Reverse sural flap for lower limb reconstruction / Retalho sural reverso na reconstrução de membros inferiores

ABSTRACT Introduction: Reconstruction of distal wounds in lower extremities can be challenging due to the lack of tissue to perform local flaps. Fasciocutaneous and muscular flaps are some options for coverage, such as the reverse-flow fasciocutaneous sural flap. Objective: To present an 18-month experience on ankle, calcaneus, and foot reconstruction using the reverse-flow sural flap, performed by the Complex Wounds Group of the Plastic Surgery Department of the University of São Paulo Medical School. Methods: An observational, retrospective and descriptive study was performed through data survey on medical records of all patients treated between November 2018 and June 2020. Results: Nine reverse-flow fasciocutaneous sural flaps were performed. All patients were men. The mean age was 38 years old. Five patients had acute wounds for traffic collision, one electrical trauma and three chronic post-traumatic injuries. The ankle was the most common injury site (6), followed by foot (2) and calcaneus (1). Four patients had complications, three of which were partial necrosis and one distal epitheliosis. No case of total necrosis was recorded. The average hospital stay was 30.1 days. Conclusion: The reverse-flow fasciocutaneous sural flap proved to be a viable, reproducible, and reliable option for distal lower limb reconstruction. Level of Evidence IV, Case Series.

RESUMO Introdução: Reconstrução de lesões distais de extremidades inferiores podem ser desafiadoras devido à limitação de tecido para retalhos locais. Retalhos fasciocutâneos e musculares são opções, como o retalho fasciocutâneo sural reverso. Objetivo: Apresentar a experiência de 18 meses do Grupo de Feridas Complexas do Serviço de Cirurgia Plástica da Faculdade de Medicina da Universidade de São Paulo no uso do retalho sural reverso para reconstruções de defeitos em tornozelo, calcâneo e pé. Métodos: Estudo observacional, retrospectivo e descritivo, com dados de prontuário de todos os casos operados no serviço entre novembro de 2018 e junho de 2020. Resultados: Foram realizados nove retalhos fasciocutâneos sural reverso. Todos os pacientes eram do sexo masculino, com idade média de 38 anos. Cinco foram vítimas de acidente automobilístico, um de trauma elétrico e três apresentavam sequelas pós-traumáticas. Seis lesões localizadas em tornozelo, dois em pé e um em calcâneo. Quatro pacientes apresentaram complicações, sendo três necroses parciais e uma epiteliólise distal. Não houve perda total de retalho. O tempo médio de hospitalização foi de 30,1 dias. Conclusão: O retalho fasciocutâneo sural reverso mostrou-se uma opção viável, reprodutível e segura para reconstrução de lesões complexas em terço distal de perna e pé. Nível de Evidência IV, Série de Casos.

Modified cross-leg free skin flap for the construction of soft tissue defects of the lower leg / 中华创伤杂志

Objective:To analyze the therapeutic effect of modified cross-leg free skin flaps in repairing soft tissue defects of the lower leg.Methods:A retrospective case series study was conducted to analyze clinical data of 8 patients with soft tissue defects of the lower leg admitted to Affiliated Hospital of Zunyi Medical University from June 2018 to June 2020. There were 6 males and 2 females with the age range of 23-60 years［（39.6±5.7）years］. Area of defect was from 10.0 cm×4.5 cm to 21.0 cm×9.0 cm，with the size of flap from 12 cm×5 cm to 25 cm×10 cm. The free flaps were harvested to repair the wound of the affected leg and the blood vessels were anastomosed by cross-leg with the contralateral posterior tibial artery and vein at the first stage，including lateral circumflex femoral artery flap for 6 patients，superficial circumflex iliac artery flap for 1 and latissimus dorsi myocutaneous flap for 1. At the same time，the pedicled posterior tibial artery perforator flap or random flap was cut to wrap the vascular pedicle. After operation，both legs were placed in a parallel and straight position. After pedicle cleavage at the second stage，the posterior tibial artery and distal artery were re-anastomosed，and the flap was sutured to its original position. Incidences of pressure sores and deep venous thrombosis of the lower leg and patients' acceptance of the position were documented during leg crossing at the first stage. The survival of the flap was observed after pedicle amputation at the second stage. The appearance，texture，function of the affected limb and influence on the healthy leg were observed at the last follow-up. Simultaneously，the lower extremity functional score（LEFS）was used to evaluate the overall function of the affected leg and the Kofoed score to evaluate ankle function.Results:All patients were followed up for 6-18 months［（8.3±1.8）months］. There reported none of pressure ulcer or deep venous thrombosis of the lower leg，without resistance to body position at stage I. All flaps survived after pedicle amputation at stage II. The shape，texture and function of the injured leg were good，with no impact on function of the healthy leg at the last follow-up. The LEFS score of the affected leg and the Kofoed score of the ankle were increased from（31.5±6.9）points and（51.0±10.5）points preoperatively to（51.7±9.8）points and（84.8±8.1）points at the last follow-up（ P<0.01）. Conclusion:For patients with soft tissue defects of the lower leg，the treatment with modified cross free flap has advantages of relatively comfortable position，no impact on function of the healthy leg，good appearance and texture of the flap and satisfactory recovery of the affected leg.

