Pelvic limb reconstruction failed by propeller flap resolved with microsurgery

Reconstruction of lower limb defects is a constant challenge for surgeons, the etiology of the defect can be very variable from diabetic ulcers, traffic accidents, fall from height, oncological resections and many others. Free flaps have always been an important option because it has great results in complex reconstructions in lower limbs, it is a microvascular technique, so it has a higher level of complexity. This technique is usually reserved for extensive perilesional wide defects. On the other hand, the propeller flap, which is considered less invasive and easier as it does not involve microvascular surgery. An 18-year-old patient who had a fracture of the right tibial pylon due to a 7-meter drop, who after orthopedic treatment had a defect with exposure of ostesynthesis material of 3 cm in circumference in the medial malleolus. This defect was first managed with a propeller flap complicated with necrosis at 48 hours which was treated with sub atmospheric pressure system for 5 days and later with an ultra-thin anterolateral flap of the pelvic limb. Complete pedicled propeller flap failure is very rare but, because necrosis develops distally, even partial necrosis can expose bone, tendons, or other tissue. Some surgeons consider that propeller flap placement is risky in this location, especially the distal third of the lower leg a prefer to use free flaps. Whenever any pelvic member reconstruction plan fails in the distal third, the best and safest is the use of microsurgery even with the failure of a previous micro vascular flap.

Heparin-induced bleeding treatment in microsurgery

Microsurgery is associated with prolonged surgical times with an increased risk of deep vein thrombosis, pulmonary embolism and myocardial infarction. The use of antithrombotic means is a commonly employed tactic to prevent vascular thrombosis after microvascular free flap surgery. Flap loss is a devastating complication of microsurgical procedures that leads to detrimental outcomes. A 32-year-old male patient has a ruptured calcaneal tendon. He underwent 5 surgical cleanings with multiple failed sequential attempts at wound closure. Traumatology department in its microsurgery division where it is proposed to perform neo-tendon with graft of palmaris longus of the right thoracic extemity and radial antebrachial microvascular flap. The neo tendon was performed in addition to the micro surgical coverage with the radial antebrachial flap.When having vascular control with micro-clamps, 6000 U of unfractionated heparin was initiated, approximately 20 minutes after the end of the microvascular anastomosis, there was incoercible bleeding, which is initially treated with spray fibrin. Continued bleeding after 3 hours, so it was decided to reverse the effect of heparin with transfusion of fresh frozen plasma, 10 mg of vitamin K and fibrinogen. The effect of heparin was reversed without having thrombotic complications of microvascular anastomoses. The flap was not reexplored since they showed no signs of vascular compromise. If anticoagulants have been used and an incoercible hemorrhage is found, the effect of heparin must be reversed. In the transfer of tissues with microsurgery, the recommended and safe anticoagulation are prophylactic doses and not therapeutic doses.

Microsurgery in complex trauma of pelvic limb in a pediatric patient: case report

Complex trauma is defined as the condition secondary to the exchange of kinetic energy of two or more tissues in one limb. This entity is a surgical emergency that can have many sequelae and can even result in limb loss. An 11-year-old female patient presents complex pelvic limb trauma secondary to contuse injury caused by a helicopter’s rotor blades.  Pelvic limb reconstruction was performed with iliac crest bone graft, the fracture was stabilized with an external fixator and the skin defect was covered with an anterolateral microvascular thigh flap (ALT). There was an adequate integration of the bone graft with adequate skin coverage thanks to the ALT thigh flap. The patient presented discreet limb shortening as consequence.  Currently, microsurgery is the only medical option that meets the objectives of limb reconstruction. Microsurgical techniques can be used in pediatric and adult patients. The success of any recovery from complex trauma is vigorous surgical cleaning, avoiding sequential and/or multiple washes.

Transfusion related acute lung injury-TRALI: a review

Acute pulmonary damage caused by transfusion is characterized by the sudden onset of respiratory distress in newly transfused patients within 6 hours after the transfusion, bilateral infiltrative changes in chest X-ray, PaO2/FIO2 <300 mmHg, absence of other risk factors for acute lung injury and absence of signs suggesting cardiogenic origin of pulmonary edema. Being one of the most serious complications of blood transfusion, plasma is the most involved factor, although all blood components can cause it, and is caused by antigen reactions/leukocyte antibody and lipid activity with ability to modify the biological response on primitive leukocytes. The diagnosis is based on the integration of clinical, radiological and gasometric elements, ruling out the rest of the possible causes of acute lung injury. Its differential diagnosis should include hemodynamic overload, anaphylactic reaction, bacterial contamination of transfused blood products and transfusion hemolytic reaction. The treatment is supportive measures based on the needs and does not differ from the treatment of acute lung injury secondary to other etiologies, severe cases require endotracheal intubation and mechanical ventilation while the non-severe can be managed with oxygen therapy.

Antebrachial microvascular flap for reconstruction of the pelvic limb: case report

Complex defects in the soft tissues of the foot and ankle caused by high-energy trauma, infection, cancer or diabetes require rapid and effective treatment which decreases the risk of infection, bone healing time, hospital stay and number total of surgical approaches. Authors report a clinical case of a 23-year-old female patient who suffers high-energy trauma due to a motorcycle accident which causes exposure of the distal third of the tibia, loss of the tibial joint face, and loss of tissue throughout the region of the malleolus medial of the right pelvic extremity. Tissue transfer to the pelvic limb is performed using left contralateral radial antebrachial free flap as donor area. This case report aims to emphasize the key aspects of the high energy trauma approach by using microvascular flaps, as well as the satisfactory evolution of the patient that directly affects the prognosis for life and function.