methods: A cost-minimization study was performed with use of a decision-analysis model. Natural history, success, and tendon transfer and osteotomy rates were estimated from the literature. Costs were estimated from a single center. Results: The literature on patients without nerve root avulsion supports an 80% rate of biceps recovery between three and six months of age. On the basis of this value, microsurgical intervention at three months was more expensive than microsurgical intervention at six months. Microsurgical intervention at three months cost more than twice as much as intervention at six months. Sensitivity analysis revealed that when the rate of biceps recovery was 40% and surgery at three months was three times more successful than surgery at six months, then both treatments had equal costs. Conclusions: It is unlikely that microsurgical intervention at three months for the treatment of rupture injuries of the brachial plexus will be successful enough to produce overall cost savings. While our results should not be used to dictate policy decisions as they are not definitive and remain contingent on future studies, it is still reasonable to consider economic factors and quality-of-life outcomes in brachial plexus birth palsy treatment strategies and future research. Level of Evidence: Economic and decision analysis, Level II. See Instructions to Authors for a complete description of levels of evidence.