Efficacy of bilayer artificial dermis graft plus single layer dermal template for repair of lower extremity wounds with large area of exposed bone / 中华创伤杂志

Objective:To compare the efficacy of bilayer artificial dermis graft plus single layer dermal template and bilayer artificial dermis graft only in repairing lower extremity wounds with large area of exposed bone.Methods:A retrospective case-control study was conducted to analyze the clinical data of 34 patients with 37 wounds of the lower extremity involving large area of exposed bone admitted to Beijing Jishuitan Hospital from November 2009 to November 2020. There were 27 males and 7 females, aged 9-67 years [35.5(29, 45)years]. The exposed bone in the lower leg, ankle and foot was greater than 10 cm 2 in size (the shortest distance from edge to edge of bony exposure was more than 2 cm). At the first stage, the wounds were grafted with bilayer type artificial dermis only for 21 wounds of 20 patients in Group A, and grafted with bilayer type artificial dermis plus single layer dermal template for 16 wounds of 14 patients in Group B. At the second stage, the auto-skin graft was performed in the two groups. The wound healing rate was observed in all patients, and was compared between the two groups at 2 weeks and 2 months after the second stage operation. At the same time, the interval between first stage and second stage surgery was measured. The Vancouver Scar Scale (VSS) was used to evaluate the scar in the skin grafting area in the two groups at 5-6 months after the second stage operation. Results:All patients were followed up for 1 to 24 months [5(2, 7.5)months]. The total excellent and good wound healing rate in all patients was 81%(30/37) at 2 weeks and 97%(36/37) at 2 months. There was no significant difference between the Group A and Group B in the excellent and good wound healing rate at 2 weeks [(76%(16/21) vs. 88%(14/16)] and at 2 months [95%(20/21) vs. 100%(16/16)] ( P>0.05). In Group A, the bilayer artificial dermis was grafted into 4 wounds again to complete exposed bone coverage. However, all wounds in Group B were covered initially without re-grafting. The interval between the two-stage operation was 20(16, 21)days in Group A after the 4 patients who underwent secondary artificial dermal transplantation were excluded, showing no significant difference from 21(21, 23)days in Group B ( P>0.05). At 5-6 months after the second stage operation, the VSS score in Group B [(8.0±1.2)points] was significant less than that in Group A [(9.2±1.1)days] ( P<0.05). In the sub-index of VSS, the score of color and softness of scar in Group B [(2.0±0.6)points, (1.6±0.5)points] were significantly improved compared to those in Group A [(2.5±0.5)points, (2.2±0.7)points] ( P<0.05). Conclusions:The artificial dermis grafting is effective in treatment of lower extremity wounds with large area of exposed bone. However, the bilayer artificial dermis graft plus single layer dermal template can avoid artificial dermal re-graft in repair of large area of exposed bone, and the interval between two-stage operation is not significantly prolonged. Moerover, the color and texture of scar after skin grafting and wound repair efficiency and quality are improved.

Cobertura de lesões em pé e terço inferior da perna com retalho fasciocutâneo reverso da panturrilha (Carriquiry) / Coverage of the lower third of the limb and foot injuries using reverse sural fasciocutaneous flap described by Carriquiry

Introdução: Lesões no terço distal dos membros inferiores, com exposição de ossos, articulações, tendões e vasos sanguíneos, não são passíveis do uso de enxertos de pele. Isto ocorre porque o leito vascular é exíguo e pela pobre granulação das feridas, podendo apenas ser corrigidas com retalhos musculares, miocutâneos, fasciocutâneos ou transferência microcirúrgica. Métodos: O retalho em seu limite inferior é demarcado a partir de 5 cm acima dos maléolos. Superiormente, é marcado num comprimento suficiente para cobertura total da lesão. Realizada incisão em demarcação prévia, e elevados pele e tecido subcutâneo juntamente com a fáscia muscular. O nervo sural é preservado em seu leito original. A elevação do retalho se dá até o ponto inferior marcado (o pedículo). Neste ponto, o retalho é transposto numa angulação suficiente para alcançar a lesão. Resultados: Oito casos foram operados utilizando o retalho descrito. Todos apresentavam exposição de ossos e tendões em região distal da perna, dorso do pé ou ambos, nos quais foram utilizados o retalho fasciocutâneo reverso da perna com a técnica proposta por Carriquiry. Os casos apresentaram resultados estético e funcional satisfatórios. Conclusão: O retalho utilizado se presta à correção de lesões do terço inferior da perna e do pé. É relativamente fácil de ser confeccionado, com bom suprimento vascular, e não há perda funcional do leito doador.

Introduction: Skin grafts are not effective to cover lesions in the distal third of the lower limbs that expose the bones, joints, tendons, and blood vessels due to a limited vascular bed and poor granulation of the wounds. These lesions can only be corrected with microsurgical transfer or muscle, myocutaneous, or fasciocutaneous flaps. Methods: The lower border of the flap was marked 5 cm above the malleolus. The upper border was marked after providing sufficient length for complete coverage of the lesion. The incision was performed at the marked upper border, and the skin and subcutaneous tissue were elevated together with muscle fascia. The sural nerve was preserved in its original bed. The flap was lifted to the marked lower border (the pedicle). At this point, the flap was transposed at a sufficient angle to cover the lesion. Results: Eight cases of surgery were conducted using the flap described above. All cases had exposed bones and tendons in the distal region of the limb, back of the foot, or both, in which the reverse sural fasciocutaneous flap with the technique proposed by Carriquiry was used. The cases showed satisfactory esthetic and functional results. Conclusion: The used flap can correct lesions of the lower third of the limbs and foot. It is relatively easy to make, with good vascular supply, and there is no functional loss of the donor area.

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.

Outcome of Islanded Gastrocnemius Musculocutaneous Flap in Orthopaedic Practice

@#Introduction:Large wounds in the leg require combination of local flaps or free flap for wound coverage. Gastrocnemius musculocutaneous flap (GMCF) allows a large wound to be covered by a single local flap. However, the conventional GMCF is often associated with donor site morbidity where the exposed soleus raphe causes poor uptake of the skin graft. Islanding the skin on the muscles allows the donor site to be closed primarily, thus avoiding the donor site morbidity. Materials and Methods: Medical records of twelve patients who underwent islanded GMCF surgery from 2004 till 2018 were reviewed retrospectively. Results: The mean age was 31 years old. Eight cases were with open fracture of the tibia, two degloving injury exposing the patella, one open fracture of patella and necrotising soft tissue infection. The wound size ranged from 12cm2 to 120cm2. All flaps survived. Three patients required skin grafting at the donor site while in the rest the donor sites were able to be closed primarily. Four patients developed deep infection, one healed after vacuum dressing, one after bone transport and one after split thickness skin graft. One patient ended up with below knee amputation after developing chronic osteomyelitis of the tibia. Conclusion: Islanded gastrocnemius musculocutaneous flap is an effective simple alternative for coverage of large soft tissue defects from the knee to half of the leg distally with minimal donor site morbidity. Aggressive debridement of unhealthy tissue is necessary to prevent infection following wound coverage with this flap.

Reconstruction of extensive soft-tissue defect of leg using free anterolateral thigh flap with the contralateral leg vessels as the recipient vessels / 中华整形外科杂志

Objective@#To explore the clinical effects of the reconstruction of extensive leg defects using the free anterolateral thigh flap with the contralateral leg vessels as the recipient vessels.@*Methods@#From January 2012 to January 2018, ten patients were treated with severe and extensive leg defects in the department of orthopedics of the First Affiliated Hospital of Nanchang University. There were 7 males and 3 females with an average age of 35, from 17 to 56. There were no main vessels for angiogenesis around the wounds in all cases. The size of defects ranged from 20 cm×13 cm to 29 cm×15 cm. The position of defects were anterior of shank in 5 cases, medial in 3 cases and medial posterior in 2 cases. The various flaps were harvested from the anterolateral thigh region of healthy leg and transferred to repair the leg defects. The healthy vessels of the contralateral leg were chosen as the recipient vessels. The musculocutaneous flap, fascia flap or perforator was removed according to the size of the defect and whether it was necessary to fill the dead space of the wound. The limbs were placed in parallel position and was fixed by external fixator. The pedicle division training was started 1 week after operation, the period of pedicle division and external fixator removing was from 21 days to 32 days. When the pedicle was divided, the vascular end of the limb and the distal end were anastomosed to re-established the continuous vessels.@*Results@#All 10 flaps survived completely after surgery. The size of flaps ranged from 23 cm×14 cm to 32 cm×16 cm. The recipient vessels that were used included the posterior tibial vessels in 5 cases and anterior tibial vessels in the remaining 5 cases. All the vessels in flap pedicle were anastomosed to the recipient vessels in an end-to-end fashion. The anastomotic sites and vascular bundles were covered by using a local flap in 2 cases, skin tension reducer in 1 cases, and free skin graft in the remaining 7 cases. Very mild infection occurred in one case and was controlled by dress changing. A small-sized necrosis of the grafted skin occurred in another patient. All patients were followed up for 6 to 18 months with an average of 12 months. The function of the lower extremities almost recovered. All patients were happy with the final functional and aesthetic outcomes.@*Conclusions@#Although there some drawbacks of the technique, such as long-term immobilization of the lower extremities, multiple staged surgeries, for strictly selected patients, the healthy vessels of the contralateral leg could be served as recipients vessels when a free myocutaneous, fasciocutaneous, or perforator flap was used to reconstruct the extensive and severe injury of the leg, particularly in the absence of usable vessels in the ipsilateral leg.

Use of the cross-leg distally based sural artery flap for the reconstruction of complex lower extremity defects

Cross-leg flaps are a useful reconstructive option for complex lower limb defects when free flaps cannot be performed owing to vessel damage. We describe the use of the extended distally based sural artery flap in a cross-leg fashion for lower extremity coverage in three patients. To maximise the viability of these extended flaps, a delay was performed by raising them in a bipedicled fashion before gradual division of the tip over 5 to 7 days for cross-leg transfer. Rigid coupling of the lower limbs with external fixators was critical in preventing flap avulsion and to promote neovascular takeover. The pedicle was gradually divided over the ensuing 7 to 14 days before full flap inset and removal of the external fixators. In all three patients, the flaps survived with no complications and successful coverage of the critical defect was achieved. One patient developed a grade 2 pressure injury on his heel that resolved with conservative dressings. The donor sites and external fixator pin wounds healed well, with no functional morbidity. The cross-leg extended distally based sural artery flap is a reliable reconstructive option in challenging scenarios. Adequate flap delay, manoeuvres to reduce congestion, and postoperative rigid immobilization are key to a successful outcome.

Effect of Pre-training and Post-training Nordic Exercise on Hamstring Injury Prevention, Recurrence, and Severity in Soccer Players

OBJECTIVE: To investigate the effect of adding Nordic exercise as post-training in decreasing hamstring initial, recurrent injuries rates, and their severity. METHODS: In this randomly controlled trial study, 34 professional football players aged 21 to 35 years were randomly assigned into two groups (17 players each) from Sporting clubs at Alexandria, Egypt. For group one, Nordic hamstring exercise (NHE) was performed pre-training and post-training. For group two, NHE was only performed pre-training. The control group was the same team during the previous season. Length of the trial was 12 weeks. The Australian football association injury form was used to collect incidence of injuries for each subject in both groups. RESULTS: Pooled results based on total injuries showed that group one had significantly less hamstring initial injuries (92% less) than the previous season, while group two had 80% less initial injuries and 85% less recurrent injuries than previous season. Regarding the severity of injuries in term of mean number of absent days, it was 1 day for group one and 2.7 days for group two while it was 7.95 days for the previous season during total risk time of 116.3±13.2 and 117.6±5.7 exposure hours for group one and group two, respectively. CONCLUSION: The use of NHE as a prevention protocol was effective in reducing all hamstring injuries with the use of NHE during pre-training and post-training having the greatest effect.

Clinical efficacy of free flap in repairing Gustilo ⅢB and ⅢC fractures of tibia and fibula combined with soft tissue defects / 中华创伤杂志

Objective To investigate the clinical efficacy of free flap transplantation in repairing the Gustilo type ⅢB and ⅢC fractures of tibia and fibula combined with soft tissue defects.Methods A retrospective case series study was conducted on the clinical data of 46 patients who had Gustilo type ⅢB and ⅢC fractures of tibia and fibula with soft tissue defects admitted from June 2013 to January 2017.There were 34 males and 12 females,aged 1-67 years (mean,39 years).The wound defect areas ranged from 6 cm × 20 cm to 7 cm × 38 cm.According to the Gustilo fracture classification,there were 31 cases of type ⅢB and 15 cases of type ⅢC.According to the AO fracture typing,there were five cases of type A,23 type B,and 18 type C.All patients were repaired with free flap transplantation,among which 40 patients were treated with anterolateral thigh flap and six with latissimus dorsi flap.The areas of anterolateral thigh flap ranged from 6 cm × 13 cm to 14 cm ×32 cm,and those of the latissimus dorsi flap from 6 cm × 22 cm to 7 cm × 40 cm.Efficacy was evaluated by flap survival rate,complications,fracture healing time,lower limb function scoring system (LEFS),and skin flap function.Results All limbs were salvaged successfully.One case of total flap necrosis and eight cases of postoperative crisis occurred.After active exploration and treatment,three cases were seen distal local necrosis,and the total survival rate was 91％.Infection at the donor site was found in two cases.The complication incidence rate was 4％.All patients were followed up for 7-42 months,with an average of 19 months.The fracture healing time averaged 43.5 weeks,and the LEFS score averaged 54 points.According to the seven indexes of flap function,the results were excellent in 1 1 cases,good in 29 cases,fair in four cases,and poor in two cases,with an excellent and good rate of 87％.Conclusion Free flap transplantation can achieve satisfactory efficacy in treating Gustilo type ⅢB and ⅢC of tibia and fibula combined with soft tissue defects,with high limb salvage rate and good function recovery.

Incidence and causes of lower-limb amputations in the city of Ribeirão Preto from 1985 to 2008: evaluation of the medical records from 3274 cases / Incidência e causas de amputações dos membros inferiores em Ribeirão Preto de 1985 a 2008: avaliação de 3274 casos

ABSTRACT: Objective: It was to identify trends of traumatic and non-traumatic causes of lower limb amputations, as well as the role played by population aging, traffic violence increase, public health policy of diabetes control program and drivers anti-alcohol laws on these amputations. Method: Hospitalization data recorded in the discharge forms of 32 hospitals located in the region of Ribeirão Preto, Brazil, from 1985 to 2008 were analyzed. Result: A total of 3,274 lower-limb amputations were analyzed, of which 95.2% were related to non-traumatic causes, mainly infectious and ischemic complications of diabetes mellitus. Cancer (2.8%) and congenital (1.3%) causes were included in this group. Only 4.8% were related to traumatic causes. Traumatic amputation average rate was 1.5 amputations in 100,000 habitants with a slight tendency of increase in the last 5 years. Non-traumatic causes showed an average rate of 30.0 amputations for 100,000 habitants and remained relatively constant during the whole period. Non-traumatic were much more predominant in patients older than 60 years and traumatic amputations occurred more frequently in patients younger than 39 years. Conclusion: The overall rates of amputation and the rates of traumatic and non-traumatic amputations remained nearly constant during the study period. The impact of diabetes control policies and the introduction of traffic safety laws could not be identified on the amputation rates.

RESUMO: Objetivo: Identificar as tendências temporais de causas traumáticas e não traumáticas de amputações de membros inferiores, e os efeitos do envelhecimento da população, do aumento de violência no trânsito, da política de saúde pública do programa de controle de diabetes e das leis de controle do uso de álcool em motoristas sobre as taxas de amputações. Método: Foram analisados os dados das folhas de alta de pacientes submetidos a amputações de todos os 32 hospitais localizados na região de Ribeirão Preto, Brasil, de 1985 a 2008. Resultado: De 3.274 amputações de membros inferiores, 95,2% estavam relacionadas a causas não traumáticas, principalmente complicações do diabetes mellitus. Câncer (2,8%) e causas congênitas (1,3%) foram incluídos neste grupo. Apenas 4,8% estavam relacionados às causas traumáticas. A taxa média de amputação traumática foi de 1,5 amputações por 100.000 habitantes, com uma ligeira tendência de aumento nos últimos 5 anos. As causas não traumáticas mostraram uma taxa média de 30 amputações por 100.000 habitantes e mantiveram-se relativamente constantes durante todo o período. As causas não traumáticas foram predominantes em pacientes com mais de 60 anos, e as amputações traumáticas ocorreram mais frequentemente em pacientes com menos de 39 anos. Conclusão: A taxa total de amputações e as taxas de amputações traumáticas e não traumáticas permaneceram praticamente constantes durante o período de estudo. O impacto das políticas de controle do diabetes e da introdução de leis de repressão do uso de álcool no trânsito não pode ser identificado nas taxas de amputação.

Effect of tuina along the pathways of meridians plus rehabilitation training on lower limb swelling after surgical repair of fracture / 针灸推拿医学（英文版）

Objective:To investigate the effect of tuina along the pathways of meridians on lower limb swelling after surgical repair of fracture.Methods:A total of 72 cases with lower limb fractures were randomly allocated into an observation group (n=36) and a control group (n=36). On the third day when the draining tube was removed after surgery, patients in both groups started same rehabilitation training. The patients in the observation group received additional tuina therapy along the pathways of meridians, twice a day for 7 d. Then the swelling and deswelling time of patients in both groups were observed.Results:After 7 d of treatment, the swelling degree of patients in both groups were significantly alleviated (P<0.05); and the alleviation was more significant in the observation group than that in the control group (P<0.05). There was between-group statistical difference in clinical effect (P<0.05). The follow-up visit 6 months after treatment showed a significantly shorter deswelling time in the observation group than that in the control group (P<0.05).Conclusion:Tuina along the pathways of meridians plus rehabilitation training can effectively prevent or alleviate (fracture) postoperative lower limb swelling.

Application of peripheral nerve block in anesthesia management of patients with trauma of the tibia and fibula / 第二军医大学学报

Objective To explore the value of peripheral nerve block for anesthesia management in patients with lower extremity injuries, so as to discuss its role in future war injury. Methods Totally 58 patients with open fracture of the lower limbs were anesthetized for external fixation and debridement, with the procedure simulating the anesthesia of war extremity injury management. After antishock treatment, the patients were randomly divided into Group P and Group S, with 29 in each group. Patients in Group P were anesthetized using fascia iliaca block combined with sciatic nerve block under ultrasound guidance, and spinal-epidural anesthesia was used in Group S. The general condition of patients, anesthesia complications, anesthesia efficiency, analgesia duration after anesthesia and patients overall satisfaction (VAS score) were compared between the two groups. Results There was no significant difference between the two groups in the general condition before anesthesia. After anesthesia, 20 patients (71%) in Group S suffered circulatory collapse and 2 patients (7%) in Group S suffered respiratory depression, and their conditions were stable (only with 1 patient dropped off due to intubation after anesthesiologist treatment). While no anesthesia complication occurred in Group P. Patients in Group P had a significantly shorter pre-operative anesthesia time than that in Group S (P<0. 01), and intra-operative infusion volume in Group P was lower than that in Group S (P<0. 01). The post-operative analgesia time in Group P was significantly longer than that in Group S (P<0. 01). The overall satisfaction and analgesia effect of patients in Group P was better than those in Group S (P<0. 01). Conclusion Peripheral nerve block anesthesia technique is safer and more comfortable than traditional spinal-epidural anesthesia for patients with trauma of the tibia and fibula.

Versatility of the medial gastrocnemius muscle flap in reconstructing lower limb soft tissue lesions / Versatilidade do uso do retalho do músculo gastrocnêmio medial na reconstrução de lesões de partes moles de membros inferiores

Introduction: Covering complex lower limb wounds is a major challenge. The medial gastrocnemius muscle flap is usually indicated for reconstruction of loss of substance of the knee and proximal third of the leg. The objective of this study was to evaluate the results using gastrocnemius muscle flaps in lower limb wounds. Methods: A total of 28 patients with loss of substance in the lower limbs were treated with medial gastrocnemius muscle flaps. Data were obtained from clinical records of patients who underwent surgery from 2003 to 2012. Results: In 28 patients who underwent surgery, the age range was 4 to 57 years, with a mean of 30.6 years. The etiology of the lesions was a motorcycle accident in 16 cases (57.1%), being run over in 8 cases (28.6%), car crash in 2 cases (7.2%), meningococcemia in 1 case (3.6%), and snake bite in 1 case (3.6%). After an average follow-up of 15 months (range: 6 to 26 months), all patients had stable coverage. The mean number of preoperative debridements was 2.4 (range: 1 to 8). In 22 patients, the flaps were made without the release of the muscle origin and in 6 patients the muscle flaps were separated from their origin in the femur. Conclusions: Transfer of a gastrocnemius muscle flap is a simple and safe procedure in the treatment of lower limb injuries. The application of the medial gastrocnemius muscle flap was demonstrated in different situations, with satisfactory results and easy reproducibility.

Introdução: A cobertura de feridas complexas de membros inferiores é um grande desafio. O retalho muscular do gastrocnêmio medial é comumente indicado para reconstrução de perdas de substância do joelho e terço proximal da perna. O objetivo desse trabalho é avaliar os resultados da utilização do retalho muscular do gastrocnêmio nos casos de ferida em membros inferiores. Métodos: Um total de 28 pacientes com perda de substância de membros inferiores foi tratado com retalho muscular do gastrocnêmio medial. Os dados foram obtidos em registros clínicos dos pacientes operados no período de 2003 a 2012. Resultados: Vinte e oito pacientes foram operados, com idades variando de 4 a 57 anos, e média de 30,6 anos. A etiologia das lesões foi acidente por motocicleta em 16 casos (57,1%), atropelamentos em oito casos (28,6%), acidente automobilístico em dois casos (7,2%), meningococcemia em um caso (3,6%) e acidente ofídico em um caso (3,6%). Depois de um seguimento médio de 15 meses (variação de 6 a 26 meses), todos pacientes mostraram cobertura estável. O número médio de desbridamentos pré-operatórios foi 2,4 (variação de 1 a 8). Em 22 pacientes, os retalhos foram confeccionados sem a liberação da origem muscular e em seis pacientes os retalhos musculares foram separados de sua origem no fêmur. Conclusões: A transferência do retalho muscular do gastrocnêmio é um procedimento simples e seguro no tratamento de lesões de membros inferiores. Foi demonstrada a aplicação do retalho muscular do gastrocnêmio medial em diferentes situações, com resultados satisfatórios e fácil reprodução.

Algoritmo terapéutico para pacientes con fractura diafisaria de tibia / Therapeutic algorithm for patients who suffer from tibial diaphyseal fractures

Fundamento: la fractura de la diáfisis tibial constituye una enfermedad traumática muy frecuente. Sin embargo, no existe una conducta estandarizada para el tratamiento de estos enfermos, de allí la importancia de llegar a un consenso sobre los pasos a seguir en pacientes con esta afección. Objetivo: validar un algoritmo de tratamiento para pacientes con fracturas diafisaria de tibia. Métodos: para la validación del algoritmo, se empleó el método de Delphi, mediante la consulta a un grupo de expertos constituido por 16 especialistas en Ortopedia y Traumatología, pertenecientes a cinco instituciones médicas del país. Los profesionales consultados presentaron como promedio 18,5 años de experiencia profesional, un doctor en Ciencias Médicas, seis con categoría científica de Master, cinco especialistas de segundo grado, un profesor titular. Resultados: se calcularon los valores correspondientes a la matriz de frecuencias absolutas, matriz de frecuencias acumuladas, matriz de frecuencias relativas acumuladas y matriz indicativa de los puntos de corte. Conclusiones: el algoritmo propuesto por los autores resultó validado en cuanto a: diseño, aplicabilidad, pertinencia, reproductibilidad y sentido práctico.

Background: tibial diaphyseal fracture is a common traumatic condition. However, there is not a standardized consensus to treat patients with this condition. That is why, it is important to get to a consensus for treating patients with tibial diaphyseal fractures. Objective: to validate a therapeutic algorithm for the management of patients with tibial diaphyseal fractures. Methods: Delphi method was applied for the validation of the algorithm. A group of experts was consulted. This group was composed of 16 specialists in Orthopedics and Traumatology from five teaching hospitals in all the country. The consulted professionals have 18, 5 professional years of experience on average. One of them is a Doctor of Medical Sciences, one is a titular professor, six are Masters, and five are second degree specialists. Results: the values corresponding to different matrices (absolute-frequencies matrix, accumulated-frequencies matrix, indicative cutting-points matrix) were calculated. Conclusions: the proposed algorithm was validated regarding: design, applicability, pertinence, and practical sense.

Fijación externa en paciente con fractura abierta del pilón tibial: a propósito de un caso / External fixation in a patient with open tibial pylon fracture: a case report

FUNDAMENTO: las fracturas del pilón tibial son enfermedades traumáticas muy frecuentes debido a un mecanismo de compresión axial de la extremidad. OBJETIVO: mostrar un paciente con fractura del pilón tibial tratado mediante fijación externa triangular. CASO CLÍNICO: paciente de 52 años de edad, blanco, masculino con antecedentes de salud anterior, que sufrió caída de un caballo, luego comenzó con dolor, inflamación e impotencia funcional localizado a nivel distal de la pierna derecha, que le impedía la marcha y el apoyo de la extremidad. En el examen físico se observó deformidad en varo por encima del tobillo, así como herida medial de bordes irregulares de aproximadamente tres centímetros muy contaminada. La palpación reveló movilidad anormal y crepitación a nivel del foco de fractura. A la exploración neurovascular no se detectaron anormalidades. El paciente fue tratado mediante la colocación de aguja de Kirschner para la fractura del peroné y fijación externa en configuración triangular. CONCLUSIONES: la fijación externa constituye una modalidad efectiva en el tratamiento de pacientes con fracturas abiertas del pilón tibial.

BACKGROUND: tibial pylon fractures are traumatic diseases that appear very frequently due to a mechanism of axial compression of the extremity. OBJECTIVE: to present the case of a patient with tibial pylon fracture treated by means of triangular external fixation. CLINICAL CASE: a fifty-two-year-old, white, male patient with antecedents of being a healthy person who fell from a horse and then presented pain, inflammation, and functional impotence located at distal level in the right leg that impaired him from walking and leaning on his extremity. A varus deformity above the ankle and a very contaminated 3-odd cm medial wound of irregular margins, were found in the physical examination. Palpation showed an abnormal mobility and crepitation at the level of the fracture focus. No abnormalities were observed in the neurovascular examination. The patient was treated with the placement of Kirschner wires for the fibula fracture and with external fixation in triangular configuration. CONCLUSIONS: external fixation is an effective method in the treatment of patients with open tibial pylon fractures.

Reconstrução de dorso do pé com retalho supramaleolar lateral de fluxo reverso em menor de 4 anos de idade / Reconstruction of the dorsal foot with a retrograde flow lateral supramalleolar flap in a 4-year-old child

INTRODUÇÃO: Lesões em terço distal da perna podem deixar expostas áreas nobres, que devem ser recobertas. O retalho supramaleolar lateral faz parte de uma série de retalhos descritos na última década, é fasciocutâneo elevado no aspecto lateral da perna inferior, sendo empregado como um retalho pediculado com base distal. O objetivo do presente relato de caso é apresentar os resultados cirúrgicos e a eficácia do retalho supramaleolar lateral em lesões extensas no membro inferior com perdas de substâncias significativas em criança de 4 anos. RELATO DE CASO: Paciente A.K.E.S., sexo feminino, foi internada há 13 anos, vítima de atropelamento, com lesão extensa em dorso de pé esquerdo com exposição de áreas nobres de aproximadamente seis centímetros de diâmetro. Após desbridamento, no quinto dia foi realizada cobertura da lesão com retalho fasciocutâneo supramaleolar lateral. A paciente teve alta para acompanhamento ambulatorial, evoluindo sem intercorrência. Ela retornou ao serviço apenas 13 anos após com sobrepeso e reclamando do aumento de volume no dorso do pé. Foi realizada lipectomia do terço distal do retalho, evoluindo sem intercorrência. Um segundo procedimento do terço proximal foi programado para seis meses após. DISCUSSÃO: Lesões no terço distal da perna podem expor áreas nobres. Os retalhos supramaleolar lateral, sural e de perfurantes pediculados possuem aplicações semelhantes, mas apresentam peculiaridades técnicas individuais. Como vantagens no retalho supramaleolar lateral: não há necessidade de microanastomoses, é rápido para ser executado e simula a área receptora em várias características locais. CONCLUSÃO: É um retalho de maior facilidade de execução e reprodutível, podendo ser realizado em crianças menores de 5 anos. Tem sua aplicação como alternativa para lesões em terços inferiores da perna, tornozelo e pé.

INTRODUCTION: Injuries in the distal third of the leg may expose noble areas that should be covered. The lateral supramalleolar flap is one of a series of flaps described in the last decade; it is an elevated fasciocutaneous flap in the lateral aspect of the lower leg, and is employed as a distally based pedicled flap. The purpose of this case report is to present the surgical results and the effectiveness of the lateral supramalleolar flap in extensive lower limb injuries with significant loss of substance in a 4-year-old child. CASE REPORT: Patient A. K. E. S., a girl, was admitted 13 years previously. She had been in an accident, and had extensive injuries on the dorsum of the left foot, with exposure of noble areas approximately 6 cm in diameter. After debridement, lesion coverage was performed on the fifth day by using a fasciocutaneous lateral supramalleolar flap. The patient was discharged for outpatient monitoring and progressed without complication. She only returned to the hospital 13 years later, overweight and complaining of swelling on the dorsal aspect of the foot. Lipectomy of the distal third of the flap was performed, with uncomplicated progress. A second procedure for the proximal third was scheduled six months later. DISCUSSION: Injuries in the distal third of the leg may expose noble areas. Lateral supramalleolar, sural, and pedicled perforating flaps have similar applications, but show individual technical peculiarities. The lateral supramalleolar flap has no need for microsurgery, is rapidly performed, and simulates the receiving area while considering several local characteristics. CONCLUSION: This flap is easily implemented and reproducible, and can be used in children younger than 5 years of age. It is an alternative for injuries in the lower third of the leg, the ankle, and the foot.

Alternativas para el tratamiento de las fracturas complejas de pilón tibial / Alternatives for the treatment of complex tibial pilon fractures

Las fracturas de pilón tibial representan una de las fracturas más graves, no sólo por la complejidad de su tratamiento, sino también por las importantes secuelas que pueden originar. Además de que un importante porcentaje de éstas son abiertas o con importante afectación de partes blandas, lo que dificulta aún más su tratamiento. Se revisaron 37 pacientes con fractura de pilón tibial tratados de forma quirúrgica, analizando los resultados con la escala de valoración funcional FREMAP y con los criterios radiográficos de Burwell-Charnley. Aunque no existe consenso en relación al tratamiento ideal, parece evidente que el tratamiento combinado con fijación externa e interna con placa ofrece los mejores resultados.

Tibial pilon fractures are one of the most severe types of fractures, not only due to the complexity of their treatment, but also due to the important sequelae they may cause. Moreover, an important percentage of them are open fractures or importantly involve the soft tissues, thus making treatment even more difficult. Thirty-seven patients with tibial pilon fractures treated surgically were included in this study. The results of the FREMAP functional assessment scale were analyzed together with Burwell-Charnley's radiographic criteria. Although there is no consensus on which is the best treatment, it is evident that combined treatment including external and internal fixation with a plate provides the best results.

Actinomicosis de una pierna: una localización infrecuente / Actinomycosis of the leg: an infrequent location

FUNDAMENTO: la actinomicosis es una enfermedad rara que después del advenimiento de los antibióticos se diagnóstica menos, puede asentar en cualquier sitio pero la localización primaria en una pierna es excepcional. OBJETIVO: presentar el caso de un paciente con actinomicosis de la piel de la pierna derecha, el cual constituye el primero reportado en el país. CASO CLÍNICO: paciente masculino de 32 años sin antecedentes patológicos de interés, el cual en un viaje al campo sufre de una lesión punzante en la pierna derecha. A los dos días de lo ocurrido, presentó lesión de 3 a 4 cm en dicha región, acompañado de fiebre de 38oC, acudió a un facultativo que le indicó antibiótico y antiinflamatorio y no mejoró. Concurrió al servicio de urgencia, ya con una lesión en peor estado por lo que se le realizó desbridamiento del absceso y antibiótico. Se le indicaron múltiples exámenes y sólo fueron positivos la velocidad de sedimentación globular, la proteína C reactiva y el cultivo, el cual fue positivo por primera intensión para estafilococo áureo y por segunda oportunidad se aisló el actinomyces israelii. Se realizó estudio histopatológico que confirmó el diagnóstico de actinomicosis. Se impuso tratamiento con penicilina G, 4 millones de UI cada 6 horas durante 4 semanas y tratamiento quirúrgico. Al mes se instauró terapéutica con amoxicilina (500 mg), 1 cápsula cada 6 horas durante seis meses. Después de esta terapéutica el paciente se encuentra asintomático. CONCLUSIONES: esta enfermedad debe considerarse en el diagnóstico diferencial de cualquier nódulo, induración o absceso en tejidos blandos. El diagnóstico definitivo requiere cultivo en un medio especial y la histopatología como complemento.

BACKGROUND: acticnomycosis is an uncommon disease which has diminished since the introduction of antibiotics. It can appear in any site of the body but the primary location in the leg is exceptional. OBJECTIVE: to present the case of a patient with actinomycosis of the skin of the right leg which constitutes the first case reported in the country. CLINICAL CASE: a thirty-two-year-old male patient without pathological antecedents of interest that suffered a stabbing injury in the right leg while camping. Two days later, the patient presented a 3-4cm lesion in the mentioned region, as well as a fever of 38oC. The patient went to the doctor who prescribed him an antibiotic and an anti-inflammatory but he did not get better. He went to the emergency service presenting the lesion in worse conditions. The patient underwent multiple exams and only the following were positive: erithrosedimentation rate, C reactive protein, and the culturing that was first positive for staphylococcus aureus and secondly actinomyces israelii was isolated. A histopathological study confirmed the diagnosis of actinomycosis. The patient had to undergo a treatment with penicillin-G, 4 million IU every 6h for four weeks, and surgery. A month later, a therapeutic treatment with amoxicillin (500 mg), a capsule every 6h for six months, was established. After the treatment, the patient is asymptomatic. CONCLUSIONS: this disease should be considered in the differential diagnosis of any nodule, induration or abscess in soft tissues. The definitive diagnosis requires a culturing in a special environment and histopathology as a complement.

Fasciocutaneous flaps for covering foot and ankle injuries / Retalhos fasciocutâneos para cobertura de lesões no pé e tornozelo

OBJECTIVE: to present some cases from our service and to confirm that sural and lateral supramalleolar flaps are good options for covering the soft tissues of the foot and ankle. METHODS: twenty-two flaps were constructed in 21 patients of ages ranging from 15 to 72 years. Male patients predominated (66.6%) and in 47.6% of the cases the injury resulted from accidents involving motorcycles. RESULTS: among the 22 flaps, 12 were sural and 10 were lateral supramalleolar; in one case, two flaps were used. In all the cases, the injuries were successfully covered and the patients recovered well. During the postoperative follow-up, the commonest complication was epidermolysis, occurring in eight cases (three in a sural flap and five in a supramalleolar flap), among which two cases progressed to distal necrosis of the flap (one sural and the other supramalleolar). One patient wanted the flap reviewed for esthetic reasons. CONCLUSIONS: sural and supramalleolar flaps are very reliable. They preserve the main trunk arteries, are quickly dissected, have low hospital cost, enable coverage of extensive areas, present esthetically acceptable damage to the donor area and do not impair motor function...

OBJETIVO: mostrar alguns casos do nosso serviço, além de confirmar como boas opções os retalhos sural e supramaleolar lateral na cobertura de partes moles do pé e tornozelo. MÉTODOS: foram feitos 22 retalhos em 21 pacientes, entre 15 e 72 anos. Houve predomínio do sexo masculino, com 66,6%, e em 47,6% as lesões foram decorrentes de acidentes que envolveram motocicletas . RESULTADOS: dos 22 retalhos, 12 foram do tipo sural e 10, supramaleolar lateral. Em um caso usaram-se os dois retalhos. Em todos os casos houve sucesso na cobertura das lesões, com boa recuperação dos pacientes. No seguimento pós-operatório a complicação mais comum foi a epidermólise, com oito casos, três no retalho sural e cinco no supramaleolar, dos quais dois progrediram para pequena necrose distal do retalho, um deles sural e o outro supramaleolar. Um paciente desejou rever o retalho por questão estética. CONCLUSÕES: os retalhos sural e supramaleolar são bastante confiáveis, preservam os troncos arteriais principais, são de rápida dissecção, têm baixo custo hospitalar, permitem cobertura de áreas extensas e apresentam dano estético aceitável na área doadora sem prejuízo funcional motor